Author: Madeline Kameny

Congrats to Our Grads!

The Interdisciplinary Health Communications (IHC) program at UNC-Chapel Hill, which houses the Upstream blog, is an inter-departmental initiative in the new science of health communication. This year, several wonderful students are graduating with degrees or certificates through IHC. Let’s recognize them!

First is Arshya Gurbani, who has earned her MA in Media and Communication:

Next is Matty Johnson, MS in Library Science and IHC Certificate, who will be going on to pursue his PhD:

Hannah Tuttle, MPH, IHC Certificate:

Casey Evans, MPH and Registered Dietitian, IHC Certificate:

Josh Boegner, MPH, IHC Certificate:

Congrats to our wonderful 2018 graduates, who will be using their health communication knowledge for great things!

Primary Care Access in Rural Areas

Rural areas of the U.S. face unique barriers to healthcare that must be approached with a systematic framework. One access issue is a lack of primary care practitioners (PCPs) in rural areas: despite existing incentive structures for PCPs to complete residencies in rural areas, there is still a provider shortage, leading to limited access to providers for rural residents. A lack of providers in a given area could manifest itself in fewer appointment slots or longer wait times, for example. Poor access to primary care has been found to be both an effect of poverty and a cause of further health disparities.

A study of barriers to preventative screenings in Appalachia found that “lack of knowledge about prevention and cost” were the primary obstacles, impacting 51% and 36% of participants, respectively. In Graham County, NC, a county in Appalachia that is 100% rural, the local Department of Public Health asked key informants about healthcare issues in their community. When asked how much they believed physical environment and social determinants of health contribute to health problems in the county, most ranked social determinants (such as alcohol/drug abuse, economy, and education) as a major contributor. However, their top health priority was access to care. This suggests that residents are aware of the importance of primary care as an upstream factor impacting their overall ability to access healthcare. To address this issue, we cannot overlook the socioeconomic barriers that individuals face to access, as well as the other challenges happening in their lives simultaneously.

Sources:

http://www.ncsl.org/research/health/meeting-the-primary-care-needs-of-rural-america.aspx

https://news.harvard.edu/gazette/story/2016/02/money-quality-health-care-longer-life/

https://www.ncbi.nlm.nih.gov/pubmed/7848026

http://www.grahamcounty.org/Departments/Health/Forms/2015 Graham County CHA.pdf

Health Orientations for New Patients

Orientations for new patients are one technique for setting the stage for positive patient experiences with a new clinic, especially for those who are unfamiliar with the healthcare system. These orientations have been shown to be successful in reducing stress for cancer patients, preparing patients for beginning psychotherapy, and reducing no-show appointments in a primary care setting, which improves clinic efficiency.

As the Patient Navigator at a Federally-Qualified Health Center (FQHC) from 2016 to 2017, I was tasked with creating this type of program for immigrant and refugee patients, whose cultural differences and unfamiliarity with the American healthcare system often serve as a barrier to successful clinic interactions. From speaking to clinic providers on various levels, as well as patients from refugee communities, I established the following priorities for the orientation curriculum:

  1. Prescription refill process
  2. Calls to our clinic – what to expect, how to request an interpreter, how to speak to a nurse
  3. Difference between preventative and acute care, and emergencies, and benefits of seeing your provider at least once a year
  4. How to make and cancel appointments, and why no-shows reduce our efficiency
  5. Different occupations that clinic staff hold, and how staff can connect patients to other resources they may need
  6. General information about the American healthcare system that may be confusing, such as insurance coverage and social services application processes
  7. Patient rights and responsibilities
  8. Interactions with providers – letting patients know that they can and should ask questions when confused, or when misunderstood by an interpreter or provider

I quickly found that creating a curriculum like this presents several challenges. For example, “refugees and immigrants” is a broad group of people, representing those from wildly different education levels and familiarity with Western healthcare systems. Many times, it was impossible to know patients’ backgrounds before meeting with them to discuss our clinic. I had to be careful to be informational without seeming patronizing, while basing communication strategy on the perceived level of understanding of the patient, which can also be influenced by cultural norms.

Patient orientations have a great potential to reduce patient stress, improve understanding of clinic operations, and give the power back to the patient when it comes to their own health. However, cultural differences must be given weight when developing this type of program. Using community leaders or liaisons for curriculum development and delivery may be a way to bridge that gap.

Sources:

https://onlinelibrary.wiley.com/doi/abs/10.1002/(SICI)1099-1611(199805/06)7:3%3C207::AID-PON304%3E3.0.CO;2-T

https://onlinelibrary.wiley.com/doi/abs/10.1002/1097-4679(198311)39:6%3C872::AID-JCLP2270390610%3E3.0.CO;2-X

https://onlinelibrary.wiley.com/doi/full/10.1046/j.1525-1497.2000.00201.x

https://www.sciencedirect.com/science/article/pii/S0277953610003199

Using Oral History in Public Health

Public health prides itself on being interdisciplinary – but there’s always more to learn. I recently discovered a field of study whose department at UNC was looking to collaborate with public health students. This discipline is called oral history, and the Southern Oral History Program at UNC is a pioneer in its field.

Oral history works to preserve narratives by interviewing, recording, and archiving life stories. The narrator is often from a part of society whose voices have been silenced, and wants to contribute his or her life story to historical archives. For this reason, unlike with traditional qualitative interviews in public health, the narrator’s identifying information is often attached to his or her story. When oral historians use life stories in their research, the narrators play an important role in ensuring that their stories are portrayed accurately. They also receive a copy of their interview, preserved in a written format, for themselves and future generations.

Oral history would be especially useful in conducting public health needs assessments, seeking community expertise for solving a local health problem, finding more robust quotes for supporting policy movements, or discovering the experiences of living through a particular outbreak or natural disaster. Public health research already uses qualitative interviewing techniques, but could greatly benefit from more collaboration with oral historians. We traditionally go into interviews with pre-established questions about specific health topics. We may get some background of the participant’s life, but hearing this as a narrative rather than a response could help us build a deeper understanding of the person sitting across from us.

Sources:

http://www.oralhistory.org/

www.sohp.org

Discrimination and Health Part II: People of Color

Last week, I talked about how discrimination faced in healthcare settings can impact LGBTQ+ individuals’ attitudes towards healthcare, and how facing discrimination in everyday life can negatively impact their health outcomes. People of color (PoC) in the U.S., including immigrants, refugees, and Indigenous Peoples, face this double-barreled oppression as well.

Of course, one way racism affects health is through the broad structures that have placed many PoC groups at disadvantaged positions, intersecting with poverty – one study found that almost 100,000 black people die prematurely each year who would not die were there no racial disparities in health.

But discrimination itself, even on an individual level, can impact the health and healthcare experiences of PoC. Microaggressions, or everyday interactions rooted in racism, are a daily stressor for PoC, and these stressors can lead to premature illness and mortality.

Of course, this discrimination doesn’t just happen in daily interactions, but also in medical settings, which rightfully leads to mistrust and under-use of healthcare for PoC. Language and cultural barriers faced by immigrants can have similar effects.

Because race, socioeconomic status, and health are so intertwined, it may never be possible to know what levels of discrimination have the greatest ultimate effects on health outcomes. But we know they all have at least some, which should be enough to demand action.

Sources: https://www.ncbi.nlm.nih.gov/pubmed/12042611

https://www.hindawi.com/journals/tswj/2013/512313/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2821669/#!po=2.38095

https://health.usnews.com/health-news/patient-advice/articles/2016-02-11/racial-bias-in-medicine-leads-to-worse-care-for-minorities

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2696665/

https://www.ncbi.nlm.nih.gov/pubmed/17001262

Discrimination and Health Part I: LGBTQ+ Americans

Past research has suggested that discrimination can impact health outcomes – perhaps through vehicles such as stress of daily interactions and negative experiences with the healthcare system. One group whose experiences with discrimination can be linked to negative health outcomes is LGBTQ+ Americans. A study found that over half of LGBTQ people have experience slurs and offensive comments, and over half have been sexually harassed or experienced violence, or had an LGBTQ friend or family member experience such trauma.

We can make the connection between discrimination and trauma through various factors. One is through microaggressions –  seemingly harmless daily interactions with others who express, in this case, homophobic or transphobic views. These have been found to negatively impact health. Another is through discrimination within the healthcare system that lead LGBTQ Americans to seek healthcare less frequently. 18% of this population has avoided necessary medical care. Various forms of discrimination they face at the hands of medical professionals, police, and community members are much worse for those of color and those who are transgender.

Unfortunately, we can already see the health outcomes of discrimination to this population – they have higher rates of psychiatric disorders, substance dependence (including higher tobacco use), and suicide; lesbian women are less likely to get preventative services for cancer, and gay men are at higher risk for certain STIs.

How can we work to eliminate these gaps, even when interpersonal discrimination may take longer to tackle as our culture continues to evolve? HealthyPeople2020 provides several recommendations. First, healthcare providers should discuss sexual orientation and gender identity (SOGI) respectfully with patients, and collect data on it. Medical students should be trained in LGBTQ culturally-responsive care. In addition, we must be spokespeople against legal discrimination of this population in social services such as employment, housing, and health insurance.

Sources:

https://www.healthypeople.gov/2020/topics-objectives/topic/lesbian-gay-bisexual-and-transgender-health

https://www.npr.org/documents/2017/nov/npr-discrimination-lgbtq-final.pdf

https://www.centerforhealthjournalism.org/2017/11/08/how-racism-and-microaggressions-lead-worse-health

https://www.psychologytoday.com/us/blog/microaggressions-in-everyday-life/201011/microaggressions-more-just-race

http://www.apa.org/topics/health-disparities/fact-sheet-stress.aspx

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2747726/pdf/nihms134591.pdf

Khat: Dangerous drug, cultural pastime, or self-medication?

Khat is made from young leaves from the khat tree that are commonly chewed in the Horn of Africa and the Arab Peninsula. The drug produces stimulating effects and is said to make the chewer animated, energized, and social. Chewing can be done individually or as a social activity – in these gatherings, a communal tobacco pipe is placed at the center of the circle and passed around in addition to the khat. Khat chewing has become an extremely popular practice in the Horn of Africa – an estimated 90 percent of Somali men partake. Research suggests that this practice is associated with physical, psychological, and social risks, and the Somali diaspora is already one that faces high rates of PTSD and other mental health issues. Khat chewing may worsen these issues in the long run, but can also serve as a source of self-medication for those without resources for dealing with trauma.

There is controversy over khat in the countries where Somali refugees are resettling. Abukhar Awale, a Somali TV talk show host, suffered khat addiction himself and became a proponent of the ban. He called khat “the biggest barrier to our integration…segregating Somali youngsters from wider society…they do not contribute, they don’t speak English, they don’t feel they are part of the society.” On the other side, many argue that khat itself is not the problem, but the symptom of a society ravaged by war and trauma. They point to over-policing of people of color and the fact that the ban was associated very little support for those who were made to quit.

Sources:

http://www.itv.com/news/wales/2015-06-24/communities-criticise-lack-of-support-in-year-since-herbal-stimulant-khat-was-banned/

https://www.aljazeera.com/indepth/features/2015/03/somaliland-abuzz-ethiopia-khat-convoys-150325100843701.html

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4075009/

Image retrieved from: TripSavvy

Pollution and Pregnancy: A Match Made in Hell

A recent study in the journal Biological Psychiatry has found that mothers exposed to air pollution during pregnancy have children at higher risk of cognitive health problems, due to brain alteration during fetal development. Such abnormalities resulted in issues such as impulse control and behavioral problems. Researchers believe that long-term impacts could include high-risk activity, such as addiction, as well as mental health disorders and low academic achievement.

Previous research has associated high levels of pollution with poor development in the womb, but this study found that these risks occur even when pregnant mothers were living in places with air pollution levels deemed acceptable. This raises questions of whether our air quality measurement standards are adequate and accurate.

Researchers compare this troubling finding with the field’s existing knowledge of the dangers of smoking during pregnancy – Dr. John Krystal, editor of the journal that published the study, draws the parallel that both scenarios involve “inhaling toxins.” We already know that other environmental factors (like stress, lead exposure, and pesticides) can lead to adverse outcomes during pregnancy, but it seems that regulatory policies for some environmental risks fall short of others. Translating research findings to the public – and focusing on productive solutions instead of instilling fear in those with no choice of residence – are key roles for public health moving forward.

Sources:

https://www.usnews.com/news/national-news/articles/2018-03-14/air-pollution-within-levels-considered-safe-changes-brain-development-leads-to-cognitive-impairment

http://time.com/3757864/air-pollution-babies/

http://www.biologicalpsychiatryjournal.com/article/S0006-3223(18)30064-7/fulltext

Africa Vs. Big Tobacco

Lowering tobacco use has been one of the great successes of public health in the past 50 years, and continues to be a focus of research and intervention. This was achieved through policy and health communication. This journey has shown us that it is possible to change the culture and narrative around behavior, despite steady corporate influence. While tobacco is still a significant public health hurdle in the U.S., there is confidence in the direction we’re headed given what we’ve accomplished.

Unfortunately, tobacco companies are infiltrating other countries with less developed infrastructure for tackling this issue. Currently, low and middle income countries represent 80% of the world’s smokers, as well as smoking-related deaths. Africa in particular is falling victim to extremely powerful tobacco marketing campaigns – smoking prevalence in Lesotho rose from 15% to 52% just between 2004 and 2015, and the industry even manipulated public health policy in Nigeria. Big tobacco is no stranger to targeting advertising strategies to vulnerable groups.

In order to reverse this, we need to support strategies that African countries have already begun to administer. Ghana and Madagascar have implemented tobacco advertising bans; several nations have introduced graphic labels on cigarette packs; South Africa has increased tax on tobacco products; and Kenya has implemented a system for tracking and tracing illicit tobacco product sales.

Already having the knowledge of the danger of tobacco will hopefully help other countries prevent the industry’s hold from strengthening. We must support their efforts before it’s too late.

Sources:

https://medicalxpress.com/news/2018-03-big-tobacco-world-vulnerable-profits.html

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4105326/

https://tobacco.ucsf.edu/how-tobacco-industry-manipulated-public-health-policy-nigeria

https://medicalxpress.com/news/2018-03-big-tobacco-world-vulnerable-profits.html

https://www.thecommunityguide.org/findings/tobacco-use-and-secondhand-smoke-exposure-mass-reach-health-communication-interventions

https://betobaccofree.hhs.gov/

https://www.rwjf.org/maketobaccohistory

 

The Highs and Lows

In the hospital, the nurse told me that by the time I turned 10 they’d have a cure. This voice echoed in my head for years, as I imagined those very doctors and nurses working overtime in their labs, after their long days helping kids like me. Each birthday after the 10th one, I became more and more bitter thinking about that nurse, realizing she had delivered a false promise.

Type 1 diabetes (T1D) is misunderstood, even within the public health field. It’s rare – only 3% of all diabetes cases in the U.S. – and cannot be cured. T1D people live 12 years shorter on average.

T1D is an autoimmune disorder that occurs when the pancreas stops producing insulin. Unlike for Type 2, scientists still aren’t sure why. They have found that some T1D patients share a particular HLA (human leukocyte antigen) complex, but in order for this to trigger an immune response, it has to be triggered by something else, like a viral infection. Because it takes years for the T-cells to completely destroy the beta cells of the pancreas, it can be hard to track.

But this theory checks out for me: I had a nasty virus as an infant, and was diagnosed with T1D 5 years later.

Managing T1D is incredibly difficult. Every variable of everyday life affects blood sugars, and interact with each other such that it’s nearly impossible to know what causes a high or low. Today, by blood sugar was 152 when I woke up, I ate 18 carbs for breakfast, gave 2.1 units of insulin, and remained steady through the morning. Tomorrow, I might wake up at 152, eat 18 carbs, give 2.1 units, and end up with a dangerous low in the middle of an important meeting.

Despite this, I am lucky. I have health insurance, allowing me to have technology that makes it more likely I’ll beat the odds. For the uninsured, the estimated cost of T1D is over $13,000 a year – and that’s just for the bare minimum. What are we doing for the people who need the 6th most expensive liquid on earth to survive, but can’t afford it?

Sources:

https://www.scienceabc.com/eyeopeners/what-which-are-the-most-expensive-liquids-in-the-world.html

http://www.diabetes.org/advocacy/news-events/cost-of-diabetes.html

https://www.npr.org/sections/health-shots/2015/01/06/375395383/tight-control-of-type-1-diabetes-saves-lives-but-its-tough

https://www.endocrineweb.com/conditions/type-1-diabetes/type-1-diabetes-causes

https://login.medscape.com/login/sso/getlogin?urlCache=aHR0cHM6Ly93d3cubWVkc2NhcGUuY29tL3ZpZXdhcnRpY2xlLzg2MTU0Mg==&ac=401

 

Photo retrieved from: Insulin Nation