Download SBS Exercise 3: A Case Study in the Role of Social and Community

SOCIAL & BEHAVIORAL SCIENCES EXERCISE 3: A CASE
STUDY OF THE ROLE OF SOCIAL AND COMMUNITY
FACTORS IN THE ONSET AND SOLUTION OF PUBLIC
HEALTH PROBLEMS
INSTRUCTOR’S GUIDE VERSION 1.0
SBS Exercise 3: A Case Study in the Role of Social and Community Factors in the Onset
and Solution of Public Health Problems
Time to Complete Exercise: 30 Minutes
LEARNING OBJECTIVES
At the completion of this exercise, participants should be able to:
 Identify the role of social and community factors in the onset of a public health problem
 Identify social and community factors that contribute to the solution of a public health
problem
 Explain the rationale for using incentives and enablers to support treatment adherence
 Identify incentives and enablers that are responsive to individual and community needs and
preferences
ASPH SOCIAL AND BEHAVIORAL SCIENCES COMPETENCIES ADDRESSED
E.3. Identify individual, organizational, and community concerns, assets, resources and deficits
for social and behavioral science interventions
E.6. Describe the role of social and community factors in both the onset and solution of public
health problems
ASPH INTERDISCIPLINARY/CROSS-CUTTING COMPETENCIES ADDRESSED
G.10. [Diversity And Culture] Develop public health programs and strategies responsive to the
diverse cultural values and traditions of the communities being served
Please evaluate this material by clicking here:
http://www.zoomerang.com/Survey/?p=WEB229TEY5ZR27
This case study was developed by the staff at the Global Tuberculosis Institute's Northeastern
Regional Training and Medical Consultation Center and was funded by the Centers for Disease
Control and Prevention. It is published for learning purposes only.
Case study author:
Paul W. Colson, PhD
Program Director, Charles P. Felton National Tuberculosis Center
For further information, please contact:
New Jersey Medical School Global Tuberculosis Institute (GTBI)
225 Warren Street P.O. Box 1709
Newark, NJ 07101-1709 or by phone at 973-972-0979
Suggested citation: New Jersey Medical School Global Tuberculosis Institute. /Incorporating
Tuberculosis into Public Health Core Curriculum./ 2009: Social and Behavioral Sciences Exercise 3: :
A Case Study Of The Role Of Social And Community Factors In The Onset And Solution Of Public
Health Problems INSTRUCTOR’S GUIDE Version 1.0.
Date Last Modified: November 16, 2009
1
SOCIAL & BEHAVIORAL SCIENCES EXERCISE 3: A CASE
STUDY OF THE ROLE OF SOCIAL AND COMMUNITY
FACTORS IN THE ONSET AND SOLUTION OF PUBLIC
HEALTH PROBLEMS
INSTRUCTOR’S GUIDE VERSION 1.0
NOTE FOR INSTRUCTORS
This guide is intended to accompany the PowerPoint slide set, “Social & Behavioral
Sciences Exercise 3: A Case Study of the Role of Social and Community Factors in the
Onset and Solution of Public Health Problems.”
Reading assignment:
El-Sadr W, Medard F, Dickerson M. The Harlem Family Model: a unique approach to the
treatment of tuberculosis. J Public Health Manag Pract. 1995; 1:48-51.
Introduction
In designing public health interventions, it is important to first obtain an accurate view of
social and community factors in the targeted area. These include social factors (e.g.,
income distribution, health issues, family structures, social cohesiveness) and community
factors (eg, geography, transportation, availability of health care, etc.). Appropriate public
health interventions will acknowledge the realities of these factors and attempt to capitalize
on those that will promote a desired outcome.
This case study uses the community of Harlem in New York, NY, and the design of a
directly observed therapy (DOT) program for tuberculosis (TB) patients as an example of
assessing and planning for social and community factors. The instructor may want to
review A Primer on TB to increase his/her basic understanding of the disease.
The slide set consists of 7 sections:
1. Introductory materials, including ASPH competencies and learning objectives (slides 12);
2. Conceptual information on planning public health interventions, including a list of social
and community factors (slide 3);
3. Background information on TB, including basic health information, the US TB control
strategy, key elements of DOT programs, and examples of incentives and enablers
(slides 4-8);
Date Last Modified: November 16, 2009
2
SOCIAL & BEHAVIORAL SCIENCES EXERCISE 3: A CASE
STUDY OF THE ROLE OF SOCIAL AND COMMUNITY
FACTORS IN THE ONSET AND SOLUTION OF PUBLIC
HEALTH PROBLEMS
INSTRUCTOR’S GUIDE VERSION 1.0
4. A description of the Harlem community, as told by a life-long Harlem resident. This
information features photographs of people and places in Harlem (slides 9-30);
5. A discussion of public health intervention design, using the Harlem DOT model as an
example (slides 31-43);
6. A discussion of public health intervention design, using social and community factors not
found in the Harlem community (and thus where the Harlem DOT model is not
applicable) (slides 44-50); and
7. Conclusion (slide 51)
The first 4 sections and the conclusion can be presented in a didactic fashion.
The fifth and sixth sections consist of an interactive exercise. Certain characteristics are
presented (eg, the community has many individuals who are poor) and the students are
asked to brainstorm about how to design intervention elements to respond to specific
characteristics. The instructor should collect suggestions from the students before moving
to the next slide, which presents specific aspects of the Harlem model that respond to this
characteristic (eg, if patients are poor, the program should provide meals, food, clothing,
and other forms of tangible assistance; and help with finding work or obtaining public
benefits).
In the fifth section, the following characteristics of the Harlem model are presented:

Many individuals are poor

Many individuals are homeless or marginally housed

Many individuals are single, with little social support

Many individuals are substance abusers

Many individuals have HIV and/or other health problems

The community is geographically small or easy to navigate
The presentation uses the above social and community factors in Harlem as an example of
how to assess these factors and design an appropriate public health intervention.
Date Last Modified: November 16, 2009
3
SOCIAL & BEHAVIORAL SCIENCES EXERCISE 3: A CASE
STUDY OF THE ROLE OF SOCIAL AND COMMUNITY
FACTORS IN THE ONSET AND SOLUTION OF PUBLIC
HEALTH PROBLEMS
INSTRUCTOR’S GUIDE VERSION 1.0
Examples of targeted incentives, such as group outings, meals, and celebrations, can be
found on page 50 of the assigned reading (El-Sadr et al., 1995).
The presentation also acknowledges that other social and community factors relevant to
TB, but not found in Harlem, may exist; namely, a large geographic area or poor
transportation, a relatively affluent area with a tradition of private health care, and overt
stigmatization. In the sixth section, the students are asked to brainstorm about how to
design intervention elements to respond to these characteristics, much as they were asked
to do in the fifth section.
In the conclusion, the point is summarized that this exercise is based on social and
community factors in Harlem and the public health intervention of DOT for TB. This
methodology could be used in various communities and with various public health
interventions.
The slide set can be accessed through the following URL:
http://www.umdnj.edu/globaltb/audioarchives/onlineslides/Social%20and%20Behavioral%2
0Sciences/Presentation_Files/index.html
Background Information on Tuberculosis Rates in the 1980s
In the mid to late-1980s, large cities in the United States witnessed a dramatic resurgence
of TB with reversals of downward trends and rates of new cases doubling. New York City
was particularly hard hit, with cases tripling from 1979 to 1992. The de-funding of public
TB control programs coincided with long-term upward trends in urban poverty, increased
immigration from countries where TB is endemic, and in some cities, housing shortages.
Rising homelessness was particularly acute in New York City, where families excluded
from low-income housing joined newly deinstitutionalized mental health patients in
overcrowded shelters. Outbreaks of TB in shelters, hospitals, and prisons revealed that
Date Last Modified: November 16, 2009
4
SOCIAL & BEHAVIORAL SCIENCES EXERCISE 3: A CASE
STUDY OF THE ROLE OF SOCIAL AND COMMUNITY
FACTORS IN THE ONSET AND SOLUTION OF PUBLIC
HEALTH PROBLEMS
INSTRUCTOR’S GUIDE VERSION 1.0
infection-control systems for congregate facilities were inadequate. The 1980s also saw a
rise in substance use in major US cities, and injection drug and crack cocaine users were
disproportionately affected by the new surge in TB. Such individuals were often
incarcerated; jails and prisons served as a nexus for further transmission. Additionally,
upon release ex-offenders often became homeless and homeless shelters thus served to
further spread TB infection. Finally, the emergent epidemic of HIV/AIDS created a national
pool of immuno-compromised individuals uniquely vulnerable to TB disease.
In the midst of the resurgence of TB was a frightening sub-epidemic of multi-drug resistant
(MDR) TB, stemming in large part from widespread non-completion of treatment
(inadequate prescribing practices by physicians also played a role). MDR-TB required a
more complex, longer course of treatment and, in immuno-compromised patients, led to
extremely high fatality rates if not adequately treated. Many of these causative factors
intersected, so that for instance, the population within an urban shelter system included
high numbers of substance users who tended to be malnourished and spent time together,
often engaging in behaviors that put them at high risk for HIV infection, and who had no
regular access to health care or were reluctant to access services for fear that their drug
use would be investigated. Such a group would be at high risk for TB infection and for
progression to TB disease in the absence of appropriate treatment.
In response, federal, state, county, and local resources were invested in rebuilding TB
surveillance and treatment programs, and in strategies to help ensure completion of TB
treatment while providing alternatives to mandatory detention. The most important of
these strategies has been DOT for outpatients, in which patients receive daily or twiceweekly doses of TB medications from a health care worker who witnesses that each dose
is ingested. DOT may be done in a clinical setting, patient residences, schools,
workplaces, or other agreed-upon settings. DOT is often combined with other outpatient
services, including substance use treatment programs, and includes access to social
service providers.
Date Last Modified: November 16, 2009
5
SOCIAL & BEHAVIORAL SCIENCES EXERCISE 3: A CASE
STUDY OF THE ROLE OF SOCIAL AND COMMUNITY
FACTORS IN THE ONSET AND SOLUTION OF PUBLIC
HEALTH PROBLEMS
INSTRUCTOR’S GUIDE VERSION 1.0
The routinization of DOT has led to a decline in the incidence of detention of TB patients,
and much improved rates of treatment completion. This improvement, along with
increased funding and interagency collaboration, improved surveillance, diagnostic
techniques, and changes in recommended drug regimens, enabled TB control programs to
regain the ground lost in the 1980s and early 1990s, so that in the early 21 st century, TB
disease incidence in the United States is at historic lows.
Bibliography
Bayer R, Wilkinson D. Directly observed therapy for tuberculosis: history of an idea.
Lancet. 1995; 345:1545 -1548.
Chaulk CP, Kazandjian VA, Public Health Tuberculosis Guidelines Panel. Directly
observed therapy for treatment completion of pulmonary tuberculosis: consensus
statement of the Public Health Tuberculosis Guidelines Panel. JAMA. 1998; 279:943-948.
Haddad MB, Wilson TW, Ijaz K, Marks SM, Moore M. Tuberculosis and homeless in the
United States, 1994 – 2003. JAMA 2005;293 (22):2762-2766.
Volmink J, Garner P. Directly observed therapy for treating tuberculosis (review). The
Cochrane Library, issue 3, 1-23. 2007.
Weis SE, Slocum PC, Blais FX et al. The effect of directly observed therapy on the rates of
drug resistance and relapse in tuberculosis. N Engl J Med. 1994; 330:1179 -84.
Date Last Modified: November 16, 2009
6