Colorado is joining about a dozen other states that are not requiring health insurance companies to revive canceled health plans.
No one mentioned cancellation notices. And no one expressed concerns about costs. Instead, at a sparsely attended public meeting about health insurance issues Tuesday evening, potential customers wanted to know if they could skip filling out Colorado’s complex Medicaid application.
Health exchange board members on Monday pressed for immediate improvements to Colorado’s mandatory Medicaid application, but state officials, who contend that Colorado is a “shining example” among the states, refused to promise that a full slate of short-term fixes will be completed before Dec. 15.
Colorado has no quick fix for a seemingly endless Medicaid application that health exchange board members believe is driving away customers and decreasing the number of people buying health insurance through Colorado’s new multi-million dollar health exchange.
In Choosing Wisely, physicians across the spectrum of medical specialties nationwide have created lists of procedures, tests and drug treatments that deserve second thoughts before doctors order them or patients accept them.
African Women Prevent HIV, Open Doors to Health
A report by Health Policy Solutions.
Posted on May 24, 2011
By Katie Kerwin McCrimmon
The Somali women gather in the living room of a townhome in Denver’s Lincoln Park neighborhood, just across Colfax Avenue from the Auraria Higher Education Center. The scarves on their heads shimmer like the nearby downtown skyscrapers on this Saturday evening in May.
The host has created a centerpiece of lemons in a glass vase and will serve dinner to her guests, an iconic American meal: pizza.
Some of the women have brought their children. One cuddles a month-old baby, her seventh child. The host has both a self-assured college-aged daughter, who is studying at Colorado State University, and a toddler daughter, who happily jumps from lap to lap. A 10-year-old fourth-grader sits next to her mom, eyes wide as she takes in the chatter.
The gathering of about a dozen people feels like a small party or an informal book club meeting until the guests of honor start speaking.
“You have to watch your men and your teenagers,’’ says Zahra Kulane as she discusses the key topic for the evening - HIV.
Part I: Immigrant integration
- News: Refugees find path back to medicine
- News: Fleeing death threats, Iraqi surgeon starts over
- Opinion: Immigrants bring valuable skills to health care system
This week. Part II: African women attack HIV, teach health prevention
Kulane has lived in the U.S. since 1993 and has been training for two years in Denver to work as a community health outreach worker. Her husband owns a successful Denver restaurant and she has lived here far longer than most of the other women. She speaks excellent English and knows her way around the community.
Each month, Kulane and her fellow community health workers attend training sessions to increase their knowledge of health issues. Some are also studying to become nurses or to work as certified nursing assistants. Each month, they hold small gatherings, like this one, with friends and friends of friends to spread the word about a concept that is new to most of these refugees and immigrants: preventive health care.
Back home in Africa, many people only visit a hospital or see a doctor if a family member is dying. The concept of preventive health care or screenings for early detection of diseases like cancer of the prostate or breast is a foreign concept to many new immigrants.
Altogether the 14 community health workers speak 20 languages. They get paid small stipends each month for both the training classes they take and the ones they teach. On this night, Kulane makes her presentation in Somali. Her topic this month is HIV, although she tells the guests ahead of time that it’s a general health talk. She doesn’t want to scare them away. The workers have studied a variety of health issues from obesity and nutrition to cardiovascular disease, diabetes and breast, cervical and prostate cancer.
Assisting Kulane for her May program is Dr. Oumar Ouattara. A doctor from the Ivory Coast, he came to the U.S. in 2004 and earned a masters degree from the Colorado School of Public Health. He now heads the health outreach program for the Colorado African Organization, a Denver nonprofit that supports African refugees and immigrants throughout the state.
After Kulane talks, Ouattara holds up a chart from the Centers for Disease Control with a disturbing bar graph. It shows the rates of new HIV infection by race and ethnic group in the U.S. Stretching way beyond any other line is the bar representing black men, both those born here and African immigrants.
HIV rates among black women also far outpace infection rates for white or Hispanic women. According to the CDC, blacks accounted for nearly half of all people living with HIV and 45 percent of those with new infections. The rate of new HIV infections for black men was six times as high as that of white men, while black women are nearly 15 times more likely than white women to contract HIV.
In Colorado, African women are at even greater risk than men. Of the 59 new HIV cases documented among immigrants from Africa between 2005 and 2010, 32 were among women, while 29 were among men. Nearly half of those new cases emerged among Ethiopians, the African immigrant group that has been in Colorado the longest. Many African societies are patriarchal. The wealthier the men, the more likely they are to have multiple sex partners, says Kit Taintor, executive director for CAO. The behavior among men puts their women in great danger for contracting HIV.
“The highest risk factor for HIV is being an older married woman,” Taintor said.
That makes outreach to women especially important. At the evening gathering, Ouattara delivers a message that he hopes the women will spread among friends and family members.
“HIV is just like diabetes in America. It is a chronic disease. If you take medication, then you can live with it,” he said.
Studies that CAO and others have done show that Africans both here and back home believe that HIV will kill them.
“They see it as a death sentence. If you have a death sentence, why would you want to get tested? If they know something is wrong, many will not go to the doctor until death is knocking,” Taintor said.
Ouattara and the community health workers are working to turn that attitude upside down. Again and again, their message is clear: get tested, get treated, prevent additional infections. People can live with HIV and AIDS.
Kulane delivers her kicker.
“Early detection is important. You can test for HIV even before there are symptoms. Every six months, go check,” she said, telling the women exactly where and how they can get themselves tested and encouraging them to urge their husbands or teens to do the same.
At this point, the conversations in the room take off. The women are abuzz about HIV and their thoughts about their husbands and other men in the African immigrant community.
“They are reckless,” says one woman. There is a sense among these women that many men both in Africa and here in the U.S. have sex with multiple partners even if they are HIV-positive. The women are clearly angry that some men knowingly infect their wives.
Still, in Somalia, Zahra Adam says a woman wouldn’t dare ask her husband to be tested.
“You’d get divorced right away if you said anything to your man. They get offended. They are very arrogant,” she said.
But, with her young daughter at her side, she says she’s sees African women changing their attitudes once they arrive in the U.S.
“Here the women have more power,” she said.
A model borrowed from the Latino community
Two years ago, Taintor of CAO and others were brainstorming about how to better spread key health messages among African immigrants, especially women. CAO had done some health education lectures in formal settings, but they found that men filled the rooms. They needed a way to reach more women and looked to programs that have been used to combat diseases like diabetes among immigrants from Mexico.
The idea of training women to be lay community health workers is called promotores de salud and is used in Colorado and across the country at clinics that serve Spanish speakers.
Not only does the concept help boost health education, it may also encourage more people from minority communities to enter health fields where shortages are expected to worsen sharply in coming decades.
Spreading information through word-of-mouth is also quite common in Africa, said Taintor who has lived in Malawi and Uganda.
“The best messages are going to be oral and through women. They’re the caretakers of the family. They talk amongst themselves and they’re the backbone of the family and the country,” she said.
The same method works well for immigrants who are not yet fully integrated into their new homes. Taintor estimates that there are now about 35,000 African immigrants in Colorado, nearly all of whom live in Denver. The population has grown by about 300 percent over the past decade. But it’s not easy to reach people. Funding for the community health workers comes from the Colorado Department of Public Health and Environment, which has spent about $70,000 on the program.
“They don’t listen to local radio stations. Often they’ll have music streaming online or will tune in to Al Jazeera for news,” Taintor said.
The diverse languages among African immigrants, who come from as many as 55 different countries, can also be a stumbling block. That’s why Taintor and Ouattara have deliberately sought out health workers from multiple countries who speak so many languages.
More than once, the health experts have found that political squabbles from Africa have affected gatherings here. For example, one of the health workers tried to set up a meeting for a discussion on prostate cancer in the Eritrean community. She had done a home presentation and it was so popular that members of the community asked her to give the presentation again for a larger audience. But, a flare-up between rival Eritrean factions prevented the second talk.
Holding small sessions in homes has worked especially well. Sometimes the health workers struggle to get women to come to their talks because they are so busy. Feeding them a good meal is key. Some of the health workers cook traditional African meals, but they seldom can afford an extravagant meal since they only get $30 in reimbursements and receive low monthly payments for their outreach work.
Preventive care a new concept for some immigrants
An evaluation of the program found that both the health workers themselves, and members of their audience are boosting their knowledge of key issues.
“Both the community health workers and community participants were beginning the process of reexamining many of their ideas about health and nutrition. The health workers expressed increased confidence about presenting information to their community and felt a strong sense of satisfaction and accomplishment,” the evaluators wrote.
“People are asking all these great questions and everyone is feeling empowered by the information,” Taintor said. “Opening the door to having these conversations is huge.”
In the future, Taintor is hoping that the health workers can play a bigger role serving as navigators who can accompany patients to doctors’ visits and help them understand the culture of U.S. health care.
“There are so many issues: access, lack of transportation and language barriers. I will hear of people who show up at a clinic and wait for two hours, then say, ‘the receptionist was mean to me.’ For many of these people, going to the doctor is not an enjoyable experience. They do not see it as worth taking time out of very busy lives to go. We’re brainstorming about how to handle that,” Taintor said.
Little by little, however, the concept of preventive care is trickling through the community.
“When we grow up here, we learn about cancer and preventive health,” Taintor said. “In Africa, children learn about malaria and cholera. The community health workers are providing a basic education so (immigrants) can learn about preventive care. Once they move here, malaria is not going to kill them, but diabetes might.”
In the past, if an immigrant women saw a flyer for a free breast cancer screening at her mosque, she might not have understood what it meant or how it related to her. But, after hearing a presentation on breast cancer from a community health worker, that same woman might follow through and get a mammogram.
Nike Kotun is one of the community health workers. She moved from Nigeria three years ago and is now studying at Metro State College to get a Bachelor of Science in nursing.
During one of the training sessions for the health workers, she and the other women toured a clinic called It Takes a Village in Aurora. The clinic offers free HIV and STD testing and counseling. They then take their knowledge and pass it back to people in their communities. Another training session focused on trauma. Many of the refugees have dealt with rape or war.
“Telling our stories is one of the most helpful things we can do,” said Lauri Benblatt, a Boulder therapist who has used art and dance to work with refugees and earthquake victims in Africa and Haiti. “It is scary, but you have to relive the memory.”
Kotun and the others take the lessons they learn, then pass them on.
“We give references on where people can get help,” Kotun said. “Sometimes people confide in us. If it’s an issue I cannot handle, I just talk to Dr. Ouattara.
“I like the program,” Kotun said. “I really like making a positive impact on people’s lives. We create awareness on how people can live and live well.”
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