InstRuctor’s version / October18, 2009
SBS Exercise 3: A Case Study in the Role of Social and Community Factors in the Onset and Solution of Public Health Problems
Time to Complete Exercise: 30 Minutes
LEARNING OBJECTIVES
At the completion of this exercise, participants should be able to:
Identify the role of social and community factors in the onset of a public health problem
Identify social and community factors that contribute to the solution of a public health problem
Explain the rationale for using incentives and enablers to support treatment adherence
Identify incentives and enablers that are responsive to individual and community needs and preferences
ASPH E. SOCIAL AND BEHAVIORAL SCIENCES COMPETENCIES ADDRESSED IN THIS MODULE
E.3. Identify individual, organizational, and community concerns, assets, resources and deficits for social and behavioral science interventions
E.6. Describe the role of social and community factors in both the onset and solution of public health problems
ASPH INTERDISCIPLINARY/CROSS-CUTTING COMPETENCIES ADDRESSED IN THIS MODULE
G. Diversity and Culture
G.10. Develop public health programs and strategies responsive to the diverse cultural values and traditions of the communities being served
NOTE FOR INSTRUCTORS
This guide is intended to accompany the PowerPoint slide set, “Social and Behavioral Sciences: Identifying Social and Community Factors in the Design and Implementation of Public Health Programs.”
Reading assignment:
El-Sadr W, Medard F, Dickerson M. The Harlem Family Model: a unique approach to the treatment of tuberculosis. J Public Health Manag Pract. 1995; 1:48-51.
Introduction
In designing public health interventions, it is important to first obtain an accurate view of social and community factors in the targeted area. These include social factors (e.g., income distribution, health issues, family structures, social cohesiveness) and community factors (eg, geography, transportation, availability of health care, etc.). Appropriate public health interventions will acknowledge the realities of these factors and attempt to capitalize on those that will promote a desired outcome.
This case study uses the community of Harlem in New York, NY, and the design of a directly observed therapy (DOT) program for tuberculosis (TB) patients as an example of assessing and planning for social and community factors. The instructor may want to review A Primer on TB to increase his/her basic understanding of the disease.
The slide set consists of 7 sections:
- Introductory materials, including ASPH competencies and learning objectives (slides 1-2);
- Conceptual information on planning public health interventions, including a list of social and community factors (slide 3);
- Background information on TB, including basic health information, the US TB control strategy, key elements of DOT programs, and examples of incentives and enablers (slides 4-8);
- A description of the Harlem community, as told by a life-long Harlem resident. This information features photographs of people and places in Harlem (slides 9-30);
- A discussion of public health intervention design, using the Harlem DOT model as an example (slides 31-43);
- A discussion of public health intervention design, using social and community factors not found in the Harlem community (and thus where the Harlem DOT model is not applicable) (slides 44-50); and
- Conclusion (slide 51)
The first 4 sections and the conclusion can be presented in a didactic fashion.
The fifth and sixth sections consist of an interactive exercise. Certain characteristics are presented (eg, the community has many individuals who are poor) and the students are asked to brainstorm about how to design intervention elements to respond to specific characteristics. The instructor should collect suggestions from the students before moving to the next slide, which presents specific aspects of the Harlem model that respond to this characteristic (eg, if patients are poor, the program should provide meals, food, clothing, and other forms of tangible assistance; and help with finding work or obtaining public benefits).
In the fifth section, the following characteristics of the Harlem model are presented:
- Many individuals are poor
- Many individuals are homeless or marginally housed
- Many individuals are single, with little social support
- Many individuals are substance abusers
- Many individuals have HIV and/or other health problems
- The community is geographically small or easy to navigate
The presentation uses the above social and community factors in Harlem as an example of how to assess these factors and design an appropriate public health intervention. Examples of targeted incentives, such as group outings, meals, and celebrations, can be found on page 50 of the assigned reading (El-Sadr et al., 1995).
The presentation also acknowledges that other social and community factors relevant to TB, but not found in Harlem, may exist; namely, a large geographic area or poor transportation, a relatively affluent area with a tradition of private health care, and overt stigmatization. In the sixth section, the students are asked to brainstorm about how to design intervention elements to respond to these characteristics, much as they were asked to do in the fifth section.
In the conclusion, the point is summarized that this exercise is based on social and community factors in Harlem and the public health intervention of DOT for TB. This methodology could be used in various communities and with various public health interventions.
The slide set can be accessed through the following URL:
Background Information on Tuberculosis Rates in the 1980s
In the mid to late-1980s, large cities in the United States witnessed a dramatic resurgence of TB with reversals of downward trends and rates of new cases doubling. New York City was particularly hard hit, with cases tripling from 1979 to 1992. The de-funding of public TB control programs coincided with long-term upward trends in urban poverty, increased immigration from countries where TB is endemic, and in some cities, housing shortages. Rising homelessness was particularly acute in New York City, where families excluded from low-income housing joined newly deinstitutionalized mental health patients in overcrowded shelters. Outbreaks of TB in shelters, hospitals, and prisons revealed that infection-control systems for congregate facilities were inadequate. The 1980s also saw a rise in substance use in major US cities, and injection drug and crack cocaine users were disproportionately affected by the new surge in TB. Such individuals were often incarcerated; jails and prisons served as a nexus for further transmission. Additionally, upon release ex-offenders often became homeless and homeless shelters thus served to further spread TB infection. Finally, the emergent epidemic of HIV/AIDS created a national pool of immuno-compromised individuals uniquely vulnerable to TB disease.
In the midst of the resurgence of TB was a frightening sub-epidemic of multi-drug resistant (MDR) TB, stemming in large part from widespread non-completion of treatment (inadequate prescribing practices by physicians also played a role). MDR-TB required a more complex, longer course of treatment and, in immuno-compromised patients, led to extremely high fatality rates if not adequately treated. Many of these causative factors intersected, so that for instance, the population within an urban shelter system included high numbers of substance users who tended to be malnourished and spent time together, often engaging in behaviors that put them at high risk for HIV infection, and who had no regular access to health care or were reluctant to access services for fear that their drug use would be investigated. Such a group would be at high risk for TB infection and for progression to TB disease in the absence of appropriate treatment.
In response, federal, state, county, and local resources were invested in rebuilding TB surveillance and treatment programs, and in strategies to help ensure completion of TB treatment while providing alternatives to mandatory detention. The most important of these strategies has been DOT for outpatients, in which patients receive daily or twice-weekly doses of TB medications from a health care worker who witnesses that each dose is ingested. DOT may be done in a clinical setting, patient residences, schools, workplaces, or other agreed-upon settings. DOT is often combined with other outpatient services, including substance use treatment programs, and includes access to social service providers.
The routinization of DOT has led to a decline in the incidence of detention of TB patients, and much improved rates of treatment completion. This improvement, along with increased funding and interagency collaboration, improved surveillance, diagnostic techniques, and changes in recommended drug regimens, enabled TB control programs to regain the ground lost in the 1980s and early 1990s, so that in the early 21st century, TB disease incidence in the United States is at historic lows.
Bibliography
Bayer R, Wilkinson D. Directly observed therapy for tuberculosis: history of an idea. Lancet. 1995; 345:1545 -1548.
Chaulk CP, KazandjianVA, Public Health Tuberculosis Guidelines Panel. Directly observed therapy for treatment completion of pulmonary tuberculosis: consensus statement of the Public Health Tuberculosis Guidelines Panel. JAMA. 1998; 279:943-948.
HaddadMB, Wilson TW, Ijaz K, Marks SM, Moore M. Tuberculosis and homeless in the United States, 1994 – 2003. JAMA 2005;293 (22):2762-2766.
Volmink J, Garner P. Directly observed therapy for treating tuberculosis (review). The Cochrane Library, issue 3, 1-23. 2007.
Weis SE, Slocum PC, Blais FX et al. The effect of directly observed therapy on the rates of drug resistance and relapse in tuberculosis. N Engl J Med. 1994; 330:1179 -84.
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