Category: Stories from the Field

Is Zika still a thing? My experiences as a Zika Case Manager in the field (South Florida)

by cjdor, posted in APHA IH Section, Infectious Disease, Stories from the Field

Zika was a hot topic, but now it seems like it is a thing of the past. People always ask me…”Is Zika still is a thing?” And my response is, “Of course! Just because it has declined, certainly does not mean that it isn’t still a public health threat.”

Interesting enough, comments like “Is Zika still a thing” come from physicians and various public health professionals as well as individuals living in regions with active Zika transmission. Those that express more of a concern include individuals that have planned future travel to the state of Florida and are planning to conceive, or a close family member of someone who is currently pregnant.

What is Zika?

Perhaps you never heard of Zika, or still quite aren’t sure what Zika is exactly. Zika can be described as a virus that spreads to people primarily through the bite of an infected Aedes species mosquito. It is closely related to other flaviviruses such as Zika can also be transmitted sexually from a person that has Zika to their partner as well as from a pregnant woman to her developing fetus, which can result in serious birth defects. Want to learn more about Zika? Check out some other IH section blog posts about Zika here.

My role, criteria for testing, testing/funding limitations

I was hired as one of two Zika Case Managers within my local county health department through funding allocated to the state of Florida by the CDC. One of my duties is to coordinate the testing of suspected local, or travel cases, pregnant women, and any infant born to a potentially exposed pregnant woman. The testing criteria for pregnant women include those who traveled to a Zika-active transmission area, had sexual exposure during pregnancy, or 8 weeks prior regardless of the mother’s testing status, as well as those with any abnormal ultrasound results. Testing is also recommended if the mother was not previously tested. Just like other reportable infectious diseases, it takes effective communication between health professionals at all levels to get quality information across regarding Zika. In order to get the job done, we collaborate with infection control practitioners of local hospitals, nurses, physicians, and other public health clinicians to get samples of babies collected at birth for Zika testing while also making sure that a head ultrasound and hearing test are performed on the baby. This is very important because once the baby leaves the hospital it is almost impossible to get samples collected. A majority of the pediatric clinics don’t have the means to ship the specimens to the state laboratories. Some of the general responses we have received from these clinics include not knowing how to properly prepare the specimens for shipping, having the money to do so, and lack of knowledge about billing the patient’s insurance for the procedure. Although the county health department has the access and ability to ship specimens, it would be a liability for us to ship the specimens if another facility collected the samples.

As of March 2017, the department of health has conducted Zika virus testing for more than 13,020 people statewide. At Governor Scott’s direction, all county health departments were mandated to offer a free Zika risk assessment and testing to pregnant women. Unfortunately, due to a decline in cases, and federal funding allocated to state programs winding down, free testing is no longer accessible to the community, and is only provided on a case by case basis. Zika tests can be pretty expensive ranging anywhere from $200 – $400 when conducted at a commercial laboratory and even more in some cases.

State laboratories have just about depleted federal funds received for testing initiatives. If a patient does not meet testing criteria at our department of health, we recommend testing through affiliated commercial laboratories. In addition to the many changes in testing criteria including requiring patients to show proof of insurance, there has been issues with the insurance companies and patients’ have been incorrectly billed over $1000 for their Zika tests when in fact the test was free. This has been a big issue with tests conducted as far back as November and December which we have recently been made aware of. Mosquito control services specifically for Zika efforts provided by our county health department’s Environmental Health program has ended.

Management of Infants with confirmed, or possible Zika Infection

Currently, we have reached the stage where the pregnant women that are case managed have already given birth. We are now tasked with conducting 24 month active follow-ups of all infants exposed to a positive mother via in utero. We conduct follow-up of the infants exposed regardless of whether the infant tested negative, or positive. These infant follow-ups occur at 2, 6, 12, 18, and 24 months. This is because abnormalities can still occur during child development. A majority of our babies being followed are currently between the 12 and 18 month mark.

Out of all the babies we have tested, and are currently following, only one is confirmed to be microcephalic. Looking into the future, at the 18 month follow-up mark, the infants being followed will have to be re-tested in order to confirm if the antibodies are indeed negative or positive. Another complication with testing these babies will be whether the baby has traveled since it has been born. There is a possibility that the baby could have been infected during travel and not in utero. As of July 31st 2018, Zika contracts for our county health department will end and it is unsure who will take on the responsibility for maintaining the case management of these families.

Community Outreach

Best practices we have utilized as a county has been community outreach which we collaborate across the division of communicable diseases. I have been able to work closely with a CDC field assigned Zika Community outreach nurse to assemble and distribute Zika prevention and testing kits with a specific focus on obstetrician-gynecologist and pediatricians. We have been able to identify the gaps in testing and communication among our health department and local hospitals, clinics, and private physician offices. Additional community outreach activities of focus include visiting women, infant, and children (WIC) clinics throughout the county in order to conduct health education on Zika as well as community health fairs primarily within the Haitian population due to Haiti being one of the top countries which we get the most amount of travel related cases. Unfortunately, these outreach efforts will also end at the end of this summer due to the depletion of funds, and our CDC field assigned nurse’s contract ending.

Where we are now

As of right now, Florida still does not have any identified areas with ongoing, active Zika transmission. Florida is a hotspot for vacationers, especially the counties of Miami-Dade and Broward. Since the local transmission of Zika in 2016 in both counties, it seems that very few individuals consider Zika as being a major concern. Very few physicians’ are screening for Zika. Some still aren’t sure what it is exactly, and how it can affect an unborn fetus. Congenital Zika infection is still a global health threat to pregnant women and their infants. Zika is still a fairly new infectious disease, and we are learning as we go, especially the risks after pregnancy. The reality is that Zika is here to stay. Funding for zika prevention and treatment should be a top priority in order to aid in the health and wellbeing of children and families across the United States.

Achieving health equity in global health through workforce diversity

by Jean Armas, posted in APHA IH Section, Careers, Health Equity, Human Rights, Maternal and Child Health, MDGs / SDGs, Policy and Advocacy, Stories from the Field, Women's Health

This International Women’s Day we honor the achievements of women leaders working to advance the health and well-being of people all over the world. Their path to success was certainly not easy. It was fraught with numerous challenges; challenges that are not only experienced by those of us working in global health but by women across all industries.

We are considered either too soft and feminine or too bossy and pushy to be seen as competent leaders. Our work culture lacks family-oriented, work-life balance policies which enable us to contribute to our field in significant ways. We lack female mentors to encourage us to grow and push us to overcome any obstacles we encounter in our career. We work for organizations where the people who make the big decisions on what policies and programmatic areas to focus on are men. The struggles we face trying to advance in our careers are reflected in the lack of gender equality in the global health workforce. While women make up 70% of the global health workforce, only 25% of leadership positions in global health are held by women.

We have known for a long time that when women are given equal opportunities for leadership at all levels of decision-making in economic, political, and public life, everyone in society does better. Female leaders in health “promote access to contraceptives, empowerment programs for girls, women’s rights to family planning and maternity care, safe abortions, and protecting environmental assaults on children’s health.” In addition, women leaders at all levels of governance have shown to be the primary driver toward financing public goods such as health, education, hospitals, clean water, and sanitation. Women’s participation and leadership in economic, political, and public life is so critical to advancing societies that it is even written into one of the sustainable development goals. When women have a voice at all levels of decision-making, we are closer to eliminating the inequities that lead to disparities in health.

More global health organizations are recognizing the need for women leaders and organizations such as Women in Global Health are working toward achieving gender equality in global health leadership. Last year the World Health Organization’s newest Director-General, Dr Tedros Adhanom, appointed eight women to senior leadership, effectively outnumbering the men. In doing so, he took one big leap toward achieving gender equity at the WHO – a goal that was first set in 1997 and that took two decades to realize.

Gender equality is not the only type of diversity we need to strive toward in our global health leadership however. Diversity in global health leadership must also focus on inclusion of people from different ages, race and ethnicity, sexual orientation, social class, geography, religion, and other characteristics of personal identity.  As a woman and a first-generation Filipino-American working in global health in the United States, I often find myself at global health and public health conferences and meetings wondering why there are very few leaders that encompass the diversity that I represent on stage (and occasionally even in the audience). The people who make the decisions with the biggest impact in global health must reflect the diversity of the people we serve.  

Learning from, understanding, and seeing the world through another person’s point of view is at the heart of working in global health and a driving reason for why I chose to work in this field. In order to truly reflect the diversity of this field though, the definition of diversity itself needs to go far and beyond the characteristics of one’s personal identity. To fully be inclusive, we must also be open to learning from, understanding, and seeing the world through the perspectives of individuals in the global health workforce with diverse backgrounds, life experiences, and competencies. Our field could benefit from the ideas of diverse individuals in solving some of the world’s most pressing global health problems. These ideas cannot always come out of our own echo chambers. 

Achieving diversity in the global health workforce is everyone’s job. It requires each one of us to recognize and overcome the personal biases (whether they are subconscious or not) which prevent us from hiring and working with more diverse talent. For those of us responsible for making decisions, we must work to create policies at all levels which not only promote but require inclusion. It’s only then that we can achieve true diversity in our workforce and our leadership. It’s only then that we can progress further in achieving health equity.

Stay tuned for part two of my series on Achieving health equity in global health through workforce diversity in which I will discuss different ideas for how we can achieve diversity in the global health workforce.

IHSC career development webinar recording “En Route from the Ebola Tent to Congress” now available

by ihsection, posted in APHA IH Section, Careers, Events and Webinars, Policy and Advocacy, Section Announcements, Stories from the Field

The APHA International Health Student Committee hosted a webinar called “En Route from the Ebola Tent to Congress” on September 27, 2017 with Deborah Wilson, RN and MPH candidate at Johns Hopkins Bloomberg School of Public Health. Debbie led an interactive webinar walking attendees through a day in the life of an Ebola Treatment Center, including a bit about the political fallout upon returning to the USA, and how her experiences shifted her from direct patient care to public health policy.

If you have any questions, please email: apha.ihsc.careers@gmail.com

Health Literacy: Is Educational Attainment Enough?

by ihsection, posted in APHA IH Section, Guest Blog, Stories from the Field

This is a guest blog post by Dr. Heather F. de Vries McClintock PhD MSPH MSW, IH Section Member and Assistant Professor in the Department of Public Health, College of Health Sciences at Arcadia University. It is the second blog  in a three-part series the IH Blog will feature this summer, Global Health Literacy: Conceptual Basis, Measurement and Implications.

Part II: Health Literacy: Is Educational Attainment Enough?

For over a decade I worked in primary care practices providing health education to patients with a broad range of educational and professional backgrounds, from persons who had dropped out of high school to those with dual doctoral degrees. I recall that when I first started I assumed that persons with higher levels of educational attainment would more readily understand and incorporate health education into their daily lives. I soon realized that I was entirely wrong. While persons who had higher levels of education were somewhat more likely to comprehend health information, a large proportion of these persons were unable to adequately understand and act on the health information presented to them. I remember sitting with a patient who had a doctoral degree who explained to me how his depression medication worked best when taken only on Sundays. Conversely, one patient who had not completed high school explained to me the intricacies of high blood pressure management with such clarity that it would have rivaled any veteran educator’s attempts at explaining it. All of these experiences fostered my interest in this concept of health literacy. What was health literacy? How could we adequately measure and improve it? What caused poor health literacy? Was it poor communication, a lack of numeracy skills, cultural barriers or other factors? The complexity of these questions fascinated me and I have pondered them over the last several years in my research.

In recapping my exploration let’s start by discussing how health literacy was initially distinguished from educational attainment. Much evidence has demonstrated that social factors occurring outside of the clinical encounter, namely education and income, profoundly influence health outcomes. Health disparities based on population (e.g. age, race, class, disability) or geographic residence (e.g. neighborhood, urban, country) are significant and have been the subject of much investigation. While a myriad of indicators have been explored in relation to such disparities, many investigations report that educational attainment is the most influential predictor of health. This relationship has been substantiated in a wide range of settings and time periods as well as by the application of varying methodological approaches and indicators of health. Educational attainment improves health through mechanisms on the individual level (e.g., health literacy and skill development); community level (e.g., location of residence characteristics); and macro level (e.g., policies, legislation, infrastructure).

The term health literacy (HL) was introduced and differentiated from educational attainment or literacy beginning in the 1970’s. During this time it was found that while one’s HL level was related to educational attainment (years of schooling) or reading ability/literacy, there was not a perfect linear correlation between educational attainment/literacy and HL. Research showed that individuals who functioned successfully at home or work often lacked adequate literacy to function within the context of a health care system. While varying opinions on the definition of HL have existed over time and are the subject of ongoing debate, generally speaking, being health literate meant that one could read, understand, and act on health information that was provided to them. HL encompassed proficiency in more than just reading ability but also writing, speaking, and listening as well as computational abilities (numeracy). A health literate individual was able to understand health information and use that health information appropriately. For example, a health literate elderly adult who received instructions from a primary physician on how to take medication for blood pressure would both understand the instructions and then take the medication as instructed by the physician. Thus, those with low HL were unable to adequately function within the healthcare environment increasing their risk for poor outcomes.

Some recent initiatives have sought to document stories related to health literacy. To this end, the U.S. federal government hosted an initiative called ‘Stories from the field’ as a part of a program to reduce the burden of low HL. In one story a doctor in Wisconsin struggled with his patients’ lack of comprehension of his instructions during medical encounters. He pondered whether it was poor communication on his part or whether there were other causes. After research and reflection he identified low HL as a prominent underlying cause and founded a small statewide literacy organization aimed at improving low HL called Wisconsin Literacy.

In order to address what has been called a “Health Literacy Epidemic,” both governmental and non-governmental initiatives have been developed to improve HL and in turn, reduce it’s public health burden. A transdisciplinary approach has been encouraged and specific guidelines have been established to foster improved communication. The U.S. Department of Health and Human Services (HHS) developed a National Action Plan to Improve Health Literacy. Broad goals and strategies of this plan are to improve HL in every sector and organization that provides health information and services. With the aim of fostering effective communication the federal government created The Plain Language.gov which is an internet clearinghouse of information pertaining to the use of clear and understandable language. This initiative defines plain language as “… communication your audience can understand the first time they read or hear it. Language that is plain to one set of readers may not be plain to others.” The Plain Language Action and Information Network (PLAIN), a group of federal employees from many different agencies and specialties who support the use of clear communication in government writing, work to manage the initiative’s website. The Partnership for Clear Communication was established to spread awareness and address the issue of low HL. It established the “Ask me 3” program which informs healthcare consumers of 3 questions that should be asked during a medical encounter: (1)“What is my main problem?” (2) “What do I need to do?” (3) “Why is it important for me to do this?”  The Health Literacy Tool Shed, is a database created and administered by Boston University and the National Library of Medicine to foster collaboration and resource-sharing related to health literacy. The online search engine includes 129 tools related to the assessment of health literacy which range in terms of their purpose and design. They are either general in scope or focus on a certain domain(s) within the construct of health literacy (e.g. numeracy). Many of these tools aim to assess HL related to a specific medical condition (e.g. arthritis or cancer), categorization of health (e.g. oral health) or population (e.g. Dutch, Japanese).  Some tools were developed for rapid assessment.

For the global examination of HL the Institute of Medicine Roundtable on Health Literacy was convened to bring together leaders in the global health field to discuss activities and progress around the world related to HL. The United Nations as well as over a dozen countries were present at this meeting. The roundtable discussed different country’s unique approach to addressing low HL. For example, in Australia HL initiatives are part of the national Commission on Safety and Quality in Health Care. Canada connects HL with health promotion activities and the public health sector governs HL initiatives. A consensus from the meeting was that educational systems do not provide their students with the skills to adequately use health information and access health services. Furthermore, participants agreed that there was a lack of capacity for health care services to meet the needs of persons with low HL. This was accompanied by a lack of data on the nature and scope of the problem of low HL as well as the effectiveness of interventions targeting HL. This issue was particularly pronounced in LICs and LMICs, in which very little research had examined HL in any form.

Given the lack of evaluation of HL in LICs and LMICs there is an urgent need to develop a measure HL that can be feasibly employed. Establishing a measure that can assess the burden of low HL as well assess it’s relation to health outcomes is important so that effective interventions can be developed and deployed. Please stay tuned for Part III: The Evaluation and Measurement of Health Literacy in which I discuss my research group’s work in creating and establishing a measure of HL for use in LICs and LMICs.

McClintock.Picture

Dr. Heather F. de Vries McClintock, is currently Assistant Professor of Public Health at the College of Health Sciences at Arcadia University. Her research broadly focuses on the prevention, treatment, and management of chronic disease and disability globally. Recent research aims to understand and improve health literacy and the quality of care provision for persons in Sub-Saharan Africa.

Innovative Malaria Research in Southeast Asia: a UCI GHREAT Initiative (Video Review)

by ihsection, posted in Information and Social Media, Research, Stories from the Field

by Niniola Soleye

The University of California, Irvine (UC Irvine) recently released the first video in their four-part series showcasing the success of their Global Health Research, Education and Translation (GHREAT) Initiative. The initiative is headed by IH section member Dr. Brandon Brown. The goal of the video series is to demonstrate how GHREAT projects are enhancing health and saving lives all over the world. This first video was shot in Thailand and focuses on malaria research in Southeast Asia.

Myanmar has the largest number of malaria cases in Asia. Due to the poor economic conditions in the country, people immigrate to neighboring countries, including Thailand, to look for employment opportunities. Additionally, there has been an increase in drug-resistant malaria and an influx of counterfeit drugs. That, coupled with poverty and people not having funds to travel to the hospital or buy medicine, has resulted in malaria becoming a major public health problem in the region.

UC Irvine faculty, staff, and students partnered with the ministry of health, hospital workers, local health workers, and academic researchers in China, Myanmar, and Thailand to study malaria control in the border regions, and develop solutions for containing the malaria outbreak.

The video shows the UC Irvine team observing local health workers as they perform diagnostic blood-tests for malaria in Thai villages. Their observations led them to focus their efforts for this project on developing an innovative, non-invasive diagnostic test using saliva instead of blood.

Untreated, malaria can lead to death two to three weeks after infection, so early diagnosis and treatment are key. Blood testing requires workers to send samples away daily, delaying the start of treatment. Using saliva would allow for a fast, portable, low-cost diagnostic tool, all critical factors in a developing country setting.

One scene that stood out showed a young child getting tested for malaria. She was crying because she didn’t want to get her finger pricked, and also because she was afraid of the health worker. In situations like that, the new test would be quite beneficial.

Overall, the video does a good job of emphasizing how direct, firsthand experiences and observations are important when trying to innovate and solve problems in global health. I would have liked to hear more about the technique behind the saliva test, their border control efforts, how they plan to deal with the counterfeit drug problem, and how they’ll address drug-resistant malaria but the video doesn’t go into detail on those topics.

Click here to watch the video.