Master's Project Title:

Health, Safety, and Wellness: Public Health Practice Within A Hmong Home Healthcare Agency (Executive Summary)

MCH Student:

Billy Moua

Date of Defense:

April 28, 2017



The Personal Care Assistance (PCA) program is funded through Medicaid, and aims to provide daily living and health management services to individuals who are living with a disability or elderly individuals. In Minnesota, there are about 27,000 Personal Care Attendants/Assistants (PCAs) who provide services to eligible patients (Minnesota Department of Human Services, 2015). Additionally, the major components of coordination between PCA and client (those receiving services) is mediated through private home healthcare agencies. Within the context of my experience, I worked with Harmony Home Health Services, a Hmong home healthcare agency located in St. Paul, MN. The agency operates as a “choice agency” which gives the client the ability to recruit a PCA of their choosing to provide services; oftentimes family members are designated as the personal care attendant.

Although the research literature is scarce, the current scholarship on healthcare agencies and its related services reveal that the client population report increased rates of depression, and increased risks for adverse health events (Madigan, 2007; Pickett et al., 2012; Doran et al., 2013). Furthermore, Pickett and colleague’s recent work show that racial health disparities exist within the client population (2014). Despite the dearth of home healthcare literature, the existing scholarship provides relevant insight to my experience working with Harmony Home Health Services, a Hmong home healthcare agency located in St. Paul, MN.


My experience spanned August to December 2016, and consisted of two parts: 1) working with the Harmony Home Health Services staff to broaden their understanding of public health theory and practice, and 2) conducting client home visits with agency staff to ensure worksite safety for PCAs, and also conduct a small strengths-based assessment of client health.

For the first component of my experience, I organized three sessions for office staff to introduce two important theories relevant to public health and maternal and child health, which were the fundamental cause of disease theory and the social-ecological model (Link and Phelan, 1995; McLeroy et al., 1988). I believed that these two theories/models were relevant to the work of home healthcare agencies because of the social circumstances that both PCA and clients experienced. All clients were low-income, and 48 out of 50 clients were Southeast Asian Refugees (16 identified as being Karen and 32 identified as Hmong).

For the second component of my experience, I accompanied Harmony staff to conduct home visits for the purposes of worksite safety insurance. In this position, I had to ensure transparency and cultural competency (not appear intrusive), and developed a short, semi-structured interview that consisted of two formal questions with follow-up probes. I was able to conduct 50 home visits to fulfill the needs of the safety assessment; additionally, I gained qualitative data that enabled me to perform first-cycle coding and axial coding, which ultimately produced five global themes (included below).


As described above, I worked with Harmony Home Health Services, a local, privately-owned, Hmong home healthcare agency in St. Paul, MN. The administrative staff consists of three Hmong individuals, and 50 personal care attendants (with 50 clients). Relative to other home healthcare agencies in the state, Harmony Home Health is considered a smaller agency. The agency focuses on cultivating and sustaining healthy living for diverse and underrepresented communities, in particular, they are proud in being a bastion for Hmong and Karen communities. Harmony’s mission in achieving health equity aligned with my field experience; by embedding public health theory into their practice, and by conducting a mini-assessment for their agency, they are beginning to retune their practices and policies based on this experience.


As stated above, the mini-assessment from my short, semi-structured interviews produced enough data for implementation of first cycle coding, axial coding, and theme generation.

Summary of Global Themes
Theme 1 Personal Care Assistants Fulfill Basic Needs

  • Cooking
  • Cleaning
  • Coordinating healthcare activities
Theme 2 Engaging in Outdoor Activities Support Health & Wellbeing

  • Nature as a connection to cultural background
  • Visiting the Como Zoo
Theme 3 Interacting and Maintaining Social Networks Is Essential

  • Visiting family members
  • Having phone conversations with friends
  • Attending church
Theme 4 Close Connection with PCA Bring Added Sense of Security

  • PCA’s possess foresight in providing services
  • Services are more than an occupational task
Theme 5 Clients experience feelings of guilt

  • Loss of independence
  • Role-reversal in family social structure


Lessons Learned

Working in the setting of a small, locally-owned business was a learning experience for all parties involved. In my experience, I had to reflect on my course work and critically assess what pieces of information were most relevant, and had to formulate my messaging in a way that was accessible for agency staff, PCAs, and clients. Additionally, another lesson learned from this experience was that refugee communities, especially newly arrived communities like the Karen, are in great need of resources. Unfortunately, many of these resources are non-existent (for instance, Karen-speaking nurses and clinicians).


I recommend further research be intentionally conducted on this client population, and the PCA program in general. Statistics surrounding PCA services are hard to find, and there is little to no scholarship on this topic as it relates to Minnesota. I also would voice my thoughts on expanding the view of traditional sites of public health, oftentimes public health professionals are advancing work through public sectors of society, and forget or underestimate the potential that lies within the private realm. What if we could influence private interests to advance public health causes?


Persons with disabilities or health conditions are often labeled as perpetually vulnerable, but it was refreshing to see the assets they possess. Additionally, working with a small business broadened my view on where public health exists, and gave me reason to dream even larger.


Abbott, K. M., Bettger, J. P., Hanlon, A., & Hirschman, K. B. (2012). Factors associated with health discussion network size and composition among elderly recipients of long-term services and supports. Health communication27(8), 784-793.

Doran, D. M., Hirdes, J. P., Blais, R., Baker, G. R., Poss, J. W., Li, X.,  Jantzi, M. (2013). Adverse events among Ontario home care clients associated with emergency room visit or hospitalization: a retrospective cohort study. BMC Health Services Research13, 227.

Link, B. G. and Phelan, J.C. (1995).  Social Conditions as Fundamental Causes of Disease.” Journal of Health and Social Behavior, (Extra Issue):36:80-94. 

Madigan, E. (2007). A Description of Adverse Events in Home Healthcare. Home Healthcare Nurse, 25(3), 191-197.

McLeroy, K. R., Bibeau, D., Steckler, A., & Glanz, K. (1988). An ecological perspective on health promotion programs. Health Education & Behavior, 15(4), 351-377.

Minnesota Department of Human Services. (2015) Personal Care Assistance (PCA) Services. MHCP Provider Manual. Retrieved from

Pickett, Y. R., Greenberg, R. L., Bazelais, K. N., & Bruce, M. L. (2014). Depression treatment disparities among older minority home healthcare patients. The American Journal of Geriatric Psychiatry, 22(5), 519-522.
Pickett, Y. R., Raue, P. J., & Bruce, M. L. (2012). Late-life depression in home healthcare. Aging Health, 8(3), 273+.