2015 Annual Public Health Graduate Student Showcase P U B L I C H E A LT H I N N O VAT I O N I S U S
Student!Name:!Haban!Alghamdi,!MPH!Class!of!2014! Project!Title:!Detrimental!Eﬀect!of!BloodRProduct!Transfusion!on!Survival!for!PaEents!with!Breast! Cancer!in!Florida!(1996R2007)!
Background:!There!has!been!a!large!body!of!evidence!discussing!the!immunological!eﬀects!of!blood! transfusion!on!survival!in!paEents!with!a!number!of!diﬀerent!types!of!cancers.!However,!few!studies! have! examined! the! eﬀect! of! blood! transfusion! on! survival! in! breast! cancer! paEents! and! those! that! have!had!inconsistent!results.!!
Methods:!Data!from!the!Florida!Cancer!Data!System,!Agency!for!Health!Care!AdministraEon!(AHCA)!and!the!US!Census! were!linked!for!female!breast!cancer!paEents!in!Florida!(1996R2007)!to!understand!the!associaEon!of!blood!transfusion! with! female! breast! cancer! paEents’! survival.! MulEvariate! regression! analyses! for! overall! survival! were! adjusted! for! potenEal!confounders!related!to!blood!transfusions,!including!age,!gender,!race,!treatment!received,!and!coRmorbidiEes.!!!!!!!!!!!!!!!! Results:! Among! 120,940! paEents! idenEﬁed,! 17,686! (14.6%)! received! blood! transfusion! during! the! course! of! their! treatment.!Transfused!paEents!had!a!shorter!overall!median!survival!Eme!(7.7!years)!compared!to!nonRtransfusion!group! (12.7! years).! Among! paEents! who! received! transfusion,! Blacks,! nonRHispanics,! and! paEents! with! lower! SES! categories! had! lower! overall! median! survival.! MulEvariate! analysis! indicated! that! blood! transfusion! is! a! signiﬁcant! independent! predictor!for!survival!(HR=1.08;!95%CI:1.03,1.13;!p<0.001)!a6er!adjusEng!demographic,!clinical,!and!comorbid!factors.! ! !!!!!!!!!! Conclusions:! Our! study! concludes! that! blood! transfusion! is! a! signiﬁcant! independent! risk! factor! for! survival! in! female! breast!cancer!paEents.!! DPHS!Recogni5on
Detrimental Effect of Blood-Product Transfusion on Survival for Female Breast Cancer Patients in Florida (1996-2007) Hattan A. Alghamdi, MBBS, MPH, Class of 2014 Margaret M. Byrne PhD, Feng Miao MSc, Dido Franceschi MD, Tulay-Koru Sengul PhD Department of Public Health Sciences, Department of Surgery, Sylvester Comprehensive Cancer Center University of Miami Miller School of Medicine, Miami, Florida
BACKGROUND • •
Numerous studies have examined the immunological effects of blood transfusion among cancer patients. •
Few studies have examined the effect of any blood transfusion regardless of the treatment choice on survival in breast cancer patients and these have had inconsistent results.
• • •
Data from the Florida Cancer Data System, the Agency for Health Care Administration (AHCA), and the US Census were linked for female breast cancer patients in Florida (1996-2007) to understand the association of blood transfusion with female breast cancer patients’ survival. Multivariate regression analyses for overall survival were adjusted for potential confounders related to blood transfusions, including demographics, clinical, and comorbidities.
Among 120,940 patients identified, 17,686 (14.6%) received blood transfusion during the course of their treatment. The majority of patients were White (90.4%) and non-Hispanics (90.2%); most live in neighborhoods with middle-high (37.9%) and middle-low (29.2%) SES. Patients who had transfusion were older (mean=66 years), with more advanced tumor stages (24.6% distant metastasis vs. 20% regional, direct extension ± lymph nodes). Transfusion rates were higher in Blacks (18.8%) than in Whites (14.3%) and other races (8.2%). Patients who received chemotherapy (16.8%) had higher rates of blood transfusion compared to the non-chemotherapy group (13.8%). Transfused patients had a shorter overall median survival time (7.7 years) compared to non-transfusion group (12.7 years). Among patients who received transfusion, Blacks, non-Hispanics, and patients with lower SES categories had lower overall median survival. Table 1: Univariate and Multivariate Cox Regression Models
Figure 1: Demographics characteristics SES�Highest
Adjusted HR (95%CI)
Unadjusted HR (95%CI)
1.70 (1.66, 1.74)
1.08 (1.03, 1.13)
1.46 (1.41, 1.52)
1.28 (1.22, 1.35)
0.80 (0.71, 0.91)
0.91 (0.79, 1.05)
0.91 (0.87, 0.96)
Figure 2: Kaplan-Meier Curves by blood transfusion
CONCLUSION • Among patients who received blood transfusion, Blacks have shorter survival times and they are more likely to receive blood transfusion when compared to Whites; Hispanic ethnicity has better survival. • Our study concludes that blood transfusion is a significant independent risk factor for decreased survival in female breast cancer patients.
Hispanic Origin No
0.92 (0.89, 0.96)
1 (reference) <0.001
SES 1 (reference)
0.81 (0.78, 0.84)
0.93 (0.89, 0.97)
0.70 (0.68, 0.73)
0.87 (0.83, 0.91)
<0.001 0.80 (0.76, 0.83)
0.57 (0.55, 0.59
Multivariate model includes demographics and clinical characteristics and comorbidilties. HR (95%CI): Hazard Ratio and 95% Confidence Interval; SES: Socioeconomic status derived from the US Census and characterized into lowest (≥20 %), middle-low (≥10 and <20 %), middle-high (≥5 and <10 %), and highest (<5 %) SES based on percentage of a neighborhood living in poverty.
ACKNOWLEDGMENTS The study is part of a larger study that was funded by Florida Biomedical Research Program (#1KG06). Institutional Review Boards (IRBs) from both University of Miami and Florida Department of Health approved the main study.
2 ! Student!Name:!Julia!Amundson,!MD/MPH!Class!of!2017! Project!Title:!Trauma!Capacity!PreparaEons!for!the!2014!FIFA!World!Cup!in!Rio!de!Janeiro,!Brazil!
Background!&!Objec4ve:!Ryder!Trauma!Center!is!a!Level!1!trauma!center!internaEonally!recognized! for! clinical! excellence.! In! 2012,! they! iniEated! the! Ryder! Trauma! Center! –! Rio! de! Janeiro! Training! Program!to!build!and!staﬀ!two!trauma!centers!at!state!hospitals!in!Rio!de!Janeiro,!Brazil.!These!trauma! centers!expand!disaster!preparedness!infrastructure!for!the!2014!FIFA!World!Cup.!My!objecEve!is!to! observe!public!health!preparaEons!for!a!large,!internaEonal!sporEng!event.! Ac4vi4es:!Abended!weekly!planning!and!assessment!meeEngs!in!Miami!during!a!6Rmonth!period!prior!to!traveling!to! Rio!de!Janeiro,!Brazil!in!June/July!2014.!Created!a!saEsfacEon!survey!for!Brazilian!program!parEcipants,!piloted!during!my! Eme!in!Brazil.! Observa4ons:!New!trauma!infrastructure!in!Rio!de!Janeiro!is!comparable!to!American!trauma!infrastructure.!However,! there!is!a!signiﬁcant!disconnect!between!the!availability!of!newly!created!infrastructure!and!the!paEent!census!uElizing! these! faciliEes.! ! The! saEsfacEon! survey! did! not! garner! expected! results! due! to! excessive! length,! parEcipants’! fear! of! providing!idenEfying!data,!and!the!variability!of!the!quesEon!format.! Conclusions:! To! appropriately! triage! trauma! paEents! to! the! new! trauma! centers,! there! must! be! beber! coordinaEon! between!emergency!medical!services!and!trauma!centers.!Experiences!from!piloEng!the!survey!were!used!to!reRwrite!a! shorter!survey!using!solely!Likert!scale!quesEons,!implemented!a6er!my!departure,!results!pending. Global!Health!Scholar
Trauma Capacity Preparations for the 2014 FIFA World Cup in Rio de J aneiro, Braz il J ulia Amundson MD/MPH Class of 2017, University of Miami Department of Public Health Sciences, Miller School of Medicine
Insights Gained New trauma infrastructure at HEAT and HEAPN is comparable to American trauma infrastructure.
The Ryder Trauma Center – Rio de J aneiro Training Program began in 2012. GOALS Build and staff trauma centers at two staterun hospitals in Rio de J aneiro, Brazil; Hospital Estadual Alberto Torres (HEAT) and Hospital Estadual Adã o Pereira Nuñ es (HEAPN). Expand disaster preparedness for potential mass casualty events at the 2014 FIFA World Cup and the 2016 Summer Olympic Games. Ryder Trauma Center is a L evel 1 adult and pediatric trauma center internationally recognized for clinical excellence.
Activities Outside of the Trauma Center at HEAT
Attended weekly meetings with Ryder Trauma Center - Rio de J aneiro Training Program staff. Assisted with cardiac-respiratory arrest and teamwork simulations. Assessed Brazilian management of trauma cases. Created and implemented a satisfaction survey for Brazilian program participants.
There is a disconnect between the availability of trauma infrastructure and the patient census arriving to utilize these resources, due to poor coordination between Emergency Medical Services and trauma centers. High volume of traumas are seen daily in the Emergency Departments at the State Hospitals. Most Brazilian healthcare workers rotate through several healthcare facilities, interrupting the continuity of teamwork and training. L anguage barriers pose a significant obstacle to the implementation of training programs, rendering translators an indispensable resource.
Running neonatal cardiac-respiratory arrest simulations w ith one of the nurse managers at HEAPN
Survey did not garner expected results due to excessive length, participants’ fear of providing identifying data, and the variability of the q uestion format.
Conclusions & Future Recommendations Original survey, too long and too much variability in q uestion format – used as a pilot survey and then rew ork ed
Trauma Simulation at HEAPN in preparation for the 2014 FIFA World Cup
Continuing medical education req uirements for health workers at HEAT and HEAPN would help to standardize the knowledge and skills of the trauma employees as well as build confidence.
Obj ectives Observe public health preparations for a large sporting event via the addition of trauma capacity at two state hospitals in Rio de J aneiro, Brazil – from planning to implementation. Make recommendations to improve public health preparations for the 2016 Summer Olympic Games. Create and implement a survey to gauge changes in confidence, knowledge, and skill levels of the medical staff at HEAT and HEAPN.
In order to appropriately triage trauma patients to the new trauma centers at HEAT and HEAPN, there should be better coordination between Emergency Medical Services, Emergency Departments, and the trauma centers.
Experiences from piloting the survey were used to re-write a new, shorter survey utilizing solely L ikert Scale q uestions, implemented after my departure, results pending.
Ack now ledgements
Rio de J aneiro, Braz il
EMS officer at HEAT
Capstone Faculty Advisor: Dr. Meaghan McNulty Faculty Mentors: Dr. Antonio Marttos, Dr. Gabriel Ruiz, Dr. Carl Schulman Funding: This field experience was in part supported by funds form the Global Health Scholar Award
3 ! ! Student!Name:!Taghrid!Asfar,!MSPH!Class!of!2014! Project!Title:!Smoking!Behavior!Among!Adult!Childhood!Cancer!Survivors:!What!are!We!Missing?!
Background:!Childhood!cancer!survivors!(CCSs)!are!a!growing!populaEon!at!increased!risk!for!cancer! recurrence!and!late!eﬀects!of!cancer!treatment!that!can!be!exacerbated!by!smoking.!! Methods:!Using!pooled!data!from!the!1997R2010!NaEonal!Health!Interview!Survey,!we!compared!the! smoking! prevalence! and! age! of! smoking! iniEaEon! among! CCSs! (n=1,438)! with! individuals! without! cancer! history! (control! (n=383,805))! by! sex! and! by! US! regions.! Trend! analysis! using! weighted! linear! regression!of!prevalence!on!year!were!used!to!compare!the!EmeRtrend!of!smoking!prevalence!from! 1997! to! 2010! between! the! two! groups.! LogisEc! regression! analyses! were! performed! to! idenEfy! predictors! of! smoking! behavior!among!CCSs.! Results:! Compared! to! the! controls,! CCSs! were! signiﬁcantly! younger,! female,! white,! unemployed,! had! lower! income,! weighed!less,!and!more!likely!to!be!current!smokers.!The!highest!prevalence!of!smoking!was!in!the!southern!US!region! for! CCSs,! and! in! the! Midwest! for! the! nonRcancer! controls.! The! prevalence! of! current! smoking! decreased! slightly! and! consistently!among!the!controls,!but!remained!high!and!did!not!show!a!clear!EmeRtrend!pabern!among!CCSs.!CCSs!who! smoke!were!signiﬁcantly!more!likely!to!be!white,!young,!without!health!insurance,!live!below!the!poverty!level,!have!a! high!school!or!less!educaEon,!and!report!drinking!alcohol.!! Conclusions:! Smoking! prevalence! in! CCSs! is! signiﬁcantly! higher! than! the! nonRcancer! controls,! and! varies! markedly! by! region.! Health! dispariEes! due! to! socioeconomic! factors! and! low! access! to! health! care! are! strongly! aﬀecEng! CCSs,! especially! female! survivors.! TargeEng! CCSs,! especially! females,! with! tailored! smoking! cessaEon! and!prevenEon!intervenEons!is!highly!needed. DPHS!Recogni5on
Smok ing Behavior Among Adult Childhood Cancer Survivors: What Are We Missing? T ag hrid A sfar1, N oella A . Dietz
K ristopher L . A rheart1, Stacey L . T annenbaum2, L aura A . McClure2, L ora E . F leming 3 , David J . L ee1,2.
O f Public Health Sciences, University O f Miami Miller School O f Medicine, Miami, F lorida, USA Comprehensive Center, University O f Miami Miller School O f Medicine, Miami, F lorida, USA E uropean Centre F or E nvironment A nd Human Health, University O f E x eter, T ruro, Cornw all, Uk .
Thank s to maj or advances in pediatric oncology, long-term survival is anticipated for 8 0% of this population. Survivors are at increased risk for recurrence, second cancers, cardiac events, and pulmonary disease that can be caused or exacerbated by lifestyle factors such as smok ing. Smok ing has the potential to be more haz ardous for survivors, mak ing it a primary focus for prevention w ithin this grow ing population. Documenting smok ing prevalence among childhood cancer survivors (CCSs) in the US w ill establish and guide future prevention and cessation efforts among this high risk population.
Obj ectives Using a nationally representative adult sample of CCSs (defined as individuals w ho w ere diagnosed w ith cancer before 21 years of age) and individuals w ithout a cancer history (controls), w e: 1. Compare current smok ing prevalence and age at initiation stratified by gender and by US region, smok ing prevalence by age groups, and time-trend of smok ing prevalence from 1997 to 2010 betw een adult CCSs and the controls. 2. Identify risk factors for smok ing among CCSs.
Data and Methods •
• • • • • •
Data w ere pooled from the 1997– 2010 National Health Interview Survey (NHIS) (CCSs: n= 1,43 8 ; controls: n= 3 8 3 ,8 05). Records from each survey year w ere w eighted according to person-level w eights provided in annual NHIS data files. Prevalence estimates w ere adj usted for the complex sample design. Age of initiation w as expressed as mean + Standard Deviation. Smok ing prevalence by age group w as calculated using inverse variance w eighted least sq uare regression analysis. Weighted linear regression of prevalence on year w ere used for the trend analysis. Logistic regression analyses w ere performed to identify predictors of current smok ing among CCSs.
Risk factors for being current smok er among adult CCSs. Covariatesa
Age of Sm ok ing Initiation
Age of smok ing initiation in female CCSs compared to females w ithout cancer by US region.
16 14 12 10 8
Ch ildh ood Cancer Survivors (n= 1 , 4 3 8 )
Sam ple N Sex Male Fem ale Age 1 8 -4 0 4 1 -6 4 > 6 5 Race/ Eth nicity N on-Hispanic W h ite N on-Hispanic Black Hispanic Oth ers Poverty level Status Poor/ near poor N ot poor Em ploy m ent W h ite collar Service Farm er Blue collar Unem ploy ed Body Mass Index Under/ N orm al w eigh t Overw eigh t Ob ese Sm ok ing Status Current Form er N onsm ok er G eograph ic Region N orth east Midw est South W est
W eigh ted N
4 3 0 1 0 0 8 7 8 9 3 7 8 2 7 1 1 1 2 4 1 52 1 3 5 2 7
Sam ple N
2 7 593 3 51 52 7 0
3 4 .8 8 6 5. 1 2
1 .6 3 1 .6 3
1 6 93 4 3 2 1 4 4 6 2
4 3 94 8 7 2 1 3 7 4 5 1 3 7 97 2
55. 55 2 7 .0 2 1 7 .4 4
1 .6 5 1 .4 8 1 .3 9
1 6 953 8 1 50 0 0 9 6 4 2 58
6 7 53 2 2 58 57 5 4 50 98 1 2 2 0 8
8 5. 3 5 7 .4 0 5. 6 9 1 . 54
Fem ale Survivors Fem ale Control
N on-Cancer Controls (n= 3 8 3 , 8 0 5)
0 . 96 0 .7 1 0 . 59 0 .3 5
2 3 93 8 1 57 591 6 91 6 0 1 7 6 7 3
W eigh ted N
958 7 8 1 94 1 0 1 4 96 0 3 2 90 6 3 97 2 9 7 94 2 6 8 50 2 7 3 0 7 6 4 6 1 3 91 2 7 7 4 0 2 3 53 2 3 2 9 2 50 2 0 7 6 4 96 93 3 93
4 8 . 58 51 . 4 2
0 .1 1 0 .1 1
< 0 .0 0 0 1
4 5. 92 4 0 .2 4 1 3 .8 4
0 .1 8 0 .1 4 0 .1 1
< 0 .0 0 0 1
7 0 .4 9 1 1 . 92 1 2 .6 8 4 . 91
1 1 93 3 7 53 0 7 0 0
1 8 .3 6 8 1 .6 4
1 .2 8 1 .2 8
4 92 1 7 2 58 6 6 8
4 2 6 1 4 8 5 1 0 4 7 55
2 4 1 3 90 8 0 6 2 7 3 958 6 2 91 3 4 0 2 3 1 6
3 0 . 51 1 0 .1 9 0 . 50 7 . 95 50 . 8 5
1 . 50 0 . 92 0 .2 3 0 .8 6 1 .6 0
1 3 4 1 3 7 8 4 2 53 2 1 54 3
6 3 4 4 1 9 3 4 7
3 54 2 7 6 2 3 0 8 2 5 1 8 4 0 92
4 6 .0 6 3 0 .0 1 2 3 . 93
1 .7 1 1 . 53 1 .3 5
1 50 3 2 3 1 2 8 7 0 1 8 8 50 3
51 8 3 0 0 6 1 1
2 7 1 4 53 1 8 0 4 91 3 3 3 0 0 5
3 4 . 58 2 3 .0 0 4 2 .4 2
1 . 54 1 .4 8 1 . 56
8 4 3 0 8 7 8 2 0 1 2 1 7 3 99
2 0 6 3 3 7 56 3 3 3 2
1 2 2 1 8 7 3 1 7 1 6 3
1 5. 53 2 3 .7 2 4 0 .1 2 2 0 .6 2
1 .1 6 1 . 53 1 .6 6 1 .3 2
6 8 8 8 4 8 7 1 51 1 4 0 1 8 4 8 7 58 6
1 8 8 8 4 3 97 1 4 0 6 6 3 2 0 2
52 4 7 54 51
7 2 0 1 92 2 0 2 93 7 4 7
2 5590 3 3 2 7 6 1 8 1 4 8 2 8 0 3 6 6 91 7 5
0 .2 4 < 0 .0 0 0 1 0 .1 8 0 .1 7 0 .0 9
7 7 4 4 7 2 50 6 6 4 8 1 6 0 6 4 54 4 0 7 95
0 .1 5 0 .1 5 < 0 .0 0 0 1
3 6 .4 9. 7 1 .0 1 4 .8 3 7 .8
0 .1 0 .0 0 .0 0 .1 0 .1
9 2 6 8
0.97 – 0.99
0.96 – 1.00
0.96 – 0.99
--0.94 – 2.09
Race/ Ethnicity Non-Hispanic White Non-Hispanic Black Hispanic Other
1 0.49 0.44 0.8 9
--0.28 – 0.8 5 0.23 – 0.8 5 0.3 3 – 2.3 9
1 0.57 0.61 1.3 5
--0.15 - 2.11 0.18 – 2.09 0.13 – 14.3 1
1 0.3 8 0.3 7 0.69
--0.20 – 0.73 0.17 – 0.8 1 0.22 – 2.11
W est 1 7 .3 1 8 .3
Education More than High School High School Less than High School
1 1.8 0 2.63
--1.20 – 2.69 1.65 – 4.17
1 2.97 1.98
--1.40 – 6.3 0 0.71 – 5.52
1 1.40 3 .14
--0.8 6 – 2.29 1.8 3 – 5.3 8
Employment Status Employed Unemployed
--0.8 4 – 1.8 2
--0.3 3 – 1.72
--1.12 – 2.58
Health Insurance Status Insured Uninsured
--1.64 – 3 .94
1 3 .21
--1.42 – 7.26
--0.99 – 2.3 4
Household Income At or above poverty level Under poverty level
1 1.8 7
--1.3 4 – 2.62
--0.53 – 2.14
1 2.3 7
--1.62 – 3 .47
16 14 12 10 8 6 4 2
Male Survivors Male Control
Midw est 1 5. 6
N orth east 1 6 .4
South 1 8 .2
W est 1 4 .7
1 7 .2
1 7 .2
1 7 .2
1 7 .7
Body Mass Index Overw eight and obese Under/ Normal w eight
--0.8 9 – 1.70
--0.8 9 – 3 .41
--0.71 – 1.55
Drink ing Status Nondrink er/ Former Current
--1.42 – 3 .01
--0.60 – 2.68
--1.69 – 4.15
Compliant w ith Physical Activity Guidlines2 Y es No
1 1.3 9
--0.95 – 1.95
--0.50 – 1.91
--1.01 – 2.44
Geographical Region Northeast Midw est South West
1 1.08 1.06 0.95
--0.63 – 1.8 6 0.65 – 1.73 0.53 – 1.71
1 0.71 0.68 0.73
--0.26 – 1.98 0.28 – 1.66 0.25 – 2.16
1 1.25 1.3 2 1.10
--0.67 – 2.3 5 0.75 – 2.3 5 0.54 – 2.23
Time-trend of smok ing prevalence in CCSs compared w ith individuals w ithout cancer.
< 0 .0 0 0 1 7
4 0 . 90 3 5. 1 1 2 4 .0 0
0 .1 3 0 .1 0 0 .1 1
0 .0 0 2
2 2 .0 5 2 0 .7 9 57 . 1 6
0 .1 2 < 0 .0 0 0 1 0 .1 0 0 .1 5
1 8 .6 2 4 .4 3 6 .1 2 0 .7
0 .2 0 .2 0 .2 0 .2
3 0 20 10
4 3 0 98 2 3 6 4 0 6 4 7 3 8 1 1 1 1 7 4 4 0 7 7
Control 8 8 0 6 7 8 4 6 4 1 8 1
Current smok ing status among CCSs versus individuals w ithout cancer.
3 6 7 1 4 8 2 8 7 1 4 3 4 0 94
4 7 6 4 3 959 1 8 96 3 6 0 7
0 6 9 4
Smok ing prevalence among adult CCSs by age groups compared w ith individuals w ithout cancer.
3 5 3 4.58
0 .0 3 0
South 1 6 .4 1 8 .3
1 1 .8 4 8 8 .1 6
N orth east 1 5. 9 1 7 .8
2 8 6 8 98
Midw est 1 6 .6 1 7 .9
Age of smok ing initiation in male CCSs compared to males w ithout cancer by US region.
Socio Demographics Gender Male Female
D em ograph ics of adult survivors of ch ildh ood cancer com pared w ith individuals w ith out cancer h istory in th e US.
Age of Sm ok ing Initiation
A strik ing number of adult CCSs smok e cigarettes (3 4.7%), w ith smok ing prevalence in CCSs significantly higher than the noncancer controls. CCSs start smok ing at earlier ages than controls. CCSs have not benefited from tobacco control efforts targeted to the general population. Health disparities due to SES and low access to health care are strongly affecting CCSs, especially female survivors. Future prevention/ cessation interventions among CCSs should use q ualitative methods to design and test tailored interventions to suit this uniq ue population.
15 CURRENT SMOKERS
Childhood Cancer Survivors
NEV ER SMOKERS
Acknowledgment: This study was funded by Bankhead Coley Cancer Research Program Grant #1BG06-341963.
4 ! Student!Name:!Jennifer!Auf!der!Springe,!MD/MPH!Class!of!2015! Project:!Be!Merge!and!Beyond:!Exploring!Primary!Care!and!Mental!Health!Care!CoordinaEon!in!Palm! Beach!County,!FL! ! !! Background! &! Objec4ves:! The! Mental! Health! AssociaEon! of! Palm! Beach! County! works! to! improve! access! to! mental! health! care! through! its! Be! Merge! program,! which! places! mental! health! interns! in! primary!care!oﬃces!to!administer!depression!and!anxiety!screenings!and!connect!atRrisk!paEents!with! necessary! services.! This! study! seeks! to! describe! the! outcomes! of! the! Be! Merge! program! and! the! climate!of!care!coordinaEon!in!Palm!Beach!County!in!general.!!
Methods:! Data! was! collected! using! surveys! administered! to! primary! care! providers! (PCPs)! who! are! currently! involved! with!Be!Merge!and!mental!health!providers!(MHPs)!who!had!received!referrals!through!the!program!between!June!2013! and!July!2014.!! Results:! PCPs! and! MHPs! both! expressed! a! need! for! beber! communicaEon! between! the! disciplines.! A! list! of! “ideally”! shared! informaEon! was! collected,! and! barriers! to! the! management! of! mental! health! condiEons! were! idenEﬁed.! PCPs! found!Be!Merge!to!have!overall!posiEve!impacts.!!! Conclusions:!The!Be!Merge!program!has!simpliﬁed!the!process!of!diagnosis!and!referral!of!mental!health!issues!among! parEcipaEng! PCPs,! but! coordinaEon! of! care! with! MHPs! conEnues! to! be! limited.! CommunityRwide! engagement! of! providers! and! an! examinaEon! of! ﬁnancial! structures! will! be! crucial! to! developing! a! comprehensive! care! coordinaEon! structure.!!! Quantum!Springboard
Be Merge and Beyond: Exploring Primary Care and Mental Health Care Coordination in Palm Beach County, FL Je nnifer auf der Springe | MD/ MPH Class of 2015 | Department of Public Health Sciences, University of Miami Miller School of Medicine | Mental Health Association of Palm Beach County
PCPs at offices that actively participated in Be Merge at the time of data collection and MHPs who received at least 3 referrals through the Be Merge program between J une 2013 and J uly 2014 were asked to complete a survey.
Eleven million adults in the US perceived an unmet need for mental health services last year.1 •
Increasing numbers of patients are turning to their primary care providers.2 •
Specialist-level care continues to be difficult to attain when needed.3
The chronic care model is supported by the most consistent evidence and can be applied in various settings.4
Both multiple choice and open-ended free response q uestions were included.
Results Response rate: 10 of 16 PCPs (63%), 10 of 27 MHPs (37%) •
• Describe PCPs’ and MHPs’ perceptions of the climate of care coordination in Palm Beach County.
• Time constraints • Patient hesitant to share • Patient in denial • Underlying medical problems complicate picture • L anguage barrier • Stigma surrounding mental illness • Poor access to mental health resources
• Insurance limitations • Patient fails to make appointments • Patient unwilling to seek care • L ack of available services • High cost of services • Poor rapport with MHP
Barriers to longterm management (MHPs) • Insufficient funding • Environmental factors • Client does not commit to long-term treatment • MHP shortage • L ack of residential treatment programs • Insurance limitations • Clinically complex case • L ack of access to community resources
All participating PCPs stated that they would recommend Be Merge to their colleagues in primary care. •
• Identify barriers to the identification of mental health issues, the connection of affected patients with mental health services, and the long-term management of mental health conditions. • Determine potential next steps in overcoming these barriers.
Barriers to connection (PCPs)
F ig ure 2 Prov ider-identified barriers in mental health care
Effective interdisciplinary communication is still uncommon. •
MHPs: PsyD, PhD, L CSW, L MFT, L MHC, administrators; average 12 years in practice.
Barriers to identification (PCPs)
PCPs: physicians (50%), nurse practitioners (50%); average 14 years in practice; range 1 to more than 12 months with Be Merge.
• Describe outcomes of the Be Merge program as perceived by primary care providers (PCPs) and mental health providers (MHPs).
F ig ure 3 “ I deally” shared information
This study offers a glimpse of the status of care coordination between PCPs and MHPs in Palm Beach County.
Information desired by MHPs • Demographics • Age • Gender • Payment, insurance • Reason for referral • Past medical history • Referring agency
PCPs were also asked about their perceptions of Be Merge outcomes. MHPs were also asked about financial support offered to patients.
Mental health interns in local primary care offices administer mental health screenings, discuss results with patients, and make necessary referrals.
F ig ure 1 D iagram of the Chronic Care M odel5 ,6
Information desired by PCPs
All surveys solicited information regarding demographics, ongoing and potential interdisciplinary collaborative efforts, and barriers in the management of mental health conditions.
The Mental Health Association of Palm Beach County supports care coordination through its Be Merge program.
Many providers listed additional information that they would ideally receive when making or receiving a referral
• Progress notes • Diagnosis • Interventions, medications • Patient adherence • Outcomes • Cost • Philosophy
Choice was given to complete on paper or online.
There is a national movement toward integrating various elements of healthcare to promote overall health and wellbeing. •
90% reported impact on ability to identify mental health issues, connect patients with relevant services. 40% reported impact on number of patients who mentioned mental health during the visit. 80% reported a resulting change in clinic operations.
The Be Merge program successfully simplifies the process of diagnosis and referral of mental health issues among participating PCPs. •
Small sample sizes and low response rates of this study present significant limitations; further studies should attempt to increase participation of providers both within and outside the Be Merge setting.
Community-wide engagement of providers and an examination of financial structures will be crucial to building a truly comprehensive care coordination system. •
Recent healthcare legislation that encourages interdisciplinary collaboration and parity of mental and physical health may help ensure its sustainability.
Funding Acknowledgement This Capstone Project was supported by the Q uantum Foundation Springboard Grant of Palm Beach County.
Works Cited 1. US Department of Health and Human Services. R esults from the 2013 N ational Survey on Drug Use and Health: Mental Health F inding s. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014. 2. Olfson, Mark, et al. “ Trends in Office-Based Mental Health Care Provided by Psychiatrists and Primary Care Physicians.” J ournal of Clinical Psychiatry 75.3 (2014): 247-253. 3. Sanchez, Katherine, et al. “ Current strategies and barriers in integrated health care: a survey of publicly funded providers in Texas.” G eneral Hospital Psychiatry 32 (2010): 26-32. 4. Thota, Anilkrishna B., et al. “ Collaborative Care to Improve the Management of Depressive Disorders: A Community Guide Systematic Review and MetaAnalysis.” A merican J ournal of Preventive Medicine 42.5 (2012): 525-538. 5. Wagner, Edward H, et al. “ Improving Chronic Illness Care: Translating Evidence into Action.” Health A ffairs 20.6 (2001): 64-78. 6. Goodrich, David E., et al. “ Mental Health Collaborative Care and it Role in Primary Care Settings” . Current Psychiatry R eports 15 (2013): 383-394.
5 ! Student!Name:!Cecily!Barber,!MD/MPH!Class!of!2017! Project!Title:!Health!through!Walls:!Health!in!HaiEan!Prisons!! Background!&!Objec4ve:!HaiE!has!17!prison!insEtuEons!with!an!oﬃcial!capacity!of!5,958.!The!current! total! prison! populaEon! is! esEmated! at! 10,250:! occupancy! is! at! 172%.! Health! through! Walls! (HtW)! began! working! in! HaiE! in! 2009,! the! ﬁrst! ever! prison! health! project! funded! by! USAID.! ! Goals:! (1)! to! assess! the! impact! of! HIV! and! TB! on! the! HaiEan! prison! system,! (2)! to! assess! the! role! of! HtW! in! managing!infecEous!diseases!within!the!stressed!HaiEan!correcEonal!system.!! Methods:! Traveled! to! St.! Marc! to! help! HtW! staﬀ! conduct! a! 2Rday! medical! blitz! at! St.! Marc! prison.! ! Organized! and! analyzed!data!from!medical!blitzes!completed!at!13!prisons.!Assisted!with!HIV!and!TB!case!management!and!abended! peer!educaEon!programs!in!the!main!prisons!in!PortRauRPrince.!! Results:!TesEng!rates!for!HIV!and!TB!were!high,!ranging!from!71R100%,!and!rates!of!HIV!prevalence!were!o6en!higher,! ranging!from!1.6R10.3%!in!the!13!prisons,!than!the!HaiEan!prevalence!rate!esEmated!at!2.1%!in!2012.!! Conclusions:!Although!the!HaiEan!prison!system!is!disorganized,!stressed!and!overcrowded!with!alarmingly!high!rates!of! preRtrial! detenEon! and! infecEous! disease,! HtW! serves! a! disEnct! role! in! supplemenEng! the! HaiEan! Prison! Authority’s! medical!services!through!paEent!educaEon!programs!and!HIV/TB!case!management.!! ! Global!Health!Scholar
Health through Walls: Haitian Prison Health Cecily B arber MD/MPH Class of 2017, Department of Public Health Sciences, University of Miami Miller School of Medicine
According to the International Centre for Prison Studies, Haiti has 17 prison institutions with an official capacity of 5,958 The total prison population is 10,250: occupancy is at 172% 70.6% are pre-trial detainees In 2012, Haiti’ s adult HIV prevalence was 2.1% UNICEF estimated that 150,000 people of all ages were living with HIV and 12,000 were children
• • • •
1. To assess the impact of HIV , TB and Syphilis on the Haitian prison system a. Assist HtW staff to conduct 2-day medical blitz at St. Marc prison b. Organize and analyze data from medical blitzes completed at 13 prisons 2. To assess the role of HtW in managing infectious disease in Haitian prison a. Attend counseling and education program run by peer educators at male Prisone Civile and female prison in Petionville prison b. Shadow HtW physicians, nurses and case managers
HIV and Syphillis testing and disease prevalence in 13 Haitian prisons % HIV test
% HIV positive
% syphilis tested
% syphilis positive
6% 9% 6%
Community Partner: Health through Walls (HtW) began working in Haiti in 2009, the first ever prison health project funded by USAID • HtW has full-time staff in 6 of 16 prisons throughout Haiti • HtW manages HIV and TB cases, supervises prisoner-run sanitation crews, trains prisoners as peer educators and provides medical treatment support to the Haitian Prison Authority (DAP) • In an effort to expand its programs, HtW has conducted medical screening blitzes in 8 additional prisons across Haiti
I worked with HtW to conduct a 2-day medical screening blitz of all 423 prisoners at St. Marc prison Each prisoner received a comprehensive exam, HIV and STD testing, a chest X -ray, and access to psychiatric evaluation
Obj ectives • 1. To assess the impact of infectious disease, specifically TB and HIV , on the Haitian prison system 2. To assess the role of HtW in managing infectious diseases in the Haitian correctional health care setting •
• Portable Chest X -ray machine, HtW office, Prisone Civile, Portau-Prince, Haiti, 2014 Pharmacy station, Medical Blitz, St. Marc prison, Haiti J une 2014
Despite the 2010 earthq uake, the ensuing cholera epidemic, high rates of HIV and TB, HtW works with the Haitian Prison Authority (DAP) to improve prison sanitation, increase health care access and q uality, and build a more sustainable infectious disease tracking system The Haitian prison system continues to be disorganized, stressed and overcrowded with alarmingly high rates of pre-trial detention HtW serves a distinct role in supplementing the Haitian Prison Authority’ s medical services through patient education programs and HIV / TB case management The spread of HIV from the Haitian prison to the general population is complex and needs to be evaluated further
Next steps •
Compile and analyze data on TB testing and prevalence from prisons where medical blitzes were completed Analyze HIV , syphillis and TB data to investigate the difference in rates between urban and rural prisons Collect and compile data on HIV cases that have been followed by case managers after release from prison Analyze data collected from patient education pre and post-q uestionnaires Complete medical blitzes in the remaining 2 prisons in Haiti
Ack now ledgements • Department of Public Health Sciences, University of Miami, Miller School of Medicine, Miami, FL • Dr. J ohn May and Karine Duverger, Health through Walls (HtW) • International Centre for Prison Studies (ICPS) • UNICEF • WHO
6 ! Student!Name:!Amanda!Barnes,!MD/MPH!Class!of!2016! Project!Title:!A!Preliminary!Needs!Assessment!in!Miami!CommuniEes!for!a!Violence!InterrupterR Model!Gun!Violence!PrevenEon!IntervenEon! Background!&!Objec4ve:! !Violence!epidemiologists!have!equated!the!spread!of!gun!violence!to!be! similar!to!that!of!a!contagious!disease.!Based!on!this!theory,!the!violence!interrupter!model!(VIM)!of! gun! violence! prevenEon! uElizes! “violence! interrupters”! to! mediate! developing! conﬂict! situaEons.! The!current!research!endeavors!to!conduct!a!needs!assessment!to!evaluate!the!appropriateness!and! potenEal!eﬀecEveness!of!a!gun!VIM!in!a!Miami!community!demographically!similar!to!communiEes! in!which!this!model!has!already!proven!successful.! Methods:! ! Community! members! from! Historic! Overtown! are! being! recruited! at! this! Eme! via! monthly! community! organizaEon! meeEngs.! Eight! recruited! parEcipants! will! take! part! in! a! 2Rhour! focus! group! in! February! 2015.! Four! such! sessions! are! planned;! they! will! be! recorded,! transcribed,! and! qualitaEvely! analyzed.! Discussion! topics! include! the! parEcipants’:!(1)!PercepEon!of!gun!violence!in!their!community,!(2)!Ideas!on!soluEons!to!this!problem,!and!(3)!Views!on! the!appropriateness!of!a!VIM!intervenEon!in!their!community.!! Results:!The!previous!success!of!VIM!intervenEons!sets!a!hopeful!precedent.!However,!engagement!of!the!community!is! essenEal!to!maximize!beneﬁt!and!avoid!ineﬃcient!usage!of!resources.!IniEal!reacEons!have!been!recepEve,!but!formal! data!analysis!will!reveal!the!appropriateness!of!VIM!for!the!community!of!interest.!! Conclusion!&!Future!Direc4ons:!Data!analysis!is!to!be!completed!in!March!2015.!! Springboard
F irearm V iolence Prev ention in M iami D ade County Amanda Barnes, MD/MPH Class of 2016; Tanya Zakrison MD, MPH; Noella Dietz, PhD
Department of Public Health Sciences, University of Miami Miller School of Medicine
The Violence Interruption Model (VIM)
Methods • Community members from Historic Overtown are being recruited at this time via monthly community organization meetings.
• Gun violence is a major public health concern in the United States. • Firearm-related fatality is the second most freq uent cause of death among young people aged 15-25. • There has been a resurgence of interpersonal gun violence in Miami Dade County. This problem disproportionately affects young African American men.
Operation Ceasefire, Chicago
• This current research aims to conduct a needs assessment to evaluate the appropriateness and potential effectiveness of a gun V iolence Interruption Model (V IM) in a Miami community demographically similar to communities in which this model has already proven successful1, 2, 3, 4.
Ryder Trauma Center, Miami
• Operation CeaseFire in Chicago, IL (Gary Slutkin, MD) is the first V IM program • Infectious disease model to understand “ spread” of interpersonal violence • Strong community involvement
Miami Dade V iolence Profile • From 2012-2013 total violent crime in the state of Florida decreased by 2.4% while total violent crime in MDC actually increased by 0.4%. More than one-third of these crimes in MDC involved a firearm. • According to V elis et al (2010) individuals residing in MDC are more likely to die from homicide than the rest of the country. Amongst those in MDC who are victims of homicide, “ a substantial proportion of homicide victims were 22 years of age or younger” . A significant proportion of this violence has been related to gang activity.
Discussion topics include the participants’ : • Perception of gun violence in their community. • Ideas on solutions to this problem. • V iews on the appropriateness of a V IM intervention in their community (after educating participants about the intervention with a short video presentation).
Sample Focus Group Discussion Q uestions • “ I would like to hear your thoughts on any problems you may be concerned about in your community.”
• Recruits people who have been incarcerated, involved in gangs, or affected personally by violence
• “ Why do you feel that these things are a problem? How do you think that these issues have changed over time? ”
• Population predominantly non-Hispanic Black, age 15-35 • Direct interaction with carriers, non-didactic approach • 100% reduction in gang-related, retaliatory violence in several Cure V iolence sites. • Highly variable implementation Evidence of effectiveness in reducing shots fired, inj ury, death, and retaliatory violence (100% reduction) Known now as the Cure V iolence Program, V IM has been replicated in many communities both in the United States and internationally.
1. Evaluation of Baltimore’ s Safe Streets program: Effects on attitudes, participants’ experiences, and gun violence. J ohns Hopkins School of Public Health, Center for the Prevention of Y outh V iolence. Accessed Feb 16 2014 at http: / / www.rwjf.org/ content/ dam/ web-assets/ 2012/ 01/ evaluation-of-baltimore-s-safe-streets-program 2. Picard-Fritsche, S and Cerniglia, L . A public health approach to gun violence: An evaluation of Crown Heights Save Our Streets, a replication of the Cure V io lence Model. Center for Court Innovation. Accessed Feb 16 2014 at http: / / www.courtinnovation.org/ sites/ default/ files/ documents/ SOS_ Evaluation.pdf 3. Skogan, WG, Hartnett, SM, Bump, N, Dubois, J . Evaluation of CeaseFire-Chicago. University of Northwestern. Accessed Feb 16 2014 at http: / / www.skogan.org/ files/ Evaluation_ of_ CeaseFire-Chicago_ Main_ Report.03-2009.pdf 4. Webster, DW, Mendel Whitehill, J , Curriero, FC. Effects of Baltimore’ s Safe Streets program on gun violence: A replication of Chicago’ s CeaseFire program. J ournal of Urban Health. 2013 February; 90(1): 27-40. 5. V elis E, Shawn G, Whiteman AS. V ictims’ profile analysis reveals homicide affinity for minorities and the youth. J ournal of I nj ury and V iolence R esearch. 2(2): 67-74. J une 2010.
• Trains individuals who live in the communities that they serve
• Peer-to-peer approach
• Eight recruited participants will take part in a 2-hour focus group in February 2015. Four such sessions are planned; they will be recorded, transcribed, and q ualitatively analyzed.
• “ If you had no restrictions, how would you improve _ _ _ _ _ _ issue in your community? ” • “ What do you think are the barriers to making these suggested changes? ” • “ What do you think about the V IM intervention? ” • “ How do you think a V IM intervention would affect your community? ”
Conclusions & Future Directions • The previous success of V IM interventions sets a hopeful precedent. • Initial reactions have been receptive, but formal data analysis will reveal the appropriateness of V IM for the community of interest. • Data collection scheduled for completion in March 2015. This project was founded through the UM Department of Public Health Sciences Springboard Grant
7 ! Student!Name:!Kimberly!Berger,!MD/MPH!Class!of!2017! Project:!Open!MRS!ImplementaEon!at!Marmont!Maternity!Clinic!in!Marmont,!HaiE! Background:! Project! Medishare! is! nonRproﬁt! enEty! that! provides! comprehensive! health! and! development!services!in!HaiE!since!the!2010!earthquake.!!The!organizaEon!treats!more!than!180,000! paEents! and! has! a! range! of! health! care! services! that! it! provides.! ! With! lible! resources! current! medical! records! have! been! managed! in! paper! form.! ! Project! Medishare! aims! to! transiEon! into! an! electronic!medical!record!system.! !The!use!of!Electronic!Medical!Records!(EMR)!has!been!shown!to! improve!health!care!management!and!reduce!medical!error.!! Methods:! ! Following! a! needs! assessment! done! in! July! 2013,! the! UM! Project! Medishare! team! proposed! to! deploy! the! open! source! EMR,! OpenMRS,! in! Marmont! Maternal! Health! Clinic! as! part! of! a! comprehensive! community! health! data! system.!This!project!seeks!to!implement!the!EMR,!develop!a!process!for!uElizaEon!of!EMR!in!the!clinic,!and!train!clinic! staﬀ!on!how!to!use!the!EMR.!!!! Results:!Worked!with!clinic!staﬀ!to!develop!an!EMR!that!is!userRfriendly!and!integrates!well!into!clinic!pracEce.!We!also! began!to!train!clinic!staﬀ!on!how!to!navigate!the!EMR,!which!will!help!to!reduce!disrupEons!in!clinic!workﬂow!when!the! EMR!is!deployed.!!! Conclusions:!Deployment!of!the!EMR!in!Marmont!is!the!ﬁrst!step!in!improving!community!health!care!infrastructure!in! HaiE’s!central!plateau.!Although!this!project!experienced!several!setbacks,!signiﬁcant!progress!was!made!in!developing! an!EMR!that!the!clinic!staﬀ!will!be!saEsﬁed!with.!The!next!step!in!this!project!will!be!to!deploy!the!EMR!and!establish!a! troubleshooEng!network.!! Global!Health!Scholar
Electronic Medical Record Deployment In Rural Haiti Department of Public Health Sciences
Kimberly Berger MD/MPH Class of 2017, University of Miami Department of Public Health Sciences, Miller School of Medicine
BACKGROUND • Following needs assessments done in J uly 2013, the UM Project Medishare team proposed to deploy the open source EMR, OpenMRS, in Marmont, Centre, Haiti as part of a comprehensive community health data system.
• Developed an open source EMR for the Maternal Health Center. • The EMR was successfully formatted to resemble the previously used paper charts and allow for easier aggregation of data for reporting purposes.
• Use of Electronic Medical Records (EMR) has been shown to improve health care management and reduce medical error2
• Determined that a ‘point of contact’ model is the most efficient way to utilize an EMR at the Maternal Health Center.
• Coherent data collection is especially important for improving developing nation’s health care system 1
• Began training of clinic staff on how to navigate the EMR.
• Challenges to implementing EMR systems in resource poor areas: • L ack of stable electricity and internet • Cost of implementation: monetary and time spent training • Ensuring the EMR is conducive to clinic workflow • L ack of local technical support
Sites of OpenMRS deployment
• OpenMRS was developed by Partners in Health and has been deployed in over 70 countries with similar resource settings to the Maternal Health Center in Marmont.
• Although this project experienced several setbacks, significant progress was made in developing an EMR • Community involvement and local resource development is important in every stage of EMR implementation.
COMMUNITY PARTNER • Project Medishare is a non-profit organization based in Haiti committed to developing sustainable programs that promote the health of the community. • Services provided by Project Medishare in the Central Plateau include: • Providing affordable or free medical care in multiple stationary and mobile clinics • Training Haitian health professionals • Promoting preventative health care and community health education • Maintaining a community health worker program • Provide maternal health care services • Improved medical record infrastructure will allow for better continuity of care, improved surveillance and reporting, and more accurate medical records.
• Improving the health informatics structure in the Maternal Health Center will allow for better continuity of care, improved reporting to the Haitian Ministry of Health, and even create a potential data source for outside health research. • Deployment of the EMR in the Maternal Health Center is the first step in improving community health care infrastructure Example of OpenMRS patient chart
OBJ ECTIV ES • • •
Assist with the implementation of an openMRS electronic medical record system at the Maternal Health Center. Train clinic staff on using openMRS. Evaluate and coordinate processes for using the openMRS system. Determine what is the most efficient way to utilize EMR. Assess process bottlenecks: where time is being lost while using the electronic medical record system.
• Deploy EMR at Maternal Health Center • Train local personnel to manage and tailor the system to meet community needs. • Implement the EMR at other Medishare clinics, including mobile clinics, to create a comprehensive community health data system. Patient rooms at Maternal Health Center
REFERENCES 1. Fraser, H. S., Blaya, J ., Choi, S. S., Bonilla, C., & J azayeri, D. (2006). Evaluating the impact and costs of deploying an electronic medical record system to support TB treatment in Peru. A MI A A nnual Symposium Proceeding s, 2006 , 264– 268. 2. J oaq uin A. Blaya, Hamish S.F. Fraser and Brian Holt E-Health Technologies Show Promise In Developing Countries Health A ffairs, 29, no.2 (2010): 244251
FUNDING This field experience was supported with funds from the Global Health Scholar Award
CONTACT Kimberly Berger MD/ MPH Public Health Student University of Miami Email: k.berger1@ med.miami.edu
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Community-Based Primary Health Care in Action in Rural Nicaragua Scott L B erg er MD/MPH Class of 2017, Department of Public Health Sciences, University of Miami Miller School of Medicine Dr. L aura Paraj on, A lex is Sieg el, and Desiree Sanabria, A MO S Health & Hope, Manag ua, N icarag ua
Introduction AMOS Health &
Non-government organization (NGO) that partners with 27 rural communities— as of J une 2014— to improve health outcomes through the model of community-based primary health care (CBPHC).
Obj ectives (continued) Naw aw acito Water Supervision
Naw aw acito 1. Assess overall health outcomes (diarrhea, disease, q uality of life) in families with SAM-III Water Filter 2. Identify areas for q uality improvement in filter maintenance
L imited use of their own vegetables and cheeses; not eating at tables; many children drink coffee Two pregnant mothers were encouraged by other mothers using evidence-based information to plan for a delivery at MINSA
Methods AMOS is located in Managua, Nicaragua
Banco de Siq uia and Nawawacito are both located in the southeastern autonomous state of Regió n Autonó mica Atlá ntica Sur (RAAS)
Height, weight, and hemoglobin levels
Shares current practices and evidence with AMOS so that they can do ongoing evaluations and research so that appropriate evidence-based practices can be shared with and benefit their community and others
Banco de Siq uia Malnutrition & Anemia
Knowledge, Assessment, and Practice (KAP) interviews with mothers Women’ s Focus groups Water Filter Interview & Surveys
Recipient maintenance, spout maintenance, filter covers, and hand washing are areas for q uality improvement
Evaluation of filter water q uality, recipient water q uality, filter maintenance techniq ue, and rate of water filtration
Activities Health Fair
Community Empow erment— focus groups, photovoice, and community health worker programs— helped get men, women, and children involved in improving community health. Three-Way Partnership— NGOs, community members, and MINSA worked together to implement a strategy for maternal and child health
Obj ectives Banco de Siq uia: 1. Evaluate current prevalence of anemia and malnutrition in children under 5 2. Identify observations of factors that may contribute to anemia and malnutrition in children 3. Identify observations made by the community as future intervention targets
Water sanitation; trash disposal; and eating habits identified by Photovoice as areas community members want to address L ower rates of diarrhea, improved taste, and improved q uality of life unanimously reported with the SAM-III water filter
Photovoice with men, women, and children
Trained by AMOS as a first responder, liaison for the Ministry of Health (MINSA), and leader for implementing evidence-based practices introduced by AMOS
24% iron deficiency anemia. 23.5% malnutrition by weight, 18% malnutrition by height
SAM-III Water— lower rates of contamination, lower rates of diarrhea, and improved self-reported q uality of life Focus Group & Crafts
Water Filter Surveys
Ack now ledgements Thank you to my field team— L orente L ester, Guillermo, Carlos, Sarah Williams, J ared Stoneman, Summer Preg, Madeline Plaster, and Harris Short— and to my fellow Global Health Interns. This field experience was supported with funds from the Global Health Scholar Award
9 ! Student!Name:!Stephanie!Blankenship,!MD/MPH!Class!of!2016! Project:!Knowledge!and!Acceptability!of!Anal!Cytology!Screening!Among!Women!HIV+!Women!at! Jackson!Memorial!Hospital!! Background:! Medical! providers! have! iniEated! anal! cytology! screening! for! HIVRposiEve! women,! who! experience! higher! rates! of! HPV! infecEon! and! HPVRrelated! anal! cancer! than! the! general! populaEon.! Lack!of!educaEon!about!HPV!and!anEcipated!discomfort!may!limit!paEent!acceptance!of!screening.! The!current!study!invesEgates!a~tudes!toward!highRresoluEon!anoscopy!(HRA),!the!followRup!test!for! women!with!abnormal!anal!cytology.!! Methods:! Women! at! Jackson! Memorial! Hospital! were! invited! to! complete! an! anonymous! survey! assessing! their! understanding!of!HPV!and!anal!cancer!risk!factors.!Subjects!reported!the!level!of!pain,!discomfort!and!embarrassment! they!expected!and!subsequently!experienced!during!HRA!on!a!100mm!Visual!Analogue!Scale!(VAS).!! Results:!Among!a!convenience!sample!of!55!women,!only!oneRﬁ6h!(21.8%)!reported!knowing!“a!lot”!about!the!health! problems!HPV!causes.!Less!than!half!(47.3%)!believed!HPV!increases!the!risk!of!anal!cancer;!34.5%!recognized!HPV!as!an! anal!cancer!risk!factor.!Mean!level!of!pain,!discomfort!and!embarrassment!expected!before!HRA!as!reported!on!the!VAS! was! 56.4mm,! 69.4mm! and! 59.4mm,! respecEvely,! compared! to! 38.2mm,! 57.5mm! and! 50.7mm! actually! experienced! during!HRA.! Conclusions:!Enhanced!paEent!educaEon!about!the!link!between!HIV,!HPV!and!anal!cancer!and!the! importance!of!HRA!is!necessary!to!increase!acceptance!of!anal!cancer!screening.!
Know ledge and Acceptability of High-Resolution Anoscopy among HIV + Women at J ack son Memorial Hospital Stephanie A . B lank enship MD/MPH Class of 2016 , Department of Public Health Sciences, University of Miami Miller School of Medicine
Results Table 1. Patient D emograp hics
HIV + women are at high-risk of cervical and anal HPV co-infection. Anal cancer incidence is significantly higher in HIV + women than in the general population. •
Incidence of HPV -associated anal cancer has increased over the past thirty years, but the medical community has not agreed on routine screening and early treatment protocols for anal HPV infection, contributing to the rising incidence. •
Gynecologists at J ackson Memorial Hospital have initiated anal cytology screening among HIV + women via anal Pap smear testing.
High-resolution anoscopy (HRA) is the follow-up test for women with abnormal anal cytology. HRA helps determine the degree of precancerous anal dysplasia and direct therapy. L oss to follow-up at J ackson among HIV + women with abnormal anal Pap smear results presents a significant challenge, as many women do not return for HRA.
Age Y ears (n=48) Ethnicity Hispanic or L atino Haitian Other Income 0-9,999 10,000-19,999 20,000-29,999 30,000-39,999 ≥40,000 Education College degree or higher V ocational/ Technical School Finished high school/ received GED Did not finish high school
Results Table T Ta b 2 . K nowledge of H PV and Anal Cancer
Mean (SD) 46.4 (10.3)
Kno ledge of Health Problems Know ca caused by HPV ha never heard of HPV I have don t know about the health I don’ problems HPV causes I kknow a little about the health problems HPV causes I kknow a lot about the health problems HPV causes
N (%) (n= 41) 16 (39.0) 10 (24.4) 15 (36.6) N (%) (n= 50) 26 (52) 12 (24) 7 (14) 3 (6) 2 (4)
Being older Being overweight Smoking Having anal sex High number of sexual partners Having a weak immune system Having HIV Having HPV
The mean age of women participating was 46.4 years (SD 10.3). Among women reporting their ethnicities, 16 (39%) were Hispanic. 37 (80%) women surveyed were black, of which 10 (27%) identified their ethnicity as Haitian.
Only one-fifth (21.8%) reported knowing a lot about the health problems HPV causes. •
L ess than half (47.3%) recognized HIV as an anal cancer risk factor. Only one-third (34.5%) recognized HPV as a risk factor. •
Among women not interested in having HRA, two-thirds (64%) reported they did not know enough about it.
7 (12.7) 19 (34.5) 12 (21.8)
What do you think increases your chance of getting anal cancer?
N (%) (n= 53 ) 5 (9.4) 5 (9.4) 22 (41.5)) 21 (39.6))
N (%) (n= 55)
N (%) (n= 55)
5 (9.1) 6 (10.9) 18 (32.7) 17 (30.9) 9 (16.4) 10 (18.2) 26 (47.3) 19 (34.5)
After undergoing HRA, the majority (75.9%) reported it was not as bad as expected.
Mean level of pain and discomfort expected prior to undergoing HRA was significantly greater than levels actually experienced during HRA (p<0.05), though mean level of embarrassment did not show a statistically significant difference (p=0.53).
HIV -positive women with abnormal anal cytology seen at a gynecology clinic at J ackson Memorial Hospital were offered the opportunity to complete a survey about their HRA experience. A convenience sample of 55 women agreed to participate, although not all women answered every q uestion.
Patients reported the level of pain, discomfort and embarrassment they expected to experience and actually experienced during HRA on a 100mm V isual Analogue Scale (V AS) on pre- and post-HRA surveys.
Health care providers also completed a survey to share their perception of their patients’ level of pain and discomfort during HRA. •
Descriptive statistics were calculated using SPSS 22.0.
Paired samples t-tests compared mean level of pain, discomfort and embarrassment patients expected prior to undergoing HRA to levels actually experienced during HRA using a 95% confidence interval.
Independent samples t-tests compared mean level of pain and discomfort patients reported experiencing during HRA to the health care provider’ s perception of their patients’ experiences using a 95% confidence interval.
The objective of this study was to identify knowledge gaps among women regarding HPV and anal cancer risk factors, and to assess their attitudes toward HRA and experience undergoing HRA. Additionally, the study served to investigate perceptions of the patient experience during HRA among health care providers. This study was approved by the University of Miami Institutional Human Subjects Review Board (20130906).
Not at all Somew hat N (%) N (%)
How familiar are you with what is involved in having HRA? (n=53) How helpful do you think having HRA is to diagnose cancer early? (n=55) How worried are you about having HRA? (n=54) How interested are you in having HRA? (n=54)
Why are you NOT interested in having HRA? I don’ t know enough about it I don’ t have anal sex I would be too embarrassed It might hurt I had one before and don’ t want another It costs too much I don’ t want the info in my medical chart I have more important problems I don’ t want to know if I have anal cancer Other
The lower levels of pain and discomfort health care providers perceived among their patients during HRA compared to the higher levels patients reported experiencing on the V AS were both statistically significant ( p<0.05).
Table 4. Attitudes after undergoing H RA
Table 3. Attitudes before undergoing H RA •
V ery N (%)
N (%) (n= 25) 16 (64) 11 (44) 6 (24) 8 (32) 2 (8) 2 (8) 1 (4) 3 (12) 3 (12) 6 (24)
T-tests Pain (mm) Mean level expected 56.6 vs. 38.2 vs. experienced by the (p=0.000) patient
Discomfort (mm) 69.4 vs. 57.5 (p=0.037)
Embarrassment (mm) 59.4 vs. 50.7 (p=0.053)
Mean level 38.2 vs. 25.2 experienced, as (p=0.014) reported by the patient vs. perceived by the provider
57.5 vs. 33.2 (p=0.000)
If you have previously had colposcopy, w hich w as more…
Colposcopy N (%)
HRA N (%)
Same N (%)
Painful? (n=41) Embarrassing? (n=40) Comfortable? (n=40)
9 (22) 3 (7.5) 3 (7.5)
8 (19.5) 11 (27.5) 9 (22.5)
24 (58.5) 26 (65) 28 (70)
When I had the HRA procedure, I thought it w as…
Agree N (%)
Disagree Not N (%) Sure/ Ne utral N (%) 14 (26.9) 7 (13.5) 24 (48) 5 (10) 2 (3.8) 4 (7.7) 7 (13) 6 (11.1)
Scary (n=52) Not a big deal (n=50) Necessary (n=52) Not as bad as I expected (n=54)
31 (59.6) 21 (42) 46 (88.5) 41 (75.9)
L ack of knowledge among women regarding the link between HPV , HIV and anal cancer presents an opportunity for health care providers to enhance patient education.
F igure 1: 100mm V isual Analogue S cale
Providers need improved understanding of the patient experience during HRA to effectively counsel patients about their concerns and increase adherence to screening.
Mean Level of Pain, Discomfort and Embarrassment Patients Expected vs. Experienced during HRA, as reported by Patients and Perceived by the Health Care Provider
Implementation of an educational video that emphasizes the importance of anal cancer screening despite anticipated discomfort is indicated to increase adherence to HRA.
Ack now ledgements This project was supported by funds from the Springboard Grant. Thank you to Dr. J ulie Kornfeld, Dr. L anetta J ordan, Felicia Casanova, Rosa V erdeja, Manny Ocasio and the Department of Public Health Sciences for their support of this project. Many thanks to Dr. J onell Potter, Dr. J orge Garcia, Dr. Karla Maguire and the Department of Obstetrics and Gynecology for their advising and continued support. Thank you also to my fellow students assisting with this project, Priyanka Debnath, Alec Szlachta-McGinn, Ali Aserlind and Emma L ipshultz.
10 ! Student!Name:!Gaelle!BrunRCoban,!MD/MPH!Class!of!2017! Project:!Global!Women’s!Health!with!an!NGO!in!Mysore,!India! Background:! ! The! Public! Health! Research! InsEtute! of! India! (PHRII)! in! an! NGO! out! of! Mysore,! India! dedicated! to! improving! women’s! health! through! public! health! research! and! intervenEons.! ! Their! acEviEes!are!based!at!a!women’s!clinic!in!Mysore!and!performed!out!of!a!mobile!van!travelling!to!rural! villages!outside!of!Mysore.!!!My!goal!was!to!observe!and!idenEfy!the!challenges!faced!by!these!women! and!communiEes,!and!to!see!how!they!were!addressed!by!PHRII.! Methods:! Shadowed! medical! personnel! during! the! camps! and! clinics,! and! helped! by! tesEng! for! blood! types! and! HIV/ AIDS.!Observed!several!group!and!individual!interviews,!which!were!aimed!at!idenEfying!health!behaviors!and!assessing! the!community’s!impact!on!women’s!health.! !Talked!to!the!nurses!and!doctors!at!PHRII!to!get!their!take!on!the!current! situaEon!of!women’s!health!in!these!rural!villages.! Results:!!Gained!insight!into!the!current!challenges!faced!by!proponents!of!improving!women’s!health!in!India,!and!into! the!general!state!of!the!Indian!health!system.! ! !Some!challenges!include!women’s!dependency!upon!their!husbands!to! get! to! doctor’s! appointments,! the! distance! of! hospitals! from! their! villages,! and! remnants! of! discriminaEon! against! scheduled!castes!and!tribes.! Conclusions:!!Hardships!faced!by!women!in!this!rural!area!include!health!illiteracy,!inadequate!access!to!care,!and!gender! and! caste! discriminaEon.! ! ! PHRII’s! eﬀorts! in! connecEng! pregnant! women! to! prenatal! care! are! just! one! step! of! many! necessary!to!ensure!these!rural!tribes!and!villages’!health!care!needs!are!met.! Global!Health!Scholar
GLOBAL WOMEN’ S HEALTH WITH AN NGO IN MY SORE,INDIA Department of Public Health Sciences
Gaelle Brun-Cottan, BA, BS MD/MPH Class of 2017, University of Miami Department of Public Health Sciences, Miller School of Medicine
Insights Gained MAPS
Public Health Research Institute of India (PHRII) The Mission • To deliver q uality health and reproductive care regardless of economic status. • To provide health education in underserved areas. • To do public health research to improve women’ s health.
Barriers for access to prenatal care is the distance of regional hospitals (a minimum of one hour by car) for women in rural Mysore. •
Husband and in-laws have to consent to a hospital birth for it to happen (this is part of the reason why the educational camps are for the whole village). •
Caste discrimination and discrimination toward the displaced tribes, despite governmental assistance, is a barrier for health care of any kind.
Group Counseling at a Medical Camp
Fieldw ork Overview Areas of Activity • Traveled with mobile vans providing education and care in remote villages around Mysore- a new one every week. • Observed cervical cancer screening clinics in Mysore. • Interacted with PHRII partners at J .S.S. Hospital in Mysore.
PHRII has a set monthly and yearly schedule of village visits that allows for communication with the population Accredited Social Health Health Activist (ASHA) and for a good turnout of people for their camps, around ten pregnant women per village.
Individual Blood/ Urine testing at a Medical Camp
PHRII is currently working on a way to evaluate its medical and educational interventions, which is particularly difficult in a mostly illiterate population.
Obj ectives • To improve my understanding of the status of Indian health care and women’ s health in India. • To observe the functioning of a small nongovernmental organization in Mysore. • To gain insight into HIV / AIDS vertical transmission and prevention. • To contribute to research in women’ s health • To understand how culture affects women’ s health and health care.
One page of advice for pregnant women.
CONTACT Ack now ledgment:
Individual Blood/ Urine testing at a Medical Camp in a school (with me assisting).
This field experience was supported with funds from the Global Health Scholar Award. With special thanks for my preceptor Dr. Purnima Madhivanan.
Gaë lle Brun-cottan, BA, BS MD/ MPH Public Health Student University of Miami Email: g.bruncottan@ med.miami.edu Phone: (617) 460-5473
11 ! Student!Name:!Katherine!Camﬁeld,!Emma!Crichton,!Erin!Dunn!&!Jennifer!Shiroky,!MD/MPH! Class!of!2017! Project:!Assessing!Community!Needs!and!Health!Knowledge:!Enhancing!DOCS!Health! EducaEon!IniEaEves! Background!&!Objec4ves:!!The!Mitchell!Wolfson!Sr.!Department!of!Community!Service!(DOCS)!is! a! nonproﬁt! student! organizaEon! providing! screenings! via! annual! health! fairs! in! communiEes! characterized!by!health!disparity!and!poor!access!to!insEtuEonalized!healthcare.!In!Fall!2014,!four! MD/MPH! students! began! assessing! the! health! knowledge! and! needs! of! Hialeah! and! Lible! HaiE,! two! communiEes! in! which! DOCS! holds! annual! health! fairs.! Goals! include:! (1)! distribuEng! our! ﬁndings!within!DOCS!and!target!communiEes,!(2)!informing!the!services!oﬀered!at!individual!fairs,! and!(3)!tailoring!educaEonal!iniEaEves!to!meet!community!needs.!! Methods:! Principles! of! CommunityRbased! ParEcipatory! Research! (CBPR)! were! used! to! guide! the! needs!assessment.!Abended!Community!Advisory!Board!meeEngs!and!surveyed!paEents!at!the!Hialeah!and!Lible!HaiE!Health! Fairs! using! rapid! assessment! surveys.! Next! steps! include! InsEtuEonal! Review! Board! approval! for! comprehensive! surveys! of! target! communiEes! and! focus! groups! to! elucidate! gaps! in! health! knowledge,! accessibility! of! health! services,! and! to! inquire! about!appropriate!educaEonal!mediums.! Results:! Health! fair! surveys! illuminated! notable! diﬀerences! in! how! communiEes! heard! about! the! fair! and! their! access! to! healthcare!resources.!In!Hialeah,!most!heard!about!the!fair!from!ﬂyers,!whereas!in!Lible!HaiE,!from!the!radio!in!Lible!HaiE.!The! majority!had!somewhere!to!go!for!health!concerns!in!Lible!HaiE!but!not!in!Hialeah.!For!both!groups,!most!found!the!locaEons! convenient!and!abended!the!fairs!for!free!screenings.! Conclusions:!Conclusions!from!preliminary!surveys!highlighted!the!diversity!of!community!preferences!and!healthcare!access! and!aﬃrm!the!necessity!of!idenEfying!unique!community!proﬁles.! Springboard
Assessing Community Needs in Health Know ledge: Enhancing DOCS Health Education Initiatives Katherine Camfield, Emma Crichton, Erin Dunn and J ennifer Shiroky MD/MPH Class of 2017, Department of Public Health Sciences, University of Miami Miller School of Medicine
OV ERV IEW
UMMSM D OCS is a student run, non-pro organiz ation th at screens for m ost prevalent diseases in underserved and uninsured co ties in South Florida Th is project consists of conducti needs assessm ents in L i e Ha ti and Hialeah , tw o co ties w ith long-standing D OCS h ealth fairs Results w ill provide D OCS w ith inform ation on h ow to b est serve th e speci needs of th ese uniq ue co ties
OBJ ECTIV ES D evelop fram ew ork for needs assessm ents in Hialeah and L i e Ha ti co ties D escrib e prevalence of com m on ch ronic diseases w ith in co ties Investigate th e b arriers to h ealth care and understanding of h ealth topics w ith in co ties Use inform ation collected to h elp D OCS create m ore com m unity -centered h ealth fairs D evelop appropriate and e e tive h ealth education interventions
RESULTS Table 1: Results of Informal Surveys from 2014 Hialeah and Little Haiti Health Fairs.
Gender (M/ F)
How did you hear about the fair?
What brought you to the fair?
Acronyms: UMMSM: University of Miami Miller School of Medicine DO CS: Mitchell W olfson Sr. Department of Community Service
ti z e th e principles of com m unity b ased pa ticipatory research (CBPR) to carry out needs assessm ents in Hialeah and L i e Ha ti Th is involves: Building partnersh ips w ith com m unity leaders th rough th e J ay W eiss Insti te at UM Sy lvester Com preh ensive Cancer Center Com m unity Advisory Boards (CABs) of Hialeah and L i e Ha ti Conducti form al and inform al interview s w ith k ey stak eh olders and com m unity m em b ers Adm inistering Rapid Assessm ent Survey s to patients at th e 2 0 1 4 Hialeah and L i e Ha ti Health Fairs Present results to CABs and use feedb ack to guide developm ent of future form al assessm ents
Do you have a place to go for health concerns?
Hialeah Health Fair (n= 3 0) M 10(33%) F 20(66%) Y es 24(80%) No 6(20%) Flyer 10(34%) Mail 6(20%) Church 6(20%) Radio 4(13%) Friend/ Family 4(13%) Free Screenings 18(60%) Specific Concern 10(33%) Other 2(7%) Education 0(0%) Y es 10(33%) No 20(67%)
Little Haiti Health Fair (n= 52) M 12(33%) F 38(73%) No Response 2(4%) Y es 50(96%) No 0(0%) No Response 2(4%) Flyer 2(4%) Mail 2(4%) Church 1(2%) Radio 37(71%) Friend/ Family 9(17%) Other 3(58%) Free Screenings 26(50%) Specific Concern 19(36%) Other 12(23%) Education 0(0%) Y es 37(71%) No 10(19%) Other 3(6%) No Response 2(4%)
FUNDING ACKNOWLEDGEMENT This initiative was supported with funds from the UM Department of Public Health Sciences Springboard Grant
PRELIMINARY FINDINGS Inform al survey s h igh ligh ted th e diversity of com m unity preferences regarding h ealth care delivery Collab oration w ith CAB dem onstrated th at valid, com m unity -centered research req uires th e developm ent of trusti relationsh ips w ith com m unity m em b ers. Th ese prelim inary conclusions a rm th e necessity of developing m ore in depth survey to b e er understand th ese uniq ue co ties
FUTURE DIRECTIONS Gain Institutional Review Board approval for indepth surveys and focus groups w ithin Hialeah and Little Haiti • In-depth surveys w ill be a broad sample of community members that may or may not attend the annual health fairs • Focus groups w ill be created through collaboration w ith CABs Focus groups w ill: • Investigate prevalent health issues and chronic disease profiles • Gauge individual understandings and gaps in k now ledge of disease courses and treatments • Inq uire about appropriate educational mediums • Learn w hat community members expect and desire from DOCS health fairs and w hat is currently appreciated • Gain better understanding of access to care Develop informed and appropriate educational initiatives for DOCS that benefit target communities
12 ! Student!Name:!Zin!Chan,!MD/MPH!Class!of!2017! Project:!EvaluaEng!the!Cervical!Cancer!PrevenEon!and!Treatment!Program!at!PopulaEon!Services! InternaEonal!(PSI) Background:! In! Myanmar,! cervical! cancer! is! the! second! most! frequent! cancer! among! women! ages! 15R44.!PopulaEon!Services!InternaEonal!(PSI)!created!the!CCP!Program,!uElizing!VIA!screening!method! and!cryotherapy!treatment!to!reduce!cervical!cancer!morbidity!in!the!country.!This!poster!provides!an! overview!of!the!CCP!program,!as!well!as!problems!encountered!and!proposed!soluEons.!! Field! Experience:! My! main! role! at! PSI! was! to! analyze! data! pertaining! to! the! CCP! program! and! to! present! a! progress! report.!The!data!was!used!to!track!the!number!of!VIA!screenings!and!cryotherapy!treatments,!as!well!as!to!track!paEents! with!posiEve!VIA!exams!that!became!lost!to!followRup!at!the!OB/GYN.! Insights:! Large! dispariEes! exist! between! rural! and! urban! parts! of! Myanmar,! in! terms! of! healthcare! faciliEes! and! resources.! Complicated! medical! cases! are! referred! to! ciEes.! However,! rural! paEents! do! not! always! have! the! money! or! resources!to!go!to!ciEes!to!get!treated!for!their!medical!condiEons.! Conclusions:! Burmese! culture! does! not! encourage! public! dialogue! for! sexual! health.! Thus,! women! are! put! at! risk,! presenEng!with!gynecological!diseases!like!cervical!cancer!at!a!later!stage.!Public!percepEon!and!social!sEgma!needs!to! be!altered!over!Eme!to!promote!sexual!health.!! ! Global!Health!Scholar
Evaluating a Cervical Cancer Prevention and Treatment Program in Myanmar Z in Htet Chan
Population Services International
MD/MPH Class of 2017, University of Miami Department of Public Health Sciences, Miller School of Medicine
OTHER ACTIV ITIES
CERV ICAL CANCER PREV ENTION AND TREATMENT PROGRAM (CCP)
Myanmar, also known as Burma, has a population of 20.82 million women (ages 15+ ), who are at risk of developing cervical cancer. In Myanmar, cervical cancer ranks as the 2nd most freq uent cancer among women ages 15-44 years. Currently, V isual Inspection with Acetic Acid (V IA) method is utilized to screen for cervical cancer. • V IA method is cheaper, does not rely on lab analysis, and req uires fewer doctor visits. Abnormal cervical lesions show up as white treated with cryotherapy
• • • • •
Program developed under the Reproductive Health/ Maternal and Child Health Department of PSI General practitioners screen for cervical cancer using V IA Only OB/ GY N doctors can provide cryotherapy treatment • L imited supply of OB/ GY N in the country PROBLEM: Patients with positive V IA tests lost to follow-up SOLUTION: Implement referral card system with specific patient IDs to track patients who are lost to follow-up • Referral card system implemented at start of 2014
MY ANMAR/ BURMA
V isited the clinics of Sun Q uality Health providers • Ahlone, Y angon city clinic • Darpain, Y angon peri-urban village clinic Attended training workshop for birth control arm implants (Implanon) Prepared a video script draft for a multimedia project regarding the personal story of a Cervical Cancer Survivor
Implemented Referral Card
Private clinic of SQ H provider in Darpain V illage
Understand the healthcare system in Myanmar Gain comprehensive knowledge about cervical cancer, including various screening methods, treatments and prevention L earn how public health data is collected in a developing country Evaluate efficacy of the newly developed cervical cancer referral system
Population Services International (PSI) • Non-profit organization founded in 1970 • Branches in 69 different countries, with world headq uarter in Washington D.C. • Use social franchising methods to distribute health product, services, and education in developing countries • SUN Q uality Health – network of general practitioners with private clinics • SUN Primary Health – network of trained community workers • Mission: Improve the health of poor and vulnerable populations in developing countries through social marketing
OBJ ECTIV ES
Touring the facilities at the private clinic
Burmese Health Pamphlet about Cervical Cancer
Cultural competency – Women in Myanmar do not get annual gynecological check ups and only go to OB/ GY N doctors when they have a specific problem. Health Disparity – Women with positive V IA tests in rural areas do not have money or resources to go to nearby cities to get cryotherapy treatment from an OB/ GY N. Resourcefulness – Pap smears are too expensive to use widely in Myanmar. The V IA screening method is just as effective as Pap smears to screen for cervical cancer.
FIELD EX PERIENCE • •
• • •
Analyze data pertaining to the CCP program in 2014 • Track # of V IA screenings and cryotherapy treatments • Track patients lost to follow-up • Keep track of achieved DAL Y s and target DAL Y s Identify best sites to contract more OB/ GY N doctors to deliver cryotherapy treatments Present progress report of the CCP program in 2014 to Reproductive Health team Develop budget for the continuation and expansion of the CCP program •
FUTURE DIRECTIONS •
• • PSI office building in Y angon, Myanmar
Track ing Patients Lost to Follow -Up
Presenting CCP Progress Report
Promote public dialogue on women sexual health • Annual gynecological visits for women • Health pamphlets for STDs and sexual health Contract and train more OB/ GY N doctors to deliver cryotherapy treatments One Stop Treatment for cervical cancer – Collaboration between general practitioners and OB/ GY Ns to deliver cryotherapy at the same time an abnormal lesion is found in cervix
HPV Information Centre International Agency for Research on Cancer (IARC)
FUNDING This field experience was funded by the Global Health Scholars Award from the University of Miami Department of Public Health Sciences.
CONTACT Z in Htet Chan MD/ MPH Candidate University of Miami Email: zhc3@ med.miami.edu Phone: (917) 841-2222
13 ! Student!Name:!Michelle!Chong,!MD/MPH!Class!of!2017! Project:!Community!Health!and!Health!EducaEon!at!the!Jubilee!House!Community!in!Ciudad!Sandino,! Nicaragua! Background! &! Objec4ve:! The! Jubilee! House! Community! is! a! nonRproďŹ t! organizaEon! in! Ciudad! Sandino,!Nicaragua.!In!addiEon!to!providing!health!care,!the!clinic!works!alongside!health!promoters,! clinic! staďŹ€,! and! visiEng! volunteers! to! improve! the! health! and! wellness! of! the! local! community.!! ObjecEves!were!to!idenEfy!health!needs!of!the!community!and!assist!in!the!development!of!a!survey! to!assess!the!prevalence!of!Pap!test!usage.!! Methods:!Abended!focus!groups,!went!on!home!visits!with!health!promoters,!and!helped!create!material!for!educaEon! sessions.! To! develop! the! Pap! survey,! worked! with! MPH! and! PhD! volunteers! who! carried! out! the! survey! with! health! promoters.!Survey!was!conducted!over!six!days!and!reached!1,117!women.!! Results:!Only!70%!of!women!between!ages!18R29!had!ever!had!a!Pap!test,!and!80%!of!women!between!ages!30!and!69,! had!a!Pap!test.!Major!reasons!for!not!having!had!a!Pap!were!not!wanEng!to,!fear,!and!pain.!! Conclusions:!With!only!70R80%!of!women!ever!having!goben!a!Pap!test,!the!clinic!should!target!increasing!Pap!tests!as!a! way!to!improve!the!high!mortality!due!to!cervical!cancer.!Since!the!primary!reasons!were!behavioral!rather!than!lack!of! knowledge!of!the!test,!the!clinic!could!seek!to!make!the!experience!more!comfortable!for!women.!Experience!with!the! JHC!also!served!to!idenEfy!other!needs!in!paEent!educaEon!programs!and!chronic!disease!care,!for!potenEal!follow!up! work.!!! ! !!!!!!!!! ! !!!!!!!!!!!!!! Global!Health!Scholar
U nderstanding Community H ealth N eeds in Ciudad S andino, N icaragua M ichelle Chong MD/ MPH Class of 2017, Department Depar of Public Health Sciences,, University y of Miami Miller School of Medicine Ju bilee House Community, Ciudad Sandino, Nicaragua S tudy Contact: m.chong@ umiami.edu
M E TH O D S
BACK GRO U N D In 2009, cervical cancer killed 19.4 women per 100,000 in Nicaragua, a rate 6 times that of the United States Nueva V ida, a part of Ciudad Sandino with a high level of poverty and minimal infrastructure, also has a high incidence of chronic disease including asthma and infections in children and diabetes and hypertension in adults J ubilee House Community (J HC) is a non-profit community based organization in Ciudad Sandino that sponsors and helps run a fullservice primary care clinic in Nueva V ida The Nueva V ida Clinic provides: medical, dental, women’ s health care, health promotion and disease prevention services The two main current public health projects include expanding the clinic’ s patient education program and improving cervical cancer detection and treatment in local women
PAP S U RV E Y Developed a three q uestion survey collaboratively to better understand the prevalence of Pap testing, patient access to test results, and barriers to Pap test usage Thirty health promoters along with 5 public health students went door to door over 6 days to collect data from 1,117 women
Understand about the Nicaraguan health care delivery system and existing disparities Participate in public health programs and identify needs of the Nueva V ida community Survey the community to assess the usage and need for Pap smears as screening for cervical cancer
Los resultados fueron:
[ ] normal o [ ] anormal? Porqué no?
Se ha realizado No una prueba de [ ] Papanicolaou?
[ ] No ha escuchado sobre la prueba
[ ] No quiso la prueba
[ ] No había acceso a la prueba
[ ] Otra razón
[ ] No había acceso a curación
S U RV E Y RE S U L TS 70% of women between 18-29 had ever had a Pap test. Pap test prevalence was steady at 80% in the age groups from 30-69 The lowest prevalence of Pap testing was found in Etapas 2 and 4, with the highest in Trinidad Central The top three reasons for not having done Pap tests were not wanting to, fear, and pain 11.1% of surveyed women who had a Pap test never received their results 100.0%
O BJ E CTI V E S
PATI E N T E D U CATI O N Attended focus groups and education sessions for patients with chronic disease, new mothers, pregnant women, and teenage girls Observed health promoters and visiting volunteers cover different topics each session, with groups meeting monthly Worked with volunteer dietician to help create and run nutrition education sessions, and also developed and presented a session about diabetes and its complications Participated in home visits for chronic disease patients with health promoters
Percentage of women ever having a Pap by age
Percentage of women ever having a Pap by Etapa
I N S I GH TS Pap survey showed a need for improvement in testing and a need for programs to increase usage of free Pap testing offered. Patient misconceptions about the Pap test suggest that education could be an effective intervention Patient education curriculum is loosely structured, making it difficult for visiting volunteers to contribute. A more structured and organized program could help the clinic make better use of visiting volunteers Severe untreated diabetes is a huge burden on the community with leg amputations commonly seen in home visits. Work in diabetes prevention and management could be a much needed area of focus for future capstone projects
ACK N O W L E D GM E N TS This field experience was supported with funds from the Global Health Scholar Award. Etapa 1
Trinidad Cuajachillo Trinidad Norte Central
14 ! Student!Name:!Alison!Coll,!MD/MPH!Class!of!2015! Project:!Obstetric!Emergencies!and!IndicaEons!for!Referral:!EducaEon!&!Training!for!TradiEonal!Birth! Abendants!in!Rural!HaiE! Background! &! Objec4ve:! In! HaiE,! over! 60%! of! deliveries! occur! in! the! home! with! the! assistance! of! a! tradiEonal!birth!abendant!(TBA),!known!as!a!matron.! !This!ďŹ eld!experience!sought!to!understand!the! knowledge,!a~tudes!and!pracEces!of!TBAs!in!terms!of!obstetric!emergencies.!! Methods:! QualitaEve! data! was! collected! via! 19! individual! interviews! with! TBAs,! 3! focus! group! discussions! with! TBAs! (n=4,!5,!6),!and!oneRonRone!interviews!with:!the!Director!of!ReproducEve!Health!Department!of!the!HaiEan!Ministry!of! Health!(MOH),!the!Project!Medishare!Program!Manager,!and!the!2!midwives!at!the!Marmont!Maternity!Clinic.!Interviews! were!transcribed!and!coded!for!common!themes.! Results:! TBAs! play! an! acEve! role! in! prenatal! care,! labor/delivery! &! postpartum! management.! They! are! given! minimal! tools!for!deliveries!(thread,!gauze,!razor,!gloves)!and!cannot!manage!obstetric!emergencies!when!delivering!paEents!in! their!homes.!Since!February!2014,!the!Marmont!Maternity!Clinic!is!open!24/7,!and!emergency!transportaEon!is!available! to!bring!laboring!women!to!the!clinic.!The!MOH!is!no!longer!invesEng!in!the!training!of!current!or!future!generaEons!of! TBAs.! Conclusions:! Further! training! of! TBAs! in! obstetric! emergencies! is! less! of! a! priority! than! reinforcing! consistent! referral! paberns!to!the!maternity!clinic!for!prenatal!care!and!childbirth.!With!the!maternity!clinic!open!24/7,!the!MOH!no!longer! needs!TBAs!to!deliver!paEents!unless!delivery!is!imminent.! Springboard
Traditional Birth Attendants in the Central Plateau of H aiti Alison S . Coll MPH Class of 2015, Department of Public Health Sciences, University of Miami Miller School of Medicine Study Contact: AColl@ med.miami.edu This work was supported by the Springboard Grant
I N TRO D U CTI O N •
RE S U L TS : Traditional Birth Attendants
RE S U L TS : M inistry of H ealth
60% of births in Haiti occur at home with the assistance of Traditional Birth Attendants (TBAs), known as Matrons, who receive varying degrees of formal training. Project Medishare is responsible for approximately 72 matrons whose catchment area extends ~ 10km within the Central Plateau. Most matrons have been practicing over 30 years and provide prenatal care, labor and delivery services, and postpartum care to women in their communities. •
O BJ E CTI V E •
Utilize q ualitative data to understand the role of TBAs in maternal health and assess their knowledge and management of obstetric emergencies. Evaluate the matrons’contribution to maternal health as viewed by the Ministry of Health (MoH)
M ATE RI AL S AN D
M E TH O D S
A structured interview guide was used to assess the knowledge, attitudes and practices of Traditional Birth Attendants (TBAs) in the Central Plateau of Haiti. Understanding the role of TBAs was further put in context by speaking with stakeholders directly responsible for framing the healthcare delivery system. • 19 Individual Interviews with TBAs • 3 Focus Group Discussions with TBAs (n=4,5,6) • Interview with Director of Reproductive Health Department of Haitian Ministry of Health • Interview with Project Medishare On-Site Program Manager • 2 Interviews with Nurse Midwives from Marmont Maternity Clinic
1. Prenatal Care (PNC): • All patients referred to maternity clinic for PNC • Matrons do not have medications to give patients • Danger signs of edema, severe headache, vaginal bleeding and seizure are assessed 2. Intrapartum Management: • Materials used: gauze, razor blade, gloves, thread • Complications: breech position, hemorrhage, seizure • Complications managed by referral to nearest hospital 3. Postpartum Care: • Home visits made from 1 week – 1 month following delivery to check on health of baby and mother
37% of women deli deliver er at hospital or clinic MoH is no longer investing in education and training of existing or new Matrons; last intensive training occurred in 2009 Matron’ s role is transitioning – no longer encouraged to perform deliveries unless patient is unable to get to clinic in time Increasing available resources, i.e., Maternity clinic & emergency transportation, makes it possible to increase the number of deliveries in clinics and limit those occurring at home The MoH does not entrust TBAs to dispense medications
CO N CL U S I O N •
The Haitian healthcare system is evolving to address the high maternal mortality ratio. This req uires modifying the Matron’s role to reinforce the relationship between pregnant women and the formal healthcare system. Matrons will continue to play a significant role in prenatal care as patients access a Matron’s care before attending a clinic. F uture Direction for Capstone Proj ect : I mprove matrons’ assessment of prenatal dang er sig ns by disseminating an illustration- based pamphlet
L E ARN I N G PO I N TS •
• Figure 1: Model illustrating the Matron’ s role as a link between a pregnant woman and the formal healthcare system (midwives & doctors).
Appropriate interventions cannot be identified or attempted without thorough assessment and evaluation. Community-based participatory research is a prudent approach to maximize health outcomes during transitional phases. Formative evaluation is valuable in redirecting the focus of a project when the system studied is in flux.
15 ! Student!Name:!Emma!Crichton,!MD/MPH!Class!of!2017! Project:!Measuring!the!EﬀecEveness!and!Impact!of!Global!Brigades’!Public!Health!Projects! Background!&!Objec4ve:!Global!Brigades!is!a!nonRproﬁt!organizaEon!focused!on!improving!the!health! and! wellRbeing! of! people! in! resourceRpoor! naEons.! One! of! its! key! programs! is! the! Public! Health! program,!which!builds!a!large!water!storage!unit,!cement!ﬂoor,!pit!latrine,!shower,!and!cleanRburning! stove! for! every! home.! In! Honduras,! diarrhea! is! the! sixth! and! acute! respiratory! infecEons! the! fourth! leading!cause!of!death!in!children!under!ﬁve.!With!these!projects,!GB!hopes!to!see!an!improvement!in!basic!hygiene,! skin!infecEons,!diarrhea,!and!respiratory!issues.!The!purpose!of!this!study!was!to!evaluate!the!impact!on!health!and!the! saEsfacEon!with!these!projects.! Methods:! A! 44RquesEon! survey! was! created! a6er! observing! the! process! of! building! these! projects! and! was! then! administered!to!286!households!in!8!diﬀerent!communiEes!within!Honduras.! Results:! Households! reported! a! decrease! in! diarrhea,! skin! infecEons/rashes! and! respiratory! symptoms! a6er! implementaEon! of! these! projects.! Families! reported! saEsfacEon! with! the! projects! due! to! the! improved! sanitaEon! and! health.!! Conclusions:!The!projects!have!had!an!impact!in!decreasing!health!issues!in!surveyed!communiEes.!Each!improvement!in! health!condiEons!may!allow!impacts!on!the!educaEon,!earnings,!and!well!being!of!the!enEre!family.!Future!studies!are! required!to!assess!the!longRterm!impact!on!the!health!of!families!and!the!sustainability!of!the!projects.! !
Measuring the Effectiveness and Impact of Global Brigades’ Public Health Proj ects E mma Crichton MD/MPH Prog ram Class of 2017, N ik hil K alothia MPH Prog am N Y MC Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, F L G lobal B rig ades Honduras
• Global Brigades (GB) is the world’s largest student-led global health and sustainable development organization. • Their programs work in partnership with community members to improve q uality of life in under-resourced regions while respecting local culture.
The Public Health program • Aims to tackle a number of health issues (diarrhea, skin and respiratory infections) by improving basic sanitation.
After the construction of an Eco Stove: • There was a 23.1% decrease in the percentage of households that reported severe respiratory symptoms. • There was a 34.5% increase in the percentage of households that did NOT report any respiratory symptoms.
Public Health Proj ects* • a pila (a large water storage unit) • cement floors • a pit latrine • showers • clean-burning stoves
* Built by GB volunteers, community and the family members receiving the projects. Projects subsidized by donations to GB from volunteers. Projects implemented once access to clean water and microfinance system established
1. To evaluate effectiveness of Global Brigades’ Public Health Program. 2. To gain an understanding of designing and administering surveys within a community. 3. To gain an understanding of the process of working and collaborating with community members to carry out and create projects that will aid in the sustainable development of their communities.
Latrine and show er
Hygiene station – latrine + show er + pila (Water storage unit)
Hygiene station – latrine + show er + pila (Water storage unit)
Observed a public health project in action, visited communities and interviewed staff about the projects. Created a survey with the intent to assess the condition of projects, the satisfaction and health of the community members. V isited all the communities that Global Brigades has completed Public Health projects within and surveyed at least half of the homes with these projects (Table1).
• The projects have had an impact in decreasing health issues in surveyed communities. • Each improvement in health condition may allow impacts on the education, earnings, and well-being of the entire family. • Families unanimously enjoyed working with Global Brigades and foreign volunteers. • This demonstrates the importance of these projects in the daily lives of these rural communities and its people.
El J ute
El Z urz ular Palo V erde Los Trigales
El Cantó n
Fray Laz aro El Oj ochal
Emma Crichton interview ing community member in her home
Ack now ledgements Special Thanks to Ben Erker, Cole Hoover and the Global Brigades staff in Honduras This project was funded by a Global Health Scholar Award
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Increased Utility and Evaluation of the L egal Aid Society Medical L egal Partnership at the 45th St. Clinic A dam Crosland MD/MPH Class of 2015 ; F aheem F arooq MD/MPH Class of 2016 ; A malinnette R . Z ito, ito M. D. ; K ate W atson, Staff A ttorney; Christina R usso,, Staff A ttorney Department of Public Health Sciences; University of Miami L eonard M. Miller School of Medicine. Miami, Florida, USA; L egal Ai Aid Society of Palm Beach County, INC. Study Contact: bacrosland@
med. miami. edu, ffarooq @
MLP Referral System Flow chart
INTRODUCTION Nationally, 47% of low-income patients have â‰Ľ 1 unmet legal need;14% have â‰Ľ 3 unmet legal needs
med. miami. edu / The project was supported by the Q uantum Foundation Springboard Grant of Palm Beach County
Medical L egal Partnerships (ML Ps) utilize the skillsets from healthcare professionals and lawyers to address social determinants of health. L egal Aid Society of Palm Beach County, Inc. partners with West Palm Beach health affiliates to provide free legal representation in: Working and housing conditions
CURRENT PROGRESS Identified key stakeholders (nurses and medical assistants) at 45th street clinic charged with referral system management.
Education Train 45th Street Clinic staff regarding the services offered by Legal Aid Society
Revised referral form provides additional q ualitative and q uantitative patient data in ML P.
Screening Develop system w ithin the intak e process and patient evaluation to identify those w ith unmet legal needs
Access to health care Domestic violence Citizenship L egal Aid Society is currently at the 45th St. Clinic with limited referral capacity. UM MD/ MPH students serve as potential key players in sustainable ML P capacity building.
OBJ ECTIV ES
Inherent challenge in assessing long-term q uantitative health-related outcomes. Multifactorial nature of health status and disease management Overlapping social determinants of health
Increased working knowledge of partners and their respective skillsets.
Mak e referral form available to staff and relay it to Legal Aid Society
Create internal referral system at the St. Clinic that extends services rendered by Medical L egal Partnership. Evaluate the impact and efforts of the Medical L egal Partnership in student trainings. Collect data to identify possible mechanisms to better assess ML P impact.
Legal Aid Society contacts patient and w ork s to address legal issue
Characterize the utilization of legal aid services at 45th St. Clinic site.
Follow -Up & Data Acq uisition
Suggest indicators that can be measured in the future and act as proximal measurements of health outcomes secondary to ML P intervention.
Attorney relays w hat has occurred to medical staff. Patient and provider surveys assess for potiental proximal health outcome indicators
Conduct focus groups with patients regarding q uality improvement and current progress. Develop confidentiality and consent forms to aid in local ML P development via case discussions.
Restructure and update current ML P training protocols for student integration into extended referral system at the 45th St. Clinic.
Develop and administer pre-post assessment for ML P student training sessions. Propose patient and provider long-term follow-up q uestionnaire to identify generalized health outcome proxies.
Caption: Above are MD/ MPH students Adam Crosland (left) and Faheem Farooq (right) with advisor Dr. Amy Z ito (middle) at the 45th St. Clinic in West Palm Beach, FL .
Bliss, L ., Caley, S., & Pettignano, R. (2011). An interdisciplinary collaborative approach to wellness: Adding lawyers to the healthcare team to provide integrated care for patients. The International J ournal of Health and Wellness, 1(2), 130-139.
17 ! Student!Names:!Emeka!Egbebike,!MD/MPH!Class!of!2017! Project:!EvaluaEng!the!Impact!of!Endemic!Disease!in!Nigeria:!Focus!on!HIV/AIDS!&!Tuberculosis! Background! &! Objec4ve:! ! HIV/AIDS! conEnues! to! be! an! endemic! in! Nigeria,! Africa’s! most! populous! country,!while!greatly!inﬂuencing!the!burden!of!tuberculosis.!This!poster!aims!to!depict!observaEons! made! at! one! of! Nigeria’s! busiest! public! hospitals! and! highlight! key! obstacles! that! are! impeding! the! control!and!awareness!of!the!HIV/AIDS!and!tuberculosis!endemics.! Methods:! ! ObservaEon! of! paEent! interacEons! with! physicians! and! discussions! with! paEents! during! health! educaEon! sessions!comprised!the!majority!of!the!ﬁeld!experience.! !AddiEonal!training!in!HIV!counseling!along!with!discussion!on! the!public!health!impact!of!HIV/AIDS!and!tuberculosis!in!Nigeria!with!various!healthcare!workers!occurred!as!well.! Results:!! !Anecdotal!evidence!regarding!the!obstacles!to!the!control!of!HIV/AIDS!and!Tuberculosis!in!Nigeria!as!well!as! factors!that!inﬂuence!the!educaEon!and!awareness!of!these!endemics!are!included!in!the!poster.! Conclusions:!!The!rising!prevalence!of!HIV/AIDS!and!the!subsequent!inﬂuence!it!has!on!the!tuberculosis!endemic!can!be! abributed!to!misguided!informaEon!about!these!diseases!within!the!community!in!addiEon!to!certain!cultural!pracEces! and! lack! of! educaEon.! The! endemics! are! propagated! by! the! wavering! support! of! nonRgovernmental! organizaEons! secondary!to!the!Nigerian!government’s!unwillingness!to!take!control!of!the!maber.!
Evaluating the Impact of Endemic Disease in Nigeria: Focus on HIV / AIDS & Tuberculosis Department of Public Health Sciences
Emeka Albert Egbebike MD/MPH Class of 2017, Department of Public Health Sciences, University of Miami Miller School of Medicine
BACKGROUND With a population of 173.6 million, Nigeria is the most populous country in Africa. • Prevalence of HIV / AIDS between the ages of 15 and 49 in the country remains significantly high at 3.1%. • Estimated 3 million people are living with HIV / AIDS in Nigeria as of 2012. It is the second largest number of people living with HIV / AIDS in the world. • Nigeria ranks 10th among the 22 high-burden TB countries in the world. • Prevalence of HIV among TB patients in Nigeria increased from 2.2% in 1991 to 19.1% in 2001 and 25% in 2010.
University of Nigeria Teaching Hospital The University of Nigeria Teaching Hospital campus in Ituku-Ozalla Enugu is a public hospital financed by the government in southeastern Nigeria. It hosts around 550 beds and treats patients that travel from around the country. Founded in 1955, it is noted that UNTH was the site of the first open heart surgery in Africa in 1974.
APIN Clinic The AIDS Prevention Initiative in Nigeria (APIN) clinic is a free, walk-in clinic currently funded by the Center for Clinical Care and Research Nigeria (CCCRN). The clinic sees about 200 patients per day and places a primary focus on health education and counseling. My Role & Responsibilities: • Observe patient counseling sessions. Participate in Preventing-Mother-to-Child-Transmission (PMTCT) group sessions. • Practice conducting pre-test & post-test HIV testing counseling. • Discuss health education initiatives in clinic.
Trend in Prevalence & Death Rate Associated With TB, 2001-2011
1. Gain insight into the daily operations of the University of Nigeria Teaching Hospital. 2. Observe and evaluate HIV / AIDS & Tuberculosis prevention, screening, & treatment programs. 3. Engage in the sharing of ideas regarding the prevention, education, and treatment of HIV / AIDS and Tuberculosis with mentor(s) at the teaching hospital. 4. Encourage and promote the development of health education in the community concerning HIV / AIDS & Tuberculosis.
Dr. L anetta J ordan Dr. Margaret Agaji Dr. Celeste Okafor Dr. Ebele Okoli Nigerian Federal Ministry of Health World Health Organization
Prevalence of HIV by State, 2010
FIELD EX PERIENCE OBJ ECTIV ES
Tuberculosis “ Chest” Clinic The UNTH Tuberculosis “ Chest” clinic operates on the outer city limits of Enugu. The clinic treats around 25 patients per day, not including inpatients in the ward that holds up to 24 patients and those that come solely for counseling and follow-up. My Role & Responsibilities: • Observe patient counseling sessions. • Participate in morning health education rally sessions.
University of Nigeria College of Medicine University of Nigeria Department of Community Health APIN HIV / AIDS Clinic Tuberculosis “ Chest” Clinic
Trend in notification of TB, 2001-2011
Federal Republic of Nigeria (FRN) (2013). N ig eria Millennium Development G oals 2013 R eport. Abuja: National Planning Commission. Federal Ministry of Health. Department of Public Health National AIDS/ STI Control Programme. 2010 N ational HI V Seroprevalence Sentinel Survey. By Nigerian Federal Ministry of Health. Abuja: n.p., 2010. Print.
ONGOING PROJ ECT INSIGHTS GAINED There are a number of issues with current healthcare delivery in Nigeria that leaves the country unable to combat the growing burding of HIV / AIDS and Tuberculosis including: • The majority of Nigerians lack health insurance as the National Health Insurance Scheme, government provided insurance, is only available to civil workers and private health insurance is often unaffordable. • The unw illingness of the Nigerian government to take responsibility for the growing HIV / AIDS & Tuberculosis endemics have left many clinics dependent on variable support from outside non-governmental organizations. Health education in Nigeria is greatly influenced by: • Cultural & Religious Practices • Level & Type of Education • Availability of Educational Resources
FUNDING ACKNOWLEDGEMENT This field experience was supported with funds from the Global Health Scholar Award as well as the Foundation For Sickle Cell Disease Research.
The Mercy Foundation for Community Outreach is a family-owned mobile clinic that visits the small communities adjacent to Enugu, Nigeria. Currently, it provided free health evaluations with a focus on eye health. We are working obtaining funding for the clinic to transform it into the region’ s first fully functional mobile clinic.
CONTACT Emeka A. Egbebike MD/ MPH Public Health Student University of Miami Email: e.egbebike@ umiami.edu Phone: (904) 487-3993
18 ! Student!Name:!Yendi!Fontenard,!MPH!Class!of!2014! Project:!The!Hemophilia!TriumphRThe!SoluEon!to!Sickle!Cell!Disease!(SCD)!Chagrin! Background! &! Objec4ve:! ! PaEents! with! SCD,! the! most! common! inherited! blood! disorder! in! the! U.S.,! with!an!esEmated!prevalence!of!100,000!have!signiďŹ cant!unmet!healthcare!needs.!The!clinical!course!of! SCD!is!varied!but!it!is!o6en!progressive!with!mulERorgan!involvement.!Care!received!by!both!adult!and! transiEoning!pediatricRtoRadult!paEents!has!frequently!been!cited!as!disparate!and!fragmented.!The!naEonwide!network! of! Hemophilia! Treatment! Centers! (HTCs)! has! addressed! previously! unmet! needs! of! a! similar! chronic,! clinically! varied,! orphan!disease!R!hemophilia.!This!project!examines!if!HTCs!can!be!a!model!for!the!organizaEon!and!delivery!of!SCD!care.!! ! ! ! ! !!! Methods:! ! We! uElized! a! mixedRmethods! approach,! including! a! key! informant! interview! with! the! president! of! the! FoundaEon!for!Sickle!Cell!Disease!Research!(FSCDR),!and!a!literature!review!via!PubMed.!! ! Results:! HTCs! serve! as! paEentRcentered! medical! home! (PCMH)! model,! providing! access! to! a! host! of! medical! and! nonR medical! services,! comprehensive! insurance,! individually! tailored! treatment! plans! and! prophylacEc! care! to! reduce! complicaEons.!ExisEng!SCD!clinics!lack!several!elements!of!the!HTC!model!leading!to!signiďŹ cant!unmet!need!of!the!SCD! populaEon!such!as!coordinated!care.! Conclusions:!The!HTC!paEentRcentered!model!can!inform!gaps!in!the!current!organizaEon!and!delivery!of!care!for!SCD! paEents!in!the!U.S.!! DPHS!Recogni5on
Hemophilia Treatment Centers â€“ A Guide for the Future of Sick le Cell Disease Management in the United States Y endi Fontenard, MPH Class of 2014 Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, F L
INTRODUCTION SICKLE CELL DISEASE (SCD) IN THE U.S.: Description & Statistics Genetic disease in which red blood cells form an abnormal crescent shape Often progressive with multi-organ involvement (see Figure 3) Most common inherited blood disorder Absence of a national disease surveillance & monitoring system According to CDC in 2011: Estimated # of cases: 90,000-100,000 Estimated prevalence rate: 1 in 500 Blacks; 1 in 36,000 Hispanics Disease Management Req uires lifelong comprehensive care Excellent pediatric care but fragmented for transitioning and adult patients Clinics dispersed throughout the U.S. with varied scope of services Health Resource Utiliza tion & Costs 197,333 ER visits per year Hospital charges are much greater than that of some more prevalent diseases US$ 488 million in-patient costs per year US$ 460,151 discounted lifetime cost of care per patient
OBJ ECTIV ES
INSIGHTS GAINED Comparison betw een Hemophilia & SCD: Hemophilia: Similar to SCD in that it is rare, chronic, & clinically varied Estimated # of cases of Hemophilia: 20,000 (significantly < SCD) L ifelong comprehensive care is needed for both Availability of comprehensive care is greater for Hemophilia than SCD Hemophilia has a better integrated system of care nationwide than SCD: National Hemophilia Treatment Centers (HTCs) program since 1975 Network of over 100 HTCs HTCs serve as Patient-Centered Medical Homes providing both medical & non -medical services
The scope of services provided by HTCs have resulted in improved patient outcomes as illustrated in Figure 4 Fig.1 Estimated number of individuals with SCD based on state specific African American & Hispanic American birth cohort disease prevalence & 2008 U.S. Census population
SERV ICES PROV IDED BY HTCs Access to: Diagnostic services Comprehensive insurance Individual treatment plans Specialist providers Clinical Management Prophylactic treatment Patient education & counseling Social Services
OUTCOMES OF PATIENTS UTILIZ ING HTCs Reduced: Unmet health care needs Unnecessary ED use Medical expenditures per patient Under-Treatment Absenteeism Avoidable health complications Mortality
Fig.4 HTC Services & Patient Outcomes
Fig.2 Illustration of Sickling of Red Blood Cells
Examine the model of care in the U.S. for a comparative disease, i.e., Hemophilia Propose a model for the delivery of SCD care in the U.S.
CONCLUSIONS SCD & Hemophilia place a similar burden on patients, which demands comprehensive and coordinated lifelong care HTCs have been instrumental in improving health, social & economic outcomes for Hemophiliacs HTC program is suitable as a guide for modeling the delivery of SCD care
The future organization & delivery of SCD care in the U.S should include: Conduct a series of interviews with Dr. L anetta Jo rdan, president of the Foundation for Sickle Cell Disease Research (FSCDR) Provide administrative and research support for FSCDRâ€™ s grant proposal for a nationwide Sickle Cell Care Network Conduct a literature review via PubMed
1. A national SCD registry to enable monitoring of disease burden & clinical outcomes of patients 2. A national netw ork of accredited SCD clinics w ith:
Fig.3 Complications of SCD: Childhood, Adolescence & Adulthood
A similar scope of services A multidisciplinary team of medical & non-medical providers Membership reflective of local disease prevalence
19 ! Student!Name:!Chellse!Gazda!&!Greg!Milligan,!MD/MPH!Class!of!2015! Project:!IdenEfying!and!Addressing!Gaps!in!HIV!Care!at!the!45th!Street!Clinic:!A! Systems!Based!Approach!for!Adherence.! Background:! ! Florida! has! the! third! highest! prevalence! of! HIV! in! the! U.S.,! and! Southeast!Florida!maintains!the!highest!HIV!rates!in!the!state!(1).!AddiEonally,!the! CDC! esEmates! that! only! 37%! of! HIV+! paEents! are! retained! in! care! (2).! The! Palm! Beach! County! Health! Department’s! 45th! Street! Clinic! manages! HIV! but! maintains! no! means! of! monitoring! paEent! retenEon! and! no! eﬃcient! means! of! analyzing! acEve! paEent! informaEon! such! as! demographic! informaEon,! social! determinants!of!health,!or!transmission!risk!factors.!! Objec4ve:!!The!goal!of!this!project!is!to!assess!and!improve!current!systems!of!HIV!care!at!the!clinic!while!idenEfying!and! addressing!known!barriers!to!adherence.!! Outcomes:! !The!system!of!new!paEent!intake!is!standardized!through!uElizing!tablet!technology!to!input!new!paEent! informaEon!into!an!enhanced!database.!AddiEonally,!the!tablet!displays!brief!HIVRrelated!educaEonal!videos!to!each!new! paEent!and!provides!a!plaIorm!for!conEnuous!paEent!feedback.! Conclusions:! !Through!the!use!of!tablet!technology!and!improved!intake!systems,!health!department!staﬀ!and!medical! professionals! are! equipped! to! perform! correlaEve! analysis! of! factors! eﬀecEng! paEent! retenEon! and! clinical! outcomes.! This!can!be!used!to!beber!tailor!paEent!care!as!well!as!to!monitor!and!evaluate!any!future!systemic!intervenEons.!The! current!project!therefore!uElizes!a!comprehensive!approach!to!improve!paEent!adherence,!decrease!transmissibility,!and! ulEmately!decrease!the!burden!of!HIV!in!the!community.! Quantum!Springboard
Identifying and Addressing Gaps in HIV Care at the 45th Street Clinic: A Systems Based Approach for Adherence Chellse Gazda and Greg Milligan MD/ MPH Class of 2015, Department of Public Health Sciences, University of Miami Miller School of Medicine
Florida has the third highest prevalence of HIV in the U.S., and Southeast Florida in particular maintains the highest HIV rates in the state (1). •
According to the Florida Department of Health, the incidence of HIV rose 30% in Palm Beach County as recently as 2011 (2).
Adherence to HIV medical care has implications on both patient prognosis and transmissibility within a community (3). •
Nationally, only an estimated 37% of HIV + patients are retained in care, as seen below (4):
Project Outcomes •
2. Identify infrastructure changes req uired to monitor factors influencing HIV care •
Develop patient database with reporting capabilities o Categories to monitor include demographic data, social determinants of health, mental health history, HIV history and ensuing HIV -related lab data •
1. Assess systems of HIV care and barriers to patient adherence at 45th Street Clinic
Stigma Clinic hours Wait Times Medication side effects
1. Identified barriers that will inform future interventions
L ack of HIV knowledge Transportation Difficulty navigating the system
3. Generated interventions empowering patients to take ownership of their care • Structured implementation of educational videos o Deliver to each new patient intake o Utilize updated technology o V ideos brief to avoid prolonging appointment • Development of patient feedback forum
Enhanced Patient Database with Reporting Capabilities
Provide tablet computer for implementation of patient database
Gregory Milligan Chellse Gazda
2. Implemented sustainable enhanced patient database o Utilize existing personnel and intake systems o Maintain support from health department Information Technology o Potential for expansion to additional Palm Beach County Health Department Clinics
Future Directions •
Email: GPMilligan@ med.miami.edu CL Gazda@ med.miami.edu
Phone: 954-655-1516 941-724-1616
Sample Database Outputs
Palm Beach County Health Department’ s 45th Street Clinic manages HIV + patients.
3. Identify evidence-based interventions to address known factors influencing HIV retention and adherence at the clinic
There is currently no method to monitor active patient information to identify factors influencing patient retention and adherence. •
Implement structured delivery of HIV educational videos •
Generate a means of patient feedback via patient satisfaction survey
Health L iteracy o Assess effectiveness of educational videos o Create a manual for new patients to understand all aspects of their care Facilitation of system navigation Address HIV stigma Identify additional gaps through Access database and developing initiatives to close these gaps
This project was made possible through the support of the Q uantum Foundation Springboard Grant Palm Beach County
Utilize tablet computer for delivery of videos and satisfaction surveys
1. am fA R . (2004, March 3). HIV AIDS in Florida: Epidemic Clouds in the Sunshine State. R etriev ed J anu ary 3, 2015 from h p : / / www.am far.org/ content.asp x ? id= 142 2. LaMendola, Bob . 2012, March 23. HI V / A I D S S R ising in S ou th F lorida. SunSentinel. R etriev ed from h p : / / ar cles.su n-sen nel.com / 2012-03-23/ health/ -hk-hiv -rising20120323_ 1_ new-hiv -infec ons-new-cases-aids-p rogram -su p erv isor.
Enhanced Interventions (6)
3. Tu rner, Barb ara. 2002. A dherence to A n retrov iral Therap y : Hu m an I m m u node ciency V iru s- I nfected Pa ents. Journal of Infectious Disease, V olu m e 185, S 142-S 151. R etriev ed from h p : / / j id.ox fordj ou rnals.org/ content/ 185/ S u p p lem ent_ 2/ S 143.fu ll. 4. C D C .(2013, D ecem b er 27.) Key Graphics From CDC Analysis Showing Proportion of People Engaged in Each of the Five Main Stages of HIV Care. R etriev ed J anu ary 3, 2015 from : h p : / / www.cdc.gov / nchhstp / newsroom / 2012/ C on nu u m -of-C are-G rap hics.htm l. 5. S top the V iru s. 2014. HI V 101. R etriev ed Nov em b er 21, 2014. h p s: / / www.help stop thev iru s.com / hiv -edu ca on 6. New York S tate D ep artm ent of Health. 2002. Pa ent S a sfac on S u rv ey for HI V A m b u latory C are. R etriev ed D ecem b er 13, 2014. h p : / / cdn.hiv gu idelines.org/ wp content/ u p loads/ 2009/ 06/ p ss-hiv _ 091802.p df
20 ! Student!Name:!Stephanie!Gieseken,!MPH!Class!of!2014! Project:!Reducing!dispariEes/Gaps!in!Oral!Health!IntervenEons
Background:! ! In! 2012,! the! Florida! Department! of! Health! revealed! that! Florida’s! hospital! emergency! rooms!treated!approximately!17,000!children!age!18!year!and!younger!for!dental!condiEons!that!could! have! been! managed! in! dental! oﬃces,! or! avoided! with! preventable! and! primary! care.! Oral! health! diseases!are!a!major!public!health!problem!that!aﬀect!90%!of!the!worldwide!populaEon.!One!problem! with! oral! health! intervenEons,! acEviEes! and! campaigns,! is! that! they! are! o6en! not! properly! managed! and! instructed,! reducing!their!success!rates.!Challenges!remain!with!community!dispariEes!and!barriers.!!Furthermore,!professionals!lack! the!knowledge!and!training!to!treat!and!educate!their!paEents!and!communiEes.!!! !!!!!!!!!!!!! Methods:!!ObservaEons,!interviews!and!studies!of!previous!oral!health!intervenEons!gathered!from!hospitals,!ciEes!and! government!were!the!means!to!collect!data!on!the!oral!health!dispariEes!and!intervenEons.!!!!!!!!!! Results:! The! problems! on! the! eﬀecEveness! of! the! promoEon! and! prevenEve! intervenEons! came! from:! scarcity! of! resources,! cost! of! methods! used! (monetary! and! personal),! and! duplicaEon! of! eﬀorts.! There! were! also! inconsistencies! with!exisEng!programs,!massRproducEon,!theoreEcal!ﬂaws,!lack!of!sustainability,!and!lack!of!focus!on!dispariEes,!barriers! and!risk!factors.!! ! ! ! !!!! Conclusions:! EﬀecEve! health! intervenEons! are! possible! with! appropriate! public! health! strategies! (ﬂuoride! varnish! and! xylitol! gum),! personnel! training! including! “oneRtoRone! personalized! sessions,”! cluster! groups! and! risk! factors! assessments,!inclusion!of!oral!health!in!school!curriculum!and!followRup!programs.!!! DPHS!Recogni5on
Reducing Disparities and Gaps in Oral Health Interventions Gobernación del Atlántico - Secretaría de Salud Colombia (South America)
MPH Class of 2014, Department of Public Health Sciences, University of Miami Miller School of Medicine
BACKGROUND • Oral health (OH) diseases are a major public health problem that affects 90% of the population worldwide. • Resources for OH promotion are scarce and methods are expensive and often duplicated. • There is limited information on the effectiveness of OH promotion and preventive interventions. • In Colombia, 89% of the population 15-19 years old and 95% of 20 years suffer from caries.
FIELD EXPERIENCE OBJECTIVES In collaboration with the Secretary of Health in the Atlántico State (SHAS), Colombia:
• Current SHAS interventions were not effective at increasing knowledge or promoting behavioral change. • There is no evidence showing the effectiveness of dietary interventions to reduce dental caries.
Evaluate risk and protective factors for OH in the Atlántico State population.
Analyze interventions, resources, barriers and disparities to reduce OH diseases.
Provide a framework to reduce disparities through OH promotion interventions.
• Providing OH information alone does not produce longterm behavior changes. • School-based tooth brushing campaigns are not effective at improving oral hygiene. • Short term improvements in OH knowledge have limited effects on behavior and clinical outcomes.
• In Colombia there are also dental challenges with disparities and barriers as well as with professionals lack of knowledge and training to treat and educate their patients. According to data from the Secretary of Health in the Atlántico State (SHAS): • Atlántico is one of the departments with the highest prevalence in oral diseases (30%). • Among individuals ages 6 to 69, approximately 15% reported having had problems with their teeth, mouth, or gums within 30 days of the interview. • Nearly all of the population (95%) reported use of toothbrush but only 40% use dental floss. • Of those who used a toothbrush, 30% stated that they brushed three times a day. • Among younger people (ages 6 to 19), 35% reported they had received fluoride applications or rinses, and 30% claimed they had received treatments to fill cavities or repair cracks.
• A community assessment to inform about the community, its culture, resources and habits must be performed prior to implementing an intervention. The intervention should then be tailored to the community needs and resources to increase its effectiveness and efficiency rates.
Department of Atlántico, Colombia
Evidence-based nterventions have an 80% rate of success to decrease oral health diseases.
Dental education lectures
METHODS • Use existing government tools such as demographic statistics to identify the problematic communities • Assess resources, materials and dental personnel and equipment in the low SES communities. • Conduct interviews with dentist, doctors, teachers, psychologist, community leaders, and government officers. • Visit the most important hospitals, dental office, supermarkets, convenience stores, schools, and churches. • Evaluate oral health interventions previously conducted by the SHAS Dental practice and Intervention
CONCLUSIONS & RECOMMENDATIONS
The Secretary of Health in the Atlántico State has its headquarter in Barranquilla and includes 17 different subdivisions. • Plans and implements health programs, including inspections, surveillance and controls. • Promotes protective health factors and reduce risk factors associated with increased morbidity and mortality. • Links primary health to community and social services through good practice, satisfaction and quality. • For 2015 the SHAS seeks to promote healthy lifestyle, improving health services and providers.
Dental supplies and instruments used in interventions
Effective health interventions are possible with appropriate public health strategies such as the use of fluoride varnish and xylitol gum.
Personnel training is needed, including “one-to-one personalized sessions”.
Cluster groups and risk factors assessments will be helpful.
Inclusion of OH in school curriculum and follow-up programs are recommended.
Follow-up oral health intervention every 4 weeks.
Apply the horizontal approach (common risk/health factor theory) to reduce risk and promote health.
CONTACT STEPHANIE GIESEKEN B., MPH, Class of 2014 University of Miami firstname.lastname@example.org
21 ! Student!Name:!Shida!Haghighat,!MD/MPH!Class!of!2017! Project:!Disaster!Preparedness!and!Relief!in!Rural!ArgenEna! Background! &! Objec4ves:! Fundación! Barceló! is! a! private,! notRforRproﬁt! health! sciences! university! in! Santo! Tomé,! ArgenEna.! Santo! Tomé! is! a! small,! rural! town! of! 29,500! inhabitants! with! low! educaEon! levels!and!high!poverty!rates.!On!June!30,!2014,!heavy!rainfall!caused!massive!ﬂooding,!sending!Santo! Tomé!into!an!oﬃcial!state!of!emergency!for!two!weeks.!My!objecEves!were!to!evaluate!Santo!Tomé’s! disaster!relief!management!system!and!assess!the!ﬂoodRrelated!health!impacts!on!the!populaEon!and! the!public!health!infrastructure.!!! Methods:!Rotated!through!the!four!evacuaEon!centers!with!two!medical!students!and!one!abending!physician!over!a! two!week!period!speaking!with!evacuees!and!collecEng!data.! Results:!2,424!evacuees!(604!families)!were!distributed!among!4!evacuaEon!centers.!Most!common!medical!problems! included! diarrhea,! bronchiEs,! and! pharyngiEs.! Response! to! the! ﬂood! exhibited! dissonance! among! all! levels! of! governance!(municipal,!provincial!and!naEonal),!making!it!diﬃcult!to!eﬀecEvely!deliver!aid.!! Conclusions:! As! a! rural,! isolated! town! with! limited! resources,! Santo! Tomé! faces! unique! challenges! to! emergency! preparedness!and!relief.!In!order!to!be!beber!prepared!for!future!disasters,!Santo!Tomé!would!beneﬁt!from!developing! disaster!relief!protocols!and!establishing!a!hierarchy!of!leadership!during!states!of!emergency.!! ! !
D isaster Prep aredness and Relief in Rural Argentina S hida H aghighat aghighat aghi Department of Public Health Sciences; University of Miami L eonard M. Miller School of Medicine, Miami, Florida, USA S tudy Contact: S hida H aghighat, M D / M PH Candidate, Class of 2 017 This field ex p erience was in p art sup p orted by funds from the Global H ealth S cholar Award.
BACK GRO U N D •
RE S U L TS
Partner organiz ation: Fundació n Barceló is a private, not-for-profit health sciences university. Location: Santo Tome, Argentina - rural town of 29,500 inhabitants with low education, high poverty rates and majority of residents uninsured.
Emergency Response to Floods: 2,424 evacuees (604 families) distributed among 4 evacuation centers. Most common medical problems: diarrhea, bronchitis, pharyngitis.
I N S I GH TS GAI N E D
Flood: On J une 30, 2014, heavy rainfall caused massive flooding, sending Santo Tome into official state of emergency.
Rotations L ack of medical recordkeeping at the clinics made continuity of care difficult, thus decreasing q uality of care. L ack of effective administrative leadership and understaffed system led students to take on larger roles in patient care.
Activities: • Rotated through hospital and clinics partnered with Fundació n Barceló . • V olunteered at evacuation centers. • Evaluated emergency response to flood. Santo Tome (marked X ) lies on Parana River, which overflowed in J uly 2014, causing massive floods.
Pictured with 1 of 2 ambulances in town.
O BJ E CTI V E S Rotations: L earn about Argentina’ s public health system. Identify healthcare disparities between the private and public health systems.
Municipal rescue team of Corrientes searching flooded areas
Emergency Response to Floods: As a rural, isolated town, Santo Tome faces uniq ue challenges to emergency preparedness and response (limited resources, remoteness). Emergency response to flood exhibited dissonance among all levels of governance, making it difficult to deliver aid. Surprisingly, most effective response came from the local level (medical).
Third day of floods in Santo Tome, Argentina.
RE CO M M E N D ATI O N S
Floods: Evaluate emergency response to floods at local, provincial, and national level.
Emergency Response to Floods: Establish leadership hierarchy during states of emergency. Develop protocols for disaster relief plans in advance in order to be better prepared for the future.
Evaluate medical respose at local level. Assess flood-related health impacts and impact on the public health infrastructure. L ocal news station interviewing volunteer physicians at 1 of 4 evacuation centers.
Makeshift tents served as homes at evacuation centers
22 23 ! Student!Name:!Lamia!Hossain,!MPH!Class!of!2015! Project:!Assessing!the!Impact!of!Emergency!Disaster!Relief!Eﬀorts!on!Health!Outcomes!of!Bangladeshi! Trauma!VicEms!from!the!April!2013!Rana!Plaza!Factory!Collapse! Background!&!Objec4ve:!The!Centre!for!the!RehabilitaEon!and!Paralysed!(CRP)!in!Dhaka,!Bangladesh! was!founded!in!1979!in!response!to!the!desperate!need!for!services!for!spinal!injured!paEents.!A6er! the!Rana!factory!collapse!occurred!in!April!2013,!the!CRP!has!provided!shelter,!medical!assistance!and! support!groups!for!the!vicEms.!This!project!aims!to!develop!a!beber!understanding!of!the!paEents’! recovery! process,! the! impact! of! the! compensaEon! given! by! the! InternaEonal! Labor! OrganizaEon! (ILO)! and! PRIMER! on! their!health!outcomes,!and!the!paEents’!current!needs.! Methods:!Data!were!collected!from!the!CRP,!ILO,!PRIMER,!and!from!community!surveillance!in!Dhaka,!Bangladesh.!The! data!includes!health!status!before!and!a6er!compensaEon.!CommunityRbased!parEcipatory!research!provided!qualitaEve! data!on!whether!paEents!were!mentally!and!physically!able!to!work!within!one!year!of!the!disaster.! Results:!Determined!that!paEents!who!received!direct!compensaEon!from!the!ILO!and!PRIMER!for!injury!treatment!and! therapy!costs!did!not!have!beber!health!outcomes!than!those!who!lacked!compensaEon.!! Conclusions:! CRP! brought! awareness! to! disaster! public! health! in! Bangladesh! and! the! need! to! integrate! emergency! mental!health!intervenEon!and!occupaEonal!health!services!into!more!rehabilitaEon!centers.!The!ﬁndings!can!be!used!to! implement!an!intervenEon!system!that!will!beber!mediate!the!impact!of!a!future!factory!disaster!similar!to!that!in!Rana! Plaza.! Student!Name:!Erin!Hurley,!MSPH!Class!of!2014!
! Project:!TargeEng!Cancer!PaEent!CommunicaEon!in!MulEmodal!Pain!Management"!A!SystemaEc!Literature!Review!and! MetaRAnalysis!! Background! &! Objec4ve:! ! ! Pain! is! one! of! the! most! common,! feared! and! undermanaged! symptoms! associated! with! cancer.! ! CommunicaEon! in! pain! management! is! a! promising! research! focus! due! to! its! inﬂuence! on! pain! barriers.! The! objecEve!of!this!systemaEc!literature!review!is!to!provide!a!current!and!comprehensive!overview!of!studies!focusing!on! physicianRpaEent!communicaEon!amongst!cancer!paEents.!A!metaRanalysis!will!esEmate!the!eﬀect!of!communicaEonR based!randomized!controlled!trials!(RCTs)!on!pain!severity.! Method:!A!literature!review!conducted!in!5!electronic!databases!idenEﬁed!328!abstracts.!!A!total!of!31!arEcles!met!the! inclusion! criteria;! nineteen! observaEonal! studies! and! 12! RCTs! were! included.! ! Seven! RCTs! had! suﬃcient! data! for! the! metaRanalysis;!pain!severity!was!the!primary!outcome. Results:!Study!parEcipants!(N=9,007)!were!primarily!women!(62%)!and!documented!as!NonRHispanic!(61%)!and!White! (48%).!!The!following!variables!had!data!reporEng!issues:!marital!status,!level!of!educaEon,!income,!and!cancer!stage!and! treatment!history.! !The!weighted!average!eﬀect!size!across!studies!for!pain!severity!was!R0.25!(95%!CI,!R0.44!to!R0.049;! p=0.01).!! Conclusions:! !DispariEes!exist!amongst!communicaEonRbased!studies!to!improve!pain!outcomes.!The!intervenEons!had! modest!eﬀects!on!pain!severity!and!results!were!inconsistent.!Research!is!needed!to!unmask!the!complex!pathway!from! eﬀecEve!physicianRpaEent!communicaEon!to!improved!pain. DPHS!Recogni5on
TARGETING CANCER PATIENT COMMUNICATION IN MULTIMODAL PAIN MANAGEMENT: A SYSTEMATIC LITERATURE REVIEW AND META-ANALYSIS Erin Hurley
MSPH Class of 2014, University of Miami Department of Public Health Sciences, Miller School of Medicine
INTRODUCTION • •
Pain is one of the most common, feared, and undermanaged symptoms associated with cancer Patient-related barriers to pain management: •
• • •
Lack of pain knowledge Fear of opioid addiction, side effects of analgesics, and disease progression Misunderstanding of prescription instructions Belief that pain in cancer is inevitable Personal and cultural biases
Improved communication between physicians and patients has the potential to improve pain outcomes Limited number of systematic reviews and meta-analyses exist on this topic
SYSTEMATIC LITERATURE REVIEW
Figure 4: Funnel plot of standard error by Hedges g
Search Strategy, Study Selection, Data Management
• Searched 5 electronic databases: CINAHL, MEDLINE, PsycInfo, Scopus, The Cochrane Library • Search vocabulary related to cancer, pain, and communication found in titles and abstracts • Search conducted from 7/7/2014-7/14/2014 • Abstracts and full-text articles were reviewed according to the inclusion criteria • One reviewer extracted data into a spreadsheet and performed quality checks for data accuracy
Age 18+, confirmed diagnosis of any type or stage of cancer, study focus on improving cancer -related pain through communication-based approaches targeting patient-physician communication
Effect size estimated with Hedges g3 (outcome measure was mean pain severity at last follow-up) Funnel plot used to assess publication bias
Categorical data was reported as counts and percentages, continuous data was reported as means with standard deviations. Analysis is done by R statistical software2 and Comprehensive Meta-Analysis4
Figure 1: Communication Pathways to Improved health Outcomes1 Figure 2: PRISMA Flow Diagram
Summary of Participant Characteristics
Issues in Current Pain Research and Limitations • • • •
Observational Sample (n=6,083)
• Mean age= 60.1 years (SD=6.4) • Female (58.1%) • White (42.7%) • Non-Hispanic (57%) • High School Education or Less (44.9%) • Cancer Stage I-II (36.4%) • Gastrointestinal Cancer Diagnosis (34.1%) • Brief Pain Inventory used to measure pain (47.6%)
RCT Sample (n=2,924)
• Mean age= 55 years (SD=4.5) • Female (71.3%) • White (59.2%) • Non-Hispanic (70.2%) • Cancer Stage III-IV (36.7%) • Breast Cancer Diagnosis (17.3%) • Brief Pain Inventory used to measure pain (54.9%)
OBJECTIVES Provide a current and comprehensive overview of the role of patient communication in cancer pain interventions over the last decade
Describe patient population characteristics Identify any enrollment disparities
Obtain an estimate of the effect of communication-based interventions on cancer pain severity
DATA CONSISTENCY AND STANDARDIZATION
Figure 3: Forest plot of effect size (g)
Variables were not reported for ≥25% of participants • Race/ Ethnicity • Marital Status • Level of Education (Observational only) • Income • Primary Tumor Site (RCT only) • Cancer and Pain Treatment History Variables had issues with data collection standardization • Marital Status • Level of Education • Income
• • • •
Underrepresentation of males and minorities Data collection and reporting issues Small percentage of studies used health behavior theory in methodology (26% of OBS and 42% of RCTs) RCT pain outcomes were not sustained until study endpoints Inconsistent effects of interventions on pain severity Marginally significant and small effect size estimated Potential for publication and reviewer bias Small meta-analysis sample did not allow for subset analyses
Recommendations Need for improved data collection practices, theory-based methodology, a focus on at-risk populations, and long term pain management goals.
REFERENCES 1. Street, RL: How clinician–patient communication contributes to health improvement: Modeling pathways from talk to outcome. Patient Educ Couns 92:286-291, 2013 2. R Core Team (2013). R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria. ISBN 3-900051-07-0, URL http://www.Rproject.org/. 3. Hedges LV: Distribution Theory for Glass’s Estimator of Effect Size and Related Estimators. J Educ Stat 6:107-128, 1981 4. Comprehensive Meta-Analysis (Version 2) [Computer software]. (2014). Englewood, NJ: Biostat. Available from http://www.meta-analysis.com/index.php
ACKNOWLEDGMENTS The author thanks Jenny Garcia-Barcena, MSLS from the Calder Library for her assistance with the literature search and David J. Lee, PhD and Tulay Koru-Sengul, PhD for reviewing the thesis.
24 ! Student!Name:!Eunsung!Kim,!MD/MPH!Class!of!2017! Project:!Expanding!HIV!Strategy!for!AtRRisk!CommuniEes!in!Central!America!
Background! &! Objec4ve:! The! number! of! Central! American! immigrants! coming! to! the! U.S.! has! conEnually! grown! over! the! years.! ! At! the! same! Eme,! HIV! has! grown! to! be! an! epidemic! in! this! immigrant!populaEon.!In!order!to!prevent!the!spread!of!HIV!and!STIs,!the!CDC!along!with!partnering! organizaEon,!such!as!TEPHINET,!have!implemented!surveillance!strategies!to!keep!track!and!treat!these! diseases.!Worked!with!TEPHINET!to!expand!their!HIV/STI!surveillance!program!and!write!a!protocol!to!standardize!their! clinics!protocols!across!Honduras,!El!Salvador!and!Panama.! Methods:!Conducted!seven!women!focus!groups!in!seven!diﬀerent!communiEes!to!gain!insight!to!the!community’s!need! for!an!HIV/STI!clinic!and!expand!the!surveillance!program!in!Honduras.!!Each!focus!group!consisted!of!six!to!ten!women.! The! data! was! analyzed! using! tape! recordings! and! conducEng! a! themaEc! analysis.! Visited! three! currently! funcEoning! clinics!in!Honduras!to!observe!the!clinic!ﬂow.!Wrote!the!protocol!for!the!surveillance!programs!and!met!with!Panama! and!El!Salvador!representaEves!to!review!the!protocol.! Results:! !All!seven!groups!expressed!the!need!of!an!HIV/STI!clinic!in!their!community.!The!deciding!factor!for!the!new! clinics!in!Honduras!was!determined!by!health!facility’s!accessibility!and!how!much!the!community!trusted!it.! Conclusions:!For!the!CDC!and!partner!organizaEons!to!increase!uElizaEon!of!their!HIV/STI!clinic,!they!must!work!together! with!the!Ministry!of!Health!to!overcome!some!of!the!factors!impeding!communiEes!to!seek!care!in!these!clinics.!! ! Global!Health!Scholar
Expanding HIV strategy for At Risk Communities in Central America E lisa K im MD/ MPH Class of 2017, University of Miami Department of Public Health Sciences, Miller School of Medicine Contact: e.kim10@ umimia.edu
1. To assess whether specific high risk populations in Honduras would utilize government/ CDC-funded STI clinics. 2. Create a regional surveillance strategy guide to be used at all V ICITS clinics in Honduras, El Salvador and Panama.
AIDS/ STI IN CENTRAL AMERICA? HIV epidemic has grown rapidly in Central America. Top ten immigrant group in the U.S. THE STI SURV EILLANCE STRATEGY / CLINICS (V ICITS): Aimed to decrease HIV in Central America (see flow diagram). Funded by CDC-CAR (CDC Central American Regional Office). Target and high risk population: Female Sex Workers (FSW), Men who have sex with men (MSM), Transgender Girls (TG), Garí funas (African Caribbean), People living with HIV (PL HIV ). WHO IS TEPHINET? Organization that implements V ICITS strategy in Honduras, Panama, and El Salvador. Its role is to: Evaluate future SURV EIL L ANCE sites. Help set up clinic and train new staff. Provide technical support (e.g. continuing education) for effective V ICITS strategy implementation. Field Experience Partner organization Funded by CDC-CAR.
Obj ective 1 Q ualitative study utilizing focus groups. Research q uestion: How satisfied are you with the community’ s health facility? Would a V ICITS clinic be useful for the community? Eligibility criteria for women’ s focus group: Garifuna and/ or diagnosed with HIV Older than 18 years. Focus group size: 6-10 women Sampled from each of the following seven communities (see map): Trujillo, L a Ceiba, Tela, San Pedro Sula, El Progreso, Tegucigalpa, Choluteca. Data analysis: Reviewed focus group recordings and extracted q uotes pertinent to study q uestions. Performed thematic analysis from extracted q uotes.
Obj ective 1 Major factors discouraging people from using V ICITS facilities: Fear of discrimination from being transgender or homosexual and/ or having HIV . Fear of not finding/ losing a job due to STI association. Fear of being abandoned by partner or family for having HIV . Transgender participants indicated that their population felt highly stigmatized and hence were less likely to visit a V ICITS clinic. Many people dislike seeking care at nearby clinic or hospital due to lack of confidentiality. Obj ective 2 Manual and guides are useful standardization and q uality improvement tools.
Obj ective 2 Performed a literature review using CDC, WHO, and MOH (Ministry of Health) resources to understand the HIV / STI problem in Central America. Studied the original surveillance strategy protocol created by the CDCCAR. V isited three V ICITS clinics in Honduras to observe clinic flow. Met with El Salvador and Panama V ICITS project manager to review and refine the V ICITS guide to achieve standardization of protocol throughout Honduras, El Salvador and Panama. Working with Dr. Rosales (El Salvador), Samuel Escudero (Panama) and Dr. Muñ oz (Panama) on V ICITS regional guide.
The V ICITS strategy:
TEPHINET, CDC-CAR and MOHs must work together to decrease factors discouraging people from seeking care at V ICITS clinics, such as: Decrease stigma associated with HIV / STI Ensure confidentiality at STI health facilities.
My journey through Honduras to conduct focus groups
This field experience was funded by the Global Health Scholar Awards and was completed with the help of CDC-CAR and Dr. L anetta J ordan. Women focus group set-up in Trujillo
25 ! Student!Name:!Anne!Kimball,!MD/MPH!Class!of!2015! Project:!Expanding!UMMSM!Department!of!Community!Service!(DOCS)!into!Palm!Beach!County!–! Partnering!with!CommuniEes!to!Combat!the!Social!Determinants!of!Health!through!EducaEon,!Health! Screening,!and!Healthcare!NavigaEon! ! Background:!DOCS!is!a!studentRrun,!nonRproﬁt!organizaEon!at!UMMSM,!which!provides!free!medical! services! to! underserved! populaEons! around! Miami.! The! ﬁrst! year! for! DOCS! at! the! Regional! Medical! Campus!(RMC)!was!2013R2014.!The!objecEve!of!this!project!was!to!create!a!sustainable!foundaEon!for! RMC!DOCS!to!provide!important!healthRrelated!services!to!the!underserved!in!Palm!Beach!County.!! Ac4vi4es:!Purchased!necessary!supplies!to!support!health!educaEon!programs!and!screening!events!targeEng!obesity,! hypertension,!and!diabetes.!During!the!fall!semester,!RMC!DOCS!forged!partnerships!with!community!organizaEons!and! held!miniRhealth!fairs!in!African!American!and!Hispanic!neighborhoods!in!West!Palm!and!Riviera!Beach.! Results:! Independently! supported! 3! events! in! the! fall! of! 2014,! oﬀering! educaEon! and! tools! for! healthier! choices,! and! providing! free! screening! to! 57! paEents.! Five! of! these! paEents! were! idenEﬁed! to! have! “high! risk”! hypertension! and! diabetes!and!all!were!appropriately!referred!to!free!or!lowRcost!medical!care.!! Conclusions:! !RMC!DOCS!can!now!independently!sponsor!health!educaEon!and!screening!events!and!will!conEnue!to! develop! relaEonships,! idenEfy! needs,! and! improve! access! to! care! and! outcomes! for! the! underserved! communiEes! of! Palm!Beach!County.!! !
Expanding Department of Community Service (DOCS) into Palm Beach County Partnering with Communities to Combat the Social Determinants of Health through Education, Health Screening, and Healthcare Navigation A nne A . K imball MD/MPH Class of 2015 , Department of Public Health Sciences, University of Miami Miller School of Medicine
Back ground of RMC DOCS •
Map of Palm Beach County % of People Living Below the Federal Poverty Level
DOCS is a student run, non-profit organiz ation at the UMMSM, w hich provides free screening and medical services to underserved patients in the greater Miami area. •
Using main campus DOCS as a model, w e purchased supplies to support health education programs and screening events: • Obesity – Scale and tape measure • Hypertension – Blood pressure cuffs • Diabetes – Glucose monitor, lancets, test strips • Logistics – Table, chairs, storage bins, first aid and sanitary supplies, volunteer snack s • Nutrition education – Recipe book s, healthy foods
The first year for DOCS at the Regional Medical Campus (RMC) in Palm Beach County (PBC) in its current format w as 2013 -2014.
M ission: To improve the health of underserved populations in Palm Beach by providing q uality, compassionate, and culturally competent health related services through sustainable partnerships betw een UMMSM and the communities w e serve.
Courtesy of Palm Health Foundation
V ision: To implement sustainable programs that improve health outcomes, health literacy, and access to healthcare and health insurance for underserved communities in Palm Beach County.
Aims of this Springboard proj ect: • To purchase the supplies necessary to provide health-related services to these communities • To create a sustainable foundation for the organiz ation for years to come
Developed a “ Strategic Plan” for RMC DOCS •
V olunteered at Caridad Health Center bimonthly •
Established the RMC Healthcare Navigation program
Supported 3 community-partnered health events •
Helped ~ 50 families mak e healthier food choices •
Obj ectives Aims of RMC DOCS for 2014-2015: • To build relationships w ith and understand the “ have and needs” of the underserved communities in West Palm Beach, Riviera Beach, and Lak e Worth • To hold health education and screening events in partnership w ith community organiz ations • To establish a Healthcare Navigation program to help Palm Beach residents obtain health insurance • To continue to partner w ith Caridad Health Center
Accomplishments this Y ear
Pictures of Events
Provided free health screening to 57 patients •
Identified 5 patients w ith “ high risk ” conditions •
Referred all patients to free/ low -cost medical care
Nutrition Education at Back to School Event
DOCS table at Riviera Beach community health fair
Continue to develop relationships, identify needs, and improve access to care and health outcomes in the many underserved communities of PBC. Expand our services, community partners, and number of people impacted in the coming years.
Ack now ledgements Glucose testing and Diabetes education
RMC Students and Residents at Holiday Community Event in West Palm
This proj ect w as supported w ith funds from the Springboard Palm Beach Grant. Thank you to the RMC DOCS Leadership Board and to our faculty advisor, Dr. J ulia Belk ow itz .
26 ! Student!Name:!Charity!Lee,!MD/MPH!Class!of!2017! Project:!Reducing!Childhood!Mortality!in!Guatemala! Background:! The! Center! for! Disease! ControlR! Central! America! Regional! Oﬃce! (CDCRCAR)! Water! and! SanitaEon! Health! (WASH)! project! seeks! to! come! up! with! a! protocol! of! evidence! based! intervenEons! that!will!signiﬁcantly!reduce!childhood!morbidity!and!mortality!in!Xela,!Guatemala!by!addressing!the! greatest!issues!of!diarrhea,!malnutriEon,!and!pneumonia.!! Methods:!Spent!three!weeks!in!Guatemala!City!under!CDCRCAR!to!gain!a!greater!understanding!of!the! current!health!issues!and!research!through!an!extensive!literature!review.!I!abended!meeEngs!with!Pan!American!Health! OrganizaEon!(PAHO)!to!plan!for!the!Universal!Health!Care!Summit!and!the!Ministry!of!Health!(MOH)!to!plan!goals!and! budgets! for! the! new! NaEonal! Public! Health! InsEtute! of! Guatemala.! Spent! a! week! in! the! ﬁeld! in! Xela! to! evaluate! the! needs!of!the!area!for!protocol!implementaEon,!to!assess!the!quality!of!health!care!and!resources!available!at!the!child! malnutriEon! ward! under! the! United! NaEons! Zero! Hunger! Pact! at! the! regional! hospital,! to! volunteer! at! our! sister! organizaEon’s!clinic,!and!to!evaluate!the!progress!of!the!partner!NGO.!! Results:!Using!eyeRopening!experiences!and!literature!reviews,!recommended!evidenceRbased!intervenEons!that!would! be!eﬃcacious!and!sustainable!to!insEll!for!the!CDCRCAR!WASH!protocol!to!reduce!child!mortality!in!Xela.!! Conclusions:! Developed! an! understanding! of! the! necessity! of! organizaEon! of! NGOs,! acquisiEon! of! resources,! and! mobilizing!forces!by!governing!bodies!to!push!for!naEonal!surveillance!and!intervenEon!implementaEon.!!
Reducing Childhood Mortality in Guatemala Charity J . L ee
Department of Public Health Sciences
Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, F lorida, USA
ORGANIZ ATION OV ERV IEW •
The Center for Disease Control and Prevention (CDC) is a federal agency under DHHS to protect the public from disease- chronic or acute, curable or preventable, human error or deliberate attack
CDC-Central American Region (CDC-CAR) works to help strengthen the capacity to detect, prevent, and control disease and respond to public health threats in Central America by providing technical assistance to the Ministry of Health (MOH).
CDC’ s global water and sanitation hygiene (WASH) program interventions aim at saving lives and reducing illness by improving global access to clean water, adeq uate sanitation and improved hygiene for long term prevention •
Gained a general understanding of soil transmitted Helminths and other risk factors for diarrhea and related morbidities in children under the age of 5 in Guatemala like malnutrition and pneumonia
Observed how social determinants of health to bring about change through policy or education is just as important as treatment •
Examined how the lack of resources, medications, sanitation in clinics, and proper education of health care providers in clinics disables the potential for delivering q uality care
Developed a better concept of public policy, the necessity of organization, resources, and mobilizing forces by governing bodies to push for surveillance and interventions • The need for uniform water sanitation and access, along with waste disposal provision by government
The child mortality rate in Guatemala was 32 deaths per 1000 in 2012, significantly higher than the L atin American region -19 deaths per 1000 live births in 2012 (WHO, 2013) •
Realized how the disorganization of NGOs that had great intentions but lacked the leadership and skills to engineer and make projects become a sustainable reality
FIELD WORK OV ERV IEW •
Spent three weeks in Guatemala City and one week in Q uetzeltenango (X ela) working with Stephany Sanchez and Dr. Nelson Arbodela of CDC– CAR
Evaluate NGO involved in the current WASH protocol for X ela, and make recommendations on current interventions Water Sanitation and Hygiene Project
V isit regional hospital of X ela to evaluate child malnutrition programs under United Nations Z ero Hunger Pact •
V olunteer at sister organization clinic – Daughters of Charity
Attend Pan American Health Organization (PAHO) meeting to plan Universal Health Care Summit in August •
Attend meetings to plan goals and budget for newly instilled National Public Health Institute •
OBJ ECTIV E Understand health care needs, current resources of clinics and the government, and policy to plan modes of prevention of childhood disease and mortality
It is crucial that evidence based interventions be included in the CDC intervention menu so that CDC WASH protocol to reduce child mortality in X ela is efficacious and sustainable
This field experience was supported with funds from the Global Health Scholar Award at the University of Miami Miller School of Medicine.
CONTACT Charity J . L ee MD/ MPH Public Health Student University of Miami Email: cjlee513@ med.miami.edu Phone: (240) 994-4361
27 ! Student!Names:!Lauren!Lewis,!MD/MPH!Class!of!2017! Project:!UniEng!Exercise!and!Medicine:!Assessing!the!IntegraEon!of!Exercise!into!Healthcare!through! ! the!Exercise!is!Medicine!Singapore!IniEaEve! ! ! ! Background:! Exercise! is! Medicine! (EIM)! is! a! global! iniEaEve! developed! to! promote! the! healthR enhancing! beneﬁts! of! exercise.! Exercise! is! Medicine! Singapore! (EIMS)! is! one! of! many! EIM! NaEonal! Centers!worldwide!focused!on!increasing!exercise!in!Singapore.!The!objecEves!of!the!internship!were! to!learn!how!exercise!is!being!integrated!into!healthcare,!improve!EIMS!exercise!promoEon!materials,! and!increase!awareness!of!EIMS!in!Singapore.! Methods:! Shadowed! various! EIMS! team! members,! worked! on! improving! the! EIMS! course! book! used! for! exercise! prescripEon,!and!parEcipated!in!an!EIMS!exercise!prescripEon!course.!Also!abended!several!EIMS!consultaEons!within! the!community.! Results:! Accomplishments! included! adding! 2! new! chapters! to! the! EIMS! course! book,! compleEng! and! evaluaEng! the! exercise!prescripEon!course,!making!recommendaEons!for!elderlyRappropriate!exercise!equipment,!and!wriEng!2!news! media!arEcles!on!the!health!beneﬁts!of!exercise.!Observed!how!exercise!was!incorporated!into!paEent!visits.! Conclusions:! Explored! how! exercise! can! be! integrated! into! a! healthcare! system.! Grained! greater! appreciaEon! of! the! diverse! barriers! people! face! concerning! exercise,! as! well! as! witness! the! challenges! faced! by! EIMS! when! trying! to! encourage!regular!exercise!engagement!in!Singapore’s!populaEon.!Over!Eme,!more!research!should!be!done!to!examine! the!eﬃcacy!of!EIMS!projects!and!acEviEes.! Global!Health!Scholar
Department of Public Health Sciences
Field Work Overview
Activities Proj ect 1: Work ing w ithin the CSMC and Observing the Integration of Exercise into Health Care
Proj ect 2: Improving EIMS Exercise Prescription Resources
Proj ect Overview : L earn about the CSMC’ s role in Singapore and the use of EIMS in the health care setting
Proj ect Overview : Enhance the EIMS exercise prescription course book for physicians, and evaluate the exercise prescription course for fitness professionals
Exercise is Medicine (EIM) is a global initiative promoting the health benefits of exercise and calling for exercise’ s integration into health care Exercise is Medicine Singapore (EIMS) is a branch of EIM promoting the use of exercise in Singapore’ s health care system and within the community EIMS uses educational materials, workshops, community outreach, and exercise prescription and/ or referrals for patients, with the goal of making exercise a mainstay in patient visits and disease prevention and treatment
Accomplishments: • •
Toured a sports injury facility for the World University Floorball Championships
Witnessed patient-health professional dynamics in response to exercise recommendations
L earned how to appropriately prescribe exercise to different patient populations Created 2 new chapters on exercise for physically disabled and intellectually disabled persons Evaluated and received certification for the exercise prescription course
Attended several consultations with Singaporean residential housing committees and made recommendations for elderly-appropriate exercise eq uipment
Wrote a newspaper article for the local Straits Times detailing the importance of exercise for wheelchair users Wrote a magazine article for Asian Geographic on the health benefits of swimming
# 1: Learn about and participate in the EIMS initiative
Patients can face a variety of barriers when starting and maintaining exercise EIMS is helping to reduce these barriers through exercise instruction catered to an assortment of patient populations There are many approaches that can be taken to integrate exercise into a community, each with their own uniq ue challenges
# 2: Develop a comprehensive understanding of the Singapore health care system # 3 : Gain a broad perspective on how sports medicine is approached in Southeast Asia
Proj ect Overview : Introduce EIMS into Singaporean communities and expand EIMS awareness
Shadowed sports physicians, physiotherapists, and sports trainers within the CSMC and the community
Attended lectures on common sports injuries seen in Singapore and treatment techniq ues used
Proj ect 3 : Increasing EIMS Community Outreach
Global reach of EIM EIMS exercise prescription course session
Changi Sports Medicine Centre (CSMC) L argest sports medicine center in Singapore, founded in 2002; headq uarters for EIMS
Future Directions Conduct research to determine the efficacy of EIMS projects established in various communities Improve upon and create new culturally-competent EIMS applications
Mission: to help individuals recover from sports injuries and return to their previous physical activity performance level
Ack now ledgements
The CSMC and members of the CSMC team
Example of an activity performed during the EIMS exercise prescription course
EIMS exercise prescription course certificate
This field experience was supported with funds from the Global Health Scholar Award. Special acknowledgements go to Dr. Ben Tan and Dr. Cindy L in for advising me in Singapore, and to Dr. Mark Stoutenberg for providing me with guidance throughout my Capstone Field Experience.
28 ! Student!Name:!Lucila!LopezRBloise,!MPH!Class!of!2014! Project:!Cuidémonos:!CulturallyRSpeciﬁc!DidacEc!Videos!to!Increase!STI/HIV!Knowledge!among! PopulaEonsRatRRisk!in!Central!America! Background:! Sexually! Transmibed! InfecEons! (STIs),! including! HIV,! remain! a! major! public! health! challenge! globally! and! parEcularly! in! LaEn! America.! STIs! can! cause! acute! illness,! inferElity,! longRterm! disability,! and! death.! In! Nicaragua,! the! HIV! epidemic! aﬀects! less! than! 1%! of! the! general! populaEon;! instead,!it!is!concentrated!among!highRrisk!populaEons,!including!men!who!have!sex!with!men!(MSM)! and!female!sex!workers!(FSWs).!The!Center!for!Disease!Control!and!PrevenEon!(CDC)!and!the!Ministry!of! Health! implemented! STI! SenEnel! Surveillance! (VICITS)! clinics! in! order! to! gather! data! to! improve! the! quality! and! eﬀecEveness!of!programs!for!the!prevenEon!of!STIs/HIV!in!these!populaEons.! Methods:! Two! brief! and! culturally! speciﬁc! videos! were! created! to! incorporate! key! prevenEon! messages! aimed! at! increasing!STI/HIV!risk!knowledge,!promoEng!posiEve!a~tudes!toward!condom!use,!and!building!selfReﬃcacy!and!skills! to!enable!safer!sex!and!condom!negoEaEon.!Further,!a!recepEvity!survey!was!created!to!be!administered!to!paEents!in! the!speciﬁed!clinics!who!will!receive!the!videos.! Results:!The!videos!and!survey!have!been!completed.!A6er!the!videos!are!implemented,!it!is!hypothesized!that!they!will! increase!STI/HIV!risk!knowledge,!improve!condom!use!selfReﬃcacy!and!negoEaEon,!and!decrease!STI/HIV!incidence!in! the!VICITS!clinic!populaEon.! Conclusions:! Videos! shown! in! STI! clinics! for! highRrisk! populaEons! with! low! literacy! levels! are! a! novel! and! inexpensive! modality! that! can! be! used! to! increase! STI! knowledge! and! promote! selfReﬃcacy! for! condom! negoEaEon.! Public! health! messages! on! a! variety! of! health! topics! can! be! disseminated! to! various! atRrisk! populaEons! through! this! type! of! mechanism.!!! DPHS!Recogni5on
Cuidémonos: Culturally-Targeted Videos to Increase STI/HIV Knowledge among Populations-at-Risk in Central America
Lucila Bloise, M P H 1 ; Sanny Northbrook, M D, M P H 2 ; Luz M aria R om ero 2 ; Noella Dietz, P hD 1 1 Department of Public Health Sciences;; Universityy of Miami Leonard M. Miller School of Medicine. Miami,, Florida,, USA | Email: ail: email@example.com @ 2 Ministry of Health HIV IV Unit; Centers for Disease Control and Prevention on - Central American Region. Managua, Nicaragua
I NTRODUCTI ON Sexually Transmitted Infections (STIs), including HIV, remain a major public health challenge globally and particularly in Latin America. STIs can cause acute illness, infertility, long-term disability, and death. In Nicaragua, the HIV epidemic affects less than 1% of the general population; instead, it is concentrated among high-risk populations, including men who have sex with men (MSM) and female sex workers (FSWs). The Center for Disease Control and Prevention (CDC) and the Ministry of Health implemented STI Sentinel Surveillance (VICITS) clinics in order to gather data to improve the quality and effectiveness of programs for the prevention of STIs/HIV in these populations.
M ATERI ALS AND M ETHODS Two brief and culturally specific videos were created to incorporate key prevention messages aimed at: Increasing STI/HIV risk awareness and knowledge; Promoting positive attitudes toward condom use; Building self-efficacy and skills to enable safer sex and condom negotiation. The materials used were an Apple iPhone 6, Apple MacBook Pro 13”, iMovie software, and the scripts created for the purpose of these videos. An acceptability survey was created to be administered to patients who receive the videos (pending CDC approval).
OUTCOM E Two videos were created called “Maria” and “Juan.” Each video emphasized condom use while participating in risky behaviors. After the videos are implemented, it is hypothesized that participants will: Increase STI/HIV risk knowledge Improve condom use self-efficacy and negotiation Decrease STI/HIV incidence in the VICITS clinic population
FUTURE DI RECTI ONS Sites of VICITS clinics in Nicaragua
OBJECTI VE To use innovative technology to create culturally specific videos targeting at-risk populations for HIV and other STIs, namely MSM and FSWs.
Screenshot from “Juan” video
Acceptability items to be included in the survey are: Did you like the video? Would you tell your friends about it? Do you feel that the video increased your knowledge about condom use? What was the theme of the video?
Screenshot from “Maria” video
CONCLUSI ON Videos shown in STI clinics for high-risk populations with low literacy levels are a novel and inexpensive modality that can be used to increase STI knowledge and promote self-efficacy for condom negotiation. Public health messages on a variety of health topics can be disseminated to various at-risk populations through this type of mechanism.
R EFER ENCES 1. Morales-Miranda, S., Beteta, E., Alvarez, B., Delgado, S., Romero, L.M., Goins, J., Arambu,́ N, … Ramı ́rez, L.F. (2011). Sentinel surveillance of sexual behaviors and prevalence of HIV and STIs in vulnerable populations in Nicaragua. 2. World Health Organization (1999). Guidelines for sexually transmitted infections surveillance. Retrieved from http://www.who.int/reproductivehealth/publications/rtis/CDS_CSR_EDC_ 99_3/en/
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Prenatal S creening in H anoi: E ffects of Agent O range on Awareness of Birth D efects D av id M ai MD/ MPH Class of 2017, Department of Public Health Sciences, University of Miami Miller School of Medicine I n Coll Collaboration bo ti wit D r. Phan with Ph D u uc Tran T and nd th tthe h D ep artment rtm t off M edical d l Bi di Biology l and nd G Genetics ti att H anoii M edical d l U ni di niv ersity it
BACK GRO U N D During the V ietnam War, Agent Orange was a toxic herbicide sprayed by U.S. troops to eliminate crops used to feed the North V ietnamese military (Fig. 1). L inked to 150,000 birth defects passed on to future generations including spina bifida and Figure 11: L iters of Agent Orange cleft palates. sprayed calculated by individual grids spaced at 1.2 km2 L ed to increased awareness of birth defects in Northern V ietnam. Rising rates of prenatal screening seen in Hanoi. Demand for prenatal screening not fulfilled with limited funding and a shortage of genetic counselors and physicians. Health insurance in V ietnam does not cover prenatal screening costs. Uneq ual access to prenatal screening in rural and low socioeconomic communities.
F IE L D
E X PE RI E N CE O BJ E CTI V E S
Observed counselors during genetic consultations to understand the prenatal screening program in V ietnam and its limitations in providing eq ual access. Met with public health physicians to identify potential interventions at Hanoi Medical University to reduce socioeconomic disparities in prenatal screening. Participated in meetings to learn how genetic counseling complements prenatal screening in assisting women on decisions regarding pregnancy.
CO M M U N I TY PARTN E R Hanoi Medical Center: Found in 1902, it is the oldest V ietnamese University Mission: To train highly competent medical personnel to meet the healthcare demands of society. Includes the Department of Medical Biology and Genetics, a center dedicated to providing prenatal care
CO N CL U S I O N Investment of 4.8 million USD would reduce prenatal screening costs and provide more genetic counselors and physicians. The data collected from DCEs would show how medical students would respond to incentive packages in order to enhance recruitment and retention of physicians in rural areas. Raising a disabled child correlates with poverty in V ietnamâ€” genetic counseling provides parents who are carriers of genetic diseases to consider other options even before pregnancy.
RE F E RE N CE S 1. Stellman, J eanne. " The Extent and Patterns of Usage of Agent Orange and Other Herbicides in V ietnam." N ature 422 (2003):
O TH E R F I E L D
E X PE RI E N CE
681-87. 2. Trinh, H. (2012). Disparities
I N S I GH TS GAI N E D L imited access to prenatal screening in rural areas due to fewer medical facilities and resources. 53% of physicians reside in urban areas where only 28% of the V ietnamese population lives3. V ietnamese government investing 4.8 million USD to improve access to prenatal screening throughout Northern V ietnam. Discrete Choice Experiments (DCEs), a study implemented by the Ministry of Health in V ietnam, to understand medical student work environment preferences. The data will be used to design incentive packages to recruit graduating medical students to work in rural parts of V ietnam.
The V ietnam Handicapped Handicrafts: During my stay in V ietnam, I discovered an organization that employs disabled people living in V ietnam. This company trains the disabled population, which includes those affected by Agent Orange, to learn skills that are involved in making handicrafts such as paintings and toys. This organization provides an opportunity for disabled V ietnamese citizens to support themselves by earning a stable income.
in Prenatal Care Utilization. In E thnic Disparities in Prenatal Care Utiliz ation in V ietnam. L ogan. 3. V ujicic, Marco. " Attracting Doctors and Medical Students To Rural V ietnam: Insights from a Discrete Choice Experiment." W orld B ank (2010). Health, Nutrition and Population Unit.
F U N D IN G This field experience was supported with funds provided by the Global Health Scholar Award.
30 ! Student!Name:!Mallory!Monda,!MD/MPH!Class!of!2017! Project:!Standardizing!Safe!and!Eﬃcient!Burial!Procedures!for!Ebola!Deaths:!World!Health! OrganizaEon!(WHO),!Sierra!Leone!! Background:!The!Ebola!outbreak!in!Sierra!Leone!began!just!a6er!this!5Rweek!internship!commenced! with!the!World!Health!OrganizaEon’s!(WHO)!Department!of!Disease!PrevenEon!and!Control.!!At!this! Eme,! no! oﬃcial! process! existed! to! bury! the! bodies! of! those! deceased! from! Ebola! in! the! main! outbreak! region.! ! AddiEonally,! burial! staﬀ! were! not! trained! in! safe! handling! of! dead! bodies! and! confusion!over!responsibiliEes!of!organizaEons!involved!in!the!burial!process!led!to!delayed!burials.!! Bodies!accumulated!in!the!Médecins!Sans!FronEères!(MSF!aka!Doctors!Without!Borders)!outdoor!morgue,!increasing!the! likelihood!of!heat!related!body!bag!decomposiEon!and!related!Ebola!transmission!to!staﬀ.!!This!ﬁeld!experience!focused! on:!(1)!understanding!the!responsibiliEes!of!parEes!involved!in!Ebola!burials!and!(2)!idenEfying!areas!of!improvement!in! burial!safety!and!eﬃciency.!!! Methods:! ObservaEon! of! the! burial! process! was! coupled! with! MSF! and! Burial! Team! interviews! to! highlight! areas! of! improvement.!!Insights!gained!were!used!to!create!a!Standard!OperaEng!Procedure!to!be!followed!for!all!Ebola!burials.!! Results:!A!Standard!OperaEng!Procedure!was!produced,!which!outlined!a!stepRbyRstep!process!with!Emeframes!for!all! responsibiliEes!of!parEes!involved!in!the!burial!process.!!AddiEonally,!the!Burial!Team!was!properly!trained!on!safe!burial! technique.!!! Conclusions:! The! standardizaEon! of! the! burial! process! achieved! with! this! project! was! a! pivotal! accomplishment! in! prevenEng!the!spread!of!Ebola!through!risky!burial!processes!and!helped!pave!the!way!for!the!training!of!future!Burial! Teams.! Global!Health!Scholar
Standardiz ing Safe and Efficient Burial Procedures for Ebola Deaths: World Health Organiz ation (WHO), Sierra Leone M allory M onda M D / M PH Class of 2 017 , D ep artment of Public H ealth S ciences, U niv ersity of M iami M iller S chool of M edicine
Fieldw ork Overview What: 5 week internship with WHO’ s Department of Disease Prevention and Control in Kailahun, Sierra L eone. Public Health Issues: No official process existed to bury the bodies of those deceased from Ebola: • Burial staff not trained in safe handling of dead bodies • Confusion over responsibilities led to delayed burials • Bodies accumulated in Mé decins Sans Frontiè res’ (MSF) outdoor morgue • Increased delays led to more transmission opportunities to staff
Challenges Identified in Burial Process Observation of burial processes w as coupled w ith MSF and Burial Team interview s to highlight the follow ing main concerns: MSF Challenges: • Family approval needed for burials, this delayed burials over 2 days • Decomposed body bag burst from heat exposure oDirectly exposed 3 workers to infectious bodily fluids Burial Team Challenges: • Used PPE inappropriately and unsafely • Feared Ebola to the point it compromised ability to perform duties • Did not document deaths or gravesite locations • Consistently forgot materials needed for safe burials • Contacted too late in day to begin burials oIncreased risk for mistakes, therefore transmission
Key Players in Ebola Burial Process: 1.MSF: Sanitize dead bodies, store in morgue 2.Ministry of Health Burial Team: • Retrieve bodies from MSF treatment center • Delivery bodies to Grave Diggers 3 .Community Grave Diggers: Bury bodies 4.WHO: Recruited to evaluate and improve burial process
(L EFT) Grave diggers prepare for burials outside Mé decins Sans Frontiè res’ Ebola treatment center in Kailahun, Sierra L eone. Graves were left unmarked and identified via a chart managed by the burial team supervisor.
(RIGHT) MSF removes body from morgue to hand over to Burial Team. Workers are decontaminating outside of body bag with Chlorine before loading into the ambulance to drive to the graveyard.
(L EFT) Burial Team picks up body from MSF Treatment Center in Kailahun, Sierra L eone supervised by J ose Riera of the WHO. Morgue pictured in center.
Photo credit: Raconteur Report
Insights Gained WHO often conflicted w ith norms and beliefs on the ground: Ex. 1: WHO advised against full PPE attire during burials • Burial Team insisted on wearing full PPE • Team lacked understanding of Ebola transmission • PPE provided disguise: prevented community from identifying and stigmatizing workers Ex. 2: WHO recommended pre-digging graves before deaths for efficiency • Grave diggers refused • Perceived as bad omens to the living Ex 3 : Political climate prevented any WHO actions that could mak e government' s response appear inadeq uate • WHO was aware that government was not including all deaths in publicized statistics but could say nothing • WHO was aware that outbreak was more severe than government admitted yet their hands were tied
Photo credit: WHO/ T. J asarevic
Outcomes 1. Standard Operating Procedure produced : outlined step-by-step process with timeframes for all responsibilities of all parties involved in burial process MSF Responsibilities Established: V illage Chief contacts listed for burial approval when family is unreachable Permission granted to commence burial after 2 days regardless of approval • Tasked with contacting Burial Team directly when body is ready for burial • Death certificates created for MSF to provide to family as evidence of burial •
WHO Office Security Gate at Headq uarters in Freetown, Sierra L eone
Sierra L eone is located on the coast of West Africa. Kailahun is the location of the initial Ebola outbreak in Sierra L eone. Ebola was brought to Kailahun through Guinea.
Obj ectives 1. 2. 3. 4.
Understand responsibilities of parties involved in burying the dead Identify areas of improvement in burial safety and efficiency Produce official Standard Operating Procedure (SOP) for burials Train Burial Team to safely perform burials
Burial Team Responsibilities Established: • MSF gravesite map created for team to record who is buried where • L og created to document deceased biographical information • Cutoff times instituted for afternoon burials • Supply checklist created, ensuring necessary materials present at burials • Therefore reducing risk of transmission
Ack now ledgements •
2. Burial Team trained to conduct safe burials: • •
Coached on safe use of PPE Trained on methods of Ebola transmission Each member permanently assigned to hold body bag at head or feet • Reduced risk of dropping body or colliding with team members Evaluated by WHO and Red Cross and competence confirmed
This field experience was supported with funds from the Global Health Scholar Award WHO and MSF for allowing my participation in the outbreak response The patients, families, and healthcare providers who continue to fight and save the lives of Ebola victims in West Africa Dr. McNulty and Dr. Kornfield for the advice and editing expertise
31 ! Student!Name:!Ashlyn!Morse!&!Hema!Kher,!MD/MPH!Class!of!2017! Project:!The!Overtown!Health!Theater:!A!Summer!ExploraEon!of!Health,!Arts,!and!Social!Media! ! ! !!! !!!!!!!!! Background!&!Objec4ve:!Overtown!is!an!urban!enclave!with!one!of!the!highest!rates!of!poverty!and! chronic!disease!mortality!in!MiamiRDade!County.!The!Overtown!Health!Theater!project!aims!to!address! health!disparity!by!providing!an!innovaEve!educaEonal!plaIorm!to!atRrisk!youth!based!on!the!NaEonal! Health!EducaEon!Standards!published!by!the!CDC.! Methods:! Student! knowledge! and! behavioral! changes! were! evaluated! by! the! use! of! pre! and! postR curriculum! surveys.! Surveys! were! adapted! from! the! evidenceRbased! Coordinated! Approach! to! Child! Health!program.! Results:!Survey!data!revealed!negligible!and!even!adverse!changes!in!fruit!and!vegetable!consumpEon.! Improvements!were!seen!in!sweet!consumpEon!and!sedentary!behaviors.!AddiEonally,!results!showed! that!the!integraEon!of!Instagram!is!not!an!eďŹ€ecEve!strategy!due!to!lack!of!student!use!of!this!plaIorm.!! Conclusions:! More! than! half! of! the! students! who! parEcipated! in! the! survey! have! a! family! member! with! diabetes! and! more!than!half!know!someone!who!smokes.!Despite!the!fact!that!dietary!behavior!did!not!change!during!the!course!of! the!curriculum,!the!problem!of!disease!burden!and!risk!factor!saturaEon!remains.!Future!qualitaEve!data!collecEon!must! strive! to! uncover! eďŹ€ecEve! methods! to! impact! dietary! behavioral! change! in! the! youth,! possibly! by! encouraging! parent! parEcipaEon.!! Springboard
The Overtow n Health Theater Education Initiative: Engaging Y outh in Change .
A shlyn Morse and Hema K her MD/MPH Class of 2017, Department of Public Health Sciences, University of Miami Miller School of Medicine
Overtown, formerly a beacon of culture in the AfricanAmerican community, is now the poorest neighborhood in Miami with high rates of chronic disease mortality. 1
Surveys were administered to summer camp students grades 3-8 before and after implementation of the Overtown Health Theater curriculum.
The Overtown Health Theater (OHT) is a community prevention curriculum designed to address the chronic disease burden by targeting Overtown youth in grades 3-8.
Survey q uestions were adapted from CATCH, an evidence-based curriculum based on the CDC Whole Community, Whole Child Model.
The prevention curriculum integrates: • social media • theater performance • evidence-based educational resources3 • physical activity
The aims of the survey were to: • identify eating and exercise behaviors • assess for changes in these behaviors • identify chronic disease risk factor exposure • assess awareness of chronic diseases prevalence in the community
OHT engages the youth of Overtown in prevention of risky behavior and increase in age-appropriate health knowledge.
Survey participants included summer camp students from Urgent, Inc. and Touching Miami With L ove. All students received the same survey.
60% 50% % of Students Exhibiting Behavior
The use of pre and post-curriculum surveys assess knowledge gains and behavioral changes based on CDC performance indicators 1.5.1 and 188.8.131.52
Surveys included: • simple language • multiple choice q uestions • picture-based q uestions
40% 3 2% 26%
Students presenting emotional, physical, intellectual, and social barriers to health during the “ B arrier B rick s” activity.
Photos. Screenshots of O HT I nstag ram posts from T MW L and UI that use the common hashtag # overtow nhealth2014
35 students from TMWL and 19 students from Urgent, Inc. participated in the survey.
Conclusions This project was successful in reducing the amount of sweets consumed and the amount of time spent engaged in sedentary activities. Students responded well to the physical education component of the curriculum. This project was not successful in that 65% of the students surveyed indicated decreased fruit and vegetable consumption. A possible reason is the lack of dietary autonomy students have in the home. A future suggestion is to encourage parental involvement in the curriculum.
Obj ectives Address chronic disease health disparity by researching and adapting an educational platform for at-risk youth based on the National Health Education Standard 1 published by the Centers for Disease Control (CDC). 2 •
Research evidence-based health education programs from CDC. Adapt evidence-based curricula for use in the Overtown community. Evaluate effectiveness of curriculum in the Overtown community.
Ack now ledgements This project would not have been possible without Springboard Grant funds and the guidance Urgent, Inc., Touching Miami with L ove, and The Overtown Y outh Center. A special thank you to Dr. J ohn Ryan for serving as an advisor on this project, and to community members Mr. Washington, Martha Wells, and Oscar for all of their insight and hard work. 1 Y oung, April M.W., Perez, L eda M., Northridge, Mary E., V aughn, Rubiahna L ., Braithwaite, Kisha, and Treadwell, Henrie M.. Bringing to light the health needs of African-American men: the Overtown Men' s Health Study. J ournal of Men' s Health and G ender. J une 2007, 4(2): 140-148. doi: 10.1016/ j.jmhg.2007.03.002. 2,3 USDA Center for Nutrition Policy and Promotion Choosemyplate. g ov; CATCH: Coordinated Approach to Child Health identified by CDC Catchinfo. org ; SPARK: research-based PE program identified by CDC w w w . spark pe. org 41.5.1 Describe the relationship between healthy behaviors and personal health. 1.5.2 Identify examples of emotional, intellectual, physical, and social health.
32 ! Student!Name:!Daniella!Orihuela,!MPH!Class!of!2015! Project:!Development!and!Field!Test!of!Health!EducaEon!Materials!for!the!Juan!Felipe!Medical!Center! !! Background! &! Objec4ve:! Teenage! mothers! in! Cartagena! de! Indias,! Colombia! tend! to! be! from! a! low! socioReconomic!status!and!have!unplanned!pregnancies!resulEng!in!inadequate!health!resources!and! increased! risk! of! preventable! condiEons! including! infant! malnutriEon,! and! poor! postnatal! management.!This!project!takes!an!interdisciplinary!approach!to!develop!and!evaluate!a!customized! health!educaEon!booklet!aimed!at!health!communicaEon!and!empowerment!for!teen!mothers!at!the! Juan!Felipe!Gomez!Escobar!FoundaEon!R!an!internaEonally!recognized!organizaEon!that!focuses!on!young!mothers!and! their!infants.!!! Methods:!An!interacEve!booklet!was!developed!through!personal!interviews!with!paEents!and!feedback!from!Medical! Center!personnel!at!the!foundaEon.!Key!health!lessons!emphasizing!nutriEon,!development,!safety!and!postnatal!health! for! mothers! were! tailored! from! evidenceRbased! resources! and! programs! for! either! adolescent! mothers! or! a! LaEno/ Hispanic!populaEon.!NaEve!Spanish!speakers!reviewed!materials!and!evaluaEon!methods!were!adapted!from!the!PaEent! EducaEon! Materials! Assessment! Tool! (PEMAT),! a! systemaEc! method! that! evaluates! the! understandability! and! ac5onability!of!paEent!educaEon!materials.! Results:! PEMAT! quesEonnaire! with! health! professionals! resulted! in! a! 96.08%! average! understandability! and! a! 91.66%! average! acEonability! score.! OneRonRone! interviews! with! teenage! mothers! gathered! qualitaEve! informaEon! and! documented!the!acceptability!of!content,!comprehension,!cultural!acceptability!and!persuasion!of!the!booklet.! Conclusions:!Revision!of!booklet!based!from!evaluaEon!is!currently!underway.!Sustainability!of!project!is!being!explored! with!Juanfe!by!presenEng!materials!to!possible!business!partners.!! Springboard
Development and Evaluation of Health Education Materials for the J uan Felipe Gomez Escobar Foundation Daniella Orihuela MPH Class of 2014 , Department of Public Health Sciences, University of Miami Miller School of Medicine
Colombia has the highest rate of teenage pregnancy in L atin America; 20% of teenagers in the country are either mothers or pregnant Teenage mothers often lack adeq uate health resources which leads to low health education and poor infant feeding practices These infants are at a higher risk of preventable illnesses and accidents including infant malnutrition and mortality The J uan Felipe Gomez Escobar Foundation (J uanfe) is a non-profit organization based in Cartagena de Indias, Colombia that works towards reducing the rates of infant mortality A gap in health education for this population was identified during a field experience opportunity
All text was double-checked by native Spanish speakers.
III. EV ALUATION WITH PATIENTS • Interviews with patients from the J uan Felipe Medical Center: first-time teenage mothers with an infant younger than 12 months • Interview form gathered q ualitative data that looked into the concepts of affection, comprehension, selfefficacy, cultural acceptability and persuasion • Interviewed 26 young women; women received baby clothes and hygiene items for participating
Booklet' s front cover
Introduction of character Marisol
Table of contents
Sample page: Affection
Interviewing community health worker
OBJ ECTIV ES Sample of interview q uestions and rationales
Develop a customized culturally-competent health education resource for teenage mothers and their infants at J uanfe Evaluate suitability and acceptability of health education booklet by interviewing health professionals and patients (teen moms)
RESULTS II. Evaluation w ith health professionals • Average PEMAT score=96.08% in understandability • 91.66% average PEMAT in actionability III. Evaluation w ith patients • Consider renaming character “ Marisol” • Revision of “ notes” section • Participants easily used and understood information provided, including the vaccination table • Excited by the idea of including pictures of women and babies from the foundation
METHODOLOGY I. DEV ELOPMENT OF BOOKLET • Key health lessons emphasizing nutrition, development, safety and postnatal health for mothers were tailored from evidence-based resources and programs for either teenage mothers or a L atino/ Hispanic population • Dialogue with health professionals at the J uan Felipe Medical Center provided feedback and a “ wishlist” for information to include in booklet • The end product was a 34 page booklet with four sections: o Section one: Newborns o Section two: 0-6 months o Section three: 6-12 months o Section four: Mom’ s health and happiness • The booklet also included a vaccination table and an interactive notes page • A character named “ Marisol” was created as a guide for readers through lessons in the booklet • Materials are meant to be culturally appropriate, and were translated into Spanish
V accination table
Sample page: Mom’ s Health
II. EV ALUATION WITH HEALTH PROFESSIONALS • Health professionals utilized the Patient Education Materials Assessment Tool (PEMAT), a systematic method to evaluate and compare the understandability and actionability of patient education material • PEMAT q uestionnaire has 23 possible points, including 17 possible points for understandability and 6 possible points for actionability • There are two scores for the material: an understandability percentage and an actionability percentage • Both scores were calculated from each q uestionnaire and an average for each type of score was determined from all responses • The higher the score, the more understandable or actionable the material • 12 health professionals from the J uan Felipe Medical Center were interviewed • Specialties of those interviewed included pediatrics, sexual health, vaccinations, community health and psychology
Pediatrician using booklet as a guide with a patient
CONCLUSIONS Interviewing teenage mother
• • •
Booklet currently under revision based from evaluation results Health professionals enthusiastic of incorporating booklet in their teaching curricula Working with foundation administrators (including Catalina Escobar, President) on securing sponsorship for sustainable printing of booklets
ACKNOWLEDGEMENTS This capstone opportunity was supported with funds from the Springboard Grant Award at the University of Miami. I would like to thank Dr. Daniel Feaster for serving as a Capstone Advisor for this project and Miss Angela Moreno who volunteered her services for the graphic design of the booklet.
CONTACT Daniella Orihuela, MPH MPH Public Health Student University of Miami Email: dorihuela@ med.miami.edu Phone: (786) 546- 1225
33 ! Student!Name:!Chandani!Patel,!MD/MPH!Class!of!2017! Project:!Exploring!the!Quit!Tobacco!Campaign!in!Ahmedabad,!India!! Background! and! Objec4ve:! ! Tobacco! use! is! the! single! most! preventable! cause! of! morbidity! and! mortality! and! the! major! predisposing! factor! for! oral! cancer.! ! A! recent! arEcle! in! the! Times! of! India! newspaper! reported! “Ahmedabad! has! the! highest! incidence! of! oral! cancers! in! the! country.”! ! The! Healthcare! Global! Cancer! Center! (HGCC),! created! a! prevenEon! and! educaEon! campaign! (“Quit! Tobacco”)!to!combat!the!high!use!of!chewing!tobacco!to!decrease!oral!cancer!rates.! Methods:!!Met!with!representaEves!from!the!campaign!to!discuss!the!development,!implementaEon,!and!diﬃculEes!of! the!campaign.! ! !Surveyed!paEents!at!HGCC!to!determine!major!predisposing!factors!(e.g.,!age,!socioeconomic!factors,! gender)!for!tobacco!use.!! Results:! The! campaign! implemented! mulEple! awareness! events! about! the! ill! eﬀects! of! tobacco! use.! They! also! implemented!physicianRtraining!sessions!to!emphasize!the!importance!of!screening!for!oral!cancers!in!current!tobacco! users.! ! Survey! results! showed! the! populaEon! of! tobacco! users! as! male,! low! to! middle! SES,! and! tobacco! iniEaEon! in! adolescence.!!A!majority!of!paEents!have!seen!anERtobacco!messages!and!voiced!a!desire!to!quit,!but!none!knew!how!to! accomplish!this!task.! Conclusions:!The!next!goal!for!the!campaign!is!to!organize!a!quitRline!to!help!tobacco!users!ﬁnd!proper!resources.!!There! are!no!outcome!measures!due!to!a!lack!of!knowledge!about!how!to!conduct!a!comprehensive!program!evaluaEon.! !It! was!suggested!that!surveys!could!be!a!starEng!point!for!evaluaEon!purposes!to!guide!further!program!development.! !
Exploring the Q uit Tobacco Campaign in Ahmedabad, India Chandani S Patel1 Dr. Pravin Kumar Patel2, Dr. Noella Dietz1 MD/MPH Class of 2017, Department of Public Health Sciences 1, University of Miami Miller School of Medicine, Department of L aprascopic Surg ery2, R uchi Hospital c. patel2@ umiami. edu
BACKGROUND • •
Q uit Tobacco Campaign L ogic Model
Tobacco use is the single most preventable cause of morbidity and mortality worldwide. In India, the 2010 Global Health Adult Tobacco survey found 34.6% of adults use some form of tobacco (47.9% male vs 20.3% female) The Times of India reported that “Ahmedabad has the highest incidence of oral cancers in [ India] " HealthCare Global (HCG) is a cancer organization that houses centers for advanced, complicated, and recurrent cancers that span India. Services include medical oncology, surgical oncology, and radiation oncology The HCG started the Q uit Tobacco Campaign to fight against tobacco use and the high incidence of oral cancers Currently only one campaign is in place at HCG:
More campaign components need to be utilized to broaden the outreach and penetration of the campaign
Implementation of tobacco q uit line to guide individuals to the appropriate organization or personnel to help them q uit using tobacco •
Surveillance and evaluation mechanisms need to be put in place to measure the success of the campaign
• Educates people about the adverse health effects of tobacco • Encourages physicians to screen patients for oral lesions • Encourages people to go to the doctor for a screening visit
Shadow ing: • Most people present with sub-mucosal fibrosis (SMF), a pre-malignant condition that can develop into oral sq uamous cell carcinoma (SCC) • Type of tobacco use varied from patient to patient, including chewing tobacco, cigarettes, and tobacco related products (betel nuts or suparis)
FIELD EX PERIENCE •
Shadow HCG oncologists to better understand the increased prevalence of tobacco induced oral cancers •
Understand the development and implementation of the Q uit Tobacco Campaign as well as barriers to implementation and success Explore major predisposing factors (e.g., age, gender, socioeconomic status) for tobacco use through direct patient surveys
Patient Survey (n= 25): • Males dominated the patient population (96%) • Most adults started tobacco use during childhood and adolescence (4 – 18 years old) • Patients’ were from low to middle socioeconomic class
FUNDING ACKNOWLEDGEMENT This field experience was supported with funds from the Global Health Scholar Award at Miller School of Medicine
REFERENCES Y agnik, B. (2012, August 20). Cancer capital of India. Times of India. Retrieved J une 1, 2014, from http: / / timesofindia.indiatimes.com/ city/ ahmedabad/ Cancer-capital-of-India/ articleshow/ 15563166.cms
Global Adult Tobacco Survey Fact Sheet. (2010, J anuary 1). Retrieved J une 1, 2014, from http: / / www.who.int/ tobacco/ surveillance/ en_ tfi_ india_ gats_ fact_ sheet.pdf
34 ! !Student!Name:!Soﬁa!Poma,!MPH!Class!of!2015! Project:!ParEcipaEon!of!Disadvantaged!Hispanic!Families!in!ParenEng!Programs! Background:! Research! indicates! that! parenEng! programs! can! improve! mental,! emoEonal,! and! behavioral!health!among!youth,!as!well!as!reduce!the!risk!of!child!maltreatment.!However,!evidence! suggests! that! socioeconomically! disadvantaged! families! may! not! beneﬁt! as! much! from! parenEng! programs! as! other! families,! and! that! they! face! barriers! to! parEcipaEng! and! obtaining! the! full! health! beneﬁts! of! these! programs.! This! capstone! project! will! assess! barriers! and! facilitators! to! engagement! and! retenEon! of! disadvantaged! Hispanic! families! in! parenEng! programs,! as! well! as! factors! that! may! interfere!with!beneﬁ~ng!from!these!programs.!!! Methods:!QualitaEve!data!will!be!collected!through!focus!groups!with!32!Hispanic!parents!of!young!children!who!receive! services! from! ConnectFamilias,! Inc.,! a! communityRbased! agency! in! Miami’s! Lible! Havana! neighborhood.! Focus! group! discussions!will!be!transcribed!and!analyzed!using!qualitaEve!data!analysis!methods.!From!preliminary!interviews!with! stakeholders,!parEcipaEon!barriers!to!be!examined!include!limited!Eme,!transportaEon,!childcare,!sEgma,!and!the!desire! to! observe! behavioral! change! too! quickly.! Factors! that! may! impact! program! beneﬁts! include! intergeneraEonal! and! mulEple! caregiver! parenEng,! and! cultural! discipline! pracEces.! Possible! factorss! include! the! Hispanic! cultural! values! of! familism!and!respeto.! Conclusions:! Findings! are! expected! to! inform! future! parenEng! programs! and! improve! the! health! of! children! by! idenEfying! and! programRsolving! barriers! and! facilitators! to! the! iniEal! engagement! and! retenEon! of! disadvantaged! Hispanic!families!in!parenEng!programs,!as!well!as!factors!that!impact!program!beneﬁts.!!! Springboard
Participation of Disadvantaged Hispanic Families in Parenting Programs S ofí a Poma MPH Class of 2015, Department of Public Health Sciences, University of Miami Miller School of Medicine
Community Partner •
ConnectFamilias, Inc. (CF) is a community-based agency that serves Miami’ s L ittle Havana residents Two primary focus areas of CF are the prevention of child maltreatment and improving parenting CF provides care coordination and referral to evidencebased parenting programs based on need The average income of family of 4 served by CF is $ 17,029.68, which is $ 6000 less than the federal poverty guidelines for a family of 46
ConnectFamilias, Inc. Care Coordination team
Capstone Field Experience: •
Identify factors that facilitate or act as barriers to the initial engagement of low SES, Hispanic families in parenting programs Identify factors that facilitate or act as barriers to the retention of these families in parenting programs
ConnectFamilias, Inc. in Miami’ s L ittle Havana neighborhood
Research indicates that parenting programs can improve child mental and behavioral health, and reduce the risk of child maltreatment1 Improving parenting is an objective of Healthy People 2020: “ Increase the proportion of parents who use positive parenting” (EMC-2)2 Evidence suggests that low SES families may benefit less from parenting programs, with low SES youth showing poorer long-term maintenance of positive behavioral outcomes3 L ow SES Hispanic families have poorer attendance in parenting programs and report barriers to participation4,5 More information is needed about these barriers to improve parenting programs
Helped conduct a community needs assessment for the Health Foundation of South Florida grant, V iva Saludable Initiative, to understand residents’ perceived health needs Gathered q ualitative data from care coordination team and program administrators about parenting programs
Capstone Project: • •
Gather q ualitative data from 32 Hispanic parents with children aged 2 -8 who are receiving services from CF
Ask parents who have and parents who have not participated in parenting programs about their experience in and/ or attitudes about these programs Ask parents about perceived barriers and facilitators to participation in parenting programs Analyze focus group data using q ualitative analysis methods
Needs assessment showed that parenting programs were identified as a need by community members • Of all health needs, child maltreatment was a priority for 19% of residents • Anecdotal reports of community residents indicate that youth behavioral problems are a growing concern • Mental health was identified as one of the top 5 priority health areas in L ittle Havana
Q ualitative data from care coordinators found that barriers to parenting programs were related to: • L imited time • Transportation • Childcare • Stigma • Desire to observe change too q uickly • Cultural discipline practices •
Anecdotal reports from program administrators indicate: • Problems with program adherence and practicing skills at home • Intergenerational and multi-caregiver parenting may negatively impact program benefits
Implications Findings will be presented to the ConnectFamilias, Inc. team together with strategies to strengthen participation in parenting programs and promote health in community youth.
References 1. Sander, I., Schoenfelder, E. S., Wolchik, S., & MacKinnon, D. (2011). L ong-term impact of prevention programs to promote effective parenting: lasting effect but uncertain processes. A nnual R eview Psycholog y, 6 2: 299-329.
2. U.S. Department of Health and Human Services. Office of Disease Prevention and Health Promotion. Healthy People 2020. Washington, DC. Available at https: / / www.healthypeople.gov/ 2020/ topics-objectives/ topic/ early-andmiddle-childhood. Accessed October 12, 2014. 3. L eitjen, P. Raajimakers, M.A.J , Orobio de Castro, B., Mattys, W. (2014). Does socioeconomic status matter? A meta-analysis on parent training effectiveness for disruptive child behavior. J ounral of Clinical Child & Adolescent Psychology, 42(3): 384-392. 4. McCabe, K. M., Y eh, M., Garland, A. F., L au, A. S., & Chavez, G. (2005). The GANA program: A tailoring approach to adapting parent child interaction therapy for Mexican Americans. E ducation and T reatment of Children, 28 (2), 111-129. 5. Mytton, J ., Ingram, J ., Manns, S., & Thomas, J . (2014). Facilitators and Barriers to Engagement in Parenting Programs A Q ualitative Systematic Review. Health E ducation & B ehavior, 4 1(2), 127137. 6. Callejas, L . (2014). ConnectF amilias 2014 Demog raphics.
Ack now ledgements:
This Project will be supported with funds from University of Miami’ s Springboard Grant. I thank my advisors and mentors, Dr. L inda Callejas, Dr. J ason J ent, Dr. J ulie Kornfeld, Dr. Hilda Pantin, Dr. Tatiana Perrino, Rosa V erdeja and Betty Alonso for guiding this work.
35 ! Student!Name:!Amelia!Poquebe,!MD/MPH!Class!of!2017! Project:!Knowledge,!A~tudes,!and!Assessment!of!Long!AcEng!Reversible!ContracepEon!(LARC)!in! Kigali,!Rwanda! Background:! Project! San! Francisco! (PSF)! is! an! established! research! center! in! Kigali,! Rwanda! that! is! commibed! to! eﬀecEvely! and! economically! prevenEng! unplanned! pregnancies.! Rwanda! has! the! densest!populaEon!in!Africa,!and!there!is!a!goal!to!decrease!the!total!ferElity!rate!from!5.3!to!3!by! disseminaEon! of! LARC.! It! was! my! objecEve! to! gain! a! more! complete! understanding! of! Long! AcEng! Reversible!ContracepEon!(LARC)!use!among!this!populaEon.! Methods:! Worked! at! PSF! on! research! projects! and! with! family! planning! nurses! in! Government! Health! Centers! (GHCs)! throughout!Kigali.!AddiEonally,!helped!with!pilot!projects!on!how!to!expand!the!role!of!Animateurs!de!Santé!(ADS)!to! increase!LARC!uptake!in!the!Rwandan!populaEon.! Results:! Gained! a! more! complete! understanding! of! the! barriers! to! LARC! use! and! the! methods! of! LARC! educaEon! and! implementaEon.!Appreciated!how!underlying!infrastructure!(i.e.,!policy!and!subsidies)!contribute!to!broadly!impacEng! uptake! of! LARC,! as! well! as! success! group! and! individual! educaEon! intervenEons.! Concluded! that! ADS! may! be! most! eﬀecEvely!used!to!promote!LARC!in!the!community!if!there!is!incenEve!and!comprehensive!training.! Conclusions:! There! are! widespread! misconcepEons! on! LARC! that! must! be! conEnuously! addressed! to! increase! LARC! uptake.!Furthermore,!eﬀecEve!uElizaEon!of!the!ADS!may!have!great!potenEal!for!the!harder!to!reach!targets!for!LARC! use.!Experience!has!helped!to!formulate!my!intended!Capstone!Project!on!LARC!assessment!in!Miami!populaEons.! Global!Health!Scholar
K nowledge, Attitudes, and Assessment of L ong Acting Rev ersible Contracep tion: Research with Proj et S an F rancisco in K igali, Rwanda Amelia J . Poq uette Department of Public Health Sciences; University of Miami L eonard M. Miller School of Medicine. Miami, Florida, USA S tudy Contact: a.p oq uette@ umiami.edu This work was sup p orted by the Global H ealth S cholars Award…
I nsights Gained
About the O rganiza tion
To most broadly impact L ARC uptake, infrastructure and policy were addressed Uptake of L ARC was considerably increased with targeted education and counseling Cultural understanding and acceptance of contraception impact women much differently in Rwanda Task shifting and the use of healthcare workers (i.e., nurses and ADS) in different capacities has been effective to expand use of different contraception methods Use of ADS in the community has helped to relieve the flow in the GHC ADS volunteers req uire incentive to motivate them to invest in expanding L ARC use in the community
Projet San Francisco (PSF) is an established HIV research center based in Kigali, Rwanda since 1986 Mission: to effectively and economically prevent the spread of HIV / AIDS transmission and unplanned pregnancies among heterosexual couples
Background Research Rwanda has the densest population in Africa Women do not have optimal access to or knowledge of modern contraception methods Goal: decrease the Total Fertility Rate in Rwanda (currently 4.7-5.7) to 3 by the dissemination of L ong Acting Reversible Contraception (L ARC) L ARC methods are available to any woman at no cost Nurses at PSF and Government Health Centers (GHCs) insert and remove methods and counsel women on their use to effectively expand L ARC
T hank you song ong and dance, B utamw a G HC
O utside K abuye e G HC
O bj ectiv es Gain a more complete understanding of the barriers to L ARC use, education strategies used to overcome misconceptions surrounding L ARC, and how to implement its use in couples Understand the inner administrative workings of Projet San Francisco (PSF), a public health NGO that conducts research and outreach across multiple sites in Kigali, and on an international level F amily Planning lanning , Muhima ma G HC
Activ ities I nterview ing nurses, K inyinya a G HC
Worked at PSF with nurses and doctors on different research projects relating to L ARC uptake and HIV prevention Worked with the Family Planning (FP) Nurses at the GHCs to screen women for contraceptive methods, assess the appropriateness of the women’ s contraception choice, and counsel on decision made to promote L ARC Provided women with contraceptive choice (i.e., Oral contraceptives, DepoProvera, Norplant, or copper IUD) Conducted interviews with FP nurses at GHCs to assess role of the Animateurs de santé (ADS) in future L ARC dissemination to target populations Assisted with ADS pilot focus groups and training programs
L A R C methods, ethods, K abusunz u G HC This experience was made possible by funding from Global Health Scholar Award from the University of Miami, Department of Public Health A special thank you to Dr. Allen, doctors, interns, and staff at PSF for being so welcoming
Muhima ma G HC, R w anda countryside
Conclusions Misconceptions on LARC The baby will be born with the IUD on its head The IUD or the implant will migrate to their heart or other areas internally The method is ineffective The method is not safe because of a lack of menstruation Other Barriers The men control their decision General desire for children, as it is the purpose of marriage Role of ADS and LARC Promotion Work of the ADS in the community has helped to relieve the workload on the nurses ADS role in counseling women to turn to other methods would not just req uire training, but on going education and incentive
36 ! Student!Name:!Daisy!RamirezROrEz,!MPH!Class!of!2014! Project:!An!Awareness!Campaign!to!Reduce!Exposure!to!PCBs!in!Guanica!Municipality! Background! &! Objec4ve:! Recent! data! suggest! the! presence! of! hazardous! concentraEons! of! polychlorinated!biphenyls!(PCBs)!in!Guanica!Bay,!Puerto!Rico,!which!may!pose!a!serious!threat!to!the! health! of! communiEes! surrounding! the! bay.! Three! aims! of! the! project! were:! a)! to! assess! PCBs! concentraEons!in!ﬁsh,!b)!to!bring!community!awareness!to!issues!about!PCB!contaminaEons,!and!c)! to!engage!community!members!in!prevenEve!measures!to!reduce!any!PCB!exposures.!!! Methods:!A!communityRcentered!approach!was!employed!to!collect!ﬁsh!samples.!The!samples!were!analyzed!for!PCB! concentraEons.!An!educaEonal!awareness!campaign!also!was!administered!in!the!Aurea!E.!Quiles!Claudio!High!School!in! Guánica!Municipality,!and!two!rounds!of!surveys!were!administered!in!the!high!school!before!and!a6er!the!educaEonal! campaign.! Results:!Elevated!concentraEons!of!PCBs!were!found!in!two!wild!caught!ﬁsh.!Analyses!suggest!that!a)!ﬁsh!consumpEon!is! a!potenEal!source!of!community!exposure!to!PCBs,!and!b)!awareness!about!PCB!contaminaEon!increased!from!16%!to! 71%!a6er!the!educaEonal!campaign.!However,!several!students!conEnue!to!rely!on!the!bay!for!recreaEonal!acEviEes.! Conclusions:!The!concentraEons!of!PCBs!in!ﬁsh!samples!were!higher!than!those!permibed!for!human!consumpEon!by! the!FDA.!It!is!important!to!iniEate!awareness!campaigns!for!communiEes,!and!to!assess!the!eﬀects!of!such!campaigns!on! reducing!community!exposure!to!PCBs. ! Springboard
An Aw areness Campaign to Reduce Community Exposure to PCBs in Guá nica Municipality Daisy Ramirez -Ortiz 1, Dr. Naresh Kumar1, Aurea E. Q uiles Claudio High School, Dr. Noella Dietz
Department of Public Health Sciences; University of Miami Leonard M. Miller School of Medicine, Miami, Florida, USA Study Contact: d.ramirez ortiz @ med.miami.edu
Polychlorinated biphenyls s (PCBs), probable human carcinogens, were banned in the United States (US) in 1977; however, PCBs are still found at many sites in the US. L ast year, the University of Miami Superfund Program in Interdisciplinary Research and Integrated Training (UM-SPIRIT) found a hazardous concentration of PCBs in Guá nica Bay, located in the southwest of Puerto Rico (Figure 1). The concentration w as the highest (129 ppm) ever reported in the US National Oceanic and Atmospheric Administration (NOAA) dataset. This hazardous concentration in the bay poses a serious threat to the marine environment and the health of communities surrounding the bay. •
Results Table 1. PCB Concentrations in L utianus analis and E ucinostomus g ala fish from Guanica Bay
PCB concentrations in two wild fish ranged from 1,623 ng/ g to 3 ,768 ng/ g. E ucinostomus g ula had about tw o times higher levels of PCBs than the safe threshold of 2,000 ng/ g established by the Food and Drug Administration (FDA).
Student Aw areness and PCB Exposure • Survey data suggest that a) fish consumption is a potential source of community exposure to PCBs, and b) aw areness about PCB contamination of the bay increased from 16% to 71% after the awareness campaign (Figures 9 and 10). • However, several students continue to rely on the bay for recreational activities, including fishing, swimming, kayaking and sailing after the awareness campaign (Figure 11).
Figure 9. Number of students who identified PCB as a source of contamination in the bay
Figure 10. Number of students that consume fish
Aw areness Campaign Figure 1. Puerto Rico L ocation
Aims • • •
Assess concentration of PCBs in fish from Guá nica Bay. Bring community awareness about PCB contamination in the bay. Engage community members in preventive measures to reduce their PCB exposure.
M aterials and M ethods Fish Sampling • Using a community-centered approach, two fish species E ucinostomus g ula (Silver jenny) and L utj anus analis (Mutton snapper), were caught in the bay using a drift net in September 2014 (Figure 2). Fish samples were wrapped in foil, placed in zip bags, and labeled with relevant information (i.e. species, size). EPA SW-846 was used to analyze homogenized fish tissue for the concentration of Aroclors and 68 congeners of PCB. Aw areness Campaign • An awareness campaign was administered to approximately 300 students in the Aurea E. Q uiles Claudio High School in Guá nica Municipality. The campaign consisted of lectures about PCB contamination, development and dissemination of educational materials (i.e. flyers, parents newsletters) and a poster, speech, and drawing competition about the PCB contamination. Evaluation • The efficacy of the awareness campaign was assessed through pre- and postsurveys comparing behavioral changes, including PCB contamination awareness, seafood/ fish consumption, and recreational activities. Figure 2. Community member collaborating in the fish sampling
Figure 3 . Aurea E. Q uiles Claudio High School
Figure 4. Community Partners (biology teachers)
Figure 11. Recreational activities performed perfo rf rmed by students in the bay rfo
Figure 5. Students developing educational flyers
Figure 6. Scientific Poster Competition
Despite increased awareness eness about PCB contamination, cont students continue to rely on the bay for harvesting fish/ seafood and recreational purposes, therefore students (along w ith community members) may still lack a fuller understanding of environmental PCBs and their associated “ adverse” health risk s. The haz ardous concentration of PCBs in both sediment and fish may pose a maj or threat to community health. Interventions should include designating the bay as a “Superfund Site” to clean up the bay, conduct more research, and engage communities in reducing/ preventing their PCB exposure. Researchers should continue to provide aw areness and develop strategies w ith community members to reduce their exposure to PCBs.
F unding Acknowledgements Figure 7. Speech Competition
Figure 8 . Drawing Competition
This project was as supported with w funds from the Springboard Scholarship S Award & Dr. Naresh Kumar.
37 ! Student!Name:!Diana!Roman,!MD/MPH!Class!of!2015! Project:!5R2R1R0!Let’s!Go!!Healthy!Habits!to!Live!By!Pilot!Program! Background:! Childhood! obesity! is! a! public! health! concern.! Health! educaEon! is! necessary! to! prevent! future! negaEve! health! outcomes.! Along! with! the! Palm! Beach! County! Dept.! of! Health! we! created! a! modiﬁed! version! of! the! 5210! a6erRschool! obesity! prevenEon! program.! This! project! implemented! an! eight! week! program! for! students! grades! in! 3R5! enrolled! in! summer! camp! and! was! a! supplement! to! weekly!Zumba!sessions!given!by!community!partner!Digital!Vibez.!! Methods:! An! adapted! curriculum! created! with! a! train! the! trainer’s! guide,! and! onsite! training.! Implemented! to! 130! students! in! three! elementary! schools! from! Palm! Bach! County.! Data! was! collected! via! 13Ritem! pre/post! survey! administered!before!and!a6er!curriculum.! Results:! Increase! awareness! of! the! overall! 5R2R1R0! message! in! all! three! schools! (p! <0.05).! The! only! selfRimproved! reported!healthy!behavior!was!increased!water!or!milk!intake!instead!of!juice!or!soda!but!was!not!staEsEcally!signiﬁcant.! The! most! common! a~tudes! expressed! by! students! toward! healthy! behavior! change! was! to! eat! more! vegetables,! eat! dinner!with!family,!watch!less!TV!and!play!more!outside.!! Conclusions:! The! program! increased! awareness! of! the! 5R2R1R0! message! but! no! posiEve! impact! on! behavioral! choices.! Data!was!compromised!in!two!schools!due!to!incorrect!delivery!of!post!surveys!to!students!who!did!not!complete!the!full! curriculum.! Parental! involvement! may! be! a! potenEal! target! for! further! curriculum! design! due! to! the! major! inﬂuence! parents!have!in!children’s!healthy!habits.!! Quantum!Springboard
5-2-1-0 Let’ s Go! Healthy Habits to Live By Pilot Program Diana Roman1, Q uinn Hayes2, Healthy Communities Consultant 1Department 2Florida
The Department of Health of Palm Beach County has a community initiative called Community Call to Action on Obesity. 5-2-1-0 L et’ s Go! is one of the seven initiatives. However they have no specific 5-2-1-0 curriculum. The 5-2-1-0 message promotes four healthy habits including: increase fruit and vegetable consumption, decrease screen time, increase physical activity, and decrease consumption of sugary drinks 3. Partnership resulted in the creation of an education curriculum and a train the trainer course to deliver the program to children enrolled in summer camp grades 3-5 who were also receiving Z umba sessions.
Know ledge of 5-2-1-0 program
5+ fru its & v egetab les:
n= 13 0 98 % completion rate
10 m inu te ower oint resenta on. Week 1: G o F ood, S low F ood, or Whoa F ood Week 2 : Learn to read nu tr on lab el
5-2-1-0 E du ca onal cu rricu lu m
Digital V ibez, is a multimedia organization that provides Z umba dance session during summer camps to Title I schools and has an annual Z umbathon to celebrate physical activity with all participating schools.
Obesity is a pervasive national public health concern with significant health conseq uences such as diabetes, CAD, stroke, and some cancers1. In Palm Beach County in 2012-2013, 20% of children in grades 1st-5th were obese while another almost 20% were overweight2.
of Public Health Sciences, University of Miami Miller School of Medicine Department of Health of Palm Beach, Communities Health Division
2 hrs or less of screen
Feedback from the children on the program was very positive. Limitations: • Rotating staff and necessary proper training to ensure consistent implementation. • All children attended all sessions and did not complete pre and post. This could have affected behavior change data.
10 m inu te ower oint resenta on. Week 3: G ro cu ssion Week 4: S tory telling “ D ou g gged”
1 hou r of hy sical
10 m inu te ower oint resenta on Week 5: F itness dice Week 6: S S m ar hy sical ac v iity
0 su gary drinks, m ore water and low fat m ilk
10 m inu te ower oint resenta on Week 7: Make su gar ay Week 8: “ F ind the su gar” word F ind Community Call to Action on Obesity committee provided feedback on powerpoint presentation
Create an eight week educational curriculum based on an evidence based 5-2-1-0 obesity prevention program from Maine3.
Educational session was complemented by one hour of Z umba dance session each week.
Integrate curriculum with weekly Z umba session for six out of eight weeks.
Children were given a Commit2Bfit J ournal to set goals and tract their nutrition and activity
Create a trainer’ s guide, activities and surveys to evaluate impact of curriculum.
Received feedback from counselors and students on weekly activities.
Figure 2. Q uestion 12. I k now ★t-test p < 0 . 0 0 0 0 1 .
w hat 5-2-1-0 means.
Future directions: Create a parental component in order to engage parents and provide meaningful opportunities as a family to learn about the importance of healthy habits and physical activity. Perhaps this would support behavior change.
Behavior associated w ith 5-2-1-0 Among all of the schools, the students only positive self improved reported healthy behavior was increase water or milk intake instead of juice or soda but was not statistically significant with a p-value 0.260. Other behavior habits such as amount of TV watching and overall fast food consumption did not show improvement from pretest to post test.
Attitude tow ards healthy behaviors
Ack now ledgements The project was supported by the Q uantum Foundation Springboard Grant of Palm Beach County. Gratitude is expressed to University of Miami Graduate Programs in the Department of Public Health Sciences, Dr. J ulia Belkowitz, Felicia Casanova, Q uinn Hayes from the Palm Beach Department of Health for her commitment and guidance, Will from Digital V ibez for the Z umba sessions, Eli from Commit2bfit for the free fitness journal for students.
Population 130 students from grades 3-5 attending summer camp at three elementary schools in Palm Beach County. Measures 13-item pre and post surveys adapted and modified from existing 5-2-1-0 q uestionnaire tool4. Evaluated knowledge of 5-2-1-0 message, healthy behaviors and attitudes. Analysis Descriptive statistics to determine change in means between pre and post surveys.
Summer camp was an appropriate setting to implement nutritional education and improve student’ s awareness of the 5-2-1-0 message but little behavior change was documented.
References 1C enter for D isease C ontrol and Prev en on. C hildhood Ob esity F acts; A v ailab le at h : / / www.cdc.gov / healthy y ou th/ ob esity / facts.htm l 2"
Healthy Weight Pro e for Palm Beach C ou nty .” A v ailab le at h s: / / www.google.com / search? q = healthy weight ro e for alm cou nty & ie= -8& oe= -8> .
Class participation during Pow erPoint presentation of one of the components of the 5-2-1-0 message
Fitness dice th at w ould instruct students to do a parti ular ex ercise and th e num b er of repetitions
Figure 3 . The four most common attitudes tow ard healthy behavior change among all three schools.
Let’ s G o! . G oes A er S chool Toolkit Binder. A v ailab le at : / / www.letsgo.org/ rogram s/ a er-school/ toolkits/ . : / / www.letsgo.org/ rogram s/ healthcare/ rov ider-resou rces/
38 ! Student!Name:!Daniel!Salahuddin,!MD/MPH!Class!of!2017! Project:!Understanding!Healthcare!Systems!&!Delivery!in!Bobigny:!another!side!of!Paris!! Background!&!Objec4ve:!This!capstone!ﬁeld!experience!took!place!at!Avicenne!Hospital!in!Bobigny,! the! capital! of! SeineRSaintRDenis,! a! suburb! of! Paris! with! a! predominantly! underserved! immigrant! populaEon.!The!hospital!is!known!for!their!psychiatric!services!for!refugees!and!asylees!suﬀering!from! postRtraumaEc!stress.!Signiﬁcant!abenEon!was!also!given!to!tobacco!use,!as!there!is!a!30%!prevalence! of! cigarebe! smoking! among! the! French! populaEon.! Given! these! public! health! issues,! the! objecEves! were!threeRfold:!taking!a!course!to!beber!understand!the!French!health!care!system,!learning!about! the!care!and!treatment!of!unaccompanied!minors!suﬀering!from!postRtraumaEc!stress,!and!understanding!the!tobacco! control!measures!used!in!France!to!decrease!the!incidence!and!prevalence!of!cigarebe!smoking.!! Methods:!Rotated! through! the! Department! of! Psychiatry! at! Avicenne! Hospital! while! parEcipaEng! in! consultaEons! and! team!meeEngs.!! Insights!Gained:!The!care!and!followRup!of!unaccompanied!minors!suﬀering!from!postRtraumaEc!stress!is!criEcal,!as!this! is!an!extremely!vulnerable!populaEon.!Despite!recent!legislaEve!acEons!promoEng!tobacco!control!measures,!cigarebe! smoking! remains! a! signiﬁcant! public! health! problem,! parEcularly! among! young! adults.! The! posiEve! normaEve! environment!surrounding!tobacco!use!in!France!is!a!signiﬁcant!cultural!barrier!that!prevents!many!people!from!qui~ng.!
Understanding Healthcare Systems & Delivery in Bobigny: another side of Paris D aniel Salah uddin1 , L aurence Mik ondo2 , Th ierry Baub et2 , N oella D ietz 1 ep artm ent of Pu b lic Health S ciences, U niv ersity of Miam i Miller S chool of Medicine, Miam i, F L 2A P-HP, A v icenne Hosp ital, Bob igny , F rance :
Background Avicenne Hospital is a 517-bed hospital that operates with the mission of providing health care to underserved populations throughout Bobigny, a suburb of Paris. Public Health Issues: • There were approximately 4,000 registered unaccompanied minors in France in 2008. This is likely a gross underestimation due to the number who do not register with the French Child Protective Service have almost certainly grown in years since. •
There is a shortage of health care professionals in Bobigny. Residents suffer from a greater proportion of premature mortality (before age 65) among both men and women compared to premature mortality in other regions.
A Parisian street, named after Jean Nicot, a French diplomat who is credited for introducing tobacco to the country in the 16th century. An example illustrating the deep cultural and historical connection with tobacco.
Cigarette Smoking Prevalence in France by Age The main entrance of Avicenne Hospital
Cigarette smoking is a significant public health issue in France with 30% of the population being daily smokers. The overall prevalence of cigarette smoking in France increased by 2% from 2005-2010, which has been attributed to young smokers aged 18-34. •
Electronic cigarettes have been heavily marketed as a tool for smoking cessation in France.
Insights Gained • France’s historical emphasis on social justice and caring for the poor set the stage for the country’s current social infrastructure, including their healthcare system.
France has 73,000 premature deaths attributed to tobacco annually.
There are currently more investments being made in the delivery of health care services compared to those being made in public health, although this is quickly changing as a result of rising costs. •
Logo for the Public Hospital System of Paris (AP-HP), the primary hospital system in Paris comprised of 38 hospitals consolidated into 12 groups.
Distribution of AP-HP hospitals throughout the greater Paris region, including Avicenne Hospital.
Despite recent legislative action that has resulted in more strict tobacco control measures, cigarette smoking remains a significant public health problem, particularly among young adults. •
American medical students in the MICEFA Summer Program in Medicine and Public Health visiting the Pediatric Emergency Department at Armand Trousseau Hospital.
Objectives • Learn about, compare, and contrast the health care system in France to that of the United States through the “Bridging the Gap” course. •
Appreciate the significant burden of post-traumatic stress in displaced patients, especially in unaccompanied minors. •
Madame Laurence Mikondo, a nurse specially trained in smoking cessation, speaking with her client during a consultation.
Burden of Premature Mortality in Bobigny and Surrounding Areas
Left: Madame Dominique De Wilde, Director of the University Hospitals of Paris-Seine-Saint-Denis, following our interview. Right: My preceptor, Dr. Thierry Baubet, Chair of the Department of Psychiatry at Avicenne Hospital
Shortage of Health Professionals in Bobigny and Surrounding Areas
This field experience was supported the the Global Health Scholars Award, administered through the University of Miami Miller School of Medicine Department of Public Health Sciences. Additional support was also provided by MICEFA. I would personally like to acknowledge the staff at MICEFA, especially Nancy Merritt and Laurence Alemanni for their support and dedication to cross-cultural collaboration. I would also like to thank Laurence Mikondo for allowing helping me gain insight into the tobacco control practices in France, and Dominique de Wilde for allowing me to conduct an interview to learn more about AP-HP and healthcare in France. Lastly, I would like to thank my preceptor, Dr. Thierry Baubet for the wide range of learning opportunities that were afforded to me.
Understand the various methods used to treat post-traumatic stress in vulnerable populations. •
Understand the epidemiology of cigarette smoking in France. •
The positive normative environment surrounding tobacco use in France is a significant cultural barrier that prevents many people from quitting. This experience has served as a reminder of the importance of crosscultural collaboration and that there is no one “right” way to carry out a certain practice, especially if the outcomes are similar.
A glimpse of downtown Bobigny, the capital of Seine-Saint-Denis.
Explore the intersection of health and society in France regarding the holistic treatment of a patient. •
The care and follow-up of unaccompanied minors suffering from posttraumatic stress is critical, as this population is extremely vulnerable. Ensuring that they have accessed the system and are being followed by the appropriate professionals remains a significant issue.
Learn about and see the impact of smoking cessation efforts in France and the various barriers to cessation. Smoking cessation booklets endorsed by the French Society of Tobacco Studies that are used throughout the country.
C ontact I nform a on: D aniel S alahu ddin MD / MPH C andidate, C lass of 2017 dsalahu ddin@ m ed.m iam i.edu 941.545.9680
39 ! Student!Name:!Dayana!Samson,!MPH!Class!of!2015! Project:!HIV/AIDS!Adult!Mortality!in!Guatemala!from!2010R2012! Background! &! Objec4ve:! The! most! recent! HIV/AIDSRrelated! mortality! data! is! only! available! up! to! 2009! in! Guatemala.! In! order! to! best! characterize! the! current! burden! of! HIV/AIDSRrelated! mortality,! this! study! will! uElize! informaEon! from! three! HIV/AIDS! death! registries! to! characterize! HIV/AIDSR related!mortality!in!the!Guatemalan!populaEon!from!2010R2013.!! Methods:! HIV/AIDSRrelated! deaths! are! reported! to! three! independent! HIV/AIDS! surveillance! systems,! COMISCA,! SISGA! and!MANGUA!from!the!naEonal!Ministry!of!Health!in!Guatemala.!Annual!mortality!rates!were!calculated!from!2010R2012! and!pooled!across!2009R2013!per!100,000!persons!and!straEﬁed!by!sex!and!age!group.! Results:!Preliminary!analyses!indicate!a!conEnual!decrease!in!the!HIV/AIDS!adult!mortality!rate!per!100,000!adults!per! year.!Among!HIV/AIDSRrelated!mortality!rate!straEﬁed!by!sex,!women!are!dying!twice!as!much!compared!to!men.!Among! the! age! groups! there! is! a! signiﬁcant! decrease! in! the! number! of! deaths;! however,! there! is! sEll! a! need! to! increase! the! amount!of!prevenEon!protocols!for!the!highRrisk!age!ranges.!The!results!support!the!integraEon!of!HIV/AIDS!mortality! analyses!into!ongoing!surveillance.! Conclusions:! A! comprehensive! analysis! was! provided! for! HIV/AIDSRrelated! mortality! to! provide! a! more! thorough! understanding!of!the!disease!burden!associated!with!HIV!infecEon,!as!well!as!strategies!to!help!CDC!and!the!Guatemalan! government!curtail!the!burden!of!the!disease.! !! Springboard
HIV / AIDS- Related Mortality in Guatemala, 2010-2012 Dayana M Samson, MPH Class of 2014; Nelson Arboleda MD, MPH; Iris Debroy, MD Department of Public Health Sciences; University of Miami L eonard M. Miller School of Medicine. Miami, Florida, USA D S amson@ med.miami.edu This work was sup p orted by: Ministerio de Salud Pú blica de Guatemala Centers for Disease Control and Prevention- Global AIDS Program, and by UM DPHS Springboard Grant
Rates od HIV / AIDS Mortality by Ethnicity, Guatemala 2009-2013
METHODS – DATA PROCESSING
HIV / AIDS Epidemiological Corridor Accumulated cases , Guatemala 2013
Cases: 3 1 , 50 6 HIV : 4 3 % AID S: 57 %
As of 2013, UNAIDS estimates that 53,000 people are living with HIV in Guatemala and that 2,600 deaths have occurred due to AIDS. More work is needed to characterize and determine the extent of the epidemic within the Guatemalan population.
OBJ ECTIV ES This study will utilize three HIV / AIDS-related mortality registries to: •
Make informed recommendations to the Guatemalan Ministry of Health for improving their response in the prevention and treatment of HIV / AIDS.
HIV / AIDS Incidence per 100,000 Total Population
1. Significant decrease dec in i the he HIV / AIDS incidence per 100,000 total population occurred from 2010-2012 2. Twice as many women are dying compared to men 3. Between the age range of 30 and 39 there is a higher HIV / AIDS-related mortality. 4. There is four times higher HIV / AIDS-related mortality rate reporting in areas with health facilities 5. Point estimates higher incidence but under power • Highest HIV / AIDS- Related Mortality stratified by Departments and Data Source: • COMISCA: E scuintla, E l Peten,Q uetzaltenango, Retalhuleu • SISGA: E scuintla, E l Peten, Q uetzaltenango, San Marcos • MANGUA: E scuintla, E l Pen, Izabal, Guatemala
Rates of HIV / AIDS Mortality by Sex, Guatemala 2010-2012
2009 Y ear
2011 Y ears
Rates of HIV / AIDS Mortality by Age, Guatemala 2010-2012
Identify high-risk subpopulations for HIV / AIDSrelated mortality in Guatemala.
0.35 0.3 2010
2012 0.15 0.1
• The Council of Ministers of Health of Central America (COMISCA) • MANGUA, project Funded by the Fundació Sida i Societat, a non-profit organization with field work in Guatemala • SISGA: Secretarí a de la Integració n Social Centroamericana
HIV / AIDS-related deaths are reported to three independent HIV / AIDS surveillance systems:
Departments with the highest mortality may suggest that people residing in or near one of these departments might be at a higher risk for contracting HIV from other department residents. Findings suggest that the rate of HIV / AIDS-related deaths in Guatemalan is consistently decreasing. Continued surveillances and improvement in methodology approach is needed to better characterize the current situation. Findings can help to more effectively design and implement HIV / AIDS control for specific groups.
0.05 0 0 to 14
15 to 19
20 to 24
25 to 29 30 to 39 Age
40 to 49
50 to 59
60 to +
METHODS – DATA SOURCE •
3 2 9 ,8 3 – 4 7 9 ,9 7 4 7 9 ,9 8 y+
Characterize HIV / AIDS adult mortality trends in Guatemala from 2010 to 2013
2 9 ,5 2 - 1 7 9 ,6 7 1 7 9 ,6 8 – 3 2 9 ,8 2
Cases p er 1 0 0 , 0 0 0 habitantes
* Guatemala Ministry of Health May 2014 data
Deaths ooer 100,000 person
Annual mortality rates were calculated from 2010-2012 pooled across 2009-2013 per 100,000 persons and stratified by sex and age group.
Incedence per 100,000
One-sixth of HIV / AIDS cases reported in Central America come from Guatemala.
Deaths per 100,000 person
The most recent HIV / AIDS-related mortality data are only available up to 2009 in Guatemala.
HIV / AIDS surveillance
ACKNOWLEDGEMENT • • •
Springboard Grant Award from the University of Miami, Department of Public Health Sciences Thanks to Capstone Faculty Advisor: Mark Stoutenberg, PhD, MSPH; and to Manuel Ocasio, MSPH Ministerio de Salud Pú blica de Guatemala Centers for Disease Control and Prevention- Global AIDS Program
40 ! Student!Name:!Krystal!Sardinas,!MPH!Class!of!2015! Project:!Hispanic!Facilitators’!PerspecEves!in!the!Delivery!of!an!Internet!Based!IntervenEon!TargeEng! Hispanic!Adolescents!Families:!A!QualitaEve!Study!of!Familias!Unidas! Background:! InternetRbased! intervenEons! have! increased! in! popularity! due! to! convenience,! accessibility,! and! lowRcost.! The! faceRtoRface! version! of! Familias! Unidas,! an! evidencedRbased! intervenEon,!was!adapted!to!be!delivered!over!the!internet!to!Hispanic!families.!The!objecEve!of!the! current! project! was! to! obtain! feedback! from! the! facilitators! who! delivered! the! internetRbased! intervenEon! in! order! to! idenEfy! key! areas! that! require! extra! abenEon! when! developing! an! internetRbased! program.! AddiEonally,!this!project!sought!to!idenEfy!possible!implementaEon!and!disseminaEon!barriers!within!the!MiamiRDade! County!Public!School!System!(MDCPS).! Methods:!InRdepth!interviews!were!conducted!with!11!Familias!Unidas!facilitators!and!nine!MDCPS!administrators!using! two! separate! openRended! quesEonnaires.! Interviews! were! recorded,! transcribed,! and! analyzed! using! qualitaEve! descripEon.!! Results:! ! Facilitators! indicated! the! following! key! areas! needing! further! consideraEon! when! developing! a! webRbased! intervenEon:!technology!(i.e.!equipment/connecEon),!family!engagement,!and!contacEng!parEcipants.!Preliminary!data! collected! from! MDCPS! administrators! idenEﬁed! the! following! potenEal! barriers:! programs! must! saEsfy! a! school! need,! must!beneﬁt!students!and!their!families,!and!may!potenEally!require!outside!funding!and!staﬃng.! Conclusions:! ! Interviewing! key! stakeholders! in! the! community! provides! invesEgators! with! invaluable! informaEon! pertaining!to!their!intervenEons.!Diﬀering!opinions!and!perspecEves!from!stakeholders!shed!light!to!barriers!and!issues! that!may!otherwise!be!overlooked.!! Springboard
Hispanic Facilitators’ Perspectives in the Delivery of an Internet-based Intervention: A Q ualitative Study of Familias Unidas Krystal M. Sardinas MPH Classs of 2015, Department of Public Health Sciences, University of Miami Miller School of Medicine
Back ground •
Familias Unidas is an evidence-based prevention intervention targeting drug use and HIV risk behaviors in Hispanic adolescents.
By improving family functioning (parental involvement, positive parenting, and parentadolescent communication), the intervention has been shown to be efficacious in reducing drug use and sexually risky behaviors. •
An internet-based adaptation of the intervention was developed.
Obj ectives •
Identify key areas to consider when developing and implementing an internetbased intervention with Hispanic families.
Describe implementation and dissemination barriers of the Familias Unidas internetbased intervention within the Miami-Dade County School (MDCPS) system.
Methods Sample • 11 intervention facilitators • 9 MDCPS administrators Tw o Interview Guides • Grand Tour Q uestion 1: How was your experience working with Hispanic families using an internet-based intervention approach for the first time? • Grand Tour Q uestion 2: Eventually, we would like to implement the Familias Unidas internet-based intervention into the MiamiDade County School System. What are your thoughts on this? Data Analysis Q ualitative Descriptive Study: Transcriptions analyzed using q ualitative content analysis. • Coding and themes derived from interviews. •
Q ualitative Themes Training Program Facilitators
Training is essential for the facilitators
Facilitators need sufficient time during recruitment to build rapport with the families
“ I think they should do a training even before w e g o into the recruiting . ‘ T his is w hat’ s g oing to happen. W hat q uestions do you have? ’ T hen, break it up lik e you g uys did, in w hatever sessions you feel is important, but do them before w e g et to that point, you k now ? ” - Facilitator 160
“ So a big part of that eng ag ement is, you k now , the communication, that rapport building in the beg inning is essential to the rest. ” - Facilitator 170
Overcoming Barriers Need to determine who will deliver the program at the schools “ W ould it be F amilias Unidas providing it in the school, or w ould it be helping and training the [ school] counselors to provide it? B ecause if it’ s helping the counselors- that mig ht become an issue because they are already overw helmed. ” – Facilitator 153
Krystal Sardinas and part of the Familias Unidas Team
I.T. support is needed to help troubleshoot any tech problems.
“ Y eah, he’ s [ I.T. person] been w onderful, Accepting the Program he’ s been really w onderful. He’ s been a Schools want to help their families g odsend. L ik e, the family w ould have “ Y ou k now , this is something that’ s dropped out w hen they g ot that horrible Train facilitators to use home visits to virus, they couldn’ t g et their computer to g oing to benefit families, it’ s g oing to help family communication. T hey w ant w ork . He w as amaz ing . A nd then that re-engage and re-establish their families to be successful, to be really g ot the family eng ag ed, you communication with non-responsive involved… because that’ s one more k now ? ” – Facilitator 175 families. thing that w ill help them sell their Contacting Families school. ” – Facilitator 134 “ [ Home visits necessary? ] I do feel it, because if the parents are not w atching Stay in communication with families the videos, or they’ re not responding to “ Y ou have to contact the families every either your phone calls or tex ts, it’ s Collaborating w ith MDCPS sing le day. V ia throug h a call, via a tex t, because they are not eng ag ed. W e lost w hatever they feel comfortable w ith. Need to contact MDCPS them. W e didn’ t do a g ood enoug h Y ou need to be reminding them administrators such as school eng ag ement w ith them at the very constantly of w hat they need to do, but principals, Student Services, and beg inning . ” – Facilitator 103 very subtle, so you cannot be too pushy district personnel. because then you’ ll be stalk ing them. ” - Facilitator 170
Engaging & Retaining Participants
Homepage: Internet-based Familias Unidas
Dr. Barroso &
Consider and plan for potential technological barriers when developing internet-based interventions. Facilitators should develop a strong rapport with families to improve engagement and retention rates of participants. Interview school administrators to identify uniq ue school characteristics that impact program dissemination and implementation.
Ack now ledgements This project was supported with funds from the Springboard Grant. I would like to thank the Familias Unidas team for their feedback and support during this project, Dr. Barroso for her guidance with the q ualitative analysis, and Dr. Horigian, my Capstone advisor.
41 ! Student!Name:!Johanna!Segovia,!MPH!Class!of!2015! Project:!CDC’s!Surveillance!for!InfecEous!Disease!in!El!Salvador:!Building!Capacity!for!DetecEon!and! Response!for!Inﬂuenza,!Dengue!and!Chikungunya! ! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! Background!&!Objec4ve:!CDCRCentral!America!Regional’s!(CDCRCAR)!Inﬂuenza!Surveillance!Program!in!El! Salvador! collaborates! with! insEtuEons! to! build! the! capacity! of! the! country’s! public! health! system.! These! cooperaEve! agreements! integrate! epidemiology! programs,! improve! senEnel! hospitals’! surveillance! of! infecEous! diseases,! and! expand! inﬂuenza! vaccinaEon! programs! within! the! country.! The! provision! of! technical! assistance! and! allocaEon! of! resources! help! improve! senEnel! surveillance! and! enhance! epidemiologic!capacity!within!El!Salvador.!However,!the!conducEon!and!evaluaEon!of!inﬂuenza!vaccine!eﬀecEveness!against! seasonal!inﬂuenza!remains!a!challenge.!! Methods:! CDCRCAR! and! key! partners! responded! to! infecEous! disease! outbreaks! such! as! dengue! and! Chikungunya.! SenEnel! hospitals!were!provided!with!standardized!guidelines!to!improve!data!quality!through!uniform!reporEng!of!infecEous!diseases! based!on!case!deﬁniEons.!Site!visits!provided!the!opportunity!to!monitor!and!evaluate!inﬂuenza!surveillance!applied!within! each!hospital.!! Results:!A!protocol!was!designed!to!study!the!validity!of!parental!verbalRreport!of!inﬂuenza!vaccine!uptake!in!children!<5!years! of!age!and!a!pilot!study!will!be!conducted!in!the!senEnel!hospital!of!Santa!Ana.!An!operaEng!procedures!plan!was!developed! for!potenEal!Ebola!outbreak!in!El!Salvador;!dengue!and!Chikungunya!preparedness!and!response!guidelines!were!also!updated! for!accurate!surveillance.!Surveillance!data!obtained!from!site!visits!were!analyzed!to!improve!pertussis!intervenEons!as!well.!!! Conclusions:! Results! of! the! pilot! study! will! help! determine! an! eﬀecEve! and! sustainable! strategy! on! conﬁrming! inﬂuenza! vaccine! uptake! in! Central! America.! If! successful,! the! protocol! will! be! disseminated! throughout! the! region! to! evaluate! the! eﬀecEveness!of!seasonal!inﬂuenza!vaccinaEon.!
CDC’ s Surveillance for Infectious Disease in El Salvador: CDC Building Capacity for Detection and Response for Influenza, Dengue and Chikungunya J ohanna S. Segovia MPH Class of 2014 , University of Miami Department of Public Health Sciences, Miller School of Medicine
FIELDWORK OV ERV IEW
Map of Sentinel Hospitals
CDC-CAR’ s* Influenza Surveillance Program in El Salvador provides technical assistance for the implementation of sentinel surveillance and control of infectious diseases • CDC-CAR forms cooperative agreements with regional and local institutions for infectious disease monitoring, evaluation, research, and intervention implementation throughout Central America. • • •
SE-COMISCA+ FETP⌘ Sentinel Surveillance Hospitals
Sentinel surveillance site
Public health challenges • Unable to evaluate influenza vaccine effectiveness against seasonal influenza due to uncertainty of vaccination uptake from target population • Unable to assess the impact of a simultaneous outbreak of Dengue and Chikungunya
A protocol was designed to study the reliability of parental verbal-report of influenza vaccine uptake in children <5 years of age Surveillance data obtained from site visits were analyzed to improve pertussis and influenza program interventions Dengue and Chikungunya preparedness and response guidelines were updated for accurate surveillance Designed an interactive dashboard as a visual aid in monitoring Dengue and Chikungunya outbreaks A standard operating procedures plan was developed for potential Ebola outbreak in El Salvador
Suspected Chik ungunya cases Interactive dashboard to monitor outbreak s Epi Week 26 (22-28 J une, 2014)
Central American Integration System (SICA) provides economic, social, cultural, environmental & political support for Member States
Dengue and Chikungunya outbreak situation room were held at the Ministry of Health
OBJ ECTIV ES • • •
Participate in monitoring visits to sentinel hospitals Participate in surveillance projects of SE-COMISCA and TEPHINET Participate in situation room with the Ministry of Health to respond to Dengue and Chikungunya outbreaks Attend preparedness and response meetings for Ebola held by the Ministry of Health and Institute of Health Implement an intermediate epidemiology course through FETP and SE-COMISCA
FUTURE DIRECTIONS Epi Week 27 (29 J une – 5 J uly, 2014)
* CDC-CAR– CDC Central America Regional Office SE-COMISCA-- Council of Ministers of Health of Central America and the Dominican Republic Secretariat ⌘FETP– Field Epidemiology Training Program TEPHINET– Training Programs in Epidemiology and Public Health Interventions Network
A pilot study will be conducted in the sentinel hospital of Santa Ana • Results of the pilot study will help determine an effective and sustainable strategy on confirming influenza vaccine uptake • The protocol will be disseminated throughout the Central American region to evaluate the effectiveness of seasonal influenza vaccination
Source: El Salvador Ministry of Health
Conducting a site visit, San J uan de Dios Hospital in Santa Ana
This field experience and project was supported with funds from the Springboard Grant.
CONTACT J ohanna S. Segovia MPH Public Health Student University of Miami Email: segoviajs@ med.miami.edu
42 ! Student!Name:!Shari!Seidman,!MD/MPH!Class!of!2015! Project:!EvaluaEng!an!EducaEonal!IntervenEon!on!Pediatric!Emergency!Department!Usage!in!Palm! Beach!County!
Background! &! Objec4ve::! Genesis! Community! Health! Inc.! a! nonRproﬁt! clinic,! has! made! eﬀorts! to! reduce!nonRemergent!visits!to!Bethesda!Hospital's!ER.! !ER!visits!can!cost!4!Emes!primary!care!visits,! and!misuse!decreases!paEent!safety.! !This!project!teaches!lowRincome!parents!in!Palm!Beach!County! basic!pediatric!concepts.!!! Methods:! Community! health! workers! delivered! Creole! and! Spanish! classes! at! BRIDGES! and! Guatemala! Maya! Center.! Health!literacy!was!assessed!using!Pﬁzer's!“The!Newest!Vital!Sign,”!followed!by!a!quesEonnaire!and!preRtest.!A!postRtest! and!feedback!session!followed!the!class.!Parents!agreed!to!parEcipate!in!followRup!phone!calls.! Results:! Confounding! variables! in! assessing! health! literacy! invalidated! the! test.! At! least! 3! parents! (n=21)! were! nonR literate!in!their!naEve!language,!and!the!majority!of!parents!were!nonRenglish!speakers.! !There!was!an!average!of!3.14! children! per! family,! and! ER! visits! were! an! average! of! one! 1! Eme! per! 3! months.! 2/3! parents! were! unaware! of! Genesis! Community!Health!and!postRtest!scores!increased!1!point!on!average.!! Conclusions:! !This!program! !revealed!a!subset!of!parents,!likely!representaEve!of!a!larger!populaEon,!unable!to!read/ communicate!in!English,!or!read!their!naEve!language.! !A!paucity!of!health!informaEon!exists!in!Creole.!These!factors! represent!major!barriers!to!care.!!!! Quantum!Springboard
Evaluating an Educational Intervention on Reducing Pediatric Emergency Department Usage in Palm Beach Shari Seidman County MD/MPH Candidate 2015 Department of Public Health Sciences; University of Miami Leonard M. Miller School of Medicine. Miami, Florida, USA Study Contact: firstname.lastname@example.org This work was generously supported by the Quantum Foundation Springboard Grant Palm Beach County
AV AV VALIABLE ALIABLE DATA DAT ATA TA AVALIABLE
The barriers to care in an economically disadvantaged community are complex The barriers to care in an economically disadvantaged community are complex. • Health literacy is another barrier to care, in both English and non-English speaking patients, and often results in inappropriate use of the Emergency Department. • Boynton Beach has been identified as a target area in need of more primary care physicians. • In 2010, Genesis Community Health Inc. opened in Boynton Beach in order to begin treating patients in this community. It has since formed a partnership with Bethesda Hospital East, diverting patients from the Emergency Department to the clinic. • Enhances patient safety by establishing care and providing a medical home. • Reduces costs, the average ER visit can cost 2-4 times the average primary care visit.
At least 3 parents were unable to independently independentl complete plete written material due to low literacy Parents had an average of 3.14 children. The average amount of emergency room visits over the past 3 months was 1 visit. 1/3 of the parents were unaware that Genesis Community Health Inc. exists as a resource in this community. Most parents used a car or bus as their primary means of transportation. Scores of the post test increased an average of 1 point Nominal data indicated that information on abdominal pain, how to treat cuts, what to do in case of seizure, and the information on fever was information that had not been previously explained or understood before taking this course
Parents listening to Community Health Worker at BRIDGES at Boynton Beach
Every parent received one copy of "After Hours, Non Life- and-Death Almost an Emergency Booklet.”
Administering a test of health literacy to the entire group individually was impractical and time consuming. It would have been suffi sufficient f cient to administer the test of health literacy to a ffi smaller number of parents, in order to represent the larger group. Parents found the community health worker engaging; hiring a community health worker as opposed to a translator enhances the group experience. For some parents, transportation was an issue, with “bicycle”, or “none,” being their primary mode of transport. This project has identified a more compelling problem; the majority of parents could not speak or understand English, and several parents, were unable to read literature in their native language. Literacy, not just health literacy cy is a major ajor barrier to care
Educates parents of the pediatric population in Boynton Beach. Reduce non-emergent visits to the emergency room. Teach basic healthcare through educational material and classroom based learning Aid parents in making appropriate medical decisions in times of injury and uncertainty Direct parents to Genesis Community Health Inc. as necessary.
MATERIALS "After Hours, Non Life- and-Death Almost an Emergency Booklet.” “The Newest Vital Sign,” by Pfizer Powerpoint presentation in Creole and English Survey Pre and Post test Question and answer session Haitian Creole for Health Care Glossary
Community health working presenting material in Spanish at BRIDGES at Lake Worth
“Pre-test” given to all parents in the beginning of the class
• • • •
Evaluating An Education Intervention
METHODS Two community health workers delivered a class to four groups of parents at Boynton Beach BRIDGES, Lake Worth BRIDGES and the The GuatemalanMaya Center. The class was offered in Creole and Spanish. The Newest Vital Sign, was administered at the beginning of the class, followed by a brief survey and pre test. Following the class, a post test, identical to the pre-test was then administered to the parents. A verbal feedback session was held at the completion of the course and permission to follow up via phone call in three months was requested.
CONCLUSION Sample slide in Creole
Based upon verbal feedback from parents, the class was well received. We will consider translating the booklet into Creole. As we continue to hold classes and follow up with parents in three months, we will be able to better understand the impact of the intervention. We recognize the need to increase the awareness of Genesis Community f fforts Health Inc. through continued efforts in the community It is important to reach out to vulnerable populations, especially to parents, to ensure that they are receiving proper tools to ensure best health outcomes for their families.
Community health worker talking to parents in Creole.
1. Prou, M., Schorin. Haitian Creole for Health Care. Educavision.com. Mar M Marc arc arc Orou and Mel Schorin 2007. 2. Weiss BD, Mays MZ, Martz W, et al. Quick assessment of literacy in primary ar ary care: the Newest Vital Sign. Ann Fa F m Med 2005; 3: 514–22. Fam 3. Yo Y f SJ. The pediatric after-hours non-life and death almost-an-emergency ffe Yoffe booklet. Bryan, TX: The Insite Group, 2006.
43 ! Student!Name:!Jennifer!Shiroky,!MD/MPH!Class!of!2017! Project:!Assessment!of!Healthcare!AdministraEon!and!Delivery!in!Metropolitan!versus!Rural!HaiE! Background!&!Objec4ves:! !Four!week!visit!at!Hospital!Bernard!Mevs!Project!Medishare!included:!(1)! invesEgate!the!admissions,!hospital!stays,!and!mortality!rates!for!pediatric!paEents,!ages!0R15!years! old,! (2)! create! a! website! for! the! pediatric! residency! program! established! in! September! 2013,! (3)! observe!and!assist!hospital!staﬀ,!and!(4)!become!conversaEonal!in!HaiEan!Creole.! Methods:! !Shadowed!and!spoke!with!the!physicians,!nurses,!volunteers,!and!supporEve!staﬀ!during! my!ﬁrst!2!weeks.!Collected!data!from!paEent!charts!during!my!ﬁnal!2!weeks!that!will!contribute!to!a!longitudinal!study! assessing!the!impact!on!paEent!care!of!the!pediatric!residency!program!that!was!established!in!2013.! Results:! ! Two! hundred! charts! for! inRpaEent! pediatric! paEents! admibed! for! pneumonia,! seizures,! or! diarrhea! were! reviewed.!!The!pediatric!residency!website!has!been!set!up!and!maintained.!! Conclusions:! ! Data! will! conEnue! to! be! collected! and! analyzed! for! 2011! through! 2016.! A! report! will! be! wriben! on! the! inﬂuence!of!the!pediatric!residency!program!on!paEent!care.!This!report!will!be!shared!with!other!organizaEons!with!an! interest!in!training!physicians!in!developing!naEons.! !!
Establishment of a Pediatric Residency Training Program in Haiti: Examining Health Outcomes J ennifer R. Shiroky MD/MPH Class of 2017, Department of Public Health Sciences, University of Miami Miller School of Medicine
• Pediatric Residency Program established in Fall 2013
• Not enough residency training programs to meet needs of country
Number of Patients
• Urgent care hospital with emergency, intensive, surgical, and ambulatory services
• Hopital Bernard Mevs Project Medishare (HBMPM) in Port-au-Prince, Haiti
Pneumonia Seizures Diarrhea
• Project Medishare established volunteer program after 2010 earthq uake
• Insufficient medical institutions and resources available for physicians to practice in desired fields • Many medical graduates train in North America, Europe, and other Caribbean countries
0 April-J un ' 13
• V olunteers included physicians, nurses, physical therapists, respiratory therapists, and paramedics from North America to assist hospital staff
J ul-Sept ' 13
Oct-Dec ' 13
J an-Mar ' 14
• Insufficient medical institutions to meet healthcare needs
April-May ' 14
3 Month Block s
• New hospitals being built
Average Length of Stay 14
• Current hospitals working to improve
OBJ ECTIV ES
ADDITIONAL FINDINGS 8
• Assess HBMPM’ s admissions and mortality rates for the top 3 causes of pediatric death: pneumonia, diarrhea, and seizures • Create a website for the Pediatric Residency Program • Assist medical professionals • Observe and experience short term global health volunteer opportunity • Appreciate the patient and family experience • Become conversational in Haitian Creole
OUTCOMES • 200+ patient charts reviewed for: reason for admission, diagnosis, length of stay, number of employees and volunteers involved in their care, treatment plan, and follow up • Collected profiles of the residents • Pediatric Residency website set up & maintained: http: / / pediatrics.med.miami.edu/ residency • Beginner’ s level comprehension and expression of Haitian Creole
This field experience was possible thanks to: The support from the Global Health Scholar Award • Guidance from Dr. Toni Eyssallenne. •
• Chart review of pediatric cases from October 2012-J une 2014
• Experienced disconnect between volunteer tourists’ intentions and actual outcomes
April-J un ' 13
J ul-Sept ' 13
Oct-Dec ' 13
J an-Mar ' 14
April-May ' 14
3 Month Block s
Mortality Rates D iagnosis April-J un ' 1 3 J ul-Sept ' 1 3 Oct-D ec ' 1 3 J an-Mar ' 1 4 April-May ' 1 4 Pneum onia 1/ 9 (11.1% ) 2/ 7 (28.6% ) 2/ 12 (16.7% ) 2/ 8 (25% ) 0 Seiz ures 0 0 1/ 3 (33.3% ) 1/ 8 (12.5% 1/ 1 (100% ) D iarrh ea 1/ 4 (25% ) 1/ 3 (33.3% ) 0 0 0
• Gained understanding that career in global health req uires long term commitment with personal sacrifices • Embracing a new culture and language helped with connection • Observed daily functions of resource-limited hospital • Became better listener
FUTURE DIRECTIONS • Ongoing data collection through Fall 2016 • Establish hospital admissions, length of stay, and mortality rates • Analyze if residents improve health outcomes and q uality of care • Highlight role of physician training programs in improving patient care • Disseminate model of residency program to promote development of training programs for physicians in Haiti and other developing countries
CONTACT J ennifer R. Shirok y MD/ MPH Student, Class of 2017 University of Miami Email: j.shiroky@ umiami.edu Phone: (561)-706-9781
44 ! Student!Name:!John!Strutner,!MD/MPH!Class!of!2016! Project:!Public!Health!Eﬀorts!in!Northern!HaiE! Background:!Individuals!living!in!Northern!HaiE!have!been!plagued!by!poor!health!for!many!salient! reasons.! The! Cap! HaiEen! Health! Network! (CHHN)! is! dedicated! to! improving! coordinaEon! between! health! faciliEes! and! projects! in! Northern! HaiE.! CHHN’s! local! HaiEan! physician! is! Dr.! Eugene! Maklin! who!works!as!an!outstanding!physician,!public!health!worker,!and!social!advocate.! Methods:! Shadowed! Dr.! Maklin! in! the! various! projects! he! is! involved! in,! including! his! work! as! a! primary! care! physician,! iniEaEves! promoEng! public! health,! and! his! microﬁnance! project.! Delivered! a! survey! to! health! faciliEes!in!Northern!HaiE!to!help!update!CHHN’s!web!site.! Results:!Learned!how!Dr.!Maklin!is!able!to!deliver!expert!medical!care!to!thousands!of!underserved!people.!!Also!learned! about! how! Dr.! Maklin! was! able! to! construct! over! 100! wells! and! distribute! the! sanitary! supplies! necessary! to! combat! water!borne!diseases.!Lastly,!observed!Dr.!Maklin’s!microﬁnance!program!where!he!delivered!over!1,000!loans!and!has!a! 98%!return!rate.!! Conclusions:! Dr.! Maklin! and! the! CHHN! are! bringing! health! services! to! Northern! HaiE! by! conEnually! improving! communicaEons! between! health! faciliEes,! construcEng! wells,! distribuEng! sanitary! supplies,! promoEng! economic! development,!and!construcEng!a!new!hospital.!!
Public Health E fforts in N orthern Haiti John Strutner MD, MPH Class of 2017 Department of Public Health Sciences, University of Miami Miller School of Medicine Cap Haitien Health Network Contact Information: jstrutner@ med.miami.edu
• Northern Haiti is a region plagued by poor health due to multiple factors including lack of coordination between health facilities and brain drain of trained health professionals • The Cap Haitien Health Network (CHHN) is an organiz ation devoted to improving communication between health facilities and public health projects in Northern Haiti • CHHN’s local Haitian physician is Dr. Eugene Maklin who works as a physician, public health worker, and social advocate
• Understand how effective a public health physician can be especially in a resource-poor environment like Haiti • Appreciate Dr. Maklin’s ability to deliver a high level of medical care to thousands of the underserved in remote regions of Haiti whom otherwise would have no other treatment options
• Dr. Maklin tirelessly advocates for his patients and community • Through his microfinance program, Dr. Maklin has given over 1,000 loans to women who have a 9 8% return rate
O utco utcomes
O bj bbjectives ecti tives • To shadow Dr. Maklin in various projects including: • Primary care: working in five clinics throughout Northern Haiti • Public health: constructing wells and delivering sanitary supplies to rural villages • Economic development: managing a microfinance project • To give a survey to health facilities in Northern Haiti to update CHHN’s web site and coordinate health services offered in the region
• Dr. D Maklin has constructed constru r cted ru c overr 100 wells while w ile wh a delivering water purification purifi urifi f cation tablets and fi also sanitary supplies such as bleach and soap to s remote rural villages in order to combat water borne diseases such as cholera and typhoid
• D Despite the major obstacles in Haiti, Dr. Maklin a the CHHN are bringing progress and hope to and Northern Haiti through: N • Continual improvements in communications between health facilities • Construction of more wells • Continued distribution of sanitary supplies • Promotion of economic development • Construction of a new hospital in Tovar, Haiti
Funding Acknowledgment • T This field experience was supported with funds f from the Global Health Scholar Award
45 ! Student!Name:!Julien!Thomas,!MD/MPH!Class!of!2017! Project:!Understanding!Community!Health!in!Rural!Mysore,!India! Background:!!In!India!there!is!a!countryRwide!deﬁciency!in!women’s!health!and!prenatal!healthcare,! parEcularly!in!rural!communiEes.!For!this!reason!the!Public!Health!Research!InsEtute!India!(PHRII)! was! established! in! 2007! to! address! ways! in! which! women’s! health! could! be! improved.! PHRII! collaborates! with! many! partners! in! nearby! hospitals! and! communiEes! including! Accredited! Social! Health!AcEvists!(ASHAs).!Working!with!these!partners!provided!an!opportunity!to!understand!local! healthcare!challenges.! Methods:!Through!the!PHRII,!toured!healthcare!faciliEes!and!journeyed!into!the!rural!countryside!to! work!with!ASHA’s,!bringing!the!community!together!for!medical!and!educaEonal!camps.! Results:!Gained!insight!into!the!many!challenges!that!face!PHRII!when!working!with!illiterate!populaEons!in!diﬃcult!to! reach!areas!as!well!as!the!healthcare!resources!that!are!available!to!these!populaEons.! Conclusions:!Although!diﬃcult,!assessment!of!educaEonal!programming!in!order!is!recommended!to!ensure!that!PHRII! educaEonal!camps!are!eﬀecEve!in!conveying!their!informaEon!to!target!populaEons.!
Understanding Community Health in Rural Mysore, India J ulien R. Thomas
Department of Public Health Sciences
MD/MPH Class of 2017, University of Miami Department of Public Health Sciences, Miller School of Medicine
PROJ ECT BACKGROUND •
Education Camp presentation
In most developing countries in South Asia, less than half of all deliveries occur in a healthcare facility
In 2010 the maternal mortality ratio (MMR) was 450 deaths per 100,000 in India
J ourneyed into rural countryside to work with local ASHA’ s, bringing the community together for medical and educational camps •
Disparities in prenatal healthcare are greater between urban and rural areas in India than in developed countries
Assisted in field lab testing for rural and tribal medical camps •
Toured alternative health care facilities including an Ayurveda Hospital in order to understand all healthcare options available to patients
Public Health Research Institute (PHRII) •
Non-profit charitable trust established in 2007
J SS City Hospital
V illage Assembly Hall
Mission: • Carrying out and facilitating public health research aimed at improving healthcare for women and adolescent girls •
Delivering education, reproductive health services, family planning and cancer prevention to lowincome women, particularly those in hard-to-reach areas
J SS Ayurveda Hospital
V illage School
Accredited Social Health Activist (ASHA) •
National community health worker program composed primarily of young married women
V oluntary health educators and promoters living in each community •
Medical Camp testing
L earned about the recruitment and training of local Accredited Social Health Activist (ASHA) workers and their role in the community Gained a better understanding of the various barriers from literacy to accessibility, involved in providing healthcare and education to rural communities in India
Sample Education slide
Discovered effects of the caste system on the healthcare of rural and tribal populations, especially denied treatment to tribal populations at specific health centers Gained a better understanding of the forced relocation programs affecting tribal populations and their effects on the healthcare and traditions of each group
Pamphlet sample (Kannada)
FIELD EX PERIENCE OBJ ECTIV ES REFERENCES •
To observe the collaboration between PHRII and ASHA’ s to increase the access of rural and tribal populations to healthcare services To observe the implementation of health educational programs in India To understand the government healthcare services available for populations in remote regions of India
Madhivanan P, Kumar BN, Adamson P, Krupp K. Traditional birth attendants lack basic information on HIV and safe delivery practices in rural Mysore, India. BMC Public Health 2010;10: 570. doi: 10.1186/ 1471-2458-10-570.
FUNDING ACKNOWLEDGEMENT This field experience was supported with funds from the Global Health Scholar Award
J ulien R Thomas MD/ MPH Public Health Student University of Miami Email: j.thomas23@ med.miami.edu Phone: (786) 452 6170
46 ! Student!Name:!Scob!Walker!&!Mariel!Janowsky,!MD/MPH!Class!of!2015! Project:!A!Culturally!Appropriate!Approach!to!Diabetes!EducaEon!in!the!HaiEanRAmerican!Community!in! Palm!Beach!County! Background!&!Objec4ve:!Diabetes!represents!a!leading!cause!of!morbidity!and!mortality!in!the!United! States,!with!a!disproporEonate!number!of!African!Americans!aﬀected.!HaiEans!are!more!likely!to!have! higher! hemoglobin! A1C! levels! when! compared! to! nonRHispanic! whites! and! African! Americans.! ! This! is! likely! due,! at! least! in! part,! to! the! paucity! of! educaEonal! materials! available! for! this! populaEon! and! ineﬀecEveness!of!printed!materials!due!to!HaiEanRCreole!being!predominantly!a!spoken!language.! !The! use!of!videos!for!intervenEons!has!proven!to!be!eﬀecEve!for!various!health!topics!in!other!populaEons,! such!as!mammogram!screening,!infant!feeding!techniques,!and!cardiovascular!health.!!! Methods:!This!project!seeks!to!reach!the!HaiEanRAmerican!populaEon!in!South!Florida!by!developing!a! video!intervenEon!in!place!of!wriben!materials.! !By!collaboraEng!with!a!HaiEanRAmerican!screenwriter,! educators!and!HaiEanRAmerican!actors,!this!video!will!educate!paEents!on!disease!process,!management! of!diabetes!and!prevenEon!of!diseaseRrelated!complicaEons!while!maintaining!cultural!relevance.! Results:!A!20Rminute!video!in!HaiEanRCreole!that!is!available!for!use!by!diabetes!educators,!clinicians!and!public!health! professionals.!!! Conclusions:!The!video!can!be!disseminated!throughout!South!Florida!by!making!it!available!online.! !The!video!can!be! evaluated!in!the!future!by!assessing!changes!in!paEent!knowledge!using!a!pretest!and!posbest. !Quantum!Springboard
A Culturally Appropriate Approach to Diabetes Education in the Haitian-American Community Scott Walker and Mariel J anowsky Department of Public Health Sciences, University of Miami Miller School of Medicine J FK Medical Center, Palm Beach, Florida, USA
V ideo Content
Proj ect Design
Diabetes represents a leading cause of morbidity and mortality in the United States, with a disproportionate number of African Americans affected.1
This project will educate via a video format in order to respond to these educational challenges.
The video will be approximately 20 minutes and will center around a child’ s birthday pool party with HaitianAmerican friends and family in attendance.
Current research on Haitian-Americans living with diabetes is limited.
The video will be entirely in spoken Haitian-Creole to ensure understanding by the target population and will maintain cultural relevance by collaborating with Haitian-Americans and educators.
The video will consist of three scenes and one post scriptum. The post scriptum will focus on insulin administration.
The video is designed to provide secondary prevention recommendations for individuals who have either a new diagnosis or poor control of diabetes.
The seven scenes of the video will educate on the disease process of diabetes, methods to manage the disease, and evidence-based ways to prevent complications of diabetes.
Existing research suggests that Haitians are likely to have higher hemoglobin A1C levels when compared to non-Hispanic whites and African Americans.1 Educational materials are lacking for this population for a variety of reasons: • Haitian-Creole is predominantly a spoken language. • L iteracy skills may be inadeq uate. • Certain aspects of cultural relevance may be lost in translation. More Haitian-Americans live in Florida than in any other state in the country, making targeted health education particularly relevant in our community.2
Immediate goal: • Knowledge: Increase the understanding of the natural history of diabetes. L ong-Term goal: • Management: Reduce and/ or maintain hemoglobin A1C levels at or below 7%. • Behavior: Reduce short-term and long-term diabetes-related complications.
Timeline Fall 2014 • Discussed the need for video education with the Diabetes Educator at J FK Medical Center and created an outline of topics to include. • Collaborated with an educator in the HaitianAmerican community who is familiar with diabetes complications to ensure content was appropriate. • Contracted a Haitian-American screenwriter who has a close family member with diabetes and established goals for the video.
Use of V ideo for CulturallyRelevant Education V ideos that are tailored to be culturally relevant toward a specific population have shown to be effective in making positive behavioral changes. These are examples of video interventions that have been successful in targeting change: 3-9
Spring 2015 • Reviewing the script with community members to ensure relevance and evidence-base; make appropriate revisions. • Consulting with the Diabetes Educator to ensure that it meets the needs of J FK Medical Center. • Meeting with a Haitian-American producer to plan production. • Filming with the participation of Haitian-American actors and editing appropriately. • Incorporating the video into diabetes education at J FK Medical Center. Future: • MD/ MPH student at the University of Miami will work with J FK Medical Center to evaluate the effectiveness of the video. • Distributing the video to other medical centers and clinics in South Florida if effective.
The following evidence-based recommendations will be addressed in the video and are endorsed by the American Diabetes Association: 10 • Minimize consumption of foods high in carbohydrates. • Avoid regular consumption of beverages high in sugar, such as sodas and juices. • Check blood sugar at least two times per day and record the results. • Get regular exercise if physically feasible. • Foot care – always wear shoes or sandals, and check feet regularly for open wounds. • Obtain regular eye examinations, at least once every two years. • Keep blood pressure under control. • Become aware of the signs and symptoms of hypoglycemia, and how it can be treated urgently.
Theoretical Framew ork Under the Health Belief Model, a positive change in behavior can be effected when the threat of the disease or disease complications is better understood (perceived threat).11 A cue to action, such as talking to a loved one with the disease/ complications or a relevant educational program can modify the perceived threat and create positive change.11
Ack now ledgements The project was supported by the Q uantum Foundation Springboard Grant of Palm Beach County. Special thanks is given to Community Partners, Karen L ewin and M. J . Fievre. Appreciation is also given to Dr. J ulia Belkowitz, Faculty Advisor, and Felicia Casanova, Capstone Manager.
References V imalenanda et al. “ Comparison of diabetes control among Haitians, African Americans, and nonHispanic whites in an urban safety-net hospital.” Diabetes Care. 2011 J an 34(1): 58-60. US Census Bureau. The Population with Haitian Ancestry in the United States: 2009. Howe et al. “ The impact of a television soap opera on the NHS Cervical Screening Programme in the North West of England.” J ournal of Public Health Medicine. 2002 Dec 24(4): 299-304. Wang et al. “ Results of a randomized controlled trial testing the efficacy of a culturally targeted and a generic video on mammography screening among chinese-american immigrants.” Cancer E pidemiol B iomark ers Prev. 2012 Nov 21(11): 1923-32. Devieux et al. “ Reducing Health Disparities Through Culturally Sensitive Treatment for HIV + Adults in Haiti.” A B N F J . 2004 15(6): 109-115. Dhawan et al. “ Utilizing video on myocardial infarction as a health educational intervention in patient waiting areas of the developing world: A study at the emergency department of a major tertiary care hospital in India.” I nternational A rchives of Medicine. 2008 1(14): 1-14. Byrd et al. “ AMIGAS: A Multicity, Multicomponent Cervical Cancer Prevention Trial Among Mexican American Women.” Cancer. 2013 Apr 119(7): 136572. O’ Donnell et al. “ V ideo-Based Sexually Transmitted Disease Patient Education: Its Impact on Condom Acq uisition.” A m J Public Health. 1995 J un 85(6): 817-822. Scheinmann et al. “ Evaluating a bilingual video to improve infant feeding knowledge and behavior among immigrant L atina mothers.” J Community Health. 2010 Oct 35(5): 464-70. American Diabetes Association. Executive Summary: Standards of Medical Care in Diabetes – 2014 Hayden, J oanna Aboyoun. I ntroduction to Health B ehavior T heory. 2nd Ed. Wayne, New J ersey, 2014.
Julia Belkowitz, MD Nicolas Cuttriss, MD, MPH, FAAP Noella Dietz, PhD
Antonia Eyssallenne, MD, PhD Daniel Feaster, PhD Hermes Florez, MD, PhD, MPH Eric Hecht, MD, MSPH Viviana Horigian, MD Lanetta Jordan, MD, MPH, MSPH
CAPSTONE FACULTY ADVISORS
Erin Kobetz, PhD, MPH Julie Kornfeld, PhD, MPH Tulay Koru-Sengul, PhD, MHS, MA Naresh Kumar, PhD, MSc Meaghan McNulty, MD, MPH Sarah Messiah, PhD, MPH Tatiana Perrino, PsyD Mark Stoutenberg, PhD, MSPH
P U B L I C H E A LT H I N N O VAT I O N I S U S
Leonardo Tamariz, MD David Withum, MD, MPH, DrPH, DTM&H
+ PUBLIC HEALTH I N N O VAT I O N I S U S
S P E
45th Street Clinic West Palm Beach, FL AMOS Global Health Internship Sabalete, Nicaragua Apollo Hospital Ahmedabad, India Bankhead Coley Cancer Research Program Miami, FL CDC Guatemala City, Guatemala
I TH A NKS L
CDC-CAR/Ministry of Health/VICITS Clinics Guatemala City, Guatemala
To our community partners for their continuous support
+ PUBLIC HEALTH I N N O VAT I O N I S U S
S P E
Changi Sports Medicine Centre, Changi General Hospital Changi, Singapore Community Organizations and Centers, Schools West Palm Beach, FL ConnectFamilias Miami, FL Diamond View, Crystal Lakes, and Cypress Trails Elementary Schools West Palm Beach, FL
I TH A NKS L
Familias Unidas Miami, FL
Florida Department of Health in Palm Beach County West Palm Beach, FL
To our community partners for their continuous support
+ PUBLIC HEALTH I N N O VAT I O N I S U S
S P E
Foundation for Sickle Cell Disease Research Miami, FL Fundación Barceló Santo Tomé, Argentina Global Brigades Tegucigalpa, Honduras Gobernación del Atlántico Barranquilla, Columbia Gonoshasthaya Kendra (People’s Health Centre) Dhaka, India Guánica Bay Guánica, Puerto Rico Hanoi Medical University Hanoi, Vietnam
I TH A NKS L
Health Through Walls Port Au Prince, Haiti Hialeah, Little Haiti, and San Juan Bosco DOCS Clinics Miami, FL
To our community partners for their continuous support
+ PUBLIC HEALTH I N N O VAT I O N I S U S
S P E
Hospital Estadual Ad達o Pereira Nunes (HEAPN) Rio de Janeiro, Brazil Jackson Memorial Hospital ACC Clinic & UMMSOM Department of Obstetrics and Gynecology Miami, FL Juan Felipe Gomez Escobar Foundation Cartagena de Indias, Colombia Jubilee House Community Ciudad Sandino, Nicaragua
I TH A NKS L
Louis Calder Memorial Library Miami, FL
Mental Health Association of Palm Beach West Palm Beach, FL
To our community partners for their continuous support
MICEFA Paris, France
+ PUBLIC HEALTH I N N O VAT I O N I S U S
S P E
Overtown Youth Center Overtown, FL Population Services International (PSI) Yangon, Myanmar Project Medishare Thomonde, Central Plateau and Port au Prince, Haiti Public Health Research Institute of India Mysore, India Rwanda Zambia HIV Research Group Kigali, Rwanda
I TH A NKS L
Ryder Trauma Center Miami, FL
Sylvester Comprehensive Cancer Center Miami, FL The World Health Organization Freetown, Sierra Leone
To our community partners for their continuous support
University of Miami Department of Public Health Sciences Student Capstone Projects