Structuring Equity Into Minnesota's COVID-19 Response: Lessons Learned and Future Investments.

BACKGROUND: The Minnesota Department of Health (MDH) integrated 3 intentional teams into their novel coronavirus 2019 (COVID-19) response to ensure equity was not lost in the speed of response. IMPLEMENTATION: These teams-the Cultural, Faith, and Disability Communities Branch, Tribal COVID-19 Healthcare Team, and Vaccine Equity Branch were able to reach communities through trusted partners, elevate the voices of communities most impacted, respect tribal sovereignty, establish equity leadership, and set equity goals and metrics. LESSONS LEARNED: The top-down nature of incident command, combined with pre-COVID-19 systems and structures that impede equity, led to both barriers and opportunities for centering equity in response efforts. Inclusion of staff and community voice in decisions and guidance leads to better results; each community's unique needs have to be considered. Equity metrics and goals help direct resources to the most disadvantaged. State, local, and tribal public health infrastructure was built quickly and needs ongoing resources to be sustained. FUTURE INVESTMENTS: MDH is leveraging new funding to embed successful response structures into the organization. These structures are intended to build state, local, and tribal capacity and address systemic challenges at MDH. CONCLUSION: While equity can be incorporated into pandemic response and incident command structures, ongoing investment to support public health infrastructure is vital to sustaining equity.

Impact of the Hepatitis Testing and Linkage to Care (HepTLC) Initiative on Linkage to Care for Minnesota Refugees with Hepatitis B, 2012-2014.

OBJECTIVE: The Hepatitis Testing and Linkage to Care (HepTLC) initiative promoted viral hepatitis B and hepatitis C screening, posttest counseling, and linkage to care at 34 U.S. sites from 2012 to 2014. Through the HepTLC initiative, the Minnesota Department of Health (MDH) and clinic partners began conducting linkage-to-care activities with hepatitis B-positive refugees in October 2012. This intervention provided culturally appropriate support to link refugees to follow-up care for hepatitis B. METHODS: MDH refugee health and viral hepatitis surveillance programs, along with clinics that screened newly arrived refugees in Hennepin and Ramsey counties in Minnesota, collaborated on the project, which took place from October 1, 2012, through September 30, 2014. Bilingual care navigators contacted refugees to provide education, make appointments, and arrange transportation. We compared the linkage-to-care rate for participants with the rates for refugees screened the year before project launch using a two-sample test of proportions. RESULTS: In the year preceding the project (October 2011 through September 2012), 87 newly arrived refugees had a positive hepatitis B surface antigen (HBsAg) test. Fifty-six (64%) refugees received follow-up care, 12 (14%) refugees did not receive follow-up care, and 19 (22%) refugees could not be located and had no record of follow-up care. During the project, 174 HBsAg-positive, newly arrived refugees were screened. Of those 174 refugees, 162 (93%) received follow-up care, seven (4%) did not receive follow-up care, and five (3%) could not be located and had no record of follow-up care. The one-year linkage-to-care rate for project participants (93%) was significantly higher than the rate for refugees screened the previous year (64%) (p<0.001). CONCLUSION: In the context of a strong screening and surveillance infrastructure, a simple intervention improved the linkage-to-care rate for HBsAg-positive refugees.

Early identification and linkage to care of persons with chronic hepatitis B virus infection--three U.S. sites, 2012-2014.

In the United States, an estimated 0.8-1.4 million persons are living with chronic hepatitis B virus (HBV) infection. Among these persons, as many as 70% were born in countries of Asia, Africa, or other regions where HBV is moderately or highly endemic (hepatitis B surface antigen [HBsAg] prevalence ≥2%). HBV-associated cirrhosis and liver cancer are major health problems for these populations. Most persons with HBV were infected at birth or during early childhood and are asymptomatic until advanced liver disease develops. To address these concerns, CDC recommends HBsAg testing for all persons born in these areas and linkage to medical care and preventive services for those who are infected. In 2012, CDC awarded funds to nine sites to implement this recommendation. This report describes programs at three sites (New York, New York; Minneapolis-St. Paul, Minnesota; and San Diego, California) that conducted HBV testing, in clinical or community settings, and referred for medical evaluation and care those persons whose HBsAg test results were positive. During October 2012-March 2014, the three sites tested 4,727 persons for HBV infection; 310 (6.6%) were HBsAg-positive. Among the HBsAg-positive persons, 94% were informed of their results, 90% were counseled, 86% were referred for care, and 66% attended their scheduled first medical visit. These projects demonstrate that community-based programs can identify infected persons among populations with a high prevalence of HBV infection and refer HBsAg-positive persons for care. Individualized efforts to assist patients with accessing and receiving health-care services ("patient navigation services") can increase the number of persons who follow up on referrals and receive recommended care.

Health and healing: traditional medicine and the Karen experience.

OBJECTIVE: To examine the beliefs, attitudes and health-seeking behavior surrounding the use of traditional medicine among the Karen (refugees from Burma). METHODS: Three focus groups and two key-informant interviews were conducted with the Karen along with observations by researchers. RESULTS: The Karen continue to use elements of their traditional healthcare system after resettling in the U.S. Accessibility and perceived efficacy of treatments influence their health-seeking behavior. The participants discussed beliefs about health and healing, spirituality, and their experience as refugees. Implications for improving the quality of healthcare for the Karen and recommendations for further research are discussed.

Caring for the Karen. A newly arrived refugee group.

Since 2004, Minnesota has seen an influx of refugees from Burma. Many of these newcomers came from the Karen state and spent time in refugee camps in Thailand before resettling in the United States. To better understand the health needs of this population, the authors of this article conducted chart reviews at a St. Paul family medicine clinic that serves a number of Karen refugees and reviewed formal data from the Minnesota Department of Health's Refugee Health Program. Here, they briefly describe this community, the cultural issues that could affect health care providers' ability to care for Karen patients, and the health concerns of these refugees.