Dialogue with Indigent Communities: How the Voice of Public Health Makes an Impact that Matters

Erika S. Corle, MPH, Executive Assistant, Providence St. Joseph Health/St. Mary Medical Center

While finishing this blog post, two major earthquakes struck the very area that I am writing about. These earthquakes were the largest to hit Southern California in the past 20 years, striking Kern and San Bernardino counties. Being a member of the affected community, I can attest to the fear, the unknowing, and the hope that the areas hardest hit would not be left behind or forgotten while larger, more able areas were addressed.

I am proud that the collaboration efforts that came together so quickly by local, state, and federal officials addressed the entire affected area. Although I only had two things break, sleep has not been a resource I am blessed with; I am 82 miles from the epicenter. Since this didn’t occur in a heavily populated area, which would have required more complex response efforts, resources were dispatched and communities came together. This is a lesson in preparation for the entire state, in the event a larger, more damaging event occurred, and a shining example of how public health and community agencies work together to address natural disasters. Although the communication was delivered in a timely manner, as of this date, running water is not available for the residents of Trona, California, although portable showers were trucked in on July 9.

Poverty-stricken communities exist everywhere in our nation. These are also known as the indigent population. What do we do to ensure effective communication with this population? In the rural area in Southern California known as the High Desert, in San Bernardino County, strategic ways to influence health outcomes has left the local hospitals and the San Bernardino County Public Health Department reaching for new and innovative ways to be a stronger voice. Interviews with local advocacy experts and county public health representatives provided some impressive information and a look into the current condition of this population. Working together to communicate with these communities is done with the county public health department sharing their flyers and partnering with local hospitals and community organizations to spread the word about services.  For the High Desert in general, the county public health department requests marketing assistance from the local hospitals and other community groups to promote their resources.

San Bernardino County is the largest United States county in area at just over 20,000 square miles, with a population of two million. Successfully communicating to an area so vast with communities spaced so far apart prompts local public health departments to develop forward-thinking efforts to communicate that services are available and can be accessed. Together with the local public health department, community organizations have researched and secured grants to assist with establishing community-voiced alliances to assist in effective communication. Initiating these alliances from where the issue begins can influence the future of this population by not isolating them any further.

Communicating available services to the indigent population is currently done in this community by counseling services, mobile vans, community building, community collaboratives, enrollment assistance and family resource centers. Mr. Frank Becerra, the supervising health education specialist for San Bernardino County Department of Public Health, agrees that the High Desert region of San Bernardino County is vast and sparsely populated, when compared to the San Bernardino Valley and city area, and this can render some of this remote population unable to adequately obtain information. The significance of collaborating with faith-based groups, community-based organizations, school districts, and others establishes a communication effort that can be both maintained and improved. Existing relationships are supported, and because of these collaborations, further efforts can be made in communication, as the information regarding where the deficits are coming from can be realized. The local public health department uses avenues including social media, their website, flyers and print media, email, and direct contact via health fairs, clinics, and program staff.

Kevin Mahany, Director of Community Health at St. Mary Medical Center in Apple Valley, California, advocates communication strategies that will work for all indigent communities, i.e., Latinos, those new to the country, or other health-disparaged groups. Mahany further advises that a way to improve communication to these communities would be to have a public health official located in the High Desert community. The ability to connect with community leaders can be a lost opportunity if program investments are not realized personally, and subsequently leave a gap in local investment. Finding ways to further communicate services to ensure that the targeted population is listening is a challenge faced especially by rural populations. Mahany says that our local hospital has developed flyers that are being put into grocery bags of every shopper to build the awareness of the mobile van that stops each week at this market.

Becerra says that local city and town governments work together with county public health by maintaining contractual obligations while supporting current initiatives and efforts. Noting that this area also has the lowest in physician resources statewide, it also poses a problem when encouraging use of the public health infrastructure and promoting these services. A Community Benefits report done in 2017 by St. Mary Medical Center reports that 41.5% of the area’s residents report access issues.

Knowing that these challenges exist motivates the improvement of current efforts while exploring fresh ideas that can keep the information in front of these populations. A strong social media presence, timely information, and a commitment by local healthcare organizations and public health departments to work together promises an approach for the residents to also partner in their own communities. Paying attention to details—such as materials that make sure they are at appropriate reading levels—as well as being culturally sensitive is also essential. The indigent population has the same needs as other populations, and how we ensure the inclusion of this group is reliant upon the public health world.

Erika S. Corle, MPH, is an executive assistant to both the Chief Operating Officer and the Chief Mission Integration Officer of Providence St. Joseph Health/St. Mary Medical Center, who oversees all of Providence’s public health and community benefit efforts.

Local Health Department Intervention Critical as Hepatitis Rates Continue to Rise

NACCHO has released the following statement in response to the Centers for Disease Control and Prevention’s (CDC) newly released 2017 Annual Viral Hepatitis Surveillance Report. The report  reveals that  rates of acute hepatitis A (HAV), hepatitis B (HBV), and hepatitis C (HCV) infection in the U.S. continue to rise.

“The new report highlights the impact that viral hepatitis is having on communities across the country and underscores the need for investments in local health departments to implement and continue effective public health interventions to prevent and treat viral hepatitis,” said Lori Tremmel Freeman, NACCHO’s Chief Executive Officer.  “These efforts, along with critical work of community, state and local partners, is needed to address the spread and the numerous factors that contribute to these rising rates.  Failure to collaboratively act on these data will have significant consequences for our communities.

According to the new report, cases of HAV jumped nearly 70 percent from 2016 to 2017, an increase largely attributable to person-to-person outbreaks among people experiencing homelessness and people who inject drugs. HBV rates among persons aged 40-49 years are the highest in 15 years, partly due to lack of vaccine protection in recommended populations, and factors such as injection drug use and multiple sex partners compound the risk in older age groups. HCV infections have more than tripled since 2010 and the number of new cases is likely much higher but inestimable due to limited testing and underreporting. Large outbreaks of HCV have occurred predominantly among younger adults, primarily as a result of increasing injection drug use associated with America’s ongoing opioid crisis.

As community providers of health education and services, local health departments are on the front lines and play a vital role in addressing hepatitis through vaccination; testing and treatment; linkage to care; surveillance and outbreak response; and elimination strategy planning. However, addressing and reversing these trends will require a collaborative effort among health providers at every level. Coordinated engagement among local, state, federal, and national stakeholders is needed to develop partnerships that increase access to vulnerable, hard-to-reach populations and successfully implement effective, community-based, prevention and treatment strategies, including:

  • Expansion of hepatitis screening and linkage to care services;
  • Increased access to vaccines, especially for recommended at-risk populations;
  • Implementation of syringe services programs; and
  • Eradication of treatment barriers for people living with hepatitis.

Together, these strategies will help decrease transmission of HAV, HBV, and HCV, and increase treatment availability, which will save lives and money and decrease the burden on the nation’s health system.

NACCHO is committed to supporting local public health efforts and has developed several resources to build the capacity of local health departments to address viral hepatitis:

NACCHO Book Club: Dreamland—The True Tale of America’s Opioid Epidemic

By Emily Yox, MPH, Global Health Program Analyst, NACCHO

Each month, NACCHO will bring you a new public health book, read and reviewed by NACCHO staff. We hope to provide a well-rounded reading list that you will find enjoyable as well as informative.

Our first recommendation, Dreamland: The True Tale of America’s Opioid Epidemic, by Sam Quinones, was published in 2015 and received many accolades for the way in which the author intertwines the multiple narratives that fit into the U.S. opioid overdose epidemic. He tells stories of epidemiologists, big pharma, entrepreneurial drug dealers, and people in recovery to showcase the different perspectives of the addiction crisis in the United States. It is clear that the book was painstakingly researched but is very well written and hard to put down. Continue reading

Local Health Departments Engage in Outreach with Members of Congress

By Eli Briggs, Senior Government Affairs Director, NACCHO 

Last month, during the annual Congressional summer recess, NACCHO members worked to educate Members of Congress about the work their health departments are doing to keep people healthy and safe.

Below one NACCHO member provides details of her experience:

On July 31, 2019, Representative Lauren Underwood (D-IL) and Representative Joe Kennedy (D-MA) held a Mental Health Forum at the Kendall County Health Department in Yorkville, IL.  During the forum both Representatives Underwood and Kennedy expressed enthusiastic commitment to improving access to mental health care.  Representatives were met by a packed room of community members who were invited to provide narratives on both personal mental health and mental health systems challenges that they had faced.  Representatives Underwood and Kennedy both graciously received concerns and questions and provided responses to those participating in the forum and told participants that their future policy decisions would be informed by what they heard at the forum. The Kendall County Health Department was also pleased to have quality mental health best practices and treatment services posted for all to view at the forum.  We want to express our heartfelt gratitude to Representatives Underwood and Kennedy for their commitment to mental health. 

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From the Field: Strategies to Increase Hepatitis C Screening and Linkage to Care through SSPs

By Nicole Miller, MSN, RN; Lela Riherd, BSN, RN, CIC; Zac Doobovsky, BSN, RN, CIC; and Harp Cheema, BSN, RN, Whatcom County Health Department (WA)

This post originally ran in NACCHO’s Healthy People, Healthy Places Blog.

The Centers for Disease Control and Prevention (CDC) estimates nearly 2.4 million Americans are living with the hepatitis C virus (HCV), with transmission via injection drug use being the most common mode of HCV acquisition. In Washington State, there has been a 126% increase in newly acquired HCV infections between 2013 and 2017 that is linked to the opioid crisis. In 2018, Whatcom County had approximately 13 acute HCV cases and 306 chronic HCV cases, an increase from 4 acute and 241 chronic in 2017. On July 26, 2019, in response to these increasing numbers, Washington Governor Jay Inslee launched the Hep C Free Washington Plan to Eliminate Hepatitis C in Washington State by 2030, expanding upon a 2018 proclamation calling for a coordinated strategy between state and local public health agencies, tribal governments, and other partners to eliminate hepatitis C.

Expanding prevention and screening services and increasing access to treatment are critical to Washington’s efforts to eliminate hepatitis C, yet many barriers exist for people who inject drugs (PWID) when trying to access care and needed services. Opioid misuse is a complex issue that requires a multifaceted, collaborative approach across disciplines and agencies. The Whatcom County Health Department (WCHD) is working to expand its Syringe Services Program (SSP) and Adult Health Clinic services to address the hepatitis C challenges. By expanding our services, we hope to provide our clients with the resources they need to make informed decisions regarding their health and to encourage testing and treatment for people who are living with hepatitis C.

Syringe Services Program

SSPs are shown to be safe, effective, and play an important role in reducing the transmission of viral hepatitis and other infections. The WCHD SSP is a community-based prevention program that can provide a range of services, including access to clean syringes, safe disposal of syringes, testing for infectious diseases, and linkage to treatment services. Hepatitis A and B vaccines are also available.

The WCHD started its SSP to combat the disease transmission of HCV, HIV, and other infectious diseases among PWID. The number of participants served has increased fourfold since 2009, from 219 unique participants to 881 in 2018.

Participants in our SSP reported stigma as the most common reason for avoiding medical care. We work towards a no-judgment approach to help build a trusting relationship with our clients, which is crucial in the participant’s road to change and healthy outcomes.

The increasing number of unique participants has forced our SSP to change what we ask our clients, how we test, when we test, clinic flow, and how we provide follow up services and referrals. We made changes to our dialogue with clients to facilitate a more engaging conversation and achieve a positive rapport. Our clinic flow is set up to create a safe comfortable space that allows for point of care testing in all of our exchange rooms. Clients often reported time restrictions as a barrier to testing and this change has helped us to provide testing and results in a more timely manner to meet client needs.

A standing order was approved to draw confirmatory HCV RNA testing for any of our clients that are reactive for the point of care HCV antibody test or who have received a reactive test with us in the past with no additional follow up or linkage to care. By providing confirmatory testing we can help clients document chronic HCV and initiate treatment sooner. Clients are more likely to be compliant with care if services can be provided in one centralized location.

SSPs are a tool that can help reduce transmission of viral hepatitis and other infections as well as serve as a bridge to other healthcare or treatment services. Program participants have reported that our services decrease needle reuse and sharing. This in turn helps to reduce disease transmission in our community.

Linkage to Care

Follow-up testing and linkage to care is essential for clients with a new diagnosis, but understanding the next steps for follow-up can be challenging. Our SSP program staff met with a local community health clinic about the potential to expedite referrals that screen reactive to HCV at our SSP. We worked on creating a process that ensured the appropriate testing and linkage to care happened in a timely manner. The community health clinic created a flow sheet, standing orders for HCV testing, and signed a Memorandum of Understanding (MOU) for this process. This MOU allows expedited referrals for better client outcomes.

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NACCHO Honors Anthony L-T Chen as its 2019 Advocate of the Year

The National Association of County and City Health Officials (NACCHO) named Anthony L-T Chen, MD, MPH, Director of Health of Tacoma-Pierce County Health Department, its Advocate of the Year. This award recognizes outstanding accomplishments related to advocacy and outreach to members of Congress to create better health policy outcomes. Dr. Chen received the award the organization’s 2019 Annual Conference in Orlando. Continue reading

NACCHO Statement on Gun Violence in Texas and Ohio

By Lori Tremmel Freeman, NACCCHO CEO

“Gun violence is a profound public health crisis in America. The horrific loss of life and injury in Texas and Ohio once again fill us with sadness, anger, and frustration at yet another senseless act of violence.  These tragedies have reached epidemic proportions and as with other epidemics, we must act to protect our communities’ public safety and well-being. Continue reading