1. Caribbean Exploratory (NCMHD) Research Center Update Gloria B. Callwood, PhD, RN Presented at Caribbean Exploratory Research Center 2 nd ANNUAL HEALTH DISPARITIES INSTITUTE October 15, 2009

2. Objectives This presentation will:  Describe the organizational structure of the Caribbean Exploratory Research Center on Health Disparities  Provide an overview of significant health issues and health care barriers in the Virgin Islands  Identify key self reported health related concerns of residents  Share information on Center activities and overview of data emerging from the Center’s efforts

3. Caribbean Exploratory Research Center on Health Disparities Where we are located Who we are

4. Caribbean Exploratory Research Center on Health Disparities US Virgin Islands

5. St. Croix Campus St. Thomas Campus

6. Who are Virgin Islands Residents? The Virgin Islands is a blended multicultural Society with a direct affect on the culture and health of the population  Black 76.2%,  White 13.1%,  Asian 1.1%,  Other 6.1%,  Mixed 3.5% (2000 census)

7. Caribbean Exploratory Research Center on Health Disparities (CERC)  A National Center for Minority and Health Disparities funded Project (#1P20MD002286-03)  Organized into four cores Administrative Research Research Education and Training Community Engagement/Outreach

8. Caribbean Exploratory Research Center on Health Disparities (CERC)  Organized to: Conduct research on health disparities Provide mentoring and training opportunities for students, junior faculty and researchers Provide health screening, health promotion and health information dissemination activities Establish partnerships with community based organizations

9. Significance of Exploratory Center for the Virgin Islands  Health disparities among African American, African Caribbean and Hispanic population sub-groups in the US Virgin Islands have been well documented in national and territorial reports  There is a paucity of research focused on factors that interact to create health disparities in the US Virgin Islands.

10. Significance of Exploratory Center for the Virgin Islands Research is needed to: Generate sources of reliable data Identify, develop, and evaluate intervention strategies that will most effectively reduce or eliminate health disparities in the Virgin Islands.

11. Mortality Leading causes of death  Cardiovascular Disease  Cancer

12. Morbidity  Diabetes #4 in US at 9%*  High blood pressure #28 in US at 24.8%*  High Cholesterol # 37 in US at 31.5%*  Rated #2 in nation per 100,000 for HIV/AIDS** (DC #1)  TB-10.83 per 100,000 (2005)* Treatment success only 50 % 1995 (World Development Indicators database )World Development Indicators database Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Data, 2004* CDC HIV/AIDS Surveillance Report: Cases of HIV Infection and AIDS in the United States and Dependent Areas, 2007,**

13. Barriers Contributing to Disparities  Three potential sources of Unequal Treatment Health systems-level factors – financing, structure of care; cultural and linguistic barriers Patient-level factors – including patient preferences, refusal of treatment, poor adherence, biological differences Disparities arising from the clinical encounter

14. Health systems-level factors  Large percentage of uninsured 18-64 years 32.7% (BRFSS, 2006)  Large immigrant population Limited translation capability  Access Fragmented services Poor public transportation Hours of service

15. Patient-level factors  Low percentage preventive screening Colorectal Cancer Screening 14.8 % Women aged 40+ who have had a mammogram within the past two years 61.3% Visited the dentist or dental clinic within the past year for any reason 61% (BRFSS 2006)

16. Patient-level factors  Patient preferences Level of confidence in the health care system  Adherence Cannot be separated from cost/insurance issues Health literacy  Hesitancy to question provider

17. Clinical Encounter  Waiting time for service  Time spent with provider  Level of explanation of condition/treatment  Requirement to pay provider out of pocket

18. Insights From Focus Groups  Ranked health issues in the Virgin Islands 1. Disease and disease management 2. Financial concerns 3. Services  Facilities  Personnel  Customer services

19. Center Research Activities  Begun under Capacity building EXPORT Center Grant (Studies completed or in progress) A church based diabetes survey for St. Thomas in the US Virgin Islands Focus study of patient/provider breast cancer risk communication and breast cancer risk management Factors and life experiences affecting self management among a population of type 2 diabetic patients in the United States Virgin Islands

20. Center Research Activities cont. Health Status and Access to healthcare among African American and African Caribbean Women Knowledge, attitudes, perceptions and decision making of pregnant and parenting women of African heritage at risk for or living with HIV/AIDS: an international perspective Abuse status and health consequences for African Caribbean and African American women Study (ACAAWS)

21. One Study Key Results  Focus study of patient/provider breast cancer risk communication and breast cancer risk management N-178 aged 30-74 12.1% projected to be at moderate to high risk for breast cancer Historical information relative to personal and family health was not routinely collected from subjects The majority of subjects did not comply with recommended breast cancer screening guidelines

22. Key Study Results Women reporting having had discussions with health care providers about their personal breast cancer risk were more likely to express an interest in medical strategies for the management of breast cancer risk

23. Implications for Research, Practice and Education  Need for the development of more focused programs of research, education and outreach to promote breast health among women in the USVI  Need to enhance systems responsible for monitoring and reporting cancer trends relative to cancer incidence, mortality and survival within the territory  Need for forums for investigators, faculty, students and the community to discuss the breast health needs and concerns of women across the territory

24. Implications for Research, Practice and Education cont.  Need for educational programming for women in the community that focuses on breast cancer, breast cancer risk, breast cancer screening, and breast cancer risk management  Need for educational programming for women in the community that enhance communication with health care providers  Need for educational programming for women in the community that focus on the relationship between personal health and family health

25. Implications for Research, Practice and Education cont.  Need for training of health care providers (i.e., physicians, nurse practitioners, oncology nurse specialists, etc.) relative to the assessment and communication of breast cancer risk  Need for the development of programs of research to address issues relevant to breast cancer detection and control among women in the USVI across the care continuum.

26. Caribbean Exploratory Research Center Next Steps  Follow up on recommendations from reported studies  Facilitate the completion of ongoing studies through presentation to peers, publication and implementation of relevant interventions to reduce disparities  Host conferences aimed at garnering involvement in community based participatory, and culturally relevant research

27. Next Steps cont.  Provide support for pilot studies addressing health disparities  Mentor students, faculty and community researchers in evidenced based approaches to address disparities  Engage the community through CBOs in educational, wellness and preventative activities

28. Next Steps Cont.  Seek additional funding sources Three grant applications submitted through the Center in response to the American Recovery and Reinvestment Act call for proposals Thousands of applications submitted from across the nation One of the three submitted proposals funded for $600,000 over a two year period.  We will continue to seek opportunities for additional support of what we consider vital work to improve the health of Virgin Islanders.

29. Resources  CDC National Center for Chronic Disease Prevention and Health Promotion Behavioral Risk Factor Surveillance System (2004, 2006)  CDC HIV/AIDS Surveillance report, 2007  HEALTHY VIRGIN ISLANDS 2010: Improving Health For All(2003) Virgin Islands Department of Health  Underwood, S., Ramsay-Johnson, E., Callwood, G., Evans, E. (2007) Promoting Breast Health among Women in the U.S. Virgin Islands: A Focused Study of the Needs of Caribbean Women, JNBNA Vol. 18 (2)  Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare (2003) Institute of Medicine  U S Census Bureau (2000)

30. Thank You Questions? Supported by a grant from NIH NCMH-HD #1P20MD002286-03