Group looks for factors beyond insurance and transportation that prevent some from getting health care

Two undergraduates are involved in the community-driven research project

by Cynthia Ferguson

Access to health care is more widespread in Rhode Island than in most of the country, yet health disparities based on race, culture and class mirror the rest of the nation. Lack of insurance and inadequate transportation are generally seen as the primary barriers to health care, but is it possible that other factors play a role as well?

Participants of a group research project believe they do. The researchers, led by Dannie (Dianne) Ritchie, M.D., MPH, clinical assistant professor of family medicine, are investigating what they call "functional disenfranchisement," which they suspect prevents residents in underserved communities from getting the health care they need.

"Despite access to insurance and even health-care centers and institutions, minority populations tend to be discouraged by long-term discrimination and economic privation," Ritchie wrote in a paper describing the project. "[This] undermines the functional involvement of individuals in the current health-care system."

Participating with Ritchie on the project, which is titled the "Transcultural Community Health Initiative," are two undergraduates - John Ly, a senior concentrating in community health, and Cate Oswald, a senior concentrating in development studies with a focus on international health. Working hand-in-hand with existing organizations in five core Rhode Island communities - and building on work already done - Ritchie, Ly and Oswald are assessing the needs of these communities and of the different populations that inhabit them.

Ritchie's group is studying the needs and cultural concerns of Hispanics, Native Americans, African Americans, Asians and other immigrant groups. While all may be underserved in terms of health care, the reasons often differ from one group to the next. Language or lack of documentation may keep some from pursuing health care, while decades of discrimination and racial stereotyping may deter others. Many minorities find health-care institutions to be unwelcoming, or even hostile, according to Ritchie.

"It is the unease of the outsider looking into a fast-paced world that cannot hear their whole story or begin to address the holes that a lifetime of deprivation has created in the ability to manage the business of life," wrote the authors of the mission statement for the Family Van of Boston's Beth Israel Hospital. Oswald works on the Family Van of Women & Infants Hospital, a branch of Boston's network of Family Vans, which brings preventative health screening tools into the community.

Today's health-care system can be a source of frustration for all Americans, regardless of race, ethnicity or socioeconomic status. But for populations that are underserved and under-represented, that frustration is compounded by what Ritchie sees as a lack of cultural sensitivity. She recalls working in a hospital where nurses would routinely scold women in labor for not having sought prenatal care. These women were recent immigrants from a poor, rural country where prenatal care was virtually nonexistent, Ritchie says. "They didn't know what these nurses were talking about."

Oswald, who has worked in Ecuador and Africa, stresses the importance of letting a community determine its own needs. In her travels, she says, she too often saw well-intentioned groups impose technology or services on communities that viewed them as unnecessary or difficult to implement. "Often these organizations ended up causing more problems than they solved," she says.

Ly, whose family emigrated from Cambodia when he was young, has seen firsthand the difficulties of navigating a complex health-care system in a foreign language. Seemingly small issues, such as not understanding the meaning of "generic," can end up costing a person many dollars more for a prescription, he notes.

Ritchie, Oswald and Ly expect their project to culminate with the creation of "a workforce of trained cultural brokers and community peers dedicated to promoting the health and well-being of Rhode Islanders in a culturally sensitive manner," according to Ritchie's paper. Community health workers are community members who can help define the needs of that community, and who serve as a bridge between the health-care professionals and the people they treat.

"Our project is part of building future leadership in health advocacy and health promotion," says Ritchie. "It's a community-driven research project that involves action as well as theory." Ritchie hopes that by the end of the school year, community health workers will be identified, and implementation of a training program will be under way.