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19
Thu, Sep

Young people especially in Africa are a large portion of the population with youth comprising more than 38 percent of the population. The youth are the essence of the mission of our nations and the continent as a whole and are a vital resource of Africa. They must be involved to a big extent in the future planning of the continent. For those who are already motivated, they must be committed to push their peers in implementing different projects. Yet, we can’t ignore the large part of the youth who are struggling because they were born and raised by single mothers and often lack the basic necessities of life.

I have sat down and realized that in my country of Rwanda, there are a large number of single mother families and that the number of these families is increasing daily. I am afraid the number will continue to rise from the high rate of girls who get pregnant under the age of 18 in local areas where I come from, we have a responsibility to take action now to make sure this is prevented. 

Several factors make it difficult for women in Rwanda to achieve their full potential. Limited schooling is crucial, along with a high rate of pregnancy among women entering child-bearing age. In fact, the percentage of pregnancy among adolescents and young women is one of the highest in Sub-Saharan Africa. These factors contribute to the deterioration of health, housing, and economic conditions of the household.

For women having to support their households, a reliable source of income is crucial. However, as highlighted by several studies, there is a lack of formal work opportunities for women living in slums that would allow them to obtain a stable income. So, this issue must be addressed, we can start with my input, by ensuring that all African problems are addressed by Africans. I want to tackle this before we convert challenges into opportunities through different ways and one of the first ideas which comes to mind is an initiative, I have named NYANGE Women Sewing Initiative (N.W.S.I.)

N.W.S.I is my project to teach mainly tailoring along with trainings like conflict management, project management, design thinking, among others to vulnerable, single mothers in my region of NYANGE which is where I proposed to start the initiative. In each of the five cells of this area we must choose committed vulnerable single mothers who are ready to change their quality of life. Thus far, we have gathered them together to explain the vision of N.W.S.I -- where we want to bring the voice of single mother families to the table to help them with collaborating with the Rwandan government. We believe they will help to teach and implement this initiative which will bring more than 40 single mothers to working markets in less than two years and they will be ready to compete at the country level even abroad in the coming years. The Nyange Sector, my native community, has a high percentage of girls who are under 18 and who have already given birth or are ready for the birth of a new child and receive little support coupled with a lot of criticism from their respective families.

I believe that the tailoring project is a tremendous opportunity for those wives because it doesn’t require a large number of classes that single mothers would have to attend and it offers direct feedback from mothers who have participated in the six-month intensive training with qualified trainers. In our country we have a policy of reducing the amount of second-hand clothes because they often bring various problems to buyers like skin diseases and other manifestations, this effort will be furthered as part of what we are doing what with our initiative MADE IN RWANDA. With this project single mothers who participate will be privileged to help the country in the implementation of this project and the idea of giving the youth a voice which must be counted at the village level and in larger scale down the road. We plan to reach all of the single mothers across the country and to keep collaborating with other single mothers until we reach the whole of Africa. The new era of free trade in Africa will help to encourage African single mothers to take part in business and related activities across the continent as a whole.

I hope that everyone will collaborate in these efforts to help single mother families reach their fullest potential through the Made in RWANDA initiative. I believe that I will be saying Made In Africa in the coming years -- I am ready to work with those in need to empower them through our initiative and the faith that Africa can again lift the voices of our youth for the betterment of our continent.   

                                                                                                                        

Author bio

Regis Shema is a sixth-year medical student and active RVCP Kigali Chapter Coordinator. Regis is a conscientious, flexible, committed, and motivated volunteer in community-based activities that help to improve people’s health. She served as Rotation officer as part of a mission to expand the activities of the RVCP to the whole country. Abroad, Regis served as director of hygiene and water sanitation in Organization of Rwanda Village Community Promoters (RVCP), furthering its mission to improve the standards of living for vulnerable people across the country. In addition, she has volunteered and participated in numerous activities organized by RVCP and gained experience as a coordinator of NWSI.

 

Summary

Social determinants of health can shorten healthy life expectancy by longer than other risk factors, such as high blood pressure or obesity. Therefore, organized efforts are needed to diminish health inequalities and promote the overall well-being of vulnerable populations. Aliis Vivere is a group of students from different backgrounds, such as medicine, psychology, social work, anthropology, amongst others, which engages in solidarity actions to promote health and well-being of all, regardless of age, gender, origin, socioeconomic status, or any other condition. The group conducted a participatory health census in marginalized and vulnerable communities, as well as communities facing disaster situations, in order to identify major health challenges and offer appropriate assistance to promote physical, social, and psychological wellbeing. The aim of this project is to expand these actions to other communities and implement a series of longitudinal interventions, designed and planned with the health census. Our goal is to have an impact from an intersectoral and interprofessional point of view with divided responsibilities amongst the main stakeholders: the government, academia, civil society and, as a central component, the community itself.

Introduction

The social determinants of health are conditions which can heavily influence people’s life expectancy and health. These include social exclusion, employment conditions, education, and access to health services. However, these aspects are often overlooked by health professionals, and public policy and multi-disciplinary interventions are needed to diminish health inequalities, especially in vulnerable communities or during disaster situations. 

Poverty and social inequality shorten a healthy life expectancy by longer than other risk factors, such as high blood pressure, obesity, and alcoholism (1). In Mexico, 43.6 percent of the population is considered poor (2) and 9.4 million live in conditions of extreme poverty. Moreover, it is worth noting that some social groups suffer from greater marginalization, such as indigenous populations, where 77.6 percent are considered poor (3). Therefore, efforts to promote health and wellbeing within this country’s populations should focus on the social determinants of health to improve public health conditions.

The Mexican population faces an epidemiological paradox, because it presents both diseases that are specific to developing countries, such as infectious vector-borne diseases, acute diarrheal diseases, and acute respiratory illnesses, but also chronic degenerative conditions which are specific to developed countries, such as diabetes, high blood pressure, metabolic syndrome, among others. Chronic, non-communicable diseases are responsible for most deaths worldwide, particularly among adults over the age of 40 (3).

In Mexico, an important factor that contributes to health inequality is the limited access to health services, as well as their quality. This is a challenge especially for those who are not insured by the IMSS (Instituto Mexicano del Seguro Social) or ISSSTE (Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado). Although the Seguro Popular has provided extended coverage for more than 50 million people (3), it is true that the services provided by this insurance are not sufficient to provide adequate medical services.

The previous considerations pose great challenges which make it harder to achieve international goals to ensure healthy lives and promote wellbeing for all. The Mexican Magna Carta, Article 4, establishes that “All people shall have a right to health protection. The law will define the basis and modality for access to health services…”. This leaves governmental administrations with a titanic task to tackle in order to reestablish and maintain health services for the entire population.

Unfortunately, the current health system’s efforts are focused on palliative care instead of prevention. They are focused on treating diseases and their complications, instead of preventing their occurrence by addressing the social determinants of health. 

We believe that by creating social conditions which promote health, as well as empowering populations and encouraging interventions focusing on primary prevention, we can solve some of the challenges we face in regards to public health inequalities. Therefore, we propose a new health system which ensures access to health services for all, starting by mobilizing students, who will be the health professionals of the future.

Aliis Vivere (to live for others) is a group of students from different backgrounds that formed in order to promote health and wellbeing from an interdisciplinary perspective. It was formed in October, 2014, at the Faculty of Medicine of the National Autonomous University of Mexico (Universidad Nacional Autónoma de México, UNAM), following the disappearance of 43 students in Ayotzinapa. The group organized emergency brigades to offer health services, while also raising awareness about the sociopolitical context the Mexican students were facing at the time. The Aliis Vivere group visited different mercados (marketplaces) in Mexico City, such as “La Bola” in Coyoacán; “Mercado de San Nicolás” in Magdalena Contreras; and “Mercado el Molino” in San Lorenzo Tezonco, Iztapalapa. The group, consisting largely of medical students, conducted primary prevention efforts by taking people’s blood pressure, performing screening activities such as quick urine tests, and taking capillary blood glucose measurements. Additionally, the students offered risk factor workshops and free medical consultations.

 

   Volunteers at a popular market.

Later, following the two earthquakes that devastated several regions of Mexico on September 7 and 19, 2017, students from different backgrounds, such as psychology students, social workers, graphic designers, architects, and anthropologists joined the group in a solidarity effort to promote health and wellbeing during this disaster situation in Mexico City, Morelos, and Oaxaca. 

  Jojutla, Morelos and the volunteers.

The activities organized by the group transcended the clinical sphere. Although the group continued offering free medical consultations and provided aid to the local authorities to perform a screening of most common diseases, the group also organized recreational and educational activities, and provided psychological first aid.

In Oaxaca, Aliis Vivere intervened in two vulnerable communities of the Istmo de Tehuantepec, called Reforma de Pineda and Ejido Revolución on November 20. Reforma de Pineda, Oaxaca, is a municipality of approximately 2,800 inhabitants and 1,100 houses, of which 800 were completely destroyed by the earthquake. It has only one health center and, therefore, 81.5 percent of the population has no access to health services. 13.5 percent of people are illiterate, and 8.27 percent of the municipality’s population is of indigenous origin. 10 percent of homes have no basic services and 69 percent of the population lives in poverty conditions.

The Ejido Revolución of November 20 has approximately 300 inhabitants. It is a rural community, with a high index of marginalization. Although it has a health center, no one is in charge of it. This means that 100 percent of the people in this municipality do not have access to health services. Most homes have no basic services.

The intervention in these two communities in Oaxaca were centered on a participatory appraisal of the current health situation, where the students collaborated with local authorities, the local healthcare jurisdiction, if present, and the local population. The medical students provided free medical consultations in local health centers, with the help and guidance of responsible doctors and nurses. They also distributed medicine for people who had interrupted their treatment due to a lack of resources.

This participatory health appraisal took the social determinants of health into account, in order to create a wider outlook on local health risks. The members of the Aliis Vivere group collected information regarding the population’s access to basic services, such as clean water and health insurance coverage. It also included mental health measures, such as a quick neuropsychological assessment of the geriatric population, in order to recognize a probable cognitive impairment or dementia, and to detect probable depression or anxiety disorders.

The group organized additional activities to promote social and psychological wellbeing, such as health prevention workshops, football matches, and other physical activities, sex education workshops, and activities with children conducted by the participating psychologists. These included the reading of an interactive book with children, in order to process the consequences of the natural disaster they had endured, and activities to recognize and manage different emotions.

 

   Volunteer of Reforma de Pineda.

Rationale

The Sustainable Development Goals established the path for governments to follow all over the world. Some of these goals include ending poverty and ensuring healthy lives, as well as promoting well-being for all, at all ages. Because the social determinants of health have a greater impact on life expectancy than other risk factors, we believe that public health interventions should adopt an all-encompassing, holistic approach to diminish social inequalities and ensure access to health services for all, especially to vulnerable populations.

Objective

Create an organized response from the youth, with the support of academia, promoting a methodological and systematic approach, that allows the realization of an integral health diagnosis of the most vulnerable communities, to design a response to all needs, focusing on the social determinants of health, with shared responsibilities that put each person as the priority for any intervention.

Methodology

Many years ago, universities and young professionals have been part of the incomplete efforts to attack problems that are very big and that require very complex planning, with clear obrjectives, systematized methodology, and result in analysis to generate an impact on the communities, always putting the needs and opinions of the person at the cente.

With the new government that has been creating new opportunities for the articulation of the principal actors of our society, we will bring support with no precedence to the governmental efforts to help improve our country.

The Collective Aliis Vivere, with all our past experiences of the community work that we had gathered in the past years, focuses its main objective in the recuperation of the communities, from a scientific  point of view without leaving apart the cultural, social, and participative role that people must have in order to manage not only the process of illness, but also take part in the wide spectrum of the primary health care as the main point of interest for our interventions.

Methods

Election of the Community

This part of the process is the determinant for identifying the correct implementation, planning, and impact that is expected, and has to obey to the capacity and resources that the collective obtains, as well as the contact with the local authorities and the community itself.

As part of the efforts that have been made by Aliis Vivere group, it has been proposed to the principal of our Faculty of Medicine, Dr. German Fajardo, the implementation of a pilot with communities of the highest grades of vulnerability and margination in Mexico City and the municipalities that are around the city, while ensuring that the project grows progressively to amplify the number of communities in the middle-long term.

The sub secretariat of Integration and development of the Ministry of Health, Dr. Ana Cristina Laurell, in the first six months of her administration, has done a very complete census of the human resources, as well as the need for infrastructure and access to basic services in the eight states of the southeast region of the country, which are the poorest and amplify the project to the universities and communities in this region as one of the main objectives of the project.

The process for the selection of the community has to be done with the permission of the local authorities, to make an agreement and analyze the viability of the proposals, the applicability of the project, and the felt needs of the authorities. Yet, among everything, the obtaining of data needed for the planning of the diagnosis and the posterior interventions, with adequate financial planning are in order to make the group sustainable so that it does not require form any resources from the community,

The establishment of agreements and the setting of responsibilities of the principal stakeholders is a key component before the election of the communities, beacause it is needed to count the warranty of the team that would give the communities security, surveillance, and advisory from the local authorities. In addition, this first contact with them will help to establish a follow up plan and the activities that would be responsibilities and limitations that each group would have.

Preparation of the Team

The first step that has to be accomplished in our proposal is the reunion of a team of students, young professionals, and experienced persons, prepared to interact and the creation of a responsible mechanism that is sustainable that would permeate various generations and can allow follow up the actions to be done.

The project looks forward to organizing with the universities to promote the creation of a community social service program of health professionals, like other scientific professions, both humanitarian and artistic, to promote the multidisciplinary and interprofessional approaches in the communities.

The organization of a team in which health professionals like medical doctors, nurses, psychologists, odontologist, physiotherapist, social workers, and veterinarians, would allow the community to address the process of health-illness and truly promote primary health care, currently the paper that health professionals have in rural communities is very reductionist, because the conditions in which these conditions are set, and in many occasions the only health professional that these communities have is a last year medical student who cannot do preventive actions because of the workload.

However, this interprofessional team would have some technical and knowledge limitations, such as the cultural adaptation, social analysis of the communities, technical design of solution designing to problems like sanitizing, access to electricity, housing improvement, and many others, so that the inclusion of professionals like lawyers, anthropology, sociology, engineers, and architects, are one of the axes of the project.

The attention to the community need could result in a complete challenge, however, with the inclusion of other kinds of professionals, those who have dedicated their lives to the art and humanitairism such as dancers, actors, and painters, can help to inject in the people a different vision, promote the cultural adaptation, significant learning, and create the intentions to create new worlds and change realities.

With all these professionals involved, the universities participation is needed and vital to the project, in order to develop advisory, follow up, and preparation of a group as big as and diverse as the one that is proposed. The collaborative power of this institution would help to draw more volunteers to the project, strengthen academics, as well as the scientific and methodologic base and organizations, to ensure it has what it takes to take us to the next step of our proposal.

Preparation

Once the team who would go to the communities is built, a preparation period exclusively for preparation is indispensable, the topics that have to be included in this stage are:

  • Specific process to develop a health diagnosis;

The elaboration of a health diagnosis with methodological gathering of the data is vital, because from the information of the intervention would be designed as well as the chronology of activities and future planning.

  • Standardization for the database filling and data recollection;

Election of the tools that the team would apply for doing the diagnosis and the interpretation of the databases would be required for conducting a good analysis of the information and measuring the impact of the interventions and adjust the actions.

  • Cultural and language adaptation;

With the selection of the community, the group should take special qualification of the adequacy of the language, study the culture and customs of the selected community with the objective to make the interventions the more friendly to them, and keep the person at the center of any intervention.

  • Pedagogic tools, methodology for teaching;

An essential part of the project is the adaptation of the health promotion elements, however, a deficiency that exists in most of the health sciences programs are the lack of pedagogic elements to deliver a good capacitation that adapts to the resources, academic level, and cultural environment that the communities have.

Delivering a workshop to acquire the tools by the members of the teams will help to make sure that the quality of the interventions really respect people and get its goal.

  • The formation of first aid and disaster and emergency teams.

The preparation of the personnel that would assist in prehospital medicine is crucial, in the case of an emergency people need how to react.

That capacitation for knowing the geographical environment, the regional capacities for response to emergencies, and intentions of critical patients are needed, along with the knowledge of the location of the health care facilities and which services are available in them.

Establish a good program to help the communities to develop their own protocols of response to disasters and the formation of its own emergency teams.

Health Diagnosis

The follow-up of a systematic process for health diagnosis, which is participatory and seeks to gather the necessary data for the design of the intervention should be one of the highest priorities of the initial visits to the community.

Unlike other assistance groups of health professionals, the health diagnosis should function as the starting point for the specific programming and design of the interventions that will be carried out longitudinally and the cut-off points that should be performed.

Design of the Intervention

This step in the project must start after the interpretation of the results obtained in the diagnosis, the topics that should be considered are:

  • Establishment of the essential priorities, based on the opinion gathered from the community and the data obtained in the diagnosis.
  • Does the financial planning to set the resources needed to do the interventions, from transportation of the personnel to technical advisory to material resources, food, et al.
  • Elaboration of indicators for impact measurement.
  • Set the methods for data exchanged between stakeholders.

Intersectorial work

The division of responsibilities of the design of the intervention with the stakeholders that are involved will allow the project to be more efficient and achieve the planned goals in a faster way.

The design of the intervention would also enable the type of tasks that would be assigned to each of the actors the considered depending on its grade of professionalism, economic capacities, and technical expertise, as well as dependability and will to make the improvements needed in the health diagnosis.

Intervention

Undoubtedly, the biggest challenge, will be the implementation of all previous work. Carrying out the different tasks to get the indicators.

The intervention model could vary depending on the outcome of each diagnosis, however the general scheme proposed should include activities that promote primary health care and possible ways to diminish the social determinants of health through the following proposed activities:

  • Health promotion: Through health education, dietary hygiene measures, mental health, and oral health, among others.
  • Dignification of spaces: Attention to the restoration of the infrastructure of health, education, and food establishments, among others.
  • Establishment of a self-sustaining mechanism: Administrative training with local authorities to be able to make health, education, security projects, among others, activities adopted by the people, and regardless of the political mechanism that is carried out in the community, enable the people through the promotion of processes that are maintained.
  • Comprehensive clinical care: Although it is not the main objective of the project, maintaining adequate clinical health care services is necessary, so part of the group should be dedicated on a rotational basis to the care of patients from the point of view of all careers involved.

Monitoring, Analysis of the Results and Readjustment of Interventions

The generation of partial results is very important and the continuous analysis of these will allow for the adjustment of the intervention design, modify the scope of the project, and generate data to begin analyzing the percentage of performance indicators.

In this section of the project, considering the opinion of the community continues as one of the main actions that must be followed, the satisfaction of the team members, as well as the perception of success and recognition of the effort is one of the most complex and important tasks.

Through performance indicators, carrying out a continuum on the design of the intervention is necessary, to ensure that it is a dynamic process that really does allow us to talk about individualized interventions for each population.

Works Cited

1. The Lancet (2005). Social determinants of health inequality. Public Health, 365(9464), pp. 1099-1104. 

2. Coneval (2016). Medición de la pobreza. www.coneval.org.mx/Medicion/Paginas/

3. WHO (2018). Estrategia de Cooperación, Resumen. apps.who.int/iris/bitstream/handle/

Author Bios

Ana Paula Wirth was born and raised in Mexico City. She studied psychology at the National Autonomous University of Mexico (UNAM) and is currently studying a diploma course in “Strategic Management of Human Resources.” Ana is currently an intern at the German Corporation for International Cooperation (GmbH), where she promotes corporate sustainability by working on gender equality and disability inclusion policies, and by planning activities to ensure her co-workers’ health and wellbeing. 

Andrés Quintero Leyra was born and raised in Mexico City. He is in his final year of medical school at the National Autonomous University of Mexico (UNAM) as Medical Passant in the Centre for Research in Politics, Population, and Health at UNAM. Andrés also is a EMT-Paramedic at the Mexican Red Cross and is currently working as the Statal Academic Coordinator for the Capacitation Area in the State of Mexico. He is an active member of the International Federation of Medical Students Associations and the Mexican Association for Medical Doctors in Formation.

Nestor Emmanuel Ramírez Lugo was born in Queretaro in Mexico, he is currently a medical student at the National Autonomous University of Mexico (UNAM). Since 2017, he has served as a social volunteer on earthquake disasters in Mexico City. Nestor is a writer and collaborator of the Gaceta FacMed Journal of Medical Faculty of UNAM. He is interested in social and labor medicine and is a medical scholarship holder for the ADO group. He has been an active member of the Collective Aliis Vivere since its formation.

Jesús Abraham Hernández Cruz was born in Oaxaca and raised in Mexico City; he is currently a student of Psychology in the Metropolitan Autonomous University (UAM). He is also a Medical Doctor Passant in the rural community of Zacazonapan, State of Mexico. Jesús is a founder of the Collective Aliis Vivere and a former student representive for students in the Universitarian Council at the National Autonomous University of Mexico. He currently serves as a columnist at the digital magazine, Opinión Central and authors the column “Homestasis.”

For the purpose of this article, I will assume that we are all working in pursuit of a common goal -- of achieving better health outcomes for populations living in underserved, resource strapped communities in the United States. Within any given community, the families and children that are at the greatest risk for experiencing bad health outcomes are those in the community’s lowest socioeconomic tertile. With this understanding, my article seeks to introduce the concept of a community population health practice system -- to promote improved health outcomes for populations living within all communities -- regardless of geographic location. 

The reality before us is that our federal, state, and local public health practice system infrastructure lacks the capacity to carry out community level needs assessment surveillance. In addition, there is little or no allowance for supporting community level capacity building to facilitate a process for communities to do it themselves. Philanthropy and other non-governmental organizations (NGO) have, for decades, assumed the role of promoting community level capacity building and supporting initiatives designed to promote good health and well-being outcomes for populations residing in poor communities.

This situation has created the belief that a myriad of collective, collaborative partnership efforts are needed in order for us to achieve better health outcomes for populations residing in these communities. Many collaborative partnerships between, and among, funding agents, between population health care systems, and other nonpublic systems operating within the community do exist but their impact is rarely sustainable .

The 2018 United Nations Human Development Index (HDI) ranked the U.S. 13th down from 8th in 2006. Internationally, the infant mortality rate (IMR) is the indicator most often used as a measure of a country’s ability to take care of the health and social needs of its poor and indigent populations. The last UN report on IMR placed the U.S. in 30th place, down from 12th in 1960, 23rd in the 1980’s, and 28th in 2003. Within the U.S., IMR and MMR vary between and within states. Thus, in terms of population health index indicators the U.S. is not doing as well as other developed countries in taking care of its poor populations. The variance of rates across and within states indicates that the benefits to be derived from our public health practice systems are inequitably distributed across and within states. A common denominator within all states is that populations living in the poorer communities have the worst outcomes. Within the populations of poor communities, families and children living in poorer communities experience the worst outcomes.

The challenge we face as public health practitioners is the fact that despite decades of countless best practice initiatives and decades of extensive financial investments in community capacity building initiatives, we have not been able to achieve improved health outcomes for populations of families and children living within resource strapped communities. In terms of reversing this trend, we must re-examine our continued practice of adopting innovative approaches that often end up being a new way of doing the same old thing. Achieving the same output, of use by year expiration date best model practice -- and the same outcome, of no improvement in the fate of families and children living in poor communities, is not helping our communities to move forward. 

This article is a call for us to begin to put our collective ideas and thoughts together in creating a community population health practice system (CPHPS) operating in parallel, and in harmony with our existing clinical practice and public health practice systems. Like our existing public health practice system, it will have its three core functions for protecting and promoting community population health. These core functions are: 1) to promote communities’ needs assessment capacity building; 2) to facilitate communities’ participation in the public health practice decision-making process; and 3) to promote workforce training capacity building based on community assessed challenges, needs, and opportunities for promoting success through maximizing the use of available local resources. 

In an effort to demonstrate the potential value of a CPHPS to our existing public health practice system, I will present two examples where it would have enhanced opportunities for success. First, a state-based maternal and child (MCH) effort to improve health outcomes for mothers living in poor communities. Second, the groundbreaking, single largest philanthropic nationwide community public health practice development initiative launched in the U.S. Both represent public health practice work efforts designed to promote good health and well-being outcomes for populations residing in poor communities.  

In relation to my MCH work experience, the maternal and infant mortality rates (MMR & IMR) in the state where I served as a CDC Preventive Medicine Fellow in 1993 were among the highest in the nation. Upon review, there was a noticeable inverse relationship between under-utilization of the state’s public heath prenatal prevention care (PNC) services and the occurrence of high MMR and IMR. Communities with the lowest participation rates experienced the highest MMR. In the communities with high MMR, the PNC utilization rate was typically 20 percent below the national rate. Based on these findings a state mandated MCH goal was to improve the PNC utilization rate by 20 percent in these communities. 

The first challenge to this state mandated public health practice goal stemmed from the fact that a previous MCH department effort to improve PNC service participation by residents in poorer communities had met with no success. The policy adopted doubled the fleet of PNC buses available to transport mothers from these communities to PNC services. This policy originated from a study of the state pregnancy risk assessment monitoring system (PRAMS) data. The research findings indicated transportation was the main category mothers selected as their reason for not participating in state provided PNC prevention services. 

A review of the answers per selection category of the answers to the PRAMS data set regarding reasons for not participating in early PNC utilization revealed that the category choice of “other” received the highest percentage of responses -- getting almost twice as many responses as the category for transportation. This is an indication that there is a reason beyond what the answer choices offered. Further review of actual handwritten notes attached to the “other” category, revealed the following recorded comments:

  • The bus came at a time when mothers were occupied with getting their children off to school. Thus, they couldn’t use the bus and had no other means of transport;
  • Agency policy did not allow mothers to be accompanied by a child; given their inability to afford day care, these mothers had to pass up on the bus offer;
  • All buses had big red signs on the side that read “MEDICAID BUS,” community members referred to the bus as “the free bus” for poor people.  

In reality, the outcome of this effort is not a matter of poor compliance on the part of the community mothers but rather the failure of the policymakers and the MCH department to generate appropriate intervention policy programs and services to address the challenges residents living in poor communities face in participating in available state health promotion services. While the challenges were many, the required solution was an adjustment in the existing bus service utilization policy and not further financing for an expanded version of the same approach. 

A CPHPS practice with its three proposed core functions and its community participatory focus will possess the ability to promote capacity building for the state public health practice system and promote community awareness capacity building. For public health practice, it will provide state and local public health officials with the ability to understand community challenges to success to better generate policy, programs, and services to address the needs for residents living in the community. For community residents it will provide them with the ability to better participate in existing health promotion and sickness prevention efforts operating within the community. For public health research, it will remove the need for the category “other” in community needs assessment research. 

The 1996, “Turning Point (TP): Collaborating for a New Century in Public Health Initiative,” implemented in 14 states and 41 communities across the U.S. was a national community, public health capacity building initiative jointly funded by the W.K. Kellogg Foundation (WKKF) and The Robert Wood Johnson Foundation (RWJF). Its approach to achieving success was through promoting public health capacity building within communities. This capacity building would provide existing public health practice systems with the ability to develop and implement intervention policies, programs, and services that address the needs of the community’s populations.  

The projects’ two funded agents, an RWJF funded tertiary institution of learning and an organization representing local city and county health officials, funded by WWKF, were tasked with the responsibility of developing innovative strategies for collaborating and seeking opportunities to transform and strengthen public and community health practice through partnership development. An expected output was that through this array of collaborative partnership building the public health practice systems would be brought in contact with the communities they serve. 

The focus of promoting community public heath capacity building gave community residents some understanding concerning the technical aspects of how public health practice works in protecting the community from health threats and in promoting good health outcomes for the families and children living with the community. The 41 participating communities were tasked with the responsibility of carrying out comprehensive assessments of existing public health systems and to produce their own community public health systems improvement plans for implementation. My public health practice work was carried out with these 41 community units. 

Although it achieved many successes, the “Turning Point: Collaborating for a New Century in Public Health” was unable to meet its goal of providing our existing public health practice systems with the ability to promote better health outcomes for populations residing in poor resource trapped communities. The first major barrier to success was that the 41 communities were ill prepared for participating in a project of this technical magnitude. The lack of community organization capacity hindered the communities and their residents’ ability to participate in and benefit from any additional resources the presence of the project provided. 

Second, the two funded agents independently and collectively lacked or failed to show sufficient technical expertise and lacked the administrative infrastructure capacity necessary to generate innovative strategies for collaborating between themselves or with the state and local public health practice system. The organizational infrastructure of the association of local city and county health officials did not have the necessary capacity to facilitate public health practice learning or skills building training opportunities within the communities. 

The net impact of this deficiency was that once the RWJF and WWKF funding ended the partnerships between association and the 41 participating communities immediately collapsed -- and many of the auxiliary partnerships that were generated through the project faded away. In the face of the collapse of this partnership infrastructure support, and in the face of the existing lack of asset building, the communities were unable to sustain achievements gained.  

Over the last two decades, I have successfully applied adaptations of this “Turning Point” community public health capacity building concept model in my work as Chief Medical Officer (CMO) and director of health care services working within the British health care provision system and as a public health consultant working within the Tribal health care system. Dr. Goldman has, for the better part of the last two decades, worked on researching the costs and cost-effectiveness of public health prevention programs at the community level to prevent neglected tropical diseases and to achieve good dental outcomes for children living in poor underserved regions.

In our collective opinion applying the “Turning Point” community public health capacity building model within an institutionalized community population health practice system, with its three core functions -- is the solution to ensuring lasting improved health outcomes for populations residing in poor resource strapped communities’ -- now and for generations to come. 

Elderly care is no longer just a first world burden. The need for geriatric care excellence and services is growing every day. With the improvement and accessibility of medical services, and with the improvement of health states and increased life expectancy every day, this renders our elderly community a growing cohort in need of specialized care.

The era we are living in is becoming more and more dependent on accessibility and the value of time is increasing by the minute. Many pre-existing beliefs are being tested at the moment. It is hard to wrap your head around the development of television being the most popular distraction over the past 30 years and that now it is a dying luxury and totally replaced by on demand video streaming. The essence behind this is the developing human nature that has become all of a sudden "impatient" and needs instant gratification.

The value of time has also changed over the years. Long ago when man had to hunt for food, hunting came with its own recipe for patience. The more time moved on, the less patient we became. The expectations for achievement over one given unit of time has also grown consistently over time. Time to visit relatives was exchanged for long phone calls to pre-written texts. Time is becoming more and more valuable. The rising value of time had its impact on the general pace of life and on the approved sector of the day for organizational matters.

Although health is a priority and represents the biggest fear on the personal and population level, yet the amazing fact is that most health-related complications are caused by a delay in seeking help. This fact is strange in relation to the importance of the issue. In an attempt to justify this finding, I conducted a number of interviews with elderly people in the course of a study that was related to elderly suicide rates and underlying factors. The scope of the interview was to understand how much they value the determinants of the quality of their own lives. One of the rubrics used to measure the value of health was the delay time from the beginning of a symptom until professional help was sought. The mean time reported for this was 3.2 days which is a very high number when compared to critical times like the window between embolism and brain atrophy could be as short as 30 minutes.

Although determinants of health and a healthy life per the WHO are many and include overt factors like proper housing and prevalence of health-related habits, one of the important determinants is personal attitude towards symptoms. In Egypt we joke about being the country with 100 million physicians, not because this is an exaggeration of fact but because people take pride in "not needing" professional health advice. Everyone who has ever been prescribed an antibiotic once in their lives, has informally received a certification to consult and give "better than expert" advice. Although it is hard to assess the actual price of informal practices like these, it does not require a postgraduate degree to pick up on the threat of delays in seeking medical advice. The cost of care for complications in many health conditions has been studied and varies from condition to condition but the bottom line is that complications cost the health system a considerable amount of expenditure that can be saved and redirected to acute care or even to prevention.

 

In response to the general global culture of accessibility, health professionals and drivers of change in health care have to open their senses to new UBER reforms that change paradigms and the lens through which we define scopes of service. In one lifetime we moved from paper journals that we ordered and had to wait two weeks for, to the need for 5G speeds to download and upload effectively over the internet because dial in internet is no longer serving the need to be constantly connected. Reform in health care on the other hand is not moving at the same pace. Health care AI interventions have been designed around aid missions for the past 100 years with no real change in the structure other than the travel plans.

This has become rather strange and to be upfront about it reveals how deeply drowned we are as health professionals in our own "right answer" that we are not really open to innovation.

Let's be open 

Reality is that we need to take care of people who cannot take care of themselves. We need to make sure people are safe and that they are receiving "approved" services. In an attempt to structure accessibility of health and find a seat for university-based vocational training in the informal community-based services that are already in play, came the idea of GranCare.

  

Prof. Hala Sweed Director ASU- Geriatric Hospital

GranCare is an application that allows caregivers to sign up and upload their training certificates onto a portal where the universities authorize them as licensed home care givers. Licensing is equivalent to a predefined number of training hours and face to face consultation that they have performed. When authorized, the caregivers become "licensed" to offer home care for elderly patients who are suffering from conditions that do not necessitate hospital transfer. Training includes the capacity to identify referable symptoms, offer primary non-invasive health services and offer nursing consultations and capacity to communicate effectively with the local hospital for better health advice. Prof. Hala Sweed, Chair of the Geriatric Department and the New Geriatric Hospital in Ain Shams University Faculty of Medicine, with her ongoing project for caregiver training and certification advocated for this initiative and adopted it as her upcoming community-oriented challenge. At the moment as a part of her FAIMER Regional Institute project, she is working on developing a certification program for caregivers and a whole system of licensing and re-licensing.

An additional component is that there will be an in-house regulating system for security related approvals and follow up. This will reduce the numbers of crimes committed against elderly from caregivers who have not had a security check and who feel they are not monitored.

 

Imagine an app on your phone where you "order" a caregiver to come check on your mother's urinary catheter and maybe empty it and change her intravenous line. Once you start ordering it locates you, identifies certified caregivers who are in your area and their time of availability. You can see their reviews and how many patients they attended to. You can see the last time they renewed their licensing and which university endorsed them. You can see their area of excellence. Now you can decide and book. Your community caregiver is now assigned to you through the service provider (GranCare) and in turn his/her services are liable to feedback, complaints, escalation, and praise on the other side of the spectrum. Eng. Ayman Farouk, IT expert, consultant, and Development Director at SEE, describes the innovative approach above and offers an in-depth vision regarding the utility of Blockchain in the initiative.

Eng. Ayman Farouk MSc. Cloud solutions

Director Technology and Development SE Egypt

Blockchain as a technology can be used to ensure quality of product delivered through ensuring the quality of the chain of steps of manufacture, delivery, etc. When it used to build a secured automated market it provides services or products with a validated certificate of origin and quality of production through multilayer authorization.

The value of blockchain technology as a standardized authorization chain of process will lay the foundation of our solution. This is with reference to the similarity between production lines that produce an end product and the service that should be offered through our caregivers. In order to offer the best available service the following steps have to be ensured:

  • Proper choice of candidate for service delivery (permission to join)
  • Proper training
  • Certification and authorization to provide the service 
  • Security check for candidates
  • Records for time of availability and area of potential service 
  • Smart contracting for service delivery
  • Follow up procedure for service
  • Quality control procedures
  • Improvement of service 

This will limit third party beneficiaries in the middle of the two spectra of service. It will minimize unnecessary visits to the ER and outpatient clinics. It will limit the undesired effects of mobilizing elderly patients and faulty transfer. It will limit the need for existing on the streets during rush hours and office hours. This is in addition to the anticipated reduction in undesired health outcomes and complications and their attributed costs.

Now universities can finally find a community role that goes beyond the annual aid mission that is dispatched to the nearest rural area and is documented and shoved into a file for quality purposed and proof of adherence to our mission.

For funding purposes to implement this initiative we have enlisted the Gates Foundation through endorsement of the program The Middle East North Africa FAIMER Regional Institute. With expertise in KPI delivery and project advisors’ capacity in the area of ITC (Information Technology, and Communication), together with the appropriate funding we believe that GranCare can actually change the world of health care as we know it.

Learn more about ASUMENAFRI? here 

 

Meeting with the community Health volunteers to discuss malnutrition among other community health problems.
Photo credit: Stephen Odiwuor

Problem Statement

Malnutrition is one of the major public health issues of importance among developing countries. According to Faye O., et al (2012), malnutrition and childhood morbidity contribute a lot to child mortality and disability adjusted life years. The Global Nutrition Report, (2016), also cited that out of 667 million children under age five worldwide, 159 million under age five are too short for their age (stunted), 50 million do not weigh enough for their height(wasted), and 41 million are overweight. In Kenya, one-third of children under-five are stunted, one in six children is underweight or too thin for their age, more than seven million children who are under five years die each year from treatable and preventable conditions. Pneumonia, malaria, and diarrhea remain the leading causes of child mortality and under nutrition contributes to more than one third of all deaths (maternal and child health Kenya, 2012).

In order to meet the global nutrition targets of cutting the number of stunted children by 40 percent by 2025, reducing and maintaining child wasting by five percent by 2025, and no increase in childhood obesity by 2025, it is therefore important to involve early childhood development education and daycare centers in fighting malnutrition.

Current Approaches Being Used to Screen for Malnutrition 

A systematic review study by Bliss J. et al (2018) summarized published and operational evidence since the year 2000 describing the use of mid upper arm circumference (MUAC) for detection and diagnosis of severe acute malnutrition (SAM) in children aged  six to 59 months by caregivers and community health volunteers outside of formal health care settings. In their findings, the screening for SAM had only been done by Community Health Volunteers (CHV), and mothers/caregivers outside of formal healthcare settings. I did not find evidence of the involvement of early childhood development education center and daycare center teachers in the screening for SAM. The study emphasis was on the scalability of the use of MUAC among households. Blackwell, et al (2015), highlights the use of MUAC tapes among mothers and community health workers in Niger. Grant et al, (2018) also describes the use of MUAC tapes among mothers in Kenya. Several other organizations such as ALIMA, Medicines San Frontieres, World Vision, Valid international, and the International Red Cross among others are also in the process of adopting family MUAC (“Mother MUAC”). However, none of these initiatives involved the Early Childhood Development (ECD) education center and daycare center teachers.

Methodology

The ECD center program gives a different approach to the screening and prevention of SAM. The approach focuses on increasing the number of children who would be screened for SAM using one MUAC tape. The “mother MUAC” model approach only focuses on one MUAC tape per household, however, the ECD center model focuses on one MUAC tape for all the children enrolled in an ECD education center or daycare center. As opposed to training individual mothers on how to use MUAC, The ECD center approach focuses on training the ECD center teachers and daycare teachers on MUAC measurements, which is more sustainable than training individual mothers in developing countries. 

The screening for SAM using MUAC would be done by the ECD education and daycare center caregivers after being trained. This would enable outreach to many children in one setting.

Impact Measurement and Monitoring

The impact will be measured by analyzing the data in the data entry book. The ECD centers will have a data entry book where they will be recording the names of the children, age of the children in months, date screened using MUAC tape, and the MUAC tape measurements for each child. They will screen the children every month or after every 12 weeks. They will also indicate whether the child has been referred to the nearest health facility for further management or not. The data will be analyzed and used to make informed decisions. The teachers will also give reports to the health facilities.

Scalability

The ECD center malnutrition approach is applicable to any country having ECD education and daycare centers. It can be adopted and used in an entire country. Data from the ECD centers can also be used to influence policies.

Works Cited

Faye O, Islamb N, Essendic H, et al. Dynamic modeling of child malnutrition and morbidity: Evidence from Nairobi’s slums. July 2012

Global nutrition report. 2016. From promise to action. Accessed on July 6, 2019. Accessed on 8 July 2018. ebrary.ifpri.org/utils/getfile/collection/

Maternal and child health Kenya. 2012. Accessed on 8 July 2018. https://www.who.int/pmnch/media/

Bliss J, Lelijveld N, Briend A, et al. Use of mid-upper arm circumference by novel community platforms to detect, diagnose, and treat severe acute malnutrition in children: a systematic review. Glob Health Sci Pract. 2018;6(3):552-564. https://doi.org/10.9745/GHSP-D-18-00105

Blackwell N, Myatt M, Allafort-Duverger T, Balogoun A, Ibrahim A, Briend A. Mothers Understand And Can do it (MUAC): a comparison of mothers and community health workers determining mid-upper arm circumference in 103 children aged from 6 months to 5 years. Arch Public Health. 2015;73(1):26. 10.1186/s13690-015-0074-z.

Grant A, Njiru J, Okoth E, et al. Comparing performance of mothers using simplified mid-upper arm circumference (MUAC) classification devices with an improved MUAC insertion tape in Isiolo County, Kenya. Arch Public Health. 2018; 76:11. 10.1186/s13690-018-0260-x. 

Author bio

Author Bio

Stephen Odiwuor is a 24-year-old, final year student at the Jomo Kenyatta University of Agriculture and Technology (JKUAT), pursuing dual bachelor’s degrees in medicine and surgery (MBChB/MBBS). In 2018, Stephen won the Global Youth Ambassador Hero of the year award in the early childhood development category organized by theirworld.org. He is also a winner of the International 2019 Students Project for Health Competition (SPFH). Stephen is a proud co-founder of the Jomo Kenyatta University Medical Students Association (JKUSMA) and served as the organizing secretary of JKUSMA and as a member of the secretariat for the Jomo Kenyatta University Student Association (JKUSA). Stephen currently is Kenya National president for the Student Network Organization.

 

By Fitriana1, ABT Randita2, Dr. Kambey3, and AS Lestari4

1Community and Family Medicine Department Faculty of Medicine, Public Health and Nursing Universitas GadjahMada, Indonesia, This email address is being protected from spambots. You need JavaScript enabled to view it.
2Medical Education Department, Faculty of Medicine Universitas Sebelas Maret, Indonesia
3Department of International Cooperation for Medical Education, School of International Health, The University of Tokyo, Japan
4Depati Hamzah General Hospital, Pangkalpinang, Bangka Belitung Indonesia

Summary

The older population is increasing in developed and developing countries. The growing elderly population will produce positive and negative effects. High elderly populations will be a national burden if the elderly suffer with health problems. The aging population has high demands of comprehensive care. Effective team-based health care through inter-professional collaboration among health care providers is important to face the complexity of health problems in the elderly to improve the quality of care and patient outcomes. Interprofessional collaborative practices should be initiated in undergraduate phases through Interprofessional Education (IPE). This study uses a qualitative approach to explore the effectiveness of IPE in geriatric care through a short course of IPE program. The study shows that there were several advantages of the course of IPE learning in geriatric care from students’ perspectives. The students were able to demonstrate collaboration in assessment, planning, and intervention for improving elderly health. The students can improve their communication skills among health care students from other professions. However, there were challenges of IPE implementation in geriatric care.

Background

Over the time, composition of the elderly population is increasing in developed and developing countries due to decreasing fertility and mortality and higher life expectancy, which changes the structure of the population (Kementerian Kesehatan Republik Indonesia, 2017). Worldwide, the population of elderly people reached 962 milion in 2017, that is more than twice as large as 382 milion in 1980. The number of older people is expected to reach 2,1 billion in 2050 which indicate that there will be more older people than adolescents and youth (Department of Economic and Social Affairs United Nation, 2017). In Indonesia, the population of the elderly in 2017 is 9.03 percent of the whole population and by 2020 it is predicted at more than 27 million. This situation shows that Indonesia is one of the country’s with an aging population (Kementerian Kesehatan Republik Indonesia, 2017).

Yogyakarta is one of the provinces in Indonesia with the highest number of elderly people. The high number of the elderly population in the future will produce positive and negative effects. The positive impact will be in the health condition, activity, and productivity of the elderly. High elderly population will become a national burden if elderly suffer from health problems that will cause increasing health costs, decreasing productivity, and increasing disability (Kementerian Kesehatan Republik Indonesia, 2017). The elderly will suffer with physiological changes due to aging in all organ systems (Aalami et al.,  2003). The psychological changes also will occur in the elderly (American Psychological Association, 2016). Maintaining health in the aging population is importance to the well being of individuals and helping to reduce the burden of medical services (Nigam et al. 2012). 

The aging population also has high demand of comprehensive care (Tsakitzidis et al., 2016). Effective team-based health care through inter-professional collaboration among health care providers is important to face the complexity of health problems in the elderly to improve their quality of care and patient outcomes. Interprofessional collaborative practice (IPCP) is a valuable service priority in health care service. World Health Organization (WHO) defines collaborative practice as different health professionals who work together when delivering services.

The IPCP should be initiated in undergraduate phases through interprofessional education (IPE) to prepare healthcare providers who are knowledgeable and skillful in providing and demonstrating health care collaboration especially in elderly care. The Institute of Medicine (IOM) has issued guidance that all health care student education should focus on patient-centered care (Institute of Medicine, 2001). This study aims to explore the effectiveness of IPE programs in geriatric care.

Methods

This program is short course or elective program by registration that will be implemented in a geriatric ward for a week. The learning methods were developed through case-based group discussion and bed side teaching. The participants performed comprehensive assessments, sharing of data, formulated diagnosis, development of holistic care plans, and implementation through an interprofessional team.

By the end of this program, healthcare students are expected to:

  1. Perform a holistic elderly care assessment (involves history taking, physical examination, and other procedures if needed), plan, and intervention with interprofessional collaborative practice approach
  2. Understand their own and other professionals’ roles and responsibilities within an interprofessional health care team.

Based on the four interprofessional education collaborative practices, students’ targeted interprofessional competencies are:

  1. Respect the dignity and privacy of patients.
  2. Respect unique cultures, values, roles/responsibilities, and expertises.
  3. Engage diverse healthcare professionals.
  4. Explain the roles and responsibilities.
  5. Choose effective communication tools and techniques.
  6. Communicate in understandable words.
  7. Communicate the importance of teamwork.
  8. Shared accountability to other professionals.
  9. Show effective teamwork.

The participants of this program are 120 students from three study programs which include medicine, nursing, and health nutrition. The students divided into interprofessional teams which consisted of a minimum of two students from each study program. The number of participants of this study were 120 students.

At the end of this program, students assessed through qualitative approach and used self-reflection about the course of IPE in geriatric care. Research teams conducted in-depth interviews to explore students’ experience of interprofessional practice in geriatric care (Table 1). The informed consent obtained with the study participants. Data and identity of each participants was kept confidential.

Table 1. Questionnaire Prompts

 

Prompts

Self-Assessment

What were your details activities during course of IPE in geriatric care?
Do you think your activity can increase elderly health quality?
What lessons were obtained from the activities?
Did the activities increase your knowledge, communication and behaviour?
What obstacles were encountered in the activity?

 

Comment about Course of IPE in Geriatric Care

What is your opinion about course of IPE in geriatric care?
Are course of IPE in geriatric care activities interesting?
Can course of IPE in geriatric care activities increase students' knowledge, communication, and behavior?
Please give suggestions for course of IPE in geriatric care

Qualitative data from in-depth interviews will be recorded, transcribed, and re-checked. Inductive content analysis will be performed to identify the theme in the data. Research teams will apply a thematic analysis focused on identification of the theme using coding processes from description to interpretation. Thematic analysis will be conducted in small samples to appropriately identify, analyze, and report patterns within the data. Research teams will review the coding and assign keywords and phrases to data segments. Inductive processing will make the research team familiar with the data and better understand the experience. Comparison methods used to compare new codes with the previous ones will be used to consider conceptual similarities and differences. The research team will meet and compare the results of their analysis. The few differences will be identified and resolved through discussion to reach agreement. The final codes, categories emerged from the analysis and relationship among the categories, will be examined to generate themes (Holmes et al., 2018).

Result

Three main themes presented were identified from qualitative data analysis. Namely “IPE advantages,” “IPE challenges,” and “Suggestions for IPE in Geriatric Care Course.” Each theme has various codes that represent the respondents’ answers to the questions listed in the research instrument.

Some students pointed out that IPE learning has benefits. First, their geriatric ward visit activities would enable them to recognize various problems occurring in geriatric health based on their comprehensive assessment. Thus, they could take advantage of this situation to think about collaborative strategies to improve care for geriatric patients.

IPE learning also is seen as a beneficial activity for students. Many students reflected about the advantages of being involved in IPE learning, and this included enhancement of their communication skills. A course on IPE in geriatric care activities enabled the students to better communicate among health care students from other professions. Students also reported that they were able to increase their knowledge and behavior, which will be useful in improving their competencies. They also were able to perform holistic assessment, planning, and collaborative intervention in geriatric care.

There were some challenges in IPE learning described by the students. The challenges included overlapping of roles and responsibility especially among medical and nursing students in some cases. The student also reported that there were barriers among health care students and elderly patients in communication. 

Discussion

This qualitative study explored students’ perspectives, focusing on their perceptions of IPE learning. From the analysis of the interviews with respondents, results suggest that students positively perceive their IPE learning as it has many benefits for both students and the patients. Perceptions were also associated with challenges which must be considered.

In the IPE course, students were placed in a circumstance where they worked together as a team. This situation led to enhancement of students’ understanding about interprofessional teamwork and respect for other professions. They realized that effective communication is required to promote the health quality. Students should train more as a team because it gives them a better appreciation of other professions and shows them how to have effective communication (Keller et al., 2013; Tsang et al., 2016).

Although there are many benefits to IPE, comments from students provide evidence that one of the significant challenges is about overlapping role and someimes difficulty in communication with the patients. The other study from the Norwegian Health Care challenges of IPE implementation such as lack of collaboration between patient and providers. The different perspective about patient problems and lack of good communication also becomes a challenge in implementation of IPE (Steihaug, Johannessen, Ådnanes, & Paulsen, 2016).

Conclusion

In conclusion, this study indicates several advantages of the course of IPE learning in geriatric care from students’ perspectives. Our findings show that the course of IPE in geriatric care as a learning method of IPE makes students better able to demonstrate collaboration in assessment, planning, and intervention for improving elderly health. The students also can improve their communication skills among healthcare students from other profession. However there were challenges of IPE implementation such as overlapping roles and difficulity communicating with elderly patients. 

Works Cited

American Psychological Association. 2016. Psychology and Aging. Washington: The Retirement Research Foundation American Psychological Association

American Psychological Association. 2017. Older Adults’ Health and Age-Related Changes. Washington: American Psychological Association

Interprofessional Education Collaborative Expert Panel. 2011. Core Competencies for Interprofessional Collaborative Practice. Washington DC: Interprofessional Education Collaborative.

Keller, K. B., Eggenberger, T. L., Belkowitz, J., Sarsekeyeva, M., Zito, A. R., Lynn, C. E., … Raton, B. (2013). Implementing successful interprofessional communication opportunities in health care education : a qualitative analysis. International Journal of Medical Education, 4, 253–259. doi.org/10.5116/ijme.5290.bca6

Nigam, Yamni, John Knight, Sharmila Bhattacharya, and Antony Bayer. 2012. “Physiological Changes Associated with Aging and Immobility” 2012 (ii): 2012–14. doi:10.1155/2012/468469.

Tsakitzidis, Giannoula, Olaf Timmermans, Nadine Callewaert, and Veronique Verhoeven. 2017. “Outcome Indicators on Interprofessional Collaboration Interventions for Elderly” 16 (2): 1–17.

Tsang, E. S., Cheung, C. C., Sakakibara, T., Tsang, E. S., Cheung, C. C., & Sakakibara, T. (2016). Perceptions of interprofessionalism in health professional students participating in a novel community service initiative, 1820(June). doi.org/10.3109/13561820.2015.1055717

Author Bios

Dr. Daniel Richard Kambey is a 34-year-old Scotland trained university lecturer and educational consultant from Indonesia. He is currently a research student in Japan and has four years of experience as a university lecturer, three years as a health education professional consultant, and extensive experience as a trainer for all age ranges. 

 

FITRIANA, MD, M.Sc.FM is  a family physician, researcher, lecturer, and an executive manager from the Faculty of Medicine, Public Health, and Nursing at the Universitas Gadjah Mada (FMPHN UGM). She serves as the head of  curriculum development of Interprofessional Education (IPE) for the Academic Health System. Fitriana's field of speciality is Community Health with a focus in Prevention and Management of Metabolic Disease, Gerontology, InterProfessional Education, Interprofessional Collaboration Practice, Biopsychosocial, Family Health, Pediatric Health, Maternal Health, and the Obstetric Community. Her work involves curing patients, preventing community health problem, research, executing community development projects, and communicating with stakeholders in Yogyakarta Indonesia. Fitriana also is the recent Montegut Scholarship Awardee for WONCA Kyoto Japan 2019. 

 

Amandha Boy Timor Randita, MD, M.Med.Ed is a lecturer from the Faculty of Medicine Universitas Sebelas Maret (FM UNS) and head of curriculum development of the School of Medicine. He graduated as medical doctor from FM UNS in 2012 and received his master's degree in medical education from the Faculty of Medicine Universitas Gadjah Mada in 2016. Amandha is interested in medical education such as curriculum development, Interprofessional Education (IPE), clinical teaching, and community-based education. He is actively researching and published in national and international publications.  

 

Ayuningtyas Satya Lestari, BSN, RN is a pediatric and neonatal nurse pracitioner in Depati Hamzah General Hospital Pangkalpinang. She also serves as a team member in the integration of academic institutions and the teaching hospital. She graduated from the School of Nursing Faculty of Medicine, Public Health, and Nursing Universitas Gadjah Mada. Ayuningtyas is a researcher of Interprofessional Education (IPE), interprofessional collaboration, and nursing management improvement.  

Introduction

The Affordable Care Act (ACA) of 2010 requires non-profit hospitals to conduct a Community Health Needs Assessment (CHNA) to identify health issues in its service area and adopt an implementation plan at least every three years. Under Internal Revenue Service rules,1 a charitable hospital may gather input from persons who represent the broad interests of the community it serves through meetings, focus groups, interviews, surveys, and/or written comments. Hospitals are expected to assemble sufficient information on the medically underserved, low-income, or minority populations to identify and prioritize health needs and develop a strategy to improve the health of these groups in their communities. Hospitals are free to decide how to collect data given their financial and technical support resources. 

When conducting its CHNA, a hospital may collaborate with other charitable, for profit, or government hospitals and state and local public health departments. In 2012, the health department and three medical centers serving 45,000 residents in rural Polk County, Wisconsin conducted a community health needs assessment. It engaged more than 1,800 county residents through coordinated surveys and community forums.2 Studies have found that when hospitals collaborated with the local health department, their CHNAs were of higher quality, scarce resources could be more effectively and efficiently deployed, and common goals helped achieve positive population health outcomes3,4,5 In addition, it is important to include community members in the CHNA process to identify health needs of groups experiencing health disparities.4,6 

In 2013, Wake County, North Carolina, with its mix of large cities (Raleigh, Cary), and rural small towns, employed cluster sampling of census blocks to generate 35 face-to-face interviews in each of the county’s eight health zones, for an anticipated total of 280 interviews. One limitation was that households selected have an unequal probability of selection, and the analysis included a mathematical weight for probability of selection to reduce bias.7 In 2016, the county collected data through focus groups, telephone, and internet-based community and key leader surveys.8

Thumb Rural Health Network

The Thumb Rural Health Network (TRHN) includes eight community hospitals and three county health departments in Michigan’s “Thumb.” The Thumb refers to the three counties that extend up between Lake Huron on the east and Saginaw Bay on the West, approximately 100 miles or 161 kilometers due north of Detroit which form the thumb of the mitten-shaped Lower Peninsula (Figure 1).  

Figure 1 Thumb Regional Counties Map

TRHN was formed in 2003 and incorporated as a non-profit in 2007 to address the highest priority health care needs of Michigan’s Sanilac, Huron, and Tuscola Counties through collaborative projects. It focuses on access to health care for underserved populations, improving community health status, educational opportunities, and leadership development. Each hospital pursues its community-based mission through meaningful relationships and collaborations with other community organizations.  The estimated population of the three rural counties in July 2016 was Huron 31,481, Sanilac 41,409, and Tuscola 53,338 for a total of 126,228.  

In August 2015, the Michigan Center for Rural Health, the Hospital Council of East Central Michigan, and TRHN convened a group of TRHN members and three consultants to identify and use common data collection instruments and methodologies for each hospital’s 2016 CHNA. The group agreed to adapt and administer the University of North Dakota’s Center for Rural Health’s community survey instrument, and focus group and stakeholder interview questions. 9,10  The Center had conducted CHNAs for 21 critical access hospitals in rural communities in North Dakota utilizing a mixed methods design involving surveys, focus groups, and stakeholder interviews.

Each of the eight thumb area hospitals received the results from survey respondents in its service area as defined by zip codes, the focus group held at the hospital, and their county stakeholder interviews. The findings enabled each hospital to identify health needs, establish priorities, and create a plan to address those needs for its service area. Since each Thumb area hospital used the same survey instrument, it was possible to aggregate, analyze, and report the data by county and the tri-county region which generated reports that could facilitate countywide and regional collaboration for improving health care and delivery.

Methods

The mixed methods consisted of a community health needs assessment survey, focus group meetings, and stakeholder interviews conducted from January through December 2016. The focus groups and key stakeholder interviews were used to corroborate and enrich the survey findings. 

Survey Questionnaire

The gold standard for surveys is the random sample in which each individual is chosen entirely by chance and each member of the population has an equal chance of being included in the sample. However, limited budgets preclude most rural hospitals from conducting a random sample survey. When data is difficult to collect, an exploratory survey using mixed methods can identify health issues and improve healthcare delivery.11 The task is to collect and analyze data from respondents that can be statistically inferred to a defined population.  

The Thumb Area CHNA survey employed a non-probability purposive and convenience sampling design.  In a purposive sample, respondents are recruited based on some characteristic that will be useful for a CHNA, for example, seniors residing in independent or assisted living facilities as well as patients, clients, and employees at health care and social service facilities. Convenience sample respondents can be anyone who has access to the survey such as people in a mall, friends and family of volunteers who distribute the survey, or individuals who access the survey online. If the mixed sampling design results in a reasonable number of low-income, low-education, and senior citizen respondents, this permits an analysis of their health concerns and views on health care services. 

The Thumb Area survey asked respondents about their community’s quality of life, the availability and delivery of health services, barriers to care, and concerns about the health of adults, youth, and seniors. Demographic information included gender, educational attainment, income, age, employment status, residential ZIP code, primary health insurance, race/ ethnicity, marital status, and whether currently employed by a hospital, clinic, or health department.  

Adjustments were made to align the proportion of low-income, low-education, and senior citizen respondents with county level demographics available from the Census Bureau’s American Community Survey (ACS).12 Each year the ACS contacts more than 3.5 million households across the county, including about 4,800 in Michigan. The use of the hospital surveys, focus groups and stakeholder interviews, and ACS data was exempted by the Michigan State University Institutional Review Board.

Each hospital distributed surveys to business and community venues in their service area. Community organizations that were familiar with the health care system and/or vulnerable populations also received surveys to distribute. Respondents could leave printed surveys at central collection boxes or mail them in business-reply prepaid envelopes to the Institute for Public Policy and Social Research (IPPSR) at Michigan State University. An online version of the survey was administered using SurveyMonkey. The web link was included in press releases and public service announcements on local radio stations. Links were sent to hospitals and service providers who, in turn, forwarded it to their employees and emailed their patients or clients. Paper surveys were entered by IPPSR and then combined with the online surveys. A total of 1,758 usable surveys were received.

Focus Groups and Key Stakeholder Interviews

Each hospital held a focus group comprised of five to 12 community members, for a total of 56 participants. They represented agricultural interests, the faith community, schools, civic organizations, local government, police, health care professionals, and hospital volunteers, staff, and board members. In each county, interviews were conducted with four to five key stakeholders who were familiar with the community and its health care services and needs. The 14 stakeholders were from county departments of health and human services, county mental health agencies, an outpatient mental health clinic, a community collaborative of public and private members working together to coordinate health and human services across systems, an intermediate school district, county government, and an economic development corporation.

Statistical Analysis

Survey data were analyzed using the Statistical Package for the Social Sciences (SPSS) Version 22. This version includes a multiple response analysis which is used when more than one response is allowed for a survey question. For example, one survey question asked “Think about the AVAILABILITY OF HEALTH SERVICES in your community. What are your top three concerns?  (Choose up to THREE)” Several of the choices included ability to get appointments, availability of specialists, availability of mental health services, availability of in-home assistance, and availability of immunization services. Multiple response analysis allows the set of responses to this question to be treated as a single variable to generate frequencies and cross-tabulations.

A total of 1,758 useable surveys were received. Respondents were assigned to a hospital when their residential zip code was within its service area.  The eight hospitals received a total of 3,270 surveys, with a range of 145 to 844, and a mean of 408.75.  The difference of 1,512 between the total surveys used by the hospitals and the total of actual useable surveys received (3,270 - 1,758) reflects the number of respondents who resided in a zip code claimed by more than one hospital.  

The total usable responses for each county were Huron 706, Sanilac 845, and Tuscola 364 for a total of 1,915 and a mean of 638.3.  The difference of 157 between the total surveys for each county and the total of actual useable surveys (1,915 - 1,758) reflects the number of respondents who resided in a zip code that crossed county lines. If a respondent resided in a zip code that crossed county lines, they were excluded from the county analysis if less than 25 percent of the zip code was in the county of interest, unless they reported using a hospital in that county in the past two years. These criteria avoided double counting and increased the generalizability of the findings on the county and regional levels.

After eliminating missing data, the initial frequencies for gender and educational attainment revealed a strong selection bias.  For example, the percent female for the three counties was between 76.6 and 79.2 percent, and the percent of respondents with an associate level college degree or higher was between 60.6 and 63.1 percent. In order to reduce bias, weights were assigned by comparing the frequency distributions of these variables in the survey with their distributions in the American Community Survey (ACS).12  Since they were highly skewed, sex and age were combined into one weight.  Unfortunately, between 9.3 and 14.2 percent of the respondents across the three counties did not report their annual household incomes, so income was not weighted. Instead, education was weighted.  This meant that the answer to a specific survey question by a respondent in the under-represented group, e.g. males, received a weight greater than 1 and the answer of those in the over-represented group, e.g. females, received a weight less than 1.  

Qualitative Analysis

The focus groups and stakeholders were asked to respond to a set of 16-19 items.  Several items were lists of services provided by the focus group’s hospital or county health department.  Participants highlighted the services they did not know about.  The lists were collected and the number of participants who did not know about a listed service was recorded and rank ordered.  They also received a list of health-related issues that may affect their community: the environment, health services, the physical health, mental health, and substance abuse of adults, of youth and children, and the aging population.  They highlighted those they felt were a concern and then starred the five they thought were of the greatest concern.  These were then rank ordered by concern.

Responses to open ended questions were recorded and grouped.  Some were very easy to group, e.g. Where do people turn for trusted health information? or What particular populations or groups in the area are medically underserved?  Others generated a variety of responses, e.g. What are the major challenges facing your community? or, What would help remove barriers that may be affecting the use of local health by the community as a whole?  These were recorded, grouped by similar words or phrases, and rank ordered.

Results  

Demographics

As shown in Table 1, the weighted adjustments brought the valid percent females in the Thumb Area survey down from 78.4 to 50.6 percentpwexwnr, just above the ACS estimated range from 49.8 to 50.3 percent. The valid percent males increased from 21.6 to 49.4 percent, just under the ACS range from 49.7 to 50.2 percent. The adjustments increased the percent of respondents with a high school degree or less from 19.0 to 55.4 percent and those with some college but no degree from 18.4 to 23.2 percent. Correspondingly, the percent with an associate degree or higher decreased from 62.6 to 21.4 percent.  These are almost identical with the ACS estimates for high school degree or less (55.4%), some college no degree, (22.2%) and associate degree or higher (22.4%).

The percent of respondents with household incomes less than $25,000 rose from 21.0 to 38.5 percent while those with incomes $50,000 or more decreased from 54.0 to 35.9 percent. The adjustments barely changed the percent of households with incomes between $25,000 and $49,999 (25.0% to 25.6%).  The ACS estimate for income between $25,000 and $49,999 is higher at 30.7 percent.  However, the survey results do not include the 13.5 percent who did not report their household incomes.

Table 1 Unadjusted and Adjusted Regional Control Demographics (N=1,758)

Age was grouped into quartiles. The adjustment lowered the youngest quartile from 38 or younger to 37 or younger. The second quartile increased from 39-51 years of age to 38-53; the third increased by two years from 52-61 to 54-63, and the oldest quartile increased by two years from 62 and older to 64 and older. The ACS placed the median age in the three counties between 43.8 and 48.3 which below the top of the adjusted second quartile at 53.  

The adjusted regional demographics are in Table 2.  Almost three-fifths (59.1%) of the Thumb Area respondents were either married or remarried.  A little less than one-fifth (18.7%) were single, never married.  Only three-eights (37.2%) of households had children under 18.  A little less than half (46.6%) worked full time, 12.3 percent worked less than full time, 16.8 percent were retired, and 12.1 percent reported being disabled.  Those who reported being unemployed and seeking a job accounted for 5.1 percent of the respondents and 1.5 percent were unemployed but not seeking a job.  

Insert Table 2 Regional Demographics after Adjustment (N=1,758)

The number one self-reported source for health insurance was an employer or union (44.1%), followed by Medicare for older people (17.1%) and Medicaid for low-income, financially needy people (15.8%). Only 9.0 percent of Thumb Area respondents individually purchased a plan directly from a health insurance company or through the Affordable Care Act website, healthcare.gov.  Finally, 1.6 percent reported not having any health insurance.  

With respect to vulnerable populations, the adjusted demographics (not shown) revealed that a little more than half (55.4%) had a high school diploma or less, and about three-eighths (38.5%) earned less than $25,000 per year.  Approximately one-quarter (23.6%) of Thumb Area respondents were seniors 64 years of age or older.  However, almost all (94.4%) of the respondents self-reported that they were White, which accounts for the absence of any analysis of ethnic minorities.  

Finally, given the role of the hospitals in distributing the surveys, it is not surprising that approximately one-fifth (19.3%) of the respondents worked for a hospital, clinic, or public health department.  This skewed measurement of education and income.

Survey Findings

Table 3 summarizes the concerns of approximately half or more of the survey respondents by county as revealed in frequencies and crosstabulations.  The top concerns in all three counties were: cost of health insurance, cost of medications for the elderly, not enough specialists, not enough primary care physicians, cancer in adults, and job with livable wages.  The top concerns of respondents in two of the three counties were not enough evening or weekend hours, youth drug use and abuse including prescription abuse, and not able to get appointments.

Table 3 Top Concerns of Half or More of Survey Respondents by County

About half or more of respondents in one county were concerned about access to healthy food; assistance for low income families; obesity/overweight in adults; adult drug use and abuse including prescription abuse; don’t know about local services; retaining doctors, nurses, and health professionals; resources to keep the elderly in their homes; attracting/ retaining young families; and the cost of health care services.

Regional Focus Group Findings  

The hospital-based focus groups reflected the personal concerns of the individual participants.  Their greatest concerns about adult health were drug use and abuse, alcohol use and abuse, and obesity/overweight.  They were also concerned about the costs of health insurance and prescription drugs.  Much lower on their list was the need for evening and weekend medical appointments and retaining doctors and nurses in the community.  The top economic challenges were attracting and retaining young families, and not enough jobs with livable wages.

Regional Stakeholder Interview Findings

The stakeholders, who were from the health, social services, education, and community development sectors, added a broader communitywide perspective.  Stakeholders identified alcohol and drug problems, child and domestic abuse, and lack of mental health services as issues to address.  They indicated that the top economic challenges facing the region were good jobs and public transportation to access health care.  They hoped that hospitals would provide health and wellness programs and collaborate with other providers to cover mental health services.  They noted that some people believed that one has to be poor to use public health department clinics and services.

Limitations

Internal Revenue Service regulations covering Community Health Needs Assessments do not require a rigorous data gathering methodology, thereby allowing each hospital to decide how much to spend to collect data and whether to use the same instruments and methodology as neighboring hospitals.1  While a random sample is necessary to ensure the statistical accuracy of a survey, it is possible to adjust for selection bias and assign respondents who live in a shared service area to an appropriate hospital.  The non-probability sampling design resulted in selection bias, and therefore the survey findings were adjusted using the American Community Survey.12  Self-reported information and opinions can be inaccurate as a result of social desirability, recall, and concerns about confidentiality of income and health information.  

Shortcomings of focus groups and stakeholder interviews include participant selection, the skills of the facilitator or interviewer, and the consistency of researchers when coding a wide range of topics and opinions.  Finally, participants in a needs assessment will vary in their perceptions of what others in the community would say they need and what problems others would say the community should address.

Discussion and Implications

The analysis revealed that respondents in each county identified the same set of top concerns: physician supply, the costs of health insurance and medications, as well as cancer and obesity among adults, and drug use and abuse among youth.  The qualitative findings from the focus groups and stakeholder interviewers confirmed these survey findings.  

This mixed methods approach provided a set of reasonably accurate, interpretable data enabling each hospital to establish its own priorities and implementation strategies.  Knowing their own priorities and resources, hospitals can then participate in health planning and policy decision-making at the county and regional levels along with county agencies, community groups, and regional authorities.

The goal of implementation plans is to improve population health and health care delivery.  Highest priorities should be those that the hospitals and health departments can directly address: shortages of health personnel, clinic hours, and staff training in cultural awareness.  Second level priority should be those for which hospitals and health departments can join forces with social service, mental health and other health agencies to address substance abuse, mental health services, wellness and rehabilitation services, and resources for the elderly.

Medium priority should be given to working with community and civic organizations to provide assistance for low-income families, and with employers to provide jobs with livable wages and affordable health insurance.  Some issues, like transportation to health facilities and services, require county level support and advocacy on the part of non-government health organizations and groups.  

Acknowledgements

We acknowledge and thank Steve Barnett, President/CEO of McKenzie Health System, Sandusky, MI for his thorough review of the original manuscript.  We thank all those who responded to the survey, attended focus groups, or participated in the key stakeholder interviews.

Works Cited

1. Internal Revenue Service (IRS). Additional Requirements for Charitable Hospitals; Community Health Needs Assessments for Charitable Hospitals.  Department of the Treasury, Internal Revenue Service.  79 Fed. Reg. 78954 (December 31, 2014).  

2. Gretchen Sampson, Kim J. Miner Gearin, and Mary Boe, “A Rural Local Health Department–Hospital Collaborative for a Countywide Community Health Assessment,” Journal of Public Health Management and Practice. 21, no.1, (2015): 23–30. 

3. Cara L. Pennel, Kenneth R. McLeroy, James N. Burdine, and David Matarrita-Cascante, “Nonprofit Hospitals’ Approach to Community Health Needs Assessment,” American Journal of Public Health, 105, no. 3, (2015): e103-e113. 

4. Cara Pennel, Kenneth R. McLeroy, James N. Burdine, David Matarrita-Cascante, and Jia Wang, A Mixed-Methods Approach to Understanding Community Participation in Community Health Needs Assessments.” Journal of Public Health Management and Practice, 23, no. 2, (2017): 112–121. 

5. Kate E. Beatty, Kristin D. Wilson, Amanda Ciecior, and Lisa Stringer, Collaborations Among Missouri Nonprofit Hospitals and Local Health Departments: Content Analysis of Community Health Needs Assessments,” American Journal of Public Health, 105, no. S2, (2015): S337-S344. 

6. Thomas K. Bias, Christiaan G Abildso, Emily Vasile, and Jessica Coffman, “The Impact of Community Input in Community Health Needs Assessments,” Journal of Public Health Management and Practice, 23, no. S4. (2017): S29-S33. 

7. Edie Alfano-Sobsey, Sue Lynn Ledford, Kasey Decosimo, and Jennifer A. Horney, “Community Health Needs Assessment in Wake County, North Carolina: Partnership of Public Health, Hospitals, Academia, and Other Stakeholders,” North Carolina Medical Journal 75 no. 6, (2014):376-383. 

8. Wake County, North Carolina. 2016 Wake County Community Health Needs Assessment: Opportunities & Challenges. Executive Summary.  Available at www.rexhealth.com/app/files.pdf 

9. Karin L. Becker, Emerging Health Trends in North Dakota: Community Health Needs Assessments Aggregate Data Report.  Grand Forks, ND: Center for Rural Health, University of North Dakota, School of Medicine & Health Sciences. 2013. Available at: ruralhealth.und.edu/projects/community-health-needs-assessment.pdf

10. Karin L. Becker, “Conducting Community Health Needs Assessments in Rural Communities: Lessons Learned,” Health Promotion Practice, 16, no. 1 (2015):15-19.  

11. William L. Miller, Benjamin F. Crabtree, Michael I. Harrison, and Mary L. Fennell, “Integrating Mixed Methods in Health Services and Delivery System Research,” Health Services Research, 48, no. 6 Pt2 (2013): 2125-2133. 

12. U.S. Census Bureau. American Community Survey 2010-2014 ACS 5-year estimates.  

Author bios

Harry Perlstadt, Professor Emeritus of Sociology at Michigan State University, has evaluated health programs and initiatives for the Kellogg Foundation, USDHHS Health Resource Services Administration, and World Health Organization. He chaired the Commission on Accreditation of Programs in Applied and Clinical Sociology. He was a Fulbright lecturer at Semmelweis University, Budapest, Hungary. Harry received the 2014 American Sociological Association Distinguished Career Award for the Practice of Sociology.

He has served on the governing council, science board, and joint policy committee of the American Public Health Association and on the National Board and Research/ Scientific Advisory Committee of the American Lung Association.

Harry has a BA in political science and an MPH in health planning and administration from the University of Michigan, and a PhD in sociology from the University of Chicago.

Debra L. Rusz is a Senior Project Manager at the Office for Survey Research (OSR) within the Institute for Public Policy and Social Research at Michigan State University. She Joined OSR in 1996 as a graduate research assistant and was hired as a full-time staff member in 2001. During her research career she has predominately worked on health-related projects, but has worked on additional studies ranging from wildlife management to crime victimization. She is experienced with all aspects of phone, self-administered, and multi-mode surveys.

She holds a B.S. in Wildlife Management and a M.A. in Environmental Sociology with an emphasis in Applied Research from Michigan State University, and has done doctoral coursework in Environmental Sociology.  

Travis Fojtasek, PhD, is an independent survey research consultant. He earned his Ph.D. in medical sociology from Michigan State University in 2003. Prior to moving to Michigan, he had a successful 23-year career as a sales representative in Texas for Whirlpool home appliances. His business background brings an added dimension to his social research interest on rural health issues. Travis has worked with the Michigan Center for Rural Health for about 12 years on a number of studies on rural health issues including physician recruitment and retention, the state rural health plan (MiSORHI), physician workforce needs, an assessment of rural health clinics, the student loan repayment program (SLRP) as well as the J-1 Visa waiver program, and the rural EMS system. When not pursuing his interests in rural health issues, Travis is known in his community as an “activist” in politics, the environment, domestic violence, and promoting arts and culture as an economic driver. He also serves on several community boards. 

Kay Balcer is a Community Consultant dedicated to supporting nonprofit organizations. In 2000, she began a consulting business with the mission of “Helping Nonprofit Organizations Maximize their Potential.” She has a varied background with a degree in secondary education and more than 20 years working in the health and human services arena. She is currently the owner and operator of Balcer Consulting and Prevention Services and has worked with various nonprofits including critical access hospitals, public health departments, cross sector community coalitions, education entities, early childhood coalitions, emergency medical services, and rural businesses. Her responsibilities include strategic planning, coaching and technical assistance, needs assessments, community organizing, program development, system change efforts, local level evaluation, program development, developing and delivering training programs, grant writing, and project implementation. 

She is an alum of Michigan State University and has received training in various best practices such Mobilizing Action Through Community Partnerships, Collective Impact, ABLe Change, and Logic Model Evaluation Strategies. She is a certified Bridges out of Poverty instructor and strives to move communities to adopt a system-based approach to addressing poverty and other complex health and social issues. 

Darcy A. Czarnik Laurin is Executive Director of the Thumb Rural Health Network (TRHN) and has filled that role since 2011. TRHN works to improve comprehensive health services in Michigan’s Thumb region by collaborating to improve health and promote wellness of the population in Huron, Sanilac, and Tuscola Counties through access, public awareness, education, advocacy, and leadership. By setting aside historical competitive issues and focusing on emerging collaborative opportunities, network members are better able to address the complex health issues of the Thumb’s rural communities. Most recently, Darcy added the role of Project Director for TRHN’s Thumb Opioid Response Consortium project to her job duties.

A native of rural northern Michigan, Darcy has more than 15 years of non-profit experience working with both federal- and state-level grant funded organizations. She began her non-profit career working as a watershed coordinator designing and implementing watershed and wetland restoration initiatives. Soon after, Darcy’s focus switched to rural health, and she has since dedicated her work to helping alleviate the health challenges and disparities found in rural communities.

Darcy holds a bachelor’s degree in health sciences from Central Michigan University. She also completed the first ever NCHN and Saybrook University partnership Change Our World: Leadership and Transformation Engagement (LOTE) program.

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