Using a Community Champion to Address Rural Health

Over the past few months, I have spent a lot of time traveling and focusing on rural health, including barriers to healthy living and strategies to bridge clinical-community partnerships. Through my travels, I am reminded of the vastness of a state such as South Dakota and how truly rural much America is. Recent findings from the 2012-2016 American Community Survey report that rural areas cover 97 percent of the United States (US), but only 19.11 percent of the US population lives in them. Population shifts since 2010 from rural to urban areas have shed light on the changing landscape. Urban and rural areas are both affected by disease associated with social, environmental, and economic specific those areas, however rural America is disproportionately affected by health disparities when compared to urban areas.

Rural America suffers from higher rates of a chronic disease, mortality and lower life expectancies (Rural Health Information Hub, 2012-2018).  Recent findings from Garcia, Faul and Massetti (2017) found that rural America is “more likely to die from five leading causes, including heart disease, stroke, chronic lower respiratory disease, cancer, and unintentional injury, than their urban counterparts, highlighting a critical gap between rural and urban Americans”.  Much of the gap of health outcomes in rural areas compared to urban areas is associated with socio-economic and environmental factors specific to rural areas, including low or no access to health care services, healthy foods, or physical activity opportunities, geographic isolation, limited job opportunities, and poverty.  As the saying goes, backed by research, “zip code is a stronger predictor of health than genetics”.  This mean social, economic, and environmental factors where a person lives, work, learns and play defines health outcomes.

While the reality of rural health may now sound dim, the reality is that rural communities across America are addressing and improving the health of their communities to reduce these health disparities. Funding agencies are taking notice of the health needs in rural America and that efforts at the local level are one of the keys to positively move the needle on health outcomes.  

So just who is “they”? They include residents, albeit coalitions, decision makers, or individuals affected by disease, committed and passionate about ensuring their community is healthy. One of those residents that can advocate for change and health improvement, is a community champion.  A community champion can be a public official, community leaders, concerned citizen or a volunteer, and who is committed to leading the charge in addressing the health of their community (Center for Community Health and Development, 2018).  The notion is that a community champion lives in and understands the community and has established relationships with key stakeholders in the community who are integral to addressing those social, economic and environmental factors that affect rural health outcomes.  Imagine where you live and an outsider who does not know your community wants to come in and improve access to healthy foods, not knowing the community, any historical challenges with community collaboration, and who the residents are. While the outsider will eventually gain an understanding the community, identifying a community champion to help lead these efforts will increase likelihood of success.

Communities across the US have had success in addressing these factors with the support of a community champion. For example, South Dakota State University Extension has worked with rural South Dakota communities with high obesity rates to identify community champions to help lead efforts to address access to physical activity opportunities and healthy foods through evidence-based approaches focused on improving health behaviors and reducing death and disease. These community champions live in those communities and have the ear of key stakeholders and residents important to support local needs assessment and implementation of evidence-base approaches to address priority health issues.

So, if you live or work in a rural community and want to move the needle on health outcomes, find a community champion who can advocate for change.

References

Center for Community Health and Development, University of Kansas. (2012-2018). The Community Tool Box. Retrieved from https://ctb.ku.edu/en

Garcia MC, Faul M, Massetti G, et al. Reducing Potentially Excess Deaths from the. MMWR Surveill Summ 2017;66(No. SS-2):1–7. DOI: http://dx.doi.org/10.15585/mmwr.ss6602a1.

Health Resources and Services Administration. (2002-2018). Rural Health Information Hub. Retrieved from https://www.ruralhealthinfo.org/

Improving Maternal-Fetal Outcomes Begins with Community

 Lisa Groon, Founder Ovo Birth Center

Lisa Groon, Founder Ovo Birth Center

There were 3.978 million births in the United States in 2015. When compared with all other developed countries, the United States has the worst maternal mortality rates. The worst. Why? Because on the most basic level, we just aren’t listening to mothers. And when we don’t trust women and the physiology of birth, we see unusually high inductions and cesareans and women experience excessive medical interventions like episiotomies, and ultimately, we see higher mortality rates. Our society is no longer talking about normal, physiologic birth, and it’s resulting in dire consequences for moms and babies. Not only do families deserve a model of care that honors the whole family, but they deserve a community, because research has told us time and time again that the health in moms and babies lies in the presence of a supportive community. When families have seamless access to health care providers, resources, and most importantly, a diverse group of people who can offer a comprehensive array of options, lessons, and wisdom, they are more educated and involved in their care.

In a small study with a Northern Plains American Indian tribe, the researchers described how a community-based approach that includes elder women, fathers, midwives, and other important individuals not only increases utilization of care during pregnancy but also empowers women before, during, and after pregnancy. They also specifically requested to have midwives provide their care. Separately, a large study in India showed that implementation of community-based interventions led to reduction in neonatal mortality, increased rates of early breastfeeding, and ultimately, significant decreases in neonatal and maternal morbidity. In the 2011 Surgeon General’s Call to Action to Support Breastfeeding, societal factors including lack of knowledge, social norms, poor family and social support, embarrassment, among others were cited as having a significant impact on low breastfeeding initiation and duration rates in the US.

An approach by a midwife in Florida called the JJ Way utilizes four core tenants to address maternal health outcomes in her clinic; Access, Connection, Education, and Empowerment. Her model demonstrates consistently better health outcomes compared to the national average and she does this first by ensuring that all women who seek care, receive care and then her team invites them into a supportive community which offers kinship, wisdom, and empowerment. As her team has shown, community-based care is an important component of providing a continuum of care for low-resource communities.

It has been proven time and time again that the solution to improving maternal outcomes starts with community. It starts with making midwives available to Native American women and Centering Pregnancy programs to women in urban communities so that women can experience more favorable birth, neonatal, and reproductive outcomes. It starts with bringing back a village of families where we know our neighbors and deliver meals to new moms, breastfeed in public, and watch the other kids at the park without question.  We know that organized social services and programmatic medical care works to improve mortality rates and we can continue to improving these outcomes through collaborative systems approach, involving providers, friends, family, and neighbors. It truly does take a village to raise a child.

References

1.      Martin JA, Hamilton BE, Osterman MJK. (2016, September). Births in the United States, 2015. NCHS data brief, no 258. National Center for Health Statistics.

2.      Andrea T. Roche, MS, RD, Kimberly B. Owen, MS, Teresa T. Fung, ScD, RD. (2015). Opinions Toward Breastfeeding in Public and Appropriate Duration, ICAN: Infant, Child, & Adolescent Nutrition, Volume: 7 issue: 1, page(s): 44-53.

3.      Ickovics JR, Earnshaw V Lewis JB Kershaw TS, Magriples U, Stasko E, Rising SS, Cassells A, Cunningham S, Bernstein P, Tobin JN. (2016). Cluster Randomized Controlled Trial of Group Prenatal Care: Perinatal Outcomes Among Adolescents in New York City Health Centers, 2016. American Journal of Public Health. 106(2):359-65. doi: 10.2105/AJPH.2015.302960.

4.      New York Times (2018, February 4). Making Pregnancy Safer for Women of Color. Retrieved from https://www.nytimes.com/2018/02/14/opinion/pregnancy-safer-women-color.html

5.      Lassi ZS, Kumar R, Bhutta ZA. Community-Based Care to Improve Maternal, Newborn, and Child Health. In: Black RE, Laxminarayan R, Temmerman M, et al., editors. Reproductive, Maternal, Newborn, and Child Health: Disease Control Priorities, Third Edition (Volume 2). Washington (DC):

6.      The International Bank for Reconstruction and Development / The World Bank (2016 April 5). Chapter 14. Available from: https://www.ncbi.nlm.nih.gov/books/NBK361898/  

Sinha, B,  Chowdhury, R., Sankar, M.J., Martines, J.R., Taneja, S., Mazumder, S., Rollins, N, Bahl, R., & Bhandari, N. (2015, July 16). Interventions to improve breastfeeding outcomes: a systematic review and meta‐analysis, 2015. Acta Piadatrica. https://doi.org/10.1111/apa.13127

Addressing Antibiotic Resistance through Local Partnerships in Rochester, New York

  Christina Felsen              Co-Manager, Emerging Infections Program University of Rochester Medical Center, Center for Community Health and Prevention

Christina Felsen            Co-Manager, Emerging Infections ProgramUniversity of Rochester Medical Center, Center for Community Health and Prevention

Antibiotics provide life-saving treatment; however, approximately 30% of the antibiotic courses given in the US each year are considered inappropriate, commonly prescribed for viral infections such as the common cold.  Consequences of antibiotic misuse include allergic reactions; C. difficile, a serious and potentially life-threatening diarrheal illness; and increased antibiotic resistance.  There are limited treatment options for those infected with an antibiotic resistant organism, often leading to prolonged hospital stays, increased medical costs and sometimes death.  In some parts of the world, infections with organisms that are resistant to almost all current antibiotics including last-line carbapenems are widespread. Given the ease of global travel and the absence of new antibiotics in the pipeline, antibiotic resistance has become a global public health threat.  

The National Action Plan for Combating Antibiotic-Resistant Bacteria (CARB) strives to slow the emergence of resistant bacteria and prevent spread of resistant infections though more judicious antibiotic use. One method of doing this is for healthcare settings to implement antibiotic stewardship programs (ASP); a set of actions, policies and guidelines that ensure antibiotics are only used when needed and that when they are prescribed, the right drug is given at the right dose and for the right duration.  The Centers for Disease Control and Prevention has established Core Elements for ASP that guides inpatient and outpatient healthcare facilities on establishing ASP through implementation of 5-6 domains based on the setting that include drug expertise, education, and antibiotic data tracking and feedback.  Currently, hospitals and nursing homes have been mandated by the federal government to establish ASP.  This is especially challenging in nursing homes which are often understaffed and lack infectious disease and pharmacy expertise, as well as technological aids such as electronic medical records. 

One way to overcome these barriers is for nursing homes to form partnerships with health departments, academic centers, hospitals, etc.  For example, the Rochester Nursing Home Collaborative has partnered with several, local nursing homes to provide hospital-based infectious diseases, pharmacy, infection control, and data management expertise to nursing homes.  Together, we have created city-wide guidelines and education for testing and treatment of common infectious syndromes that often lead to antibiotic overuse in the elderly, such as urinary tract infections.  This partnership benefits not only the nursing home, but the hospital also, as elderly patients often go back and forth between the two healthcare settings.  In the future, partnerships like this will be vital for helping resource-strapped healthcare institutions establish ASP and contribute to stopping the spread of antibiotic resistant infections.  For more information, please visit www.rochesterpatientsafety.com.

Using Evidence to Move the Needle on Health Outcomes

Take a moment to consider the community where you live, work, learn, and play. What issues are affecting the health of your community? Obesity? Tobacco Use? Access to health care services? Access to healthy foods?

What if you know what issues affect the health of your community, but are not sure how to address those issues and understand how they affect all residents in your community? 

Let’s consider rural America. Evidence has shown that the health of populations in these communities are disproportionally affected by health outcomes when compared to urban communities.  Disparities in these communities are exacerbated by social, economic, and environmental factors, including poverty, limited employment opportunities, poor housing, or geographical isolation. So how might public health issues, such as obesity or access to healthy foods, be addressed in rural communities? What works in one setting may not work for others.

Decisions on how to address public health issues, albeit in a rural community, workplace, or otherwise, are often guided by various factors, including literature, funding, policy makers, or even the media. At times, these decisions may be made void of the evidence available, thus program and policies may fail if an ineffective intervention approach is utilized, inadequate evaluation methods are used to understand issues that affect all residents in a community, or poor adaptation of an intervention to a population.

Cue in Evidence-Based Public Health.  Advances in research over the past twenty years in approaches to population health and evidence-based public health practice have been informed by researchers, field experts, and practitioners to effectively…move the needle on health outcomes. So what is evidence-based public health? It is defined as “the development, implementation, and evaluation of effective programs and policies in public health through application of principles of scientific reasoning. The process involves integrating science-based interventions with community preferences to improve the health of populations.”[1]

Evidence can be acquired in different forms, from objective evidence available in scientific literature in systematic reviews, to program data, or from subjective evidence from worth of mouth or personal experiences. Regardless if evidence is gathered from objective or subjective sources, it is still evidence.

Why does it Matter?  Using an evidence-based approach to public health practice is essential to effectively impact health outcomes…essentially increase the likelihood to move the needle to achieve impact. Funding opportunities and accrediting bodies are also requiring public health agencies to integrate evidence into public health practice. Evidence can be used to inform strategic planning, grant writing and even working with partners and stakeholders to tell a story.

Specifically, evidence-based data has made notable differences in terms of policy, funding, or programmatic decisions that affect public health on various topics, from obesity to nutrition to healthy equity.[2]  For example, evidence-based reviews identified in The Community Guide recommend to address childhood obesity includes, “meal interventions and fruit and vegetable snack interventions, including school meal policies and fresh fruit and vegetable programs, to increase the availability of healthier foods and beverages provided by schools.”[3]

Strategies to integrate evidence-based decision making into public health practice can be guided by the Evidence-Based Public Health Framework, developed by leading public health researchers and practitioners.[4] The Framework helps public health professionals to “engage the community in assessment, use data systematically, make decision based on evidence, apply program planning framework, conduct sound evaluation and disseminate what is learned.”[5]

In my time as a public health professional, the amount of resources and tools available to support evidence-based public health practice has grown exponentially and continues to do so. Resources such as The Community Guide, What Works for Health available from the County Health Rankings, U.S. Preventive Services Task Force, or the Campbell Collaboration are examples of sources of quality, systematic reviews to guide evidence-base practice.

In addition, universities, prevention research centers, and leading public health agencies have resources and tools available to support training and education specific to evidence-based public health practice, including the Prevention Research Center in St. Louis, Rocky Mountain Public Health Training Center, University of Washington Health Sciences Library, Partners in Information Access for the Public Health Workforce and the Public Health Information & Data Tutorial. Local and state public health agencies are also implementing evidence-based public health practice and have resources available specific to their community or state.  

So, as you work to address the health of a community, remember that the wheel does not have to be reinvented.  Use what works to effectively practice evidence-based public health and move the needle on health outcomes.

References

[1] Brownson RC, Baker EA, Leet T, Gillespie KN, eds. Evidence-based public health. New York: Oxford University Press; 2003. Public Health and Information Tutorial. http://phpartners.org/tutorial/04-ebph/2- keyConcepts/4.2.2.html. Accessed December 2, 2008.

[2] Secretary’s Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2020. (2010, July 26). Evidence-Based Clinical and Public Health: Generating and Applying the Evidence. Retrieved from https://www.healthypeople.gov/2010/hp2020/advisory/pdfs/EvidenceBasedClinicalPH2010.pdf

[3] Guide to Community Preventive Services. Obesity: Meal and Fruit and Vegetable Snack Interventions to Increase Healthier Foods and Beverages Provided by Schools. https://www.thecommunityguide.org/findings/obesity-meal-fruit-vegetable-snack-interventions-increase-healthier-foods-beverages-schools. Page last updated: November 17, 2017. Page accessed: March 27, 2018

[4] Brownson RC, Fielding JE, Maylahn CM. Evidence-based public health: a fundamental concept for public health practice. Annu. Rev. Public Health. 2009;30175–201.

[5] Prevention Research Center in St. Louis. (2016, March 15-18). Evidence-Based Public Health: A course in chronic disease prevention. Proceeding from St. Louis, MO.

Tobacco 21: A Strategy to Protect Young Hearts in South Dakota

  Guest Author: Megan Myers,  Government Relations Director, South Dakota American Heart Association, Midwest Affiliate

Guest Author: Megan Myers, Government Relations Director, South Dakota American Heart Association, Midwest Affiliate

Heart disease is the No. 1 killer of South Dakotans, with more than 1,800 deaths annually. And since tobacco use is the No. 1 risk factor for developing heart disease in young men and women, the American Heart Association is supportive of a variety of policies to keep our youth from getting hooked on tobacco such as Tobacco 21.

By breaking the supply chain of how kids under 18 get tobacco products, raising the sales age for tobacco products from 18 to 21 could make a big difference in keeping kids from getting hooked for life and developing the chronic diseases that come along with long-term tobacco use. Ninety percent of people who buy tobacco for minors are between ages 18–20.

People who have not used tobacco by age 21 are unlikely to ever start. A policy to increase the tobacco sales age to 21 works gradually over time to reduce the rate of when people start to use tobacco and the prevalence of tobacco use. Reductions will be small initially and will grow over time, and as a result, there will be little short-term effect on tobacco sales revenue.

If every state raised the age to 21, we could reduce the nationwide smoking rate by about 12 percent and smoking-related deaths by 10 percent. That translates into 223,000 fewer premature deaths, 50,000 fewer deaths from lung cancer, and 4.2 million fewer years of life lost. Each year in South Dakota alone, we spend $373 million in health care expenditures and another $282.5 million in lost productivity related to tobacco use.

We are coming at this from a perspective of health and prevention – when we know better, we do better. It wasn’t that long ago that the U.S. military put packs of cigarettes in C-rations. Now thousands of our veterans suffer from tobacco-related illnesses such as heart disease, cancer, COPD and more.

Simply put - tobacco use is not a rite of passage or a sign of adulthood. It is a gateway to a lifetime of addiction to the only legally available over-the-counter product in the United States that, when "used as directed," can kill you and often those around you.

Five states and nearly 300 municipalities have Tobacco 21 in place. South Dakota has the opportunity to be a nationwide leader on this policy that will save thousands of lives and millions of dollars.

Unfortunately, our state legislature recently defeated a bill that would have made Tobacco 21 law, but this is a long-term strategy and our work continues. For more information and to get involved with our coalition of partners working to enact tobacco prevention and control policy, check out our American Heart Association South Dakota Facebook page or contact me at megan.myers@heart.org.

Health in All Policies – An Approach to Improve the Health of Communities and People

“The core value of public health remains its commitment to the health of populations.”[i] Health care costs are rising and chronic diseases continue to be the leading cause of death and disease, however, much of this burden is preventable. Research has evolved to identify that health outcomes are the products of multiple and overlapping determinants of health, including biological, social and environmental determinants. So how are those determinants addressed to improve health outcomes? Policy, systems, and environment change or PSE change as it’s known in the public health world, has shown to be an effective and necessary strategy to improve the health of all sectors in a community, including worksite, schools, and healthcare.

So what exactly is PSE change?  While personal choice drives whether or not an individual engages in healthy behaviors, being healthy is not just about individual choice.  PSE focuses on making the healthy choice the easy choice and is structured around “modifying the environment to make healthy choices practical and available to all community members. By changing laws and shaping physical landscapes, a big impact can be made with little time and resources. By changing policies, systems and/or environments, communities can help tackle health issues like obesity, diabetes, cancer and other chronic diseases.”[ii] Smoke-free tobacco policies, school nutrition programs, or healthy community design just some examples of PSE change approaches.

Policy change is an important component of PSE change that is becoming integral to improve population health, which are “interventions that create or amend laws, ordinances, resolutions, mandates, regulations, or rules.”[iii] Health in All Policies (HiAP) is a collaborative approach that “integrates health considerations into policymaking across sectors to improve the health of all communities and people.”[iv] This approach takes into account factors outside the health system and is strategy that can address the complex factors that influence health and equity, such as worksite environments, transportation options, or neighborhood safety. In addition, a HiAP approach ensures that decision-makers are informed about the healthy, equity, and sustainability consequences of various policy options during the policy development process.”[v]

Emerging trends in public health recognize the need to educate and prepare professionals in health and other fields to understand how their professional activities impact population health, including an understanding of systems thinking and health-across-all policies.[vi] In order to truly address the complex factors that affect health, innovative solutions, such as HiAP, a new policy paradigm, and structures that break down the siloed nature of government to advance collaboration.

Consider where you live, work, learn, and play…what policies are or are not in place that support or hinder your health?  Worksite policies focused on smoke-free environments or nutrition and physical activity behaviors have shown to be effective interventions to reduce tobacco use, weight among employees, and overall healthcare costs. Does your worksite have policies in place to support a healthy environment?

How about where you live? Are there sidewalks and safe places to be active? Coordinated approaches shown to make physical activity easier and more accessible include policies that combine transportation systems and land use design to increase street connectivity, bicycle infrastructure, access to parks and access to local destinations.[vii] This approach takes policymaking to the local level, engaging city planning and transportation professionals.  What if every new housing development built made sure that sidewalks are safe and accessible, people can walk to park and a grocery store with healthy foods, and people have the opportunity to be healthy right they live.

As a public health consultant, I have seen firsthand the benefit of policy to improve sun safety behaviors in children, worksite employees, and worksite administrators, as well as environment changes to support sun safe worksites and child care facilities. As a result of worksites and child care administrators recognizing the need to support healthy worksite and child care environments, each site now has a UV Protection Policy in place that encourages sun safety practices of staff and children, including wearing   sun protective clothing, applying and re-applying sunscreen, and developing outdoor environments that support sun safe practices, such as shade structures.  These are just some examples of how policy is an important strategy to improve the health of communities and all people.

State and local communities across the United States are engaging a HiAP approach, such as “the state of Vermont has established a cabinet level body for health in all policies when particularly target vulnerable populations or Boston’s Health in All Policies Task Force which brings together city agencies and community leaders to use health impact assessments to examine the impact of all decisions and policies on health.”[viii]

Research has identified the challenges with bringing health in all policies center the quality and quantity of evidence-based data, involving and convincing all stakeholders on the value of HiAP, given their differing points of view and different ways of understand the problem, as well as the latency of time between implementation of a policy and its effects in terms of health outcomes.[ix] After all it takes time to see shifts in health outcomes such as reductions in lung cancer or obesity rates, but prevention and HiAP do work. 

Not sure where to start or what works? Leading public health organizations identified five key elements of Health in All Policies, including “1) promote health, equity, and sustainability, 2) support intersectoral collaboration, 3) benefit multiple partners, 4) engage stakeholders, and 5) create structural or process change. Addressing each element is important to garner support for an HiAP approach. The Community Guide, is leading source of evidence-based findings that highlight intervention approaches across a diverse range of topics and specific to groups, such as 24/7 smoke-free policies in schools shown to reduce and prevent tobacco use.  In addition, resources and information is available from leading public health organizations, including the Centers for Disease Control and Prevention’s  Health in All Policies and Health in All Policies Resource Center, or the Public Health Institute’s Health In All Policies guide for State and Local Governments.

References

[i] Association of Schools and Programs of Public Health. (2013, September 3). Public Health Trends and Redesigned Education. Blue Ribbon Public Health Employers’ Advisory Board: Summary of Interviews. Retrieved from https://s3.amazonaws.com/aspph-wp-production/app/uploads/2017/10/BlueRibbonPublicHealthEmployersAdvisoryBoard_Report_FINAL_09.06.13-SJC.pdf

[ii] American Planning Association’s Planning and Community Health Center. (2018). Policy, Systems, and Environmental Change Strategies, Plan 4 Health. Retrieved from http://plan4health.us/policy-systems-and-environmental-change-strategies/

[iii] National Association of County and City Officials. (2011, October). Healthy Communities, Healthy Behaviors: Using Policy, Systems, and Environmental Change to Combat Chronic Disease. Retrieved from http://archived.naccho.org/topics/HPDP/mcah/upload/issuebrief_pse_webfinal.pdf

[iv] Centers for Disease Control and Prevention, Office of the Associate Director for Policy. (2016, June 9). Health In All Policies. Retrieved from https://www.cdc.gov/policy/hiap/index.html

[v] Rudolph, L., Caplan, J., Ben-Moshe, K., & Dillon, L. (2013). Health in All Policies: A Guide for State and Local Governments. Washington, DC and Oakland, CA: American Public Health Association and Public Health Institute.

[vi] Association of Schools and Programs of Public Health. (2015, March, 15). Population Health across All Professions Expert Panel Report. Retrieved from https://s3.amazonaws.com/aspph-wp-production/app/uploads/2015/02/PHaAP.pdf

[vii] Guide to Community Preventive Services. About The Community Guide. https://www.thecommunityguide.org/about/about-community-guide.  Page last updated: October 19, 2017. Page accessed: February 21, 2018

[viii] American Public Health Association. (2018). Health in All Policies. Retrieved from https://www.apha.org/topics-and-issues/health-in-all-policies

[ix] Bert, F., Scaioli, G., Gualano, M., & Siliquini, R. (2015, February 1). How can we bring public health in all policies? Strategies for healthy societies. Journal of Public Health Research. 4:393, DOI: 10.4081/jphr.2015.393