Author: nayavill

Three takeaways from my summer on TB

Posted on by nayavill

A map of North Carolina on a laptop in Jaclyn's backyard.I finished my practicum last week with the Tuberculosis (TB) Control Program at the North Carolina Department of Health and Human Services (NC DHHS) and wanted to share a few final reflections.

  1. Practica will inevitably change and evolve throughout the summer – but that’s not a bad thing! I originally thought I would be using surveillance data to estimate the prevalence of latent TB infections in the state. However, I was able to come up with a better strategy after consulting with the TB epidemiologist at DHHS. She illuminated some of the issues with the data reporting system we currently have and encouraged me to consult other estimates from the literature. This new direction allowed me to redirect my efforts to interpreting and assessing the quality of available estimates, which is ultimately an important skill for me as a budding “applied” epidemiologist.
  2. Practica can be a great opportunity to network and meet people outside of your normal circles. I got the chance to meet with some health departments from other states that had already done a similar educational outreach project around latent TB infections. It gave me the chance to see how other health departments structure their programs and often collaborate across states. I also got to peak into some of the case-level work that TB nurses do in North Carolina and how that feeds into the larger population-level work at the health department.
  3. Getting creative and taking initiative can help you get what you want out of your practicum. Part of my project involved compiling a list of doctors (called civil surgeons) that are active in providing medical exams for people seeking immigration status adjustment. I wanted to get some practice creating maps and my preceptor was on board, so I took some time to train on Tableau and then create a map of all active practices. This map was useful in presentations I gave to show where these doctors were concentrated, potentially helping to prioritize hotspots for the educational intervention. This map also illuminated that there were “deserts” in the state, where people might have trouble finding a nearby doctor and potentially get discouraged in the status adjustment process.

Overall, the practicum gave me an interesting look into the work that goes into planning an intervention at the state health department and learning how to use my knowledge and interests to potentially add value in unique ways. I am grateful for the opportunity to get some exposure to the government sector and practice some of the skills I’ve learned in the first year of the MPH.

– Jaclyn

The End signals the Beginning of Something New

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Summer has faded fast. The official end of my practicum with Colectivo Amigos Contra el SIDA (CAS) approaches, sooner than I might like – a gentle reminder that things outside the academia’s confines do not always obey the metronome of a school calendar. I began the summer preoccupied with how I might contribute from afar, in the virtual world, to CAS’s mission, carried out from their clinic in Guatemala City, to provide stigma-free sexual health services to gay and bisexual men. Yet as the summer has worn on, the virtual aspects of my practicum have become less significant. It’s not clear that anything would have been gained, for anyone, by me being present in Guatemala this summer, aside from frequent flier miles. Instead, the great reward – and challenge – became calibrating my expectations of what was feasible in the abbreviated course of this summer.

As I commented in my earlier blog post, CAS maintains a longstanding relationship with Gillings researchers, a collaboration whose current focus is understanding the provision and uptake of HIV pre-exposure prophylaxis (PrEP), a daily medication which is highly effective at preventing the establishment of HIV infection in those exposed to the virus. In Guatemala, CAS is the only provider of PrEP, which it offers free of charge – and remarkably, CAS has greatly expanded its pool of clients using PrEP since the onset of the pandemic. The original design of my practicum focused on developing and implementing data collection instruments, a survey for CAS’s clients and in-depth interviews with providers, that would inform the creation of a mobile app to share health information and coordinate services for CAS’s PrEP program. With delays in the Institutional Review Board (IRB) approval for this phase of the study, my focus shifted to analyzing and preparing to share qualitative and quantitative data from an earlier phase of the research partnership – that is, the dissemination of results.

Before coming back to UNC, I had been exposed to a variety of organizations in the nebulous patchwork that is “international development,” from small NGOs to government agencies. None had the commitment to research that CAS has, to cultivating and producing knowledge to better advance their mission. The accompanying ethical procedures, like IRB approvals, exist for the essential purpose of protecting the human subjects of this research. If anything, given its sometimes-troubled history, stringent ethical standards ought to be at the forefront of global health research and practice. Though I have had to be flexible in my practicum’s immediate aims, my core objective of striving to contribute to CAS’s mission, however modestly, has not wavered. Maybe this reflects my own inexperience in public health research, but I have gained a richer appreciation for the harmony of such community-based, action-oriented research partnerships.

Comparing PrEP users with non-users in the analysis of older study data has revealed differences between each group in the factors influencing PrEP uptake, differing perceptions of the stigma associated with its use, and differing reliance on technology to seek health information. The results of such comparisons will, hopefully, provide insight into how CAS might develop new initiatives to expand the reach of its PrEP program, including via a mobile app. Working through how to best share these results has presented the fresh challenge of how to integrate quantitative and qualitative data sets – and how to do so in such a way that proves most useful to the workings of a fast-paced organization with multiple programmatic objectives. With a keener appreciation for the value of such mixed methods research to public health programs, this is a process I would hope to replicate in future endeavors.

More immediately, I plan to continue as part of the CAS-UNC research collaboration beyond the official end of my practicum. Coming up are results to be shared and interviews to be conducted, both of which hopefully can coexist alongside my coursework commitments. Ten weeks may be a flash in time, but it’s certainly long enough to feel immersed in a project. And this seems only right to me. Exercising humility and creating relationships both call for, among other things, an investment of time. In my own practice, I aspire to be oriented by precisely these values, the foundation of lasting transnational ties that define global health at its best.

–Ian

Ending with evidence-based decision making

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One of the biggest takeaways from my first year as an MPH student was the importance of using evidence to inform the design and implementation of public health interventions – but what happens when there just isn’t enough evidence to make a concrete decision? This was a major practicum challenge that I didn’t anticipate. After sorting and screening and rereading titles and abstracts for hours upon hours, our article search process that started with nearly 700 publications narrowed down to only 11 – and among these, the majority only included child feces disposal practices nested as one small part of larger sanitation interventions. My research focused on the Asia-Pacific region, which has among the highest rates of open defecation globally, so I was surprised to find so few interventions targeting this behavior. Though perhaps this is due to the widespread perception that child feces aren’t as harmful as adults’.

Even large-scale sanitation interventions, like India’s Total Sanitation Campaign, have been notoriously unsuccessful at improving child health outcomes. Programs like these have focused mainly on providing hardware or subsidies for individual households to construct their own sanitation hardware (think toilets, pour-flush latrines, bathrooms) without actually working toward behavior change. Behavior-Centered Design is a new approach to solving environmental health problems and has been a major area of World Vision’s research, which is super exciting to be a part of! So maybe I didn’t find all the statistically significant effect sizes, confidence intervals or p-values that I was initially looking for to prove that yes, giving people toilets = safe child feces disposal = improved public health. But I did come across some rich qualitative data on what real communities perceive as their barriers to improved sanitation, why they engage in certain behaviors, and what they would prefer from a public health intervention. Using these determinants is the next step in designing an intervention that communities actually want.

It seems like I just blinked and the summer is gone and my practicum experience is wrapping up. Looking back to May, I now feel so much more prepared to work on real-world public health problems instead of just practicing in a classroom (but I am looking forward to being back in the classroom this fall semester to see everyone in person!). Even though I felt like my work wasn’t going as I originally planned, I learned even more than I thought I would.

–Lauren