Sexual Health Education Disparities in Asian American Adolescents - Journal for Specialists in Pediatric Nursing

Column Editor: Betsy M. McDowell

Ask the Expert provides research-based answers to practice questions submitted by JSPN readers.

Question: I have noticed that there are increasing numbers of Asian American adolescents in the United States. Even though Asian American youth are doing great academically, their level of sexual health-related knowledge is not explicitly known or understood because of the differences in their cultural backgrounds. What do I need to know in order to ensure that my assessment of their sexual health knowledge is culturally responsive?

Tsui-Sui Kao responds: Asian Americans comprise close to 4.2% of the total U.S. population. Research on the health status of Asian Pacific Americans (APA) often analyzes the population as one homogeneous group; however, the APA community includes more than 30 diverse ethnic subpopulations that vary by national origin, language, culture, citizenship, and economic status. The main subgroups include Chinese, Japanese, Korean, Filipino, Vietnamese, Asian Indian, and other cultures from Southeast Asia (U.S. Department of Commerce [USDOC], 2000). Even though as a whole, Asian Americans seem to have comparable educational backgrounds and median family incomes with Caucasian Americans, Asian Americans tend to have more family members working at the same time to maintain their financial status and lifestyle. It is important to note that 14% of the APA population lives below the poverty line, compared to 13% of the U.S. population, and that Asian Americans are less likely to use federal or state-funded health care programs such as Medicaid (National Asian Pacific American Women's Forum [NAPAWF], 2005).

Asian Americans often are perceived as a model minority, appearing to have abundant resources. In reality, their health is compromised by this misconception, and their health problems are often blamed on the conservative nature of their cultures. Healthcare disparities exist not only in new immigrants but also in the subsequent generations of Asian American children. Most Asian American children are immigrants themselves or are children of immigrants who straddle two cultures. Few studies are available to help nurses see some of the problems that Asian American adolescents encounter as a result of this bicultural identification. Nurse professionals confront increasing challenges to care for this vulnerable population, especially with the cultural sensitivity to sexual health issues (Kibria, 2002).

Nurses must be cognizant of the importance of Asian Americans' family-centered cultural values, more specifically the taboo against sex education, and the possible impacts of biculrural straddling. Grunbaum, Lowery, Kann, and Pateman (2000) noted that Asian American adolescents tend to delay sexual intercourse, but that once sexually active, they were as likely to have used alcohol or drugs or fail to use a condom during intercourse as any other ethnic group. These factors put them at greater risk for compromised sexual health; therefore, it is important for pediatric nurses to assess the sexual health of all Asian American adolescents.

Asian American Adolescents' Sexual Health

Studies show that Asian American adolescents tend to delay the onset of sexual intercourse compared to other ethnic groups (Grunbaum et al., 2000; Horan & DiClemente, 1993; Schuster, Bell, & Kanouse, 1996; Schuster, Bell, Nakajima, & Kanouse, 1998; Upchurch, Levy-Storms, Sucoff, & Aneshensel, 1998); however, they are less likely to receive sexual health-related services prior to and even after becoming sexually active (National Asian Women's Health Organization [NAWHO], 1997; Schuster et al., 1996) than other population groups. As a result, Asian American women tend to be diagnosed with more advanced stages of cervical cancer and breast cancer than Caucasian American women (Frisch & Goodman, 2000; Hedeen, White, & Taylor, 1999), and cervical cancer is the leading cause of death for Vietnamese American women (Ishida, 2001). Furthermore, new technology and research show that cervical cancer is actually caused by the human papillomavirus (HPV) (Ordonez, Espinosa, Sanchez-Gonzalez, Armendariz-Borunda, & Berumen, 2004), one of the most prevalent sexually transmitted infections (STIs). Therefore, when focusing on the sexual health of Asian American adolescents, nursing professionals should target cervical cancer detection at the same time.

Many obstacles deter Asian American adolescents from receiving proper sexual health care, such as healthcare providers' misconceptions, stereotyping, racism, sexism, and bicultural gaps between the adolescents' home culture and environmental culture. The disparities in receiving sexual healthcare services exist not only in Asian American women, but are also found in Asian American men. In a survey conducted by the National Asian Women's Health Organization, 89% of the 802 Asian American men surveyed had never received sexual or reproductive healthcare services, even though 87% reported having had at least one sexual partner in the past year (NAWHO, 1999).

Bicultural Straddling

Some research suggests that Asian Americans' reluctance to utilize sexual health-related care is rooted in their conservative cultural background (Horan & DiClemente, 1993; Okazaki, 2002; Schuster et al., 1998). Still, other research has linked health behaviors with the mistrust of healthcare providers (NAWHO, 1999). A survey of 669 Asian Americans found that despite their comparatively higher socioeconomic status (as measured by income and education), Asian Americans reported having a poorer quality of health care than the overall population. Compared with 62% of the overall population, only 45% of Asian Americans were very satisfied with their health care (USDOC, 2000).

One of the reasons for the growing problem of sexual health disparities might be associated with Asian American families' reluctance to talk about sexual health-related issues at home. According to a survey of Asian American women, one-third of the women surveyed never discussed pregnancy, STIs, birth control, or sexuality in their households (NAWHO, 1997). More than half of the women were uncomfortable discussing reproductive health with their mothers and even more uncomfortable discussing these concerns with their fathers and brothers. As a result of this cultural taboo, Asian American girls are often at increased risk for engaging in compromising sexual health-related behaviors. For example, Asian American women have the highest increase in certain STIs, such as gonorrhea and HIV/AIDS (Foo, 2002), yet they are the least likely of all minority groups to believe they are at risk and the least likely to receive sexual health care (Foo, 2002; National Council of Negro Women, 1992; USDOC, 2000).

One possible reason that sex education is a taboo subject in Asian American homes may be the fact that in the traditional Asian culture, sex education was minimized in the schools, and parents, as well as health professionals, were reluctant to discuss sexuality and sexual information (Chan, 1986). Hence, it is possible that Asian American parents lack sexual knowledge themselves, and that may discourage them from approaching the subject with their children. Even though there is no documented study to validate Asian American parents' lack of knowledge, nurses must be aware of this possibility and be more attuned to assessing the Asian American parents' and their adolescents' sexual health-related knowledge, as well as their respective comfort talking to each other about sexual health-related issues and/or concerns.

A recent study of Asian American adolescents linked adolescents' sexual activity with gender, acculturation, and parental attachment (Hahm, 2005). Among Asian American girls, the most acculturated group was three times more likely to have reported sexual intercourse than the least acculturated group. For both boys and girls, a high level of parental attachment was associated with lower odds of sexual intercourse. Hence, nurses need to give particular attention to assessing the level of acculturation among Asian American girls and build on the strengths of a healthy parent-child relationship (Hahm).

Culturally Responsive Interventions

Even though second-generation Asian Americans might have less trouble adapting to American society in terms of language, they are not necessarily without difficulties. Straddling between two cultures is not an easy task for these teens because they also are struggling with adolescent development. It is important for nurses to understand that living within two cultures in one society can profoundly affect the growth and development of the Asian American adolescent (Noda, 1989).

In order to provide culturally responsive care to Asian American adolescents, nurse professionals must first be sensitive to their cultural differences and be nonjudgmental in order to build trust with both parents and adolescents. Nurses must approach taboo subjects such as sexual health carefully and respectfully. If possible, a same-gender healthcare worker is preferred when discussing sexual health issues with an Asian American teen to minimize embarrassment.

Additionally, nurses need to educate Asian American parents about sexual health before their children reach adolescence. With the conservative nature of Asian culture, parents' lack of knowledge might become an obstacle for adolescents to develop or learn correct information related to sexual health. This in turn may compromise the adolescents' health development. Providing sexual health knowledge for Asian American parents in a culturally sensitive manner would empower them to help their teens make healthier choices.

Nurses also need to understand that Asian Americans' family-centered values may be utilized as a protective factor for the adolescents' sexual health if nurses can facilitate communication between parents and adolescents. Research has indicated that Asian American parental expectations of their adolescents is a factor in preventing alcohol abuse (Hahm, Lahiff, & Guterman, 2003) and promoting academic achievement (Hall, 2002). One can assume that parental expectations have the potential to be a protective factor against engaging in risky sexual behaviors. Nurses, therefore, should promote bonding and effective parenting skills in Asian American families, which in turn can inject parental expectations into adolescents' decision making regarding sexual health.

To summarize, the Asian American adolescent's sexual health has been ignored for a long period of time. Even though there are general beliefs that Asian Americans are model minorities, they are not without difficulties. Healthcare disparities exist not only in populations with low socioeconomic status, but also in the populations who are under-utilizing healthcare systems for various reasons. Nurses need to realize that healthcare disparities exist in the Asian American population despite the fact that their Asian American patients have presentable appearances, good educational backgrounds, and/or families with fairly good incomes. Once healthcare disparities in sexual health knowledge are acknowledged, pediatric nurses can provide care that is culturally responsive to the needs of Asian American adolescents, a growing segment of the American population.

If you would like to submit a question for consideration in the Ask the Expert column, please e-mail your question to the column editor at bmcdowell@lander.edu.

Search terms: Adolescence, Asians, Healthcare disparities, sexuality

[Reference]

References

Chan, D.W. (1986). Sex misinformation and misconceptions among Chinese medical students in Hong Kong. Archives of Sexual Behavior, 19, 73-93.

Foo, L.J. (2002). Asian American women: issues, concerns, and responsive human and civil rights advocacy. New York: The Ford Foundation.

Frisch, M., & Goodman, M.T. (2000). Human papillomavirus-associated carcinomas in Hawaii and the mainland U.S. Cancer, 88, 1464-1469.

Grunbaum, J.A., Lowery, R., Kann, L., & Pateman, B. (2000). Prevalence of health risk behaviors among Asian American/Pacific Islander high school students. Journal of Adolescent Health, 27, 322-330.

Hahm, H.C. (2005, January). Gender and acculturation differences in Asian American adolescents' sexual activity. Paper presented at the Society for Social Work and Research, Celebrating a Decade of SSWR, Miami, FL.

Hahm, H.C., Lahiff, M., & Guterman, N.B. (2003). Acculturation and parental attachment in Asian American adolescents' alcohol use. Society for Adolescent Medicine, 33, 119-129.

Hall, G.C.N. (2002). Asian American psychology. Washington, DC: American Psychology Association.

Hedeen, A.N., White, E., & Taylor, V. (1999). Ethnicity and birthplace in relation to tumor size and stage in Asian American women with breast cancer. American Journal of Public Health, 89, 1248-1252.

Horan, P.P., & DiClemente, RJ. (1993). HIV knowledge, communication, and risk behavior among White, Chinese-, Filipino-American adolescents in a high-prevalence AIDS epicenter: A comparative analysis. Ethnicity & Disease, 3, 97-105.

Ishida, D. (2001). Making inroads on cancer prevention and control with Asian Americans. Seminars in Oncology Nursing, 17(3), 220-228.

Kibria, N. (2002). Becoming Asian American: Second-generation Chinese and Korean American identities. Baltimore, MD: Johns Hopkins University Press.

National Asian Pacific American Women's Forum. (2005). Medicaid and Asian Pacific American women. Retrieved April, 19, 2005, from http://modelminority.com/article279.html.

National Asian Women's Health Organization. (1997). Expanding options: A reproductive and sexual health survey of Asian American women. San Francisco, CA: Author.

National Asian Women's Health Organization. (1999). The Asian men's health survey: Sharing responsibilities. San Francisco, CA: Author.

National Council of Negro Women. (1992). The 1991-1992 women of color reproductive health poll (Vol. 55). Washington, DC: Communications Consortium Media Center.

Noda, K.E. (1989). Growing up Asian in America. Boston, MA: Beacon.

Okazaki, S. (2002). Influences of culture on Asian Americans' sexuality. Journal of Sex Research, 39(1), 34-41.

Ordonez, R.M., Espinosa, A.M., Sanchez-Gonzalez, D.J., Armendariz-Borunda, J., & Berumen, J. (2004). Enhanced oncogenicity of Asian American human papillomavirus 16 is associated with impaired E2 repression of E6/E7 oncogene transcription. Journal of Genetics and Virology, 85(Pt 6), 1433-1444.

Schuster, M.A., Bell, R.M., & Kanouse, D.E. (1996). The sexual practices of adolescent virgins: Genital sexual activities of high school students who have never had vaginal intercourse. American Journal of Public Health, 86, 1570-1576.

Schuster, M.A., Bell, R.M., Nakajima, G.A., & Kanouse, D.E. (1998). The sexual practices of Asian and Pacific Islander high school students. Journal of Adolescent Health, 23, 221-231.

Upchurch, D.M., Levy-Storms, L., Sucoff, C.A., & Aneshensel, C.S. (1998). Gender and ethnic differences in the timing of first sexual intercourse. Family Planning Perspectives, 30, 121-127.

U.S. Department of Commerce. (2000). U.S. Bureau of Census data 2000. Washington, DC: Author.

[Author Affiliation]

Tsui-Sui (Annie) Kao, MS, RN

Doctoral Student

University of Michigan

Ann Arbor, MI

Multicultural Medicine and Health Disparities - Journal of the National Medical Association

Multicultural Medicine and Health Disparities David Satcher, Rubens J. Pamies and Nancy N. Woelfl, eds; New York: McGraw-Hill, 2006; ISBN 0-07-143680-4; $59.95

Health disparities are an acknowledged fact in American life, so much so that reducing health disparities is one of the two overarching goals in Healthy People 2010. Multicultural Medicine and Health Disparities presents 34 chapters written by a variety of guest experts which function as stand-alone essays on different aspects of health disparities in the United States. The first chapter, by Hani K. Atrash and Melissa D. Hunter, is an excellent introduction to the subject of health disparities (as defined by this volume). Topics covered include an overview of health disparities, sources of data, problems with racial and ethnic classification, factors which may be related to the observed disparities, and a review of some programs and interventions addressing health disparities. Subsequent chapters vary somewhat in content and approach but most follow the same general format: they introduce the topic, summarize relevant information and conclude with an ample reference list; many also include recommendations for reducing disparities and some include case studies. Many of the chapters cover standard topics such as black/white differences in morbidity and mortality, and the importance of cultural competence for healthcare workers. Others are more unusual, including chapters on disparities in bioterrorism preparedness, faithbased initiatives to improve health and the role of community health centers in minority health. A complete list of the chapters may be found at: http://books.mcgraw-hill. com/getbook.php?isbn=00714368 04&template=#toc.

This is an excellent reference volume and textbook. Given the definition of 'health disparities' and 'multicultural' used by the volume's editors, it's hard to think of topics which have not been included. The presentation of information is straightforward and makes excellent use of tables and graphics. My main criticism is the limited range of subject material in terms of what is considered a 'culture' and what groups are considered in defining a disparity.

A health disparity is a difference in occurrence or outcome in some health condition or health behavior among =2 groups of people. The number of possible ways to define groups for this type of comparison is virtually endless: race and ethnicity, age, gender, disability status and geographic residence are just a few of the possibilities. Multicultural Medicine and Health Disparities concentrates on disparities among population groups as defined by race and ethnicity. In this choice, it follows the frame of reference used by the Institute of Medicine's Committee on Understanding and Eliminating Racial Ethnic Disparities in Health Care, formed in 1999. Similarly, 'multicultural' within this text refers to cultures defined primarily by race and ethnicity, rather than, for instance, deafness or sexual preference.

The investigation of racial and ethnic health disparities is a worthy subject and is the easiest type of health disparity to study because of the wealth of national data available that links racial and ethnic classifications to information about health behaviors, access to healthcare, and morbidity and mortality. Because Multicultural Medicine and Health Disparities does an excellent job summarizing information concerning racial and ethnic disparities in healthcare, it will probably be the definitive statement on that topic for years to come. Unfortunately, because of its excellence, it may be seen by many as defining not just the field of racial and ethnic health disparities-but health disparities in general-so that topics omitted (for instance, inequality in healthcare for gay men and lesbians) or treated only briefly (for instance, urban/rural differences) will not be included in future discussions of health disparities.

[Author Affiliation]

Reviewed by

Sarah Boslaugh, PhD, MPH

BJC HealthCare

Health Right sees more patients than ever: ; City clinic provides free health care - Sunday Gazette-Mail

Charleston's free health clinic sees more and more patients eachyear, a trend that both gratifies and dismays executive director PatWhite. Last year, the Washington Street East clinic treated morethan 14,000 patients, encompassing 44,000 clinic visits. Volunteerstaff filled 91,000 prescriptions, worth about $8 million. Abouthalf of those medicines went to people 65 and older.

'Our patients are appreciative of the service,' says White, aformer state legislator who has headed Health Right since its 1982inception. 'I love my job. I can't imagine doing somethingdifferent. But it also makes you wonder about the richest nation inthe world having so many people fighting for their lives, withoutaccess to medical care.'

In 1984, a total of 1,620 people visited Health Right. The clinicaveraged 29 patients a day. Now it sees more than 160 a day in amodern, brick building that opened in November of 1999.

Those patients seem to grow sicker each year, she said. They showup with progressed chronic ailments, including heart disease anddiabetes.

'It takes longer to get them stabilized than it used to,' saidWhite. 'It's a lot more labor intensive.'

Federal welfare reform enacted a few years ago has also driven upHealth Right's numbers, White says. The approximately 75,000 statefamilies no longer on welfare assistance are going somewhere forhealth care, White says.

'Where they're primarily going is to free clinics,' she said.'We're finding that in many instances their health status isn't asgood as we might have hoped.'

But in the face of the increased demand, Health Right isexpanding its services. White and her volunteer staff are drawing upplans to offer free adult dental care, recruiting volunteerdentists.

They have applied for funding from the greater Kanawha ValleyFoundation, United Way and the Benedum Foundation. White said HealthRight is also trying to offer more health education services, suchas smoking cessation classes.

Health Right already offers free eye exams and glasses throughthe optical supply business Lens Crafters.

The clinic is open two evenings a week, including every otherTuesday night. It is also open some Saturdays. White said itsaverage service time is about 62 hours a week. Health Right uses theservices of 106 physician volunteers.

'Even when you go to a hospital emergency room it's not the sameas having a doctor,' White said. 'And here a nurse practitioner cantell you 'This is how you take insulin, this is why you're onmedication for your heart condition.''

Health Right's budget ran $650,000 last year, White said. Itsmedicines and physician labor are donated, of course.

The clinic draws money from a West Virginia Department of Healthand Human Resources line item, United Way, and other charities andfoundations. Health Right's board also conducts an annual fund-raiser that produces about $100,000, she said.

US health-care dissatisfaction rated high 3-nation study finds Americans less likely to permit government efforts at solutions - The Boston Globe (Boston, MA)

Americans are among the world's most dissatisfied people when itcomes to health care systems, but they are the least disposed to letgovernment try to solve the system's problems, according to athree-nation survey published today.

The survey also found that Canadians and Germans are increasinglydissatisfied with their health care systems.

The new findings suggest it is less likely than ever thatAmericans will soon look to other nations with government-led healthcare systems for answers to growing US problems with costs andgrowing numbers of uninsured citizens.

The survey, which involved nearly 4,000 adults in the threenations, found a sharp drop in recent years in the proportion ofCanadians and Germans who think their health systems work well. Theproportion of Canadians who were satisfied with their health systemplummeted from 56 percent in 1988 to 29 percent in 1994. In Germany,the drop in satisfaction was less drastic during the same period,from 41 percent to 30 percent.

In the United States, the proportion who said they were satisfiedwith the health system rose slightly, from 10 percent in 1988 to 18percent in 1994.

The rise in dissatisfaction, the authors said, reflects thosecountries' recent struggles to control health costs in the face ofnew technology and aging populations.

'There's no medical Shangri-La out there,' said Robert J. Blendon,chairman of health policy and management at the Harvard School ofPublic Health and principal author of the survey, which appears inthe journal Health Affairs. 'When you start to constrain costs,people don't necessarily want to abandon their health system, but thebloom is off the rose.'

That impression was ratified by Dr. Mimi Divinsky, a Torontogeneral practitioner who is active in efforts to keep Canada'sgovernment-financed health system intact.

'My sense is that people are really apprehensive about losing thesystem we've known since the 1960s,' Divinsky said in an interviewyesterday. 'My older patients, who remember the days beforeMedicare, are calling me and saying, `Maybe I should have my hipoperated on now, because perhaps in five years the system won't payfor it.' '

While Canada and Germany are cutting back drastically on healthcare spending, there is considerable evidence from the survey that,as Blendon put it, 'people in the other countries have fewer problemswith their health care' than Americans do.

For instance, one in eight Americans said in 1994 that theycouldn't get needed medical care in the previous year -- a measure ofthe millions of people who do not have health insurance here. Bycomparison, one in 13 Canadians and one in 17 Germans said theycouldn't get needed care.

Twenty percent of Americans said they had a problem paying doctoror hospital bills in 1994, versus only 6 percent of Canadians and 3percent of Germans. (The survey involved only people living in theformer West Germany, since the former East German states wererebuilding their health system.)

Americans didn't fare any better than Canadians in the length oftime they had to wait to see a doctor. About one in seven people inboth countries said they waited more than a week for an appointment,versus only one in 17 in Germany.

As jobless lose health care, it's often devastating, 'scary' - AZ Daily Star

Forty-three-year-old Ruben Alvira's last day of work in PimaCounty's Development Services Department was Jan. 17.

Now the married father of two is without health insurance.

'I had heart bypass surgery in 2000, and I saw the bill - it costmore than $100,000,' Alvira said. 'I have no idea what I'd do ifsomething like that happened to me now. Heart bypass surgery is nota forever thing. It's scary.'

Alvira's situation is not unique. A national report releasedFriday says that more than half of unemployed workers in Arizonawith low or moderate incomes have no health insurance. The same istrue on a national level, says the report by Families USA, anational non-profit organization that advocates affordable healthcare.

The report came out the same day that the federal governmentreleased data showing the United States lost 3.6 million jobs since2007, with half of those losses occurring in the last three months.A total of 11.6 million Americans are unemployed, the governmentsays.

Many health-care advocates say that for every percentage-pointuptick in unemployment, another 1 million people will go withouthealth insurance.

Local hospitals and health-care clinics are bracing for anonslaught of 'bad debt and charity care' write-offs in the nextyear, when the full impact of the country's recession is expected tobe felt in the health-care industry.

Bret Hicks, finance director at Tucson Medical Center, wrote offmore than $24 million in bad debt and charity care last year - afigure that's expected to grow in 2009.

Hicks said: 'There's no question with the economic downturn andpeople being uninsured or having high-deductible plans, there'salways going to be a problem. Almost everyone has some kind of a co-payment or deductible. If it's a question of keeping the heat on orthe electricity on in the house,' a hospital bill is not one of thetop priorities for people to pay.

Many lower- and middle-income workers such as Alvira say theycan't afford to pay for health coverage through the ConsolidatedOmnibus Budget Reconciliation Act of 1985, better known as COBRA. Itextends health insurance coverage from former employers for 18months.

Alvira said that to cover himself and his two children, COBRAwould cost him nearly $700 per month. In most cases, COBRA costsjust as much as the company's subsidized insurance plan, except thatthe individual pays the entire premium without the company's help.

'The average COBRA premium consumes on average 84 percent ofunemployment benefits,' said Ron Pollack, executive director ofFamilies USA. 'It is really difficult for people to get any otherkind of coverage - so-called Medicaid programs are not generous,particularly with adults.'

Indeed, because Alvira's wife works for the Tucson Unified SchoolDistrict, Alvira said the family makes too much money to qualify forthe Arizona Health Care Cost Containment System, or AHCCCS. But hesaid her health insurance is so expensive that Alvira and the kidsare going without for now, while the family tries to stayfinancially afloat.

Other unemployed Arizonans don't qualify for AHCCCS because theyown too many assets, such as a house or car.

AHCCCS, which added more than 70,000 people to its rolls in 2008 -including nearly 10,000 in Pima County - is for extremely low-income individuals and families in Arizona. In general, it's forpeople living at or below the federal poverty level, an annualincome of less than $10,400 for an individual or less than $21,200for a family of four.

Alvira, who is diabetic, had a doctor's appointment on Wednesdaybut decided to skip it to avoid the expense.

Tucsonan Arnold Moreno, 48, also is opting to go without healthinsurance because the construction work he does has been sporadic,and his income has dropped.

'To pay for health insurance is expensive, but I'm overqualifiedfor AHCCCS,' he said. 'My wife has insurance for her, but not for meand my kids.'

Moreno is diabetic, and his medications cost $500 per month. Hehas been dividing them in half to save the money. But this week heapplied for prescription-drug assistance and hopes to be taking hisfull dosage soon.

'I'm getting some work, but it's slow,' he said. 'We just allhave to hang in.'

Pollack, of Families USA, said only one in five unemployedworkers with income of 200 percent of the federal poverty level orbelow has private insurance or military coverage. And only one infour receives health coverage through Medicaid or other publicprograms.

'It is clear this is a group of people that will have enormousdifficulty retaining private health coverage,' he said. 'Losing ajob often means losing health insurance and as a result, millions ofmiddle-class and lower-income people become uninsured.'

Arizona shed 12,400 jobs in December, and the unemployment raterose six-tenths of a percentage point from November to 6.9 percentin December. Researchers at the state Department of Commerce predictthe unemployment rate will top 7 percent and might even hit 8percent before the state economy turns around.

Some relief for laid-off workers may come from Congress, whichis considering passing legislation to offset the high costs ofCOBRA.

Contact reporter Stephanie Innes at 573-4134 or atsinnes@azstarnet.com.

WHAT TO DO

Some health-care options if you lose your job:

* Find out if you can get coverage through your spouse's ordomestic partner's employer.

* Find out if you can continue your coverage through COBRA, theConsolidated Omnibus Budget Reconciliation Act of 1985.

* Find out if you or your family members are eligible forMedicaid, the Children's Health Insurance Program or any other stateor local programs, or coverage through the Department of VeteransAffairs.

ARIZONA BY THE NUMBERS

* Number of unemployed workers with incomes below 200 percent ofthe federal poverty level ($44,100 for a family of four): 92,123

* Unemployed workers who are uninsured: 50,721

* Percent uninsured: 55 percent

The Highest Possible Health Status for Indians - Human Rights

In 1976, the United States undertook in the Indian Health Care Improvement Act (IHCIA), 25 U.S.C. � 1601 et seq., a commitment to provide 'the highest possible health status for Indians.' That commitment, which was preceded by many treaties promising health care to Indian tribes, was reaffirmed in 1992. Portions of the act expired in 2001. While the authorization to provide federal funds for Indian health problems still exists in a broad 1921 statute providing for federal health care for Indians, the failure of Congress to reauthorize the health care act (including amendments to strengthen the Indian health program) for the past five years has clouded the federal commitment.

In some sections of the public, a view apparently exists that the entire federal effort to improve the health status of Indians has failed and should be abandoned. For example, Dr. David Eichler, the president of the Alaska Dental Society, has denounced the entire concept of a federally funded health program for Indian and Alaska Native peoples in the January 2006 Alaska Dental Society newsletter.

'One reason for failure.' he commented in a version of his article available on the Internet, 'is because the socialist model removes any responsibility from the client and breeds resentment because of dependency.... We establish the Natives as de facto slaves... The most effective action we could take would be to remove all special federal assistance for all American Indians' in order to allow 'their integration into American society as dignified citizens.' see Posting of Dr. David Eichler, northpoledentist@gci.net, to owner-dental-publichealth@list.pitt. edu (Mar. 1, 2006) (copy on file with author). Eichler's lack of knowledge about the origins and reasons for the federal commitment to Indian and Alaska Native health care is revealed by his statement, 'For some reason in the 1920s [sic] the federal government decided to establish by legislation that it would take upon itself the role of health care provider for American Indians.'

His point of view ignores both the federal obligation to provide health services to Indians in exchange for the relinquishment of vast tracts of Indian land and the impressive improvement in Indian and Alaska Native health care that the Indian Health Service (IHS) has made since it was founded in 1955. For example, between the early 1970s and 2002, the tuberculosis mortality rate for Indians and Alaska Natives was reduced by 80 percent, the cervical cancer rate by 76 percent, the infant mortality rate by 66 percent, and the maternal mortality rate by 64 percent.

Eichler asserts that abolishing the IHS program would improve Indian health status. Yet many Indians and Natives live in remote areas where access to non-IHS health care is very limited or nonexistent. And, notwithstanding the accomplishments of the IHS, Indians remain afflicted by many diseases at higher rates than other Americans.

In addition, since native people now live longer, they face increasing risks from certain diseases that come with age. They are in greater need of nursing care, long-term care, and home health care, which the IHS has provided rarely and reluctantly. In addition, diabetes is one of the fastest growing threats to native health. The Indian death rate from diabetes is 3.3 times that of non-1 lispanic whites. Cervical cancer death rates are still 3.8 times higher.

I have been actively involved in the administration of Indian health programs, serving as chair of the board of the Bristol Bay Area Health Corporation, a tribal organization that provides health services to Natives in the 45,000-square-mile Bristol Bay region of Alaska. I have also been chair of the Alaska Native Health Board, and I am currently chair of the Alaska Native Medical Center Joint Operating Board and the National Indian Health Board. It boggles my mind that anyone can describe the agency that has accomplished so much to improve Indian health status as 'enslaving' native people. While I have been involved in addressing Indian health problems, a major innovation has been the decentralization of the IHS program through the transfer of responsibilities from the federal bureaucracy to Indian tribes and tribal organizations. In Alaska, the entire delivery of federally funded health care to Native villages is in the hands of the villages themselves or their designees.

The United States needs to stay the course. The pending Senate bill to reauthorize the IHCIA broadens authorization to meet contemporary healthcare needs in Indian Country, including strengthening the present diabetes program and express authorization for long-term care, home health care, hospice, and assisted living. The latter are especially important in remote rural areas because the elderly should be able to stay home among their friends and family during their last years.

The bill also includes provisions to address the deterioration of federally owned Indian health facilities, including water and sewer facilities. In Alaska Native villages, due to minimal water facilities, the infant pneumonia hospitalization rate is eleven times the national average. The shocking state of many of the buildings in which Indians receive the federal health care to which they are entitled is a particularly appalling feature of the contemporary scene in Indian Country.

Congress not only needs to authorize these programs, it also needs to fund them. There is at present a backlog of $429 million for essential maintenance, alteration, and repair of Indian health facilities. This has not been a priority with the budget people in the Bush administration, who asked Congress for $52,668,000, an increase of only $1 million, an adjustment for inflation, in the 2007 budget request.

The pending bill also includes provisions designed to increase the number and effectiveness of health-care professionals in Indian Country. Building on the experience with the effective community health aide program in Alaska, it would authorize the extension of that program to Indian Country throughout the United States. The bill would also encourage the government to expedite the construction of new health-care facilities, including water and sewer facilities, to serve Indian and Alaska Native communities, addressing the serious deficiencies in both the number and condition of existing facilities, and it would strengthen the ability of Indian people to recover reimbursement for the costs of healthcare from nationally available programs such as Medicare and Medicaid, in which they are entitled to share but frequently encounter barriers to enrollment.

Without diminishing the federal commitment to health care in Indian Country, the bill would also address the availability of health care for some 650,000 Indians who live in urban areas in the United States by eliminating some of the disparities between programs for reservation Indians and urban Indians.

Indians are grateful to the American Bar Association for calling on Congress to pass the IHCIA reauthorization in 2004 and again in 2005. While gains in Indian health over the past fifty years are evident, the shortages in both staffing and facilities call for a renewed legislative initiative. Even as the United States faces the many challenges of the twenty-first century, Indian and Alaska Native health care should not be relegated to the back burner.

[Sidebar]

An elderly Navajo woman is treated at the Montezuma Creek Community Health Clinic on a reservation near Bluff, Utah.

[Author Affiliation]

Population health's tipping point.(the interview)(Interview) - H&HN Hospitals & Health Networks

MAUREEN BISOGNANO, president and CEO of the Institute for Healthcare Improvement, recently co-authored Pursuing the Triple Aim, which highlights partnerships among hospitals, employers and their communities that aim to improve population health and the individual patient experience while reducing the cost of care. Bisognano will receive the American Hospital Association/Health Research & Educational Trust TRUST Award at the AHA-Health Forum Leadership Summit this July in San Francisco.

What are the key takeaways from your book?

BISOGNANO: I'm seeing leaders who have moved beyond the vision of taking excellent care of patients--in an office visit or during a hospitalization--and see the Triple Aim as their mission. That involves not only excellent care that's safe, effective, efficient, as least costly as possible and timely, but also seeing beyond the care experience to the health of the population, and bending the cost curve. Ten years ago, when we began to talk about the Triple Aim, it was a rare executive who said, 'I can take that on for my community.'

Why do you think providers are finally embracing population health?

BISOGNANO: I think reform opens peoples' eyes to looking at their work in a very different way. The notions of bundled payments and ACOs pushed a lot of people in this direction. But the people we write about didn't mostly motivate through financial reconstruction. At Bellin Health in Green Bay, Wis., when [CEO] George Kerwin faced financial challenges at his hospital, the normal pathway would have been to cut costs or close beds. But George looked at the health of his own workforce. The health of the workforce in the United States is pretty dreadful. Many of us are ignoring the complications of chronic disease and are eating too much and working too many hours. So George went to his own workforce first, and [as they] improved in health and their ability to work, he found that his premium costs were lower. That gave him credibility to go out into his community and say to other leaders, 'You can save money by making a healthier workforce.' It not only strengthened his workforce, it strengthened Bellin as a whole.

You also talk about hospital/employer partnerships.

BISOGNANO: The great opportunity when you're working with a company like Intel or Starbucks or Boeing is that the company knows its workforce. It's a little bit more challenging when a CEO in a hospital is trying to get his or her hands around the health of the community when nobody really owns that whole community. So it's a great place to start.

These companies have very good profiles on their employees. They know how many times employees are out with back injuries, headaches or carpal tunnel syndrome. Having that data allows them to dive deeply into the key problems that are preventing their employees from being fully functional human beings. Combining that with the medical knowledge in the health care community, you can create a value stream. You get a sense of the best way to care for a patient who is newly diagnosed with diabetes, or a woman who has just found out she's pregnant. What's the best way to deal with that, and how do we put all the pieces together in a new design? It's very exciting to see the employers and the health care community redesigning care, because the cost benefits to the company are immediate. The hospital likely will see some shifts in its business model. You are going to see, perhaps, fewer MRIs and more office visits, but [the patients] are going to need managing. I call it building a bridge to a different model of care, where [providers] are seeing downsizing in some parts of their business and increases in others. It's a management requirement to be able to predict those changes and move the staff and technology to the future.

And that gets back to the idea of population health.

BISOGNANO: Right. I see proactive anticipation and new designs as key leadership challenges. When you move from managing an organization to really capturing the data in a community and building a coalition, it's not management, it's governance at a community level. You're bringing together people who come from well outside of health care--local ministers, people who run 24-hour barbershops, school nurses, mayors--and moving away from the paternalistic view of health care, which is 'We'll take care of you when you get sick,' to really co-creating health in a community.

Where does patient-centered design fit into that model?

BISOGNANO: In the book, there is an example from Memphis, where there are health care professionals, but also ministers and other people, around the table. They have their data, they know what the total population is, they know minority representation, they know how many people have diabetes and undiagnosed hypertension. All that data drives very different conversations. We see a minister talking to a physician, saying, 'You see these diabetic patients twice a year for 15 minutes. How can you possibly expect to improve their health with such brief interactions and encounters?' [The minister] said, 'I see them twice a week for two hours, so I'll take diabetes.' And he started changing the food they were serving in the church, and in his sermons, talking about the sanctity of your health and how you have an obligation to God and your family to know your health status.

The CMS shared savings pilot focuses heavily on the Triple Aim. What's your take on the program so far?

BISOGNANO: In some communities, the conversation is mostly about money. I don't have a whole lot of hope with the idea of shared savings being a part of financial negotiation. I have tremendous hope when I see the conversation being around health and health care producing the savings, and then, what [to] do with those savings. I'm seeing people really wrestle with their population--What does it look like? How many asthmatic children do we have here? What is the status? Is it getting better or worse? Some of these shared savings now are being invested into improvements in health. It's a different conversation than the financial bartering.

Finally, are you optimistic the current focus on the Triple Aim and population health will continue regardless of how the Supreme Court rules on health reform?

BISOGNANO: I was in Salt Lake City and Seattle [recently] having this very conversation and I'm optimistic. It really worries me if the legislation is repealed, that in some communities people will revert to business as usual. But the visionaries, the people whom I wrote about in the book, the people I am visiting, clearly are on a pathway to the Triple Aim. I don't see that reversing very easily.

[ILLUSTRATION OMITTED]

THE BISOGNANO FILE

C.V.

Started career as a nurse at Quincy City Hospital in Massachusetts. Joined the IHI in 1995.

On the Road

'I get to learn from the very best in health care, as I travel to teach from Africa to Sweden and across the United States. I will often visit clinics and hospitals to see things as a patient would.'

Quality Swings

'I play golf with my husband every Saturday morning at 6:09 a.m., and use QI methods to improve my game!'

Red Sox Nation

'I have a bet with [IHI Senior Fellow] Rick Norling each year on the Red Sox vs. his Yankees. I'm out quite a few more dinners than Rick is!'

PODCAST

To listen to a podcast of this interview, go to www.hhnmag.com.

VIDEOCAST