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

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?

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 McClintockis 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 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.

Mahila Mandals: Case Studies from Mumbai, India

The following post was written by Sarah Simpson, MPH-Epidemiology Candidate at the University of Medicine and Dentistry New Jersey. Sarah is an IH section member who has contributed to the blog previously. The following post is about her winter internship in Mumbai, India.


ssimpson_mumbaiHome to more than 18 million people, India’s most populous city, Mumbai, continues to be an attraction for millions looking for a better life for themselves and their families. Migrants from different parts of India, religions and cultures end up in the crowded slum communities around Mumbai. This past winter I had the opportunity to learn about urban health issues in these slum communities along with 20 other students from around the US and the world for three weeks at the Tata Institute of Social Sciences (TISS) in Mumbai.

My project group and I sped around town in rickshaws, trudged through sludge, and dust to study urban health issues in the slum areas of Shivaji Nagar. Located in the M Ward and home to some of the largest slums in India, about 600,000 people live in this area, which is located near the Deonar dumping ground, a man-made mountain of debris and trash. The health of the urban poor is complicated by many issues ranging from waterborne illnesses to infectious and communicable diseases, and when compounded by inadequate nutrition and overcrowded and poorly constructed living conditions makes for a dire situation for millions of people.

During our first day, we were introduced to the “Mahila Mandals” or women’s groups there are instrumental to addressing these public health issues. Parts of Shivaji Nagar are plotted slum areas recognized by the government; however they have minimal access to facilities and services provided by the Brihanmumbai Municipal Corporation (BMC). Imagine sharing 28 bathroom stalls (14 for men, 14 for women) with 1,000 other people and as you can imagine they quickly become unsanitary. The breakdown of government services has lead to the organization of community based organizations such as Mahila Mandals.

Instead of using a needs-based or problems-focused approach which would highlight only the worst aspects of a community, we decided to highlight the community’s assets by writing a case study using SWOT (Strengths, Weakness, Opportunities and Threats) Analysis to help us investigate how to best utilize these important community assets. We interviewed 6 Mahila Mandal groups consisting of some registered and unregistered groups and varying in size and number of members. We concluded that not only do the Mahila Mandals work to solve issues with sanitation, but they also promote immunization of children, maternal and child health education and resolve domestic violence issues. However, their impact is limited mostly due to funding and support from the local community.

At the end of our study, we recommended that the government provide more funding and implement community-based participatory research programs which would allow the communities to identify, support, and mobilize existing resources to create a shared vision of change and encourage greater creativity in solving community issues. Two community organizations like these groups and community engagement are important for continued public health and social change. Further research is needed on how to best utilize these valuable community assets.

Our internship presentation can be found at: http://prezi.com/i0lbgveimbyc/copy-of-indian-urban-slums/

References:

  1. Mili, D. Migration and Healthcare Access to Healthcare Services by Migrants Settled in Shivaji Nagar Slum of Mumbai, India. TheHealth 2011; 2(3): 82-85
  2. P A Sharpe, M L Greaney, P R Lee, S W Royce. Assets-oriented community assessment. Public Health Rep. 2000 Mar-Jun; 115(2-3): 205–211.

Perspective: A Day in the Life of Another Country’s Healthcare System

I will be the first one to admit that my job teaching English to privileged Korean children at a private academy has almost nothing to do with public health. While I have maintained most of my international-health related activities (and even added some new ones since being here), my income-generating activities are not typically health-related. There are times, however – and more than I originally expected, to be sure – when my public health knowledge and training comes in handy. For example, we have a lot of debate classes, and obesity, fast food, and eating disorders are frequent topics. It can be really enriching to bring my professional training into the classroom and engage my students beyond the textbook.

And then I occasionally get responses to writing assignments like these.
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If your first instinct is that this is just a witty response from a smart-ass middle school student, think again. I got two more with the same response.

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Teacher, what?

By and large, South Korea’s healthcare system comes very highly reviewed. The government provides universal health coverage through the compulsory National Health Insurance scheme, which covers basic services – half of the premium is paid by the individual and the other half by that person’s employer. Experts and pundits love to list it as one of the examples that America’s own expensive and oh-so-broken system should aspire to be, as South Korea only spends about 7% of its GDP on health care (compared to our whopping 17%). Koreans, of course, take great pride in their healthcare system. A prime example can be found on the popular blog Ask a Korean, where the author writes about this very same topic.

Part of the reason why the Korean did not follow the [American healthcare debate] was because the entire thing was so moronic: to the Korean, it is obvious that a country should guarantee its citizens a health insurance, and the cheapest way to achieve that is a single-payer system like Korea’s. Scores of advanced and semi-advanced countries in the world manage to do this without turning their country into Russia. (Unless, of course, if their country is Russia.) There is no point in watching a debate where the other side is arguing the sky isn’t blue.

What has been strange for us to understand was not Koreans’ views on healthcare, but on accessing it. We noticed very early on that our Korean coworkers go to the hospital for everything – and by that, I mean everything. Have a stomachache? Time to go to the hospital. Sore throat? Going to the hospital. Cold? Hospital. Fever? Flu? Twitch under your eye? You get the idea. During our first few weeks, I was always very concerned to hear that someone had gone to the hospital, but now I don’t even bat an eye.

Coming from a country where healthcare is so expensive that people wait until they are at death’s door to get treated (and then, by necessity, have to go to the hospital), I found a system with the opposite problem to be somewhat fascinating. I asked one of my friends here, who is a neurologist at a local hospital, about it, and he explained some of the reasons behind this tendency:

  1. Many Koreans think that bigger is better, which means if they go to a hospital for a simple cold, they feel like they get better service than they would get from a small clinic.
  2. Also, many Koreans feel that they need to see someone who works at a reputable facility, graduated from a prestigious university, or has multiple advanced degrees to be satisfied, even for minor ailments.
  3. Third, he explained, Korea is still a hierarchical society, which means that upper-class individuals go to upscale hospitals for treatment to get the medical treatment they feel that they deserve according to your socioeconomic status.

In a system where a procedure costs the same amount no matter where you go, these reasons make sense, particularly in a culture that is as socially competitive as this one. Of course, every healthcare system has its own issues, and Korea is no exception. Because the price for a given procedure is the same everywhere and, as a result, larger hospitals have people lined up out the door to get their runny noses looked at, providers are pressured to see as many patients as possible in the shortest amount of time to minimize wait time and maximize profit. Absolutely everyone knows that this is a terrible idea, leading to stories like the one I read in the local English-language paper about a small colonoscopy clinic in Seoul that was seeing hundreds of patients per day – and not properly cleaning their instruments because they were so rushed. Also, much like the U.S., Korea is starting to see its healthcare costs rise and must come up with a way to continue to finance them, lest they become sustainable. Still, as Americans prepare themselves for the upcoming changes that the landmark healthcare reform will bring over the next few years, it is interesting to put the uproar into perspective.

Not all of the write-up books that I received were so drastic in their responses to the runny nose question. Two of my best students also gave me slightly more sensible answers.

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