Community Health Needs Assessment as a Teaching Tool in a Family Medicine Residency.

BACKGROUND AND OBJECTIVES: Community-based primary care is a fundamental concept taught in family medicine. Best practices for community-oriented and public health training in medical training programs are underreported in the published literature. A Community Health Needs Assessment (CHNA) offers an opportunity for family medicine residents to practice research and evaluation skills while learning about public health and the community they serve. METHODS: A family medicine residency program in Harlem, NY, conducted a CHNA in order to assess their community's health landscape and as an opportunity to teach the resident trainees research skills. Primary and secondary data were collected by the residents using public databases, surveys, focus groups, and key informant interviews. Residents completed a survey at the project's completion to assess their experience with the CHNA and to obtain suggestions for improving the process in the future. RESULTS: More than 50% of the 15 residents surveyed reported that the CHNA greatly improved their comfort level speaking to patients about social factors that affect their health. Participants responded that they valued the opportunity to engage with community members and to understand their patients on a population level. The greatest challenge for most residents was lack of devoted time to complete the project considering competing residency responsibilities. CONCLUSIONS: Conducting a CHNA in a primary care training program can help the next generation of family physicians become culturally competent and community focused in their work.

A Novel Collaborative Community-Based Hepatitis B Screening and Linkage to Care Program for African Immigrants.

BACKGROUND: Sub-Saharan African nations have among the highest rates of chronic hepatitis B virus (HBV) infection worldwide, but little is known about HBV infection in African-born persons in the United States. METHODS: From October 2011 to July 2013, community-based HBV screenings were conducted targeting persons originating from Africa in New York City. Persons were identified as currently HBV infected (HBsAg positive) or exposed (HBcAb positive). RESULTS: Overall, 955 persons were screened for HBV; the median age was 45 years (interquartile range, 35-54 years) and 75.5% were men. Of these, 919 persons had no history of liver disease, of whom 9.6% (n = 88) had current HBV infection and 73.9% (n = 679) had exposure. In logistic regression, older age (odds ratio [OR], 0.97; 95% confidence interval [CI], .94-.99; P < .01) and female sex (OR, 0.35; 95% CI, .14-.75; P < .01) were less likely to be associated with HBV infection, whereas having a mother with hepatitis was associated with infection (OR, 18.8; 95% CI, 2.72-164.65; P < .01). HBV exposure was associated with older age (OR, 1.03; 95% CI, 1.01-1.04; P < .01), whereas female sex (OR, 0.46; 95% CI, .33-.66; P < .01) and history of blood transfusion (OR, 0.43; 95% CI, .22-.83; P = .01) were negatively associated. A patient navigator linked 97% of infected persons to care. Eleven persons were recommended for treatment, of whom 9 (82%) started therapy. Three persons were diagnosed with hepatocellular carcinoma on the first screening ultrasound. CONCLUSIONS: The high burden of HBV infection among African immigrants in the United States underscores a need for continued screening and linkage to care in this at-risk population.

Adapting the Andersen model to a francophone West African immigrant population: hepatitis B screening and linkage to care in New York City.

Hepatitis B virus (HBV) is highly endemic in West Africa and immigration from this region to the United States has greatly increased over the past quarter century. Using the Andersen Model as a conceptual framework, this study qualitatively examines francophone West African immigrants' perceptions of factors affecting access to HBV screening and linkage-to-care in New York City. Four focus groups were conducted with 39 purposefully selected participants. The focus groups were conducted in French, audio-recorded, translated into English, transcribed, analyzed, and coded for major themes. Participants identified increasing knowledge of HBV and opportunities to access care in a culturally-sensitive manner that decreases fatalism and avoids generating stigma as priorities. They also emphasized the importance of engaging religious establishments and social networks and employing the Internet to disseminate HBV-relevant information. Cost and health insurance are identified as future challenges that will need to be addressed in a health care environment in which undocumented immigrants are ineligible for health insurance. The qualitative analysis in this study highlights the recursive and interdependent nature of the Andersen Model, and a modification of the model is proposed that is intended to inform examinations of other minority communities' access to health care.

Health worker perceptions of integrating mobile phones into community case management of malaria in Saraya, Senegal.

BACKGROUND: Although community case management of malaria increases access to life-saving care in isolated settings, it contends with many logistical challenges. Mobile phone health information technology may present an opportunity to address a number of these barriers. METHODS: Using the wireless adaptation of the technology acceptance model, this study assessed availability, ease of use, usefulness, and job relevance of mobile phones by health workers in Saraya, Senegal. RESULTS: This study conducted seven key informant interviews with government health workers, and three focus groups and 76 surveys with lay health workers. Principal findings included that mobile phones are already widely available and used, and that participants valued using phones to address training, stock management, programme reporting, and transportation challenges. CONCLUSIONS: By documenting widespread use of mobile phones and health worker perceptions of their most useful applications, this paper provides a framework for their integration into the community case management of malaria programme in Saraya, Senegal.

Policy perspectives and attitudes towards mental health treatment in rural Senegal.

BACKGROUND: Mental health is often given low priority in health policy planning, particularly in developing countries. Several international health bodies, including the World Health Organization, recommend integrating mental health into primary care settings to reduce mortality and morbidity associated with mental illness, particularly in low-resource settings. OBJECTIVE: This study explores health care workers' and policy stakeholders' knowledge and attitudes regarding mental illness, interactions with patients in the community, and perceived training needs at a health clinic in rural southeastern Senegal. Interviews were conducted with eight key informant medical staff members and community health workers. METHODS: Interview data were analyzed and interpreted using a qualitative content analysis based on the grounded theory approach. RESULTS: The findings indicate that staff members encounter many patients with emotional/psychological problems or mental illnesses, and they employ various strategies in treating these patients. Respondents also highlighted the need for more training to address and diagnose mental health problems, especially severe psychiatric illnesses. CONCLUSIONS: Findings are used to discuss recommendations for developing a comprehensive mental health primary care treatment approach that includes screening patients for mental health problems screening, incorporating rural villagers' attitudes and beliefs about mental illness into treatment, and utilizing community health workers-who are often a first health contact for many-to work with the medical staff to identify mental health problems.

Community case management in malaria: review and perspectives after four years of operational experience in Saraya district, south-east Senegal.

BACKGROUND: Despite recent advances in malaria diagnosis and treatment, many isolated communities in rural settings continue to lack access to these life-saving tools. Community-case management of malaria (CCMm), consisting of lay health workers (LHWs) using malaria rapid diagnostic tests (RDTs) and artemisinin-based combination therapy (ACT) in their villages, can address this disparity. METHODS: This study examined routine reporting data from a CCMm programme between 2008 and 2011 in Saraya, a rural district in Senegal, and assessed its impact on timely access to rapid diagnostic tests and ACT. RESULTS: There was a seven-fold increase in the number of LHWs providing care and in the number of patients seen. LHW engagement in the CCM programme varied seasonally, 24,3% of all patients prescribed an ACT had a negative RDT or were never administered an RDT, and less than half of patients with absolute indications for referral (severe symptoms, age under two months and pregnancy) were referred. There were few stock-outs. DISCUSSION: This CCMm programme successfully increased the number of patients with access to RDT and ACT, but further investigation is required to identify the cause for over-prescription, and low rates of referrals for patients with absolute indications. In contrast, previous widespread stock-outs in Saraya's CCMm programme have now been resolved. CONCLUSION: This study demonstrates the potential for CCMm programmes to substantially increase access to life-saving malarial diagnostics and treatment, but also highlights important challenges in ensuring quality.

Barriers to community case management of malaria in Saraya, Senegal: training, and supply-chains.

BACKGROUND: Health workers in sub-Saharan Africa can now diagnose and treat malaria in the field, using rapid diagnostic tests and artemisinin-based combination therapy in areas without microscopy and widespread resistance to previously effective drugs. OBJECTIVE: This study evaluates communities' perceptions of a new community case management of malaria programme in the district of Saraya, south-eastern Senegal, the effectiveness of lay health worker trainings, and the availability of rapid diagnostic tests and artemisinin-based combination therapy in the field. METHODS: The study employed qualitative and quantitative methods including focus groups with villagers, and pre- and post-training questionnaires with lay health workers. RESULTS: Communities approved of the community case management programme, but expressed concern about other general barriers to care, particularly transportation challenges. Most lay health workers acquired important skills, but a sizeable minority did not understand the rapid diagnostic test algorithm and were not able to correctly prescribe arteminisin-based combination therapy soon after the training. Further, few women lay health workers participated in the programme. Finally, the study identified stock-outs of rapid tests and anti-malaria medication products in over half of the programme sites two months after the start of the programme, thought due to a regional shortage. CONCLUSION: This study identified barriers to implementation of the community case management of malaria programme in Saraya that include lay health worker training, low numbers of women participants, and generalized stock-outs. These barriers warrant investigation into possible solutions of relevance to community case management generally.

HIV/AIDS among African-born residents in the United States.

The number of African-born residents living in the United States (US) increased by more than 750 % between 1980 and 2009. HIV diagnosis rates in this population are six times higher than estimated incidence in the general US population. African-immigrants with HIV are also diagnosed at later stages of infection than US-born residents, but they paradoxically have lower mortality after diagnosis. There are higher rates of HIV among women, higher rates of heterosexual transmission, and lower rates of injection-drug-use-associated transmission among African-born residents in the US relative to the general US population. Despite this distinct epidemiologic profile, surveillance reports often group African-born residents with US-born Blacks. The high rates of HIV among African-born residents in the US combined with increasing immigration and incomplete surveillance data highlight the need for more accurate epidemiologic data along with appropriate HIV service programs.