Taiichi Ohno, the developer of the famous Toyota production system of the 1950’s, used the “5 Whys” as the basis of Toyota company’s success. He encouraged his teams to repeat “Why” five times, to uncover the nature of any production problem and its solution. He also encouraged his employees to, “Observe the production floor without preconceptions”.
This technique is counter to our culture, particularly in the healthcare setting, because it requires us to look at problems from an unbiased view, and to have the patience and respect to understand the cause of a problem instead of judging. The nature of our fragmented and fee-for-service healthcare system, as well as the fact that our ability to access health insurance, and therefore afford healthcare, is dependent on our employer benefits, or our income level creates barriers to care.
Especially in Texas, and particularly in the Rio Grande Valley, decisions at the state level to turn away Medicaid expansion have rendered over 60 percent of our local adult population with no insurance or ability to pay for medical care, which is ironically some of the highest priced in the world. With no public hospital, and with safety-net clinics bursting at the seams, many not taking new patients, coupled with high rates of obesity and related diseases like diabetes, depression and hypertension, many families in our community lack access to even basic healthcare to address these very real health problems.
Often, when individuals do get to see a doctor, there is not time or attention to the underlying problems that may be causing the disease or condition. This is not necessarily the fault of the medical provider, who is forced, due to payment mechanisms, to spend less and less time with patients and focus only on the immediate physical symptoms or tests. A 10 minute visit in an exam room provides a very limited snapshot of the patient, and is out of the context of their real lives, home environment and daily pressures. In other words, there is no time or space to ask the “5 Whys”.
But there is a program that is focused on doing just that—asking patients and families why they are struggling to make healthy choices, or to take medication, or to manage their diabetes and working with them on solutions. Salud y Vida (Health and Life) is a partnership between the University of Texas, School of Public Health (UTHealth, Brownsville Regional Campus), Proyecto Juan Diego, Su Clinica, Brownsville Community Health Center, Rio Grande State Center Outpatient Clinic, Hope Clinic, Tropical Texas Behavioral Health and other community organizations. It is supported by, among other funders, Methodist Healthcare Ministries, Valley Baptist Legacy Foundation, and 1115 Waiver funding.
Salud y Vida brings together health care providers, counselors, social workers, mental health workers, pharmacists and Community Health Workers (known as “Promotores”) to ask the 5 Whys, and work as a team to help empower the participants to take control of their disease, whether diabetes, hypertension and/or depression.
Since 2013, the program has touched over 5,000 people from all over the Rio Grande Valley, helping them improve their health. The key ingredient is the “promotor(a)” model, which brings a Community Health Worker into the home of the patient, to ask the deeper questions about what in the person’s environment is preventing them from improving their health or managing a disease like diabetes. The “promotor(a)” is highly trained, but is not a health care provider per say, more of a lay-person and can more easily relate to people in terms of culture, language and experience.
By using motivational interviewing techniques, the promotor(a) enters the home without preconceptions, and listens to the individuals as they dig into their barriers. There is an underlying assumption that most people want to be well—want to be healthier. From this assumption, the why questions are asked and the participants begin to identify their own way to health. Sometimes the barriers seem insurmountable, and are out of the control of the either the patient, the promotor(a) or their health care provider. But many times just listening, educating, and providing access to resources and tools makes a huge difference. The following example (names of patients changed to protect privacy) illustrates the power of this approach.
Joel and Maria live with Joel’s elderly parents and their four young children in a modest two- bedroom trailer home outside of San Benito. They struggle to make ends meet on a small and inconsistent income. Maria works as a caregiver for the elderly, including Joel’s parents. She also takes on paid house cleaning work while Joel works in construction and sells produce at a stand on the side of the highway evenings and weekends. While both work very long hours, neither has health insurance through their employer, a common predicament in our community in which many people are working in contract labor positions, seasonal labor or for smaller employers who are not required to provide health benefits.
Despite economic challenges, the family is united and supportive. While very crowded, with kids and adults sleeping in the living room and on the couch, the house is clean and organized, albeit in need of some repairs. The family purchased the used trailer a few years ago and is trying to buy the land it sits on from the owner who charges them a monthly rate that he says is going toward the purchase of their home. However recently, when they were just a day late with the payment, he told them all that they had paid over the year no longer counted and they were “starting at zero” again.
Their dream is to own their own home and for their kids to get a good education and find better jobs than they have.
Maria shares, “It’s so hard to make it on what we are paid. We don’t have enough for medications for my father-in-law who is diabetic and less for me now that I have diabetes. We used to share our insulin, which I know isn’t right, but it’s all we could do. He can go to the clinic, but until this year, I hadn’t been able to get an appointment because the clinics were full. Anyhow, it’s hard for me to take time off of my jobs to see the doctor because if I don’t work, I don’t get paid that day and we really need to the money to pay the bills.”
Joel adds, “I wish I would have had the opportunity to study and get a better job that comes with benefits, but when I was growing up I had to help my parents who were farmworkers so we moved around a lot, and I didn’t finish school. I’m going to do everything I can so my kids can finish what I didn’t!”
Joel was born here in Texas, but Maria immigrated from Mexico almost 10 years ago when they were married. They haven’t been able to afford to pay an attorney or the fees required to get her immigration papers finalized.
Maria says she found out several years ago that she has diabetes, at a health fair at her children’s school.
“I was so afraid because I saw what diabetes did to my father-in-law, who is almost blind and has had part of his foot amputated. I can’t end up like that because who would take care of my kids? I’m still so young!”
She heard about a program called Salud y Vida from a neighbor who has been attending free healthy cooking classes at a local church. She went to the class offered through Salud y Vida. A Community Health Worker, or “promotora” came to her home to check her blood sugar and help her learn more about managing her diabetes. Most importantly, she connected Maria to resources for much needed medication, transportation to the clinic, and education about how to eat better, reduce her stress, exercise and monitor her blood sugar.
“I realized I was holding a lot of stress, and can even say now I was depressed. My Salud y Vida promotora connected me with a free counselor. Even just a few appointments have made me realize how much worry I carry with me every day, and how that affects my health and my diabetes. I learned some ways to cope better, like going for a walk or to the park with the kids when I can. Also, just connecting with someone who cares has helped a lot!”
Maria is doing better now, and her doctor at the clinic is pleased with her lab results.
“I really enjoyed learning from other people like me who have diabetes. The Salud y Vida social worker got me help to pay for medications so I don’t have to share with my father-in-law anymore. It’s still a struggle, but the program has given me hope.”
Salud y Vida Social Worker, Roel Perez, says that many people feel shame about their health conditions. “That doesn’t help anyone. Our health is determined by so many factors, many of which have nothing to do with will power or discipline. Sometimes poverty, abuse, immigration status, or mental health issues undermine people’s best efforts at healthy living. We try to support and motivate them with tools and resources.”
Maria concludes, “Sometimes people think you are poor or unhealthy because of something you have done. It’s not always that simple. Of course I want to be healthy, but sometimes I feel so much on my shoulders it is almost impossible to climb out. Having the promotora come to my home, listen and show compassion, inspired me to do everything possible to control this diabetes. After all, I have it for the rest of my life, so I have to take care of myself,” because Tu Salud ¡Si Cuenta! (Your Health Matters!)