What does it take to build trust with the communities you aim to serve? A conversation with Dr. Sergio Aguilar-Gaxiola
When it comes to addressing health disparities, it’s critically important that healthcare providers and researchers take a proactive approach to building trust with the communities we aim to serve.
As founding director of the Center for Reducing Health Disparities at UC Davis, Dr. Sergio Aguilar-Gaxiola has decades of experience with this approach.
“It is possible to overcome the barriers of access to care if we can change our paradigm,” he says. “
In this episode of the Health Disparities podcast, Dr. Aguilar speaks with Movement Is Life’s Dr. Zachary Lum about his work, which focuses on health disparities, mental health in underserved populations, community-engaged research and Latino health.
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This transcript has been lightly edited for clarity.
Dr. Sergio Aguilar-Gaxiola: One of the things that I have appreciated throughout all of these years that I have been working on health disparities is that it is possible to overcome the barriers of access to care if we, if we can change our paradigm, because the prevailing paradigm is what I call, and you mentioned the waiting mode. It is when people are in need of services, they have to go somewhere to receive the services. And it is when they have to wait to go for services, usually the symptoms are set. There are complications that ensue, and normal function at many levels is by then lost. Contrast that with the seeking mode, which is we go to them, where they live, where they work, where they congregate, and we offer services at the point of need.
Dr. Zachary Lum: Hello and welcome. You’re listening to the Health Disparities podcast from Movement is Life. I’m Dr Zachary Lum. Movement is Life steering committee member and assistant professor of orthopedic surgery and chief wellness officer at the University of California Davis. When it comes to addressing health disparities, it is critically important that health care providers and researchers take a proactive approach to identify those who need care and take time to build trust with the communities we aim to serve. It’s truly my honor to be joined today by Dr. Sergio Aguilar-Gaxiola, founding director of the Center for reducing health disparities at UC Davis. Dr. Aguilar’s work focuses on health disparities, mental health and underserved populations, community engaged research and Latino Health. Dr Aguilar, welcome to the Health Disparities podcast. Thanks for being here.
Dr. Aguilar-Gaxiola: Well, thank you so much. Dr. Lum, I’m honored actually to be joining you. I want to congratulate you for the Health Disparities podcast. I have been listening to some episodes, and boy, I think that you are doing a great service in this space.
Dr. Lum: Thank you so much for that. Dr Aguilar, before we dive into the specifics of your work, can you share with us a little bit about your background and what made you interested in addressing health disparities in underserved communities?
Dr. Aguilar-Gaxiola: Yes, that has been a lifetime interest of mine. You know, my training, I trained as a physician, but I also did a master’s and a PhD at Vanderbilt University, and a couple of years, including a postdoc at UC San Francisco, and it was focused actually, my PhD is in clinical community Psychology, and I have been working with communities, with communities, not on communities, or even in communities, but with communities, for decades. And I, I don’t know, sometimes I think that is in my DNA. But let me tell you that really has been a very important mission in my life, actually, now I can tell you that my mission is. A through the Center for reducing health disparities that I founded and started at UC Davis 20 years ago. It is to serve the underserved, as simple as that, you know, and there are historically underserved populations that we have been focused on. And so it is like immigrant populations, farm workers, like other populations that usually don’t have access to care. Those are the populations that I have been interested and committed to work with.
Dr. Lum: Thank you for that. Since you did talk about the Center for reducing health disparities at Davis, can you tell me some of the key initiatives that the center has been very proud about?
Dr. Aguilar-Gaxiola: Yes, absolutely. One thing that I want to emphasize is that the work that we do, and have done for these two decades, at the Center for reducing health disparities, has been primarily focused on solutions to advancing health and mental health equity. You know, inequities have existed for forever, I would say, you know now that we have better ways to uncover them or to study them. It is very clear that there are disparities, or inequities, certainly in healthcare, and so we made the strategic decision at the center to really not to continue to define health disparities, although we do that as well, but primarily to focus on on on solutions to advancing health and mental health equity, and we do it through, primarily through community engaged approaches, working with communities and working with different groups. And as you asked me, What are some of the accomplishments that we have, I would like to mention that we have worked, for example, for eight years with a county. It’s called Solano County, is close to San Francisco, is close to Sacramento County as well, where I reside, and the leadership of the county came to speak with me. He knew about the work that I do, and he and and three other leaders of the county came to speak with with me and my team, also back in 2014 and they said, you know, we want to explore if you would be willing to work With us, because we had been working for three years with community leaders to address the disparities that three populations, and they focus on those three populations, Latinos, Filipinos and LGBTQ. And he said, we had been working through this cultural competence work group to address their needs and increase the access to care. And he said, but we haven’t been able to do that. Would you be willing to help us? And of course, we jumped at that opportunity, and we worked almost two years without any pay, because we were so fascinated and committed. And then they funded us. So we worked for about eight years closely with them. We officially started in January of 2016 and ended up, you know, almost six years later. And what I’m happy to share with you, Dr Lam, is that we documented that it is possible to advance mental health equity primarily with those three, three populations that they wanted us to focus on. But it didn’t. It didn’t stay there, because it is like, you know. The other populations, African Americans, whites and also Native Americans, were also increasing the use of mental health services in the county.
Dr. Lum: You’ve done a lot of work, just to kind of talk a little bit about that mental health. You’ve done a lot of work, extensive amounts, with mental health and Latino communities. You were the on site principal investigator for the Mexican American prevalence and services survey, which was the largest mental health study conducted in the United States on Mexican Americans? Can you speak a little bit about that? Maybe what you learned through the research and the insights on that study?
Dr. Aguilar-Gaxiola: Yes, absolutely. Well, this is a project that we call the Mexican American and prevalence services survey, and we focus on people of Mexican origin, both that were born in the US, but also those who were born in Mexico. And we included a sample of over 1000 farm workers. Actually, you know, this was done in Fresno County, or the audience. Fresno County is at the heart of the Central Valley, and it is an area notable among other things, for being the food basket of not only California, but the nation you know, through the Central Valley corridor is lots of agriculture, and also better documented disparities in access to health care and mental health care as well. So I joined hands with you know, esteemed colleagues who we collectively got funding from the National Institute of Mental Health for five years, and I conducted a study in Fresno County, and a little a little over three decades ago, it was a population based study, and what we did was To study prevalence rates, primarily of mental disorders, including substance abuse, but also chronic health conditions. And it’s something that I want to highlight is that we also very carefully study the patterns of service utilization, who were using services, who wasn’t using services, who started using services, but they stopped using the services. And also we look at risk and protective factors, and we look at the burden of disease as well. And one of the highlights of that project is that I came to appreciate, not so much, although that is important, the prevalence rates, let’s say, of depression and site disorders. I mentioned substance use, but the big story was the under utilization of services. Just to give you a sense of those who met criteria for one or more mental disorders, one of three of the US-born people of Mexican origin, were using any any of the services, comprehensive assessment that we did of various services from the general medical sector, the specialty mental health care sector, we studied the other professionals included, we included the informal sector like curanderos, folk healers, etc. So just picture this. One out of three of the US-born people of Mexico origin was using one of those or more of those services, one in six of those who were born in Mexico, and less than one in 10 of the farm workers. And guess what? Those disparities haven’t changed, actually, if anything, I’m afraid that they have been even more pronounced at the present time. And so we studied also the barriers of access to care, and documented that, and definitely those barriers continue to exist, like, for example, not being able to get services in Spanish, or lack of transportation to go to the services, or the services that are offered Monday through Friday, eight to five, when many of these populations are working and in order, and when they need to go for services, they lose a full day of earning, you know. And it is very challenging for many of them to navigate the systems so they really miss a full day of pay, which they cannot afford.
Dr. Lum: Correct, yeah, totally agree. Yeah, I totally can see why. You know, it seems like every major academic investigation that you do kind of unveils something and kind of leads down to the next career path, which you’ve so informed, enlightened us about, and myself specifically. You know, it sounds like those workers, that’s why they wouldn’t seek care, because they couldn’t, they didn’t, they weren’t able to afford it, financially, or what have you. And to that same vein, or to take that to the next step, it seems like it would be prudent to maybe bring that care to them. And so you talk a little bit about this, and your concept for healthcare organizations is that they need to be more proactive in providing care to their patients, specifically that you would rather be proactive in identifying people who need these care or this care, rather than having these patients wait until they become very ill and sick. Can you talk to me a little bit about this concept of seeking versus waiting? What is that? What does that mean to us or to yourself?
Dr. Aguilar-Gaxiola: Yeah, absolutely, I’m glad that you are asking that, because one of the things that I have appreciated throughout all of these years that I have been working on health disparities is that it is possible to overcome the barriers of access to care if we, if we can change our paradigm, because the prevailing paradigm is what I call, and you mentioned the waiting mode. It is when people are in need of services, they have to go somewhere to receive the services. And it is when they have to wait to go for services, usually the symptoms are set. There are complications that ensue, and normal function at many levels is by then lost. Contrast that with the seeking mode, which is we go to them, where they live, where they work, where they congregate, and we offer services at the point of need. We have the technology to do that. Actually, we did that out of our center, especially during the pandemic. You know, when we took free antigen tests, vaccines, we did test to treat working with fairly qualified health centers, that when we saw that someone was positive to call it right on the spot, we connected the person if they wanted to receive services on the spot with a primary care physician from two of the fairly qualified health centers that we work with so picture that the barriers of access to care that we have been documenting for so long were not there anymore because we were making it easier for them, you know, through what I I call the seeking mode. And just to give you a sense, the seeking mode actually is very valuable, because it is to intervene before the symptoms appear, or early when they appear and preserve the normal function for as long as possible.
So this is, this is a response to prevent chronic health conditions or mental health conditions before they get even more complicated. And we have been, we have several examples of that. You know, especially related to covid, but beyond that, because the latest that we were doing is to to go in and provide on the spot where people live, where people work, where people congregated in community settings to provide, for example, blood pressure tests and also screenings for depression. And we collected a lot of information about that in close collaboration with two community health networks or fairly, fairly qualified health centers and with very, very promising results. So just to summarize, Dr long, we have the technology now, through digital health means to be able to do that and not to be waiting for people to really, really, you know, come for services when they are falling apart, you know, because It will be too complicated by then. So if we catch that early in the process, I think we say, along with the persons who are treated with a lot of prolonged suffering, you know, is more cost effective. And you know, it increases, improves quality of life. So this is something that we continue to be very excited about.
Dr. Lum: Thank you for that. Yes, it was really interesting, and it makes sense, because when patients are much when they present much more ill. It’s a higher cost to the healthcare system, and it makes much more sense to be proactive, to care for these patients before they become severely ill. And what was really interesting to me was that you would take, you would go, when you say, go out into the community, go out to them, where they live, work, play, etc. You know, it really drives home the fact that you’re being proactive. Because people don’t have time, which you’ve mentioned, they can’t take time off of work to go and take care of themselves. And so being able to provide that, I think, is huge. One one thing, I wanted to kind of talk a little bit about that, and I know that you have plenty of experience, so it would be great to kind of share a little bit about how you’ve done it or succeeded, especially in a lot of these groups that are interested in providing these care is being able to establish community trust in those areas. When you have projects or whatnot, companies, etc, are interested in doing things like this. How do you, how do you earn that community trust? Because, you know, that’s a huge aspect of this.
Dr. Aguilar-Gaxiola: Yes, I’m so pleased that you asked that question, because we have been working on what, what, what is called now meaningful community engagement, that if we are to engage communities. And communities are not only, for example, the community based organizations, the community leaders you know, working with the agencies, working with law enforcement, with social services, with churches, with schools, the critical importance in all of that is, you know, to build trust. And in order to build trust, we need to listen, listen attentively and incorporate what we are listening to into whatever plans we undertake and to listen to what matters to those communities. But it is not only you know the listening. A front and center for building trust. It is also something that absolutely we need to consider, is to become ourselves as providers, trustworthy, you know, trustworthy that the populations that we are serving trust us, that they are willing to receive the services from us, because we have shown that we are trustworthy. And let me give you an example that has stayed with me and that captures what I’m telling you about when we were providing free covid tests and also vaccines, I remember going with my team to a migrant center close by, you know, it’s called Dixon migrant center, and I was very impressed, actually, to find out that some of the some of the tenants in that Housing Center were Speaking in a first name basis with our promotoras, or community health workers, I was very pleased to see that they were already they have built trust. So one thing that really still gives me chills to think about it, because I saw this mom bringing the six month baby asking if we could test him for covid. And in my mind was, Wow, that is trust, you know, to bring a mother that is protected of a six month old baby to be tested. And thankfully, the baby was negative. So our own community health workers, or promotoras, as it told her, you know, this time around, we are bringing free vaccines. Excuse me, free tests. But there is this other group from the county that are providing vaccines. Why don’t you take your kid to be vaccinated? You know he’s negative, so he can be vaccinated. And I was so impressed that the mother said, No, I’m going to be waiting until you bring the vaccines. That is trustworthiness. You know that really captures how trustworthiness is fundamental to addressing health disparities or advancing health equity.
Dr. Lum: I totally agree with that. You know, it’s interesting. As a surgeon, you know we have to deal with things like informed consent, surgical consent and having the patient’s trust is more important than something, that’s not intangible, more important than actually having a physical signature on a document. So I totally agree with that, and I think that, you know, having, again, that patient physician relationship, really establishes and bounds trust. So trust is important. It’s a key essential ingredient in all of this. I totally agree.
Dr. Aguilar-Gaxiola: Can I comment very quickly? There are three contributions that I had been very much involved with along with my center at the national level that really capture what I was talking about, the meaningful community engagement that really for those who are interested in this work, those are remarkable resources. One is the principles of community engagement that the CDC has been releasing since 1997 when they released the first edition. And then I work as the co chair for the second edition, which was released in 2011 and just to give you a sense, the second edition has been downloaded from the CDC website about 10 million times, and it is available both in English and Spanish. And I took the lead to have the Spanish version in this third edition that just was released this past January, instead of being a, as it happened on the first edition and the second edition, we added a 10th principle, which is trustworthiness, as fundamental, as a fundamental element to advancing health and mental health equity. So that is one contribution. The other one is that had been working with the National Academy of Medicine for six years, now, more than six years, and I’m the co-chair asked by the National Academy of Medicine on this work group that is called assessing meaningful community engagement in health and health care and the National Academy of Medicine has released five resources, including a conceptual model on assessing meaningful community engagement. Also released seven impact stories which really are impactful, also based on a very comprehensive list review, 28 instruments on community engagement, all for free. You know this, there is no gratuities or, I mean, there is no copyrights or anything. These are in the public domain and also a user’s guide, and we’re working on the final report, which we are hoping to release early this coming year, the third one, and I’m going to finish with that, is the Association of American Medical Colleges’ principles of trustworthiness. The AAMC has been working for four years or so, and our center collaborated for a full year with the AAMC to evaluate the principles of trustworthiness toolkit that they develop, and now we have even a survey, trustworthiness survey That is, that is easy to, easy to use. So all of these things can be measured, you know, in the way in which, in a way that you know you can, we can document that it is possible to be trustworthy or to be trusted. You know that we build trust, something that wasn’t readily available before, and I’m sorry that it took me this long, but I think that is important for the listeners to know that there are resources available to do this kind of work.
Dr. Lum: There you have it. So if you know, and we have our own community engagement program called Operation Change, but for others that are also interested, check out the principles of community engagement by Dr. Sergio Aguilar and just, I think that is a wonderful, wonderful thing that our UC Davis Center for reducing health disparities has produced. And we’re so proud that you’re, you know, an icon and a legend in our little deck of the woods. And I’m so glad to have really highlighted some of the amazing and wonderful things that you have done, and it just really scratches the surface, because it’s always great to talk to you, because hearing all the wonderful, fantastic things that you’ve you’ve been doing. So thank you so much.
Dr. Aguilar-Gaxiola: No, on the contrary. Dr Lum, I’m, I’m so grateful for this opportunity to share that information. By the way, the principles of community engagement was released by the CDC, okay, and there were over 165 professionals who participated on that and I’m one of the assistant editors, and I’m co-author in five chapters. But is, is, you know, there are many universities who have the book in their websites, and we’ll be happy to send you these resources to make them available.
Dr. Lum: Thank you so much. Dr. Sergio Aguilar-Gaxiola is the founding director of the Center for reducing health disparities at UC Davis. Thank you so much for joining us today on the Health Disparities podcast. That brings us to the end of another episode of the Health Disparities podcast from Movement is Life. I’m Dr. Zachary Lum until next time, be safe and be well.