Clipper Clinic: An Academic and Community Collaborative Model to Addressing Health Disparities within Underserved Communities

Special Article – Community Healthcare

J Fam Med. 2016; 3(2): 1052..

Clipper Clinic: An Academic and Community Collaborative Model to Addressing Health Disparities within Underserved Communities

Abu-Bakr A, Ahmed H* and Ojo-Fati O and Okuyemi KS

Department of Family Medicine and Community Health, Program in Health Disparities Research, University of Minnesota, USA

*Corresponding author: Ahmed H, Department of Family Medicine and Community Health, Program in Health Disparities Research, University of Minnesota, 717 Delaware St SE, Suite 166, Minneapolis, USA

Received: February 21, 2016; Accepted: March 16, 2016; Published: March 21, 2016

Abstract

Clipper Clinic is a free preventative health care screening service that addresses the barriers many underserved communities have in regards to accessing health care. Each Clipper is conducted in, and partnered with a local barbershop or beauty salon that is located in an underserved area. Clipper Clinic provides an alternative care delivery model that establishes fully engaged partnerships that break down silos between academic institutions, community clinics, HMOs, and community barbershops. It increases participant awareness and knowledge by providing biometric screenings, finding a medical home via “warm hand” referrals to low cost health care resources, and providing evidence based health education. At each event, free preventative services are provided including, flu shots, height and weight, blood pressure, blood glucose, cholesterol, HIV/STD testing, and cancer screening questionnaires. There are patient navigators available to provide information about insurance and guide community members through the insurance enrollment process. Over the past three years (2013-2015), clipper clinic services have reached about 611 community members with roughly 36% of the participants identifying as female and 57% identifying as male. The racial and ethnic background of screened participants included Latinos (31%), East Africans (6%), Multi-Racial (3%), and African Americans made up 44% of the total screened over the last three years. Clipper Clinic is a promising method for effectively and efficiently addressing health disparities in underserved populations by utilizing a community-academic framework, reaching multiethnic and gender target population, and allowing for a comprehensive disease focus.

Keywords: Health disparities; Underserved; Health care access; Community-academic

Introduction

The gap in preventative health care services between Caucasians and People of Color continues to be a persistent problem in the United States. The myriad of health disparities and inequities that have created this gap in care continues to grow as ten new topics including; health-related quality of life, residential proximity to major highways, unemployment, and activity limitations due to diagnosis of chronic disease, were added to the long list in the Center for Disease Control’s, CDC Health Disparities and Inequities-U.S. Report [1]. Often times, communities of color are burdened by the poor health outcomes they face due to the gap in care. Infant and maternal mortality rates, which serve as widely accepted markers of the health status of a population, highlight grave realities when the rates for Whites, Blacks, and Latinos in the United States are placed side by side [2].

In recent years heart disease, cancer, and diabetes have been cited as three of the leading causes of death within Native Americans and Alaskan Natives, Latinos/Hispanics, African Americans, Asian Americans, Native Hawaiians and Pacific Islanders, and other communities of color [3-6]. In the state of Minnesota, health disparity trends within communities of color align with the discouraging trends seen at the national level. The 2014 Minnesota Department of Health report to the legislature revealed that despite improvement in overall health outcomes, disparities between whites and people of color remain unchanged; inequities in social and economic factors serve as key contributors to health disparities in Minnesota; and exposing structural racism, where it operates and where effects are felt, is essential to determining where and how policies and programs can work to eliminate health disparities [7]. In Minnesota, the rate of HIV/AIDS among African-born people is almost sixteen times higher than White/non-Hispanic individuals; Native American, Latino/Hispanic, and African American youth have the highest rates of obesity; and African American and Latino/ Hispanic women are more likely to be diagnosed with later stage breast cancer. Furthermore, children of color are less likely to receive dental services and more likely to have cavities than their white counterparts [7]. The goal of the current public health system in the United States of America is to have a health department, public health system, community partners, and workforce that builds operational capacity/ infrastructure that impacts every community program and public health activity, which leads to better health outcomes, reduced disparities, and better preparedness at the federal, state, and local levels. The current structure of the United States (U.S.) public health system was founded on ten essential services that the system offers to the community which include; monitor health status, diagnose and investigate; inform, educate, and empower; mobilize community partnerships, develop policies and plans, enforce laws and regulations, link people to needed services/assure care, assure a competent workforce, evaluate health services and conduct research [8]. Through this system and the services it provides, U.S. citizens and residents can access care through private insurance or government regulated insurance. Once insured, citizens and residents can access hospitals, emergency departments, and community clinics. It should be noted that not all citizens or residents are insured and not all with insurance utilize the care system sue to costs and accessibility barriers. Despite the current goals and structure of the U.S. public health system, or efforts made on both a local and national scale, not much has changed over the years as there are still significant differences among races and ethnicities when it comes to these widely accepted markers of population health. The lack of change is due in part to the multiple barriers to care that communities of color face, such as, lack of affordable care, complexities of health insurance and payer status, limited hours of clinic operation, a lack of transportation, and geographic distance. These barriers cause individuals to delay treatment and self-care which increases the prevalence of negative health outcomes in communities of color in the United States.

In response to this overwhelming problem, community based health initiatives have been proposed to address these disparities; a large majority of them focusing on addressing hypertension and prostate cancer, as both relate to heart disease and cancer which are two of the leading causes of death in communities of color and Native Americans [3-6]. Furthermore, a large majority of the initiatives have taken place at community barbershops and salons because of the growing knowledge citing community assets such as barbershops and salons as appropriate venues for reaching and teaching community members about health; these venues are perceived as safe places as community members often form trusting relationships with their barber or stylist [9-11]. Positioning initiatives at barbershops and salons also address a difficult, but key step to addressing ddisparities and increasing reach. Barbershops and salons are community sites that attract diverse groups of individuals on a regular basis [10], making them prime locations to provide services and disseminate information. Additionally, a large majority of the community health initiatives that have been geared towards African Americans, are led by state or local government or educational institutions, and cater to males; creating yet another gap in care for communities of color.

In response to this overwhelming problem, community based health initiatives have been proposed to address these disparities; a large majority of them focusing on addressing hypertension and prostate cancer, as both relate to heart disease and cancer which are two of the leading causes of death in communities of color and Native Americans [3-6]. Furthermore, a large majority of the initiatives have taken place at community barbershops and salons because of the growing knowledge citing community assets such as barbershops and salons as appropriate venues for reaching and teaching community members about health; these venues are perceived as safe places as community members often form trusting relationships with their barber or stylist [9-11]. Positioning initiatives at barbershops and salons also address a difficult, but key step to addressing ddisparities and increasing reach. Barbershops and salons are community sites that attract diverse groups of individuals on a regular basis [10], making them prime locations to provide services and disseminate information. Additionally, a large majority of the community health initiatives that have been geared towards African Americans, are led by state or local government or educational institutions, and cater to males; creating yet another gap in care for communities of color. including, but not limited to, Minnesota Black Nurses Association, Fremont Clinic, and North Point Wellness. Before the initiative started in 2010, PHDR and the listed partner organizations drafted and signed a memorandum of understanding which included program objectives, Community-Based Participatory Research Principles, academic institution responsibilities, community-based organization responsibilities, roles of key individuals, as well as, group processes which name PHDR and Southside Community Health Services as authoritative co-leads for the community-academic initiative. The primary goal of Clipper Clinic is to provide quality health care and access to health-related information to underserved communities in Minnesota in a comfortable and trusted environment. Each Clipper Clinic is conducted in partnership with a local barbershop or beauty salon. At each event, free preventative services are provided including, flu shots, height and weight, blood pressure, blood glucose, cholesterol, and HIV/STD testing and counseling. There are also patient navigators from neighborhood community health centers available to provide guidance about follow-up care as needed (“warm hand-off”), information about insurance, and guide community members through the insurance enrollment process. The long term goal of this program is to reduce health disparities in Minnesota’s underserved communities. The Clipper Clinic works to accomplish this goal by;

The purpose of this paper is to highlight the community/ academic framework, multiethnic and gender target population, and comprehensive disease focus that allows this initiative to effectively and efficiently address health disparities in underserved populations.

Methods

This initiative involved two levels, community and individual participant.

Community level

The community level is made up of three main activities;

The first activity consisted of identifying partners to fit the community/academic framework. After a search and review of interested partners, the Minnesota Black Nurses Association, Southside Community Health Services (a federally qualified health center [FQHC]), Fremont Clinic (FQHC), and U Care were chosen as collaborative partners for the Clipper Clinic. Many of these organizations also played a role in identifying barbershops and beauty salons for the Clipper Clinic.

The second community level activity consisted of establishing partnerships with barbershops and salons that would serve as the host sites for Clipper Clinic. Focus was placed on barbershops and salons in socio-economically-disadvantaged communities. Communities that fit within these parameters often face many barriers to care- many of which can be addressed by the convenient services that Clipper Clinic offers. In recent years, word of mouth has become another manner of establishing partnerships in the community.

The final activity at the community level consisted of ensuring that barbers and stylists had adequate knowledge and resources to offer clients and community members so they were capable of serving as health champions for their community. From this activity, a spinoff initiative entitled, “Clipper n’ Curls”, was created and launched in 2013. Clippers n’ Curls built off of the barber and stylists education piece and placed a large emphasis on training and equipping barbers and beauticians with the skills and knowledge needed to engage the community and share important health information with their clients. In addition to equipping barbers and beauticians with knowledge regarding heart health, another part of the spin-off initiative was placing blood pressure screening equipment at the participating five locations to allow for opportunities for community members to receive blood pressure screenings and education in a trusted environment in their community at their convenience.

Individual participant level

The individual participant level is made up of two main activities;

The first activity at the individual participant level was the delivery of screenings that provided community members with biomarkers that allowed them an in-depth look at their health and alerted them of risk factors that could lead to chronic diseases including heart disease, cancer, and diabetes, three of the top ten leading causes of death in communities of color [3-6]. Moreover, this activity directly addressed health disparities, community barriers to care, and community health outcomes by equipping community members with results, education, and suggested lifestyle changes. All of the aforementioned factors lead to an increase in self-capacity, behavioral capability, and action potential in the community member receiving the services [12].

The second activity in the individual participant level consisted of utilizing evaluation tools to assess community members’ needs beyond screening as they relate to accessing referrals, further education, and insurance. Clipper Clinic practices “warm hand-offs” which allow patients to be connected to accessible and affordable insurance, clinics, mental health services, and dental services right away by navigators present on site. The tools used to evaluate these needs include; demographics forms, biometric and health care status screening forms, and satisfaction evaluations. These evaluation tools asked various questions related to the community member’s demographics, motivations for screening, access to health insurance and healthcare, screening results (except for HIV/STD), cancer prevention activities, and recommendations for additional services to be offered at Clipper Clinic events. Per the Health Insurance Portability and Accountability Act (HIPPA) purposes, the forms are kept separate and are not linked together. These tools are also used to improve and increase the service options provided at Clipper Clinic events. After the events, evaluation results are shared with program stakeholder including the community affected.

Measures

In order to collect information regarding the health status of the communities that this initiative has served; biomarker measurements were taken and reported for every individual that opted for a “full screening”. Full screenings include; blood pressure, cholesterol, and blood glucose tests; the completion of a cancer screening questionnaire, a demographics form, and an event evaluation. HIV/STD tests are provided as part of the screening service, but are optional, even when the participant has opted for the “full –screening”. Furthermore, HIV/STD results are not documented on any of the screening tools for privacy reasons. The following information outlines the Clipper Clinic screening process and how measures are collected.

Blood pressure

Blood pressure screenings were done by registered nurses who are members of the Minnesota Black Nurses Association. Blood pressures were obtained in the sitting position with both feet on the floor. Participants were encouraged to take a “calming breath” before the nurse performed the procedure. Blood pressures were taken using an automatic portable blood pressure machine. The procedure was repeated after 1 full minute of calming breaths if the results were abnormal. If the second results were abnormal, the procedure was done with a manual blood pressure cuff and stethoscope. The American Heart Association’s criterion was used to designate readings as normal or abnormal. According to the American Heart Association [13],healthy/normal ranges are combined scores of <120mm/HG and <80mm/HG for systolic and diastolic respectively. Participants received health education and nutrition counseling based on their results.

Cholesterol & blood glucose

Cholesterol and blood glucose screenings were completed by a team of registered nurses, Physicians, and trained allied health center undergraduate students under the supervision of a registered nurse. After disinfecting the participant’s hand and chosen finger, fifteen to twenty microliters of blood was obtained from the participant’s finger using one-time use/disposable lancets and 15-20 microliter glass capillary tubes. The blood sample was then placed on a blood test strip and inserted into a Cardio Chek (PTS diagnostics) machine which provided the screener with the participant’s total cholesterol level, HDL cholesterol level, and blood glucose level. Participants received health education and nutrition counseling based on their results. According to the Mayo Clinic [14], ranges for total cholesterol are; desirable ?below 200 mg/dL, borderline high ?200-239 mg/dL, high ?240 mg/dL and above. HDL ranges are; poor ?below 40mg/ dL, better 40-59 mg/dL, and best 60 mg/dL and above. For blood glucose, participants who do not have diabetes type 1 or type 2 and no other underlying chronic health issues should have a fasting blood glucose level of less than 100 mg/dL or a random blood sugar test result of less than 200mg/dL [15].

Cancer screenings

Cancer screening questionnaires were added to the Clipper Clinic in 2014, since then 376 community members have completed the cancer questionnaire. The participant receives the questionnaire when checking into the event. Prior to obtaining the participant’s blood pressure, a registered nurse asks the cancer questionnaire questions to the participants if they are eligible. Eligibility is based on the participant’s identified gender and age. Participants fifty years of age and older are asked whether they’ve ever completed a blood stool test; when their last blood stool test was; and the last time they’ve had a colonoscopy. Females who are forty years or older are asked if they’ve ever had a mammogram and when their last mammogram was. All women are asked if they’ve ever had a pap smear and when their last pap smear was. The information obtained from these screenings are used to gain insight on the preventative measures against cancer that are being taken by community members and identify participants who may benefit from connecting with a patient navigator from the University of Minnesota’s Masonic Cancer Center if they are interested. Cancer screening questions were derived from longstanding and well validated surveillance surveys conducted by the Centers for Disease Control and Prevention of the United States Public Health Service [16].

HIV/STD

HIV AND sexually transmitted disease screening are performed by certified outreach specialists from Fremont Clinic in North Minneapolis, MN. The testing specialist starts by collecting information about the participant’s sexual history (sexual orientation, number of sexual partners, contraceptive use, etc.) and asking the participant if they believe they are ready to hear the results that day. Once the first step is complete, the screening specialist explains to the participant that the screening test is reactive (meaning that a test can be reactive/positive if the participant has disease related antibodies in their blood) and not a diagnostic tool. Blood is collected from the participant via a finger poke and a Clear view 1.5 test is used to test the blood sample. After the test is complete, the participant receives information and counseling related to necessary next steps. If the test is reactive positive, the participant is referred to a positive care unit at Hennepin County Medical Center, Minneapolis MN where they receive follow-up care and additional diagnostic tests.

Once a patient has completed all screening stations associated with the Clipper Clinic process, they return their demographic form to the community event specialist and the following information is later used to evaluate community measures, blood pressure reading, total cholesterol and HDL cholesterol levels, and blood glucose level. Flow diagram 1 shows the clipper clinic event and screening process from entry to finish point (Figure 1).