Availability Is Not Accessibility

[Music] Our industry absolutely must get better at providing culturally responsive care. And that's what this podcast is about. We're going to talk about health equity or social justice for health. Achieving health equity requires addressing avoidable inequities, historical and contemporary injustices, and the elimination of health care disparities. At Providence, we believe that action must follow promising words. That is why we listen to our patients and to community partners on their experiences receiving care and then take action. Let us keep two things in mind as we listen and learn today. Number one, the themes you hear may be common in the populations represented. And two, please remember that one person's experience is not the experience of everyone in that population. Good morning, Mohammed. Thank you so much for being here today with us. I'm super excited to be chatting with you and, you know, chat a little bit more about the role of community health workers, supporting people in the community as they manage their chronic diseases or are looking to prevent chronic diseases. So, Mohammed, can we start with us with you introducing yourself and sharing a little bit about your story for how you became a cultural navigator at Swedish? Good morning, Hannah. I appreciate the opportunity to share a little bit about my work, being an RFUG myself. Coming into 2016 to this country, I have been in a situation where it's difficult to face all of these challenges for the like just moving from a culture to a completely different culture, a completely different country with the family, trying to settle in, trying to become independent, trying to find my first job, like all of these things, even just registering kids at school or knowing where is the clinic that I can get my kids to or myself. So, these kind of things were really overwhelming and challenging at the beginning. Some services here, I think people take it for granted that since this service is available, then it's accessible. The availability of the service is not a guarantee that many, many people who have cultural, linguistic and social and economic challenges can access these services. So, that's what attracted me to this kind of job. I love working with people like realizing what makes a difference in their lives because it fulfills me and it makes me happy just to do this kind of work. Yeah, I really appreciate all of that context and there's a couple things just that I just want to dive in a little bit more based on what you talked about. You said something early on that I thought was incredibly insightful and that was the juxtaposition or the comparison between availability and accessibility and those two things are actually very different and especially when we talk about healthcare services, if something's available like the ability to receive a mammogram at a hospital, that's not necessarily accessible for particular communities for a variety of reasons, transportation, financial support, cultural norms. I think that's just really important that I just want to highlight in this conversation is availability and accessibility are not the same thing and cultural navigators, community health workers, traditional health workers are uniquely poised to support the reduction of barriers to make something more accessible. Yeah, I agree. That's why we have underserved communities and that's something to me. It's the action that you take when like preparing the service when thinking about how this service can be provided to the wider communities. Not only one specific community who are able to speak English, who understand the medical system and who understand like who are able in multiple ways to access the service, but how about like, you know, these communities who might have certain disabilities in terms of that prevent them from accessing your service, who might not need, might not read the text that you provide in your flyer in English, who might not, you know, feel culturally appropriate to do this and that and make a call and discuss and, you know, request or ask. In certain cultures, like asking a question, might be like disrespectful in a way and in certain cultures, like the social dynamics within the family is really challenging to make, to get the a woman into the clinic or to get a kid into the clinic. That's a culture and we need to respect it, but then also we need to play on the way that we provide the service to be accessible to these, to be fit for these communities. Right. So, you know, what I hear you saying, Mohammed is really talking about how our systems, health systems, social service systems are oftentimes built to support one type of community and that community is oftentimes inherently privileged and has accessibility and availability kind of more on an equal playing field just by who that community is and what the norms are and what you're really suggesting is developing systems that are more responsive to multiple different types of communities and that might mean that that system needs to flex and that system needs to change. But if we're wanting to provide more equitable care, that is exactly what more equitable care is. The health system taking the leap of faith and being brave enough to say, you know what, we're going to take this mobile mammography clinic into the community because we know for a variety of reasons, having someone come to this hospital, this hospital that might not feel safe for a community, that might be inaccessible, that doesn't work. So, we want to take that to the community. That's really, really amazing. You know, the other thing that I just wanted to kind of round back on is, is you said, again, just something else really insightful, I think you said, we need to be sensitive enough to respect the culture and be brave enough to start the conversation. Can you tell me a little bit how for your community, what that trajectory looked like to be sensitive enough to respect the culture and brave enough to start the conversation? Yeah, I think for me, the main thing that play a vital role in our success is that I am a member of this community. So, that's why I think de-centering the service, the professional mindset, and then shifting the narrative or flipping the narrative and centering the community itself is something important. That's why I advocate always to approach communities organically. If you are not from within this community, no matter how how equipped you are with a professional background, it takes, there's a missing part. There's something that is not there, like the culture, the social norms, and like you organically knows the in and out of this community. Without this natural knowledge, I don't think there will be a success, even if you have the best intention in the world. So, that's something that I really encourage everyone to think of like how diverse our teams, how we are naturally reflecting the communities that we are serving. I think without considering these sensitive topics and points, it's hard to make a change. It's hard to make a positive impact. And this, as I said, requires carriage requires like bold command. conversations that might not be like, like, like, everyone might not be comfortable starting at certain times. We've talked a little bit in some of the other interviews for this podcast about the power dynamic that typically exists between a community and a health system or an individual and the provider. And oftentimes that power dynamic as the provider is the one with the academic knowledge and therefore seen as the person who's controlling the conversation and telling people what to do and not necessarily yet have built the trust with that individual to be able to have conversations one and second that is not a conversation that is happening in partnership. And how important those conversations happening in partnership with two people on an equitable playing field, how important that is for people then feeling confident and comfortable to take recommendations or take, take forward some of the suggestions that a provider is bringing health systems, doctors offices are often built on an academic. And the more dynamic, white dominant system and structure that to the more educated that you are the more power that you have the more directional influence that you have. And what we talk a lot about with our community health workers is pushing systems to value experience in the same way that we're valuing academic education. I hear you talking about organic conversations with community and trusting relationships built through shared lived experience. Can you tell me more about how you see de centering the professional mindset a really important component to bringing more equity into the way that we serve communities. Yeah, I think I would start with equity, you know, equitable representation is a must no matter how far we are from this concept like we need to do it before we achieve a success. And I think something that is really valuable for any community member is to have a presence is to have a shared space where they feel comfortable sharing. And with professional mindset, we tend to sometimes share more and dominate the conversation, even though we sometimes try to play the active listener role, but it's inherent, you know, like I myself always consciously try to see if I am doing this or not. And I think while talking to community members and I think in like in our community, there's a proverb, the meaning of that proverb even like saying that even if I come for a certain service, even if you don't provide me the service, the way you dealt with me matters the most, you know, like if I come to the doctor office, if I see someone who looks like me. Talking to me in my language, supporting the doctor or having some cultural representation that represent me. And I think a language line that really help accessibility and mutual understanding, being able to safely express my personal, my cultural, my social concerns is something that is really valuable. And I think that, as you said, usually like providers tend to dominate, like one way kind of conversation is almost there. And to me, I think, especially in my community, like two way conversation, two way relationship, two way, like, you know, a mutual kind of understanding is very important. It's disappointing for community members to be just considered as passive recipient of information from providers. It's very disrespectful to them, even if they don't share because they are not able to share. And this is a kind of honest conversation that we have with community members. Sometimes they open up to us and they say, this is my experience. Like, I have been to this clinic and multiple times trying to, you know, like share what I, but I don't feel like, you know, I am in a safe place to share this experience. Because I don't see that this is my space. I don't see that I really fully belong to this kind of space. So, that's something, you know, to be open up to feel safe. I think we get back to the point of natural representation, natural belongingness. Yeah, we know oftentimes our health systems, our clinics, our doctor's offices have such an enormous opportunity as far as representation. We do not have enough representation in areas of care. And with the representation, I hear you talking about how that representation can help to build, breaks, braver spaces where mutual conversation can happen. So that people are potentially feeling brave enough, trusting enough to talk about health concerns like a concern around a chronic disease or why preventive care is so important. But when we don't have the representation, when we don't have the flexibility of the systems, why would a community, why would an individual from a particular community open up in that way? has taught them differently potentially, right? One of the conversations that I've had a fair amount in my tenure in this role is how important the CHW workforce is in supporting our organizations equity goals. And one of the other sides of that is community health workers, cultural navigators are not enough to solve all of our representation problems. All of our equity issues. It's one really good first step, but it's not enough. Do you agree with that? Yeah, yeah. Yeah, definitely. Like a cultural navigator is a starting point to me. It's a journey. But then, you know, once you open the way for people to go through this direction, there will be definitely additional challenges because the system is not designed for them to be able to navigate and go through these ways. And the system, I think I always advocate for like reconsideration of requirements of eligibility of whatever like, you know, reconsideration with so much. You know, a cultural consideration at the same time. So like the programs are built in a way that's like keeps away our community members who may definitely not a fit for certain requirements for certain eligibility, like requirements. And that's something that we face like we try to help in several ways, but then there are certain challenges where we are ourself as navigators sometimes get disappointed because the programs are not responsive. The programs are not allowing people to get equitable access to services. And that's something that is definitely always we face on daily basis. Yeah. So what I hear you talking about and again, we've talked about this a little bit for before and some of our episodes is that to really make a true impact in a lot of this work is that well, firstly, this is a national issue. This is this is not an issue in just particular areas. This is a national policy issue that we have systems, structures that are built in a way that are not accessible and not available. Equitably to communities and then that trickles down into our systems and the way that they're building programs, which in turn are also not accessible. [BLANK_AUDIO] and available to communities. And so I think that's just a really important point in this conversation, is that there are organizations that are being brave to try new things Swedish and the work that you all are doing with the mobile mammography clinic. That's amazing. But also, we can't do that or talk about that without talking about this larger issue in our country that we have policies that are racist. And we have systems that are racist that will continue to exclude and marginalize communities and therefore we will not be able to achieve our equity goals. - Yeah. Yeah, yeah, definitely see Hannah. And this is often the feedback from community members that I meet and talk to them. Sometimes they feel like, you know, they feel disappointed because the way we respond to their needs is just like putting a bandaid on the cut or the one. Putting a bandaid is not something that heals people because that can happen when they get to the point where they crash to the system. The system is exclusive definitely. And multiple ways. And it's obvious for many people who work in high level or like on the ground with people, they will definitely realize that this system is not inclusive. That's something that we need to consider because we are again, we are just treating these symptoms but not the cause of the problems. - Thank you for that. I wanted to just spend, I know we need to wrap up. I wanted to just spend a couple of minutes talking specifically about the mobile mammography clinic because I think that's an example of piloting a project with the intention of serving a community. So can you just talk to me a little bit if you can about what all did you all do last year to build and implement this mobile mammography clinic and then what are you all looking to do in 2023? - Awesome, yeah. I think it started with just basic steps or actions that we have taken to draft our flyer. That flyer to me, like the process is something that I would love to see in every process. Like, you know, we tried to consider, you know, diverse opinions, but we are doing our best to, you know, to change the way the flyer looks like for community members. When they read it, we provided it in multiple languages. We also like, thought of like building these authentic partnerships with everyone in the community, like community-based organizations that are active on the ground, community leaders. I myself, like I gave the flyers even to like, at faith-based places, cultural food places, to kids, to adults, and I started this conversation virtually in person. I tried even to knock doors. I did my best to actively engage, you know, our community members, and it has been fruitful because, you know, the more you rely on, like multiple ways of outreach, the more you get success because one way, one size cannot fit all. So that's something that we try to do in our approach. - Yeah, so what I hear you saying is your outreach was flexible. So it kind of, even as you were starting to think about this project and how you were building the components of it, your outreach strategy was flexible, going to multiple different places, going to the community, and also your outreach strategy, if I hear you right, is using your shared lived experience with your community, Muhammad, to say, where can I go? Where are the places that I know that our meeting spaces or gathering spaces or connection spaces for these conversations? And that, I just, I wanted to pause because that's very different than a typical strategy for a health system to take when they're building or marketing a program. - Yeah, definitely. I always advocate for diversifying the ways based on like the responses of your community. If you only do your outreach through your website or through your social media, and definitely you will be reaching these population who go to the website, who use their phone or their computers to check websites. Or like, but then you miss a population that is not considering this as a way of knowing, you know? So some people like get to the mosque to ask for certain resources or certain people ask the bake a guy, what do you think about this or that? Some people rely on their kids to know more about like, the resources because of, so it's, you have to be flexible, you have to change, you don't have to be formal. As if, you know, when we started this conversation, we said like, it's not formal, it's just a conversation. So if you only rely on these traditional ways, you definitely missed the opportunity of reaching out the underserved communities. And there's a value there that this is not a one size fits all approach and it shouldn't be a one size fits all approach. And there's a celebration, I think, and an IC in your program, there's a celebration of all of those individual identities in recognizing that by being flexible and engaging in different ways based on one's individual shared lived experience, that it's a more powerful connection. And again, I think that's the uniqueness and the beauty of the cultural navigator for health systems is that cultural navigators can help advocate for their community and advocate to the systems to create change, to push change. And I'm a firm believer that that should not fully be on the backs of the community health workers. There needs to be allyship from systems to support that. But it's this amazing, this amazing facet of a community health worker is the advocate role and the educating role. And there's a duality there. CHW's cultural navigators are educating their community as you have done around the mobile mammography clinic and the importance of mammograms. And at the same time, you're educating the system on how to be more responsive, on how to be more equitable. That's so unique and so crucial. And really, I think you've mentioned something a couple of times that sometimes we take things for granted. And if there's a lesson for me in these conversations, is that health systems cannot take cultural navigators, community health workers, a traditional workforce for granted. Because the power in change is there. The power is in change as if we as a system do the deep listening that you're talking about to make significant changes. That's huge. - It's a huge, yeah. I think it's a huge because you put all these values in action, in even the words that you put on your flyer. So even I remember when we tried to draft like our program page. And we talked about limited English proficiency or people who don't speak English. And we thought of after, is this how we want to center this population and we talk multiple ways and multiple times. And we reached to a term that's more respectful that shows like the values of what we believe in. And like we use like multi-cultural and multi-lingual families instead of just limited English. Because we don't want to center English. We don't want to center. We want to center all of these diverse population. And we want to show these values that we believe in in our language, in our actions and everything that we do trying to be sensitive. I think It's a huge and it's an endless journey. It's always need to be, like you need to be conscious, you need to be able to flex and change and update yourself to be more inclusive. It's never like, okay, I'm done with this. No, it's an endless effort that everyone needs to practice in their workplace. Yeah, it's a constantly evolving journey. And it's the journey that health systems need to take and CHWs are one facet of that journey. I just wanna end on something that you said earlier that I think is incredibly valuable as we talk about the needs of the system to be flexible to support communities and how we have lofty equity goals to be able to do that. We really need to be flexible and we need to take the will that you're talking about and move that into action and move that into accountable action because there is a lot of will, I think, in systems to make change. And to me, a highlight of that action is the work that you all are doing at Providence Swedish to reduce chronic diseases within communities and focus on preventive care within communities with through the mobile mammography clinic or your work with hypertension. That's an action step. And that's an action step that's driven by diverse communities. And that feels like such a step for us. - Yeah, yeah, I think it's just, as we talked, it's just flipping the narrative of the dominant professional mindset of, this is our program here we go. It's just like that. We need to flip that narrative. We need to diversify our professional professionals in our offices. We need to adapt and change. We need to play on the way we draft our policies with the way we draft our programs. It's from, it's a connected circles. If you start from the foundation up, I think your programs, your efforts, your desire to be inclusive will be definitely fruitful. If you just rely on your intention without being inclusive in actions, and it's hard. I definitely think that it's hard. Actions are really different from our intentions 'cause we often have challenges in these actions. But I think it's worth it. And it's doable if we all work as a team. The team spirit in this work is really important also because no one can do this kind of work alone. We need to avoid this kind of method of working in silos into partnership, into a team effort, into collaboration, into partnerships. These are really important ways and methods to achieve success. - Mahabad, thank you so very much. It has been a pleasure to chat with you today and really learn from you today. There was so much you said here that I just wanna unpack for hours and hours and hours, but thank you so much. It's been an absolute pleasure. Thank you for continuing to advocate and teach our systems to do things differently. Thank you. - Thank you, Hannah. Thank you. I really appreciate the opportunity to be here and share. It's valuable for me like having the opportunity and being invited. I really appreciate your efforts in doing all of this. Thank you so much. - Thank you all for joining us as we explore the CHW role. Next up, we will be hearing from Maria and Sonia, two CHWs that work in Eastern Washington. They share their perspective on the beauty of the relationships developed between CHWs and their neighbors. - Thanks for listening. Let us all stand together, recognizing action must follow from a singer. (gentle music) (gentle music) (gentle music) (gentle music) - Thank you all for joining us as we explore the CHW role. [BLANK_AUDIO]