Public health without borders

Alumna Tala Al-Rousan (MPH ’15) uses her public health training to understand and address the health needs of Syrian refugees and other vulnerable populations around the globe.

Tala A--Rousan stands by a map in Zaatari refugee camp
Tala Al-Rousan stands by a map in Zaatari refugee camp

When Tala Al-Rousan was training to be a doctor, she often stumped her professors with challenging questions.

“Many things I asked during clinics or rotations couldn’t be answered by physicians,” Al-Rousan recalls. “They would tell me, maybe you should pursue a degree in public health because your questions are tackling social determinants of health, health disparities, and access to care.”

Social activism and the health of vulnerable populations have always been important to Al-Rousan, who grew up in Jordan and earned her medical degree at Cairo University in Egypt. As a medical student, she engaged in many public health initiatives, including raising awareness against female genital mutilation in Egypt and promoting breast cancer screening education. After receiving her degree, she joined Doctors without Borders as a medical officer and served in Yemen for several months before she moved to the U.S. in 2011.

Her husband’s job then brought her to the University of Iowa, where she enrolled in the MPH program in epidemiology.

“Data is the most powerful tool. I wanted to be equipped with the necessary tools to do quantitative research that would inform policies,” says Al-Rousan about her program choice. At the UI, she conducted research with Robert Wallace, CPH professor of epidemiology.

Al-Rousan has “a personal level of commitment to those less fortunate,” says Wallace. “Using a national U.S. database, Tala was able to write two papers on the health of older people living in mobile homes and the preparedness of older people for natural disasters. In both situations, she found that there were clear deficits in health status and in preparation for emergencies.”

She also researched Iowa prisoners’ health needs and participated in the Obermann Graduate Institute, a weeklong interdisciplinary program in which UI graduate students explore how public engagement can enhance teaching, research, and creative work.

 

The Syrian Refugee Crisis

Tala Al-Rousan meeting with refugees to discuss health concerns
Al-Rousan meeting with refugees to discuss health concerns

Al-Rousan is currently a Lown Scholar at the Harvard T.H. Chan School of Public Health and a project coordinator at Harvard Humanitarian Initiative. The Lown Scholars Program was established in honor of Dr. Bernard Lown, a Nobel Peace Prize laureate and a world-renowned cardiologist and activist whose career has advanced public health globally.

Al-Rousan is researching the impact of the Syrian refugee crisis on the health of refugees in Jordan, as well as the health of the host country’s population. Since the conflict in Syria began in 2011, more than 4.8 million Syrians have sought refuge outside their home country, with millions more displaced within its borders. The United Nations has called the situation the worst refugee crisis since World War II.

Jordan, which shares borders with Syria, is providing asylum for an estimated 640,000 refugees, presenting significant humanitarian and economic challenges to the small country of limited resources.

In late 2015, Al-Rousan spent two months in northern Jordan, where she interviewed officials from hospitals, non-governmental organizations, and the Ministry of Health about refugees’ health issues. She also conducted focus groups with refugees at Zaatari, the largest refugee camp in the Middle East. She used the information to develop a questionnaire for refugees so they could rank their health concerns.

Al-Rousan and her colleagues are currently analyzing the data to determine what the most pressing health concerns are to help guide priorities and allocate resources. A second phase of the project will use these findings to craft a public health intervention that would lessen the impact of this crisis globally.

 

Life in the Camp

The fence surrounding Zaatari refugee camp
The fence surrounding Zaatari refugee camp

“It’s like a big city,” Al-Rousan says of Zaatari, which houses roughly 80,000 people. The camp has streets, schools, hospitals, a thriving (but unauthorized) market, tents, and trailers — all surrounded by razor wire-topped fences and guards. Services are unevenly distributed, and about 1 in 3 children don’t attend school. Residents can’t leave without permission and aren’t authorized to work in Jordan, meaning many refugees have little to do but wait and hope they can return home someday.

“There are many health issues affecting this population, such as disease outbreaks, high rates of infant mortality, and others,” notes Al-Rousan. Non-communicable diseases are the leading cause of death and remain difficult to manage. At the same time, measles, tuberculosis, and other diseases are re-emerging.

The preliminary results from Al-Rousan’s research show that the burden of Syrian refugees is destabilizing an already strained Jordanian health care system. Jordan can no longer afford to pay for refugees’ health care, so chronic diseases are inadequately treated.

There is also widespread stigma around seeking mental health care, even though “mental health issues are very common in war-affected communities,” Al-Rousan says, adding that both children and adults have experienced immense trauma.

 

Building Trust 

A muddy street in Zaatari refugee camp
A street in Zaatari refugee camp

Building partnerships among different sectors was very important to her research, but very challenging, Al-Rousan says. Being fluent in Arabic helped significantly, as was her familiarity with Jordan. Equally important was “getting the government’s blessing and help” with the project, she says.

Al-Rousan’s research assistant, Zaker Schwabkey, who is based in Jordan, had many helpful personal connections as well.

“We worked with Syrians to identify people who were good at recruiting others,” explains Al-Rousan, who spent a great deal of time meeting with and listening to various groups and stakeholders. “We had to build that trust relationship.”

As for future steps, Al-Rousan plans to apply the research to refugee camps in other countries that share the same amount of refugee burden, such as Turkey and Lebanon.

“If similarities are found, then the results could be applied elsewhere,” she says. “There’s a huge need and huge opportunity for public health research on refugees all over the world. It is a public health disaster.”

 

We All Are Connected

Tala Al-Rousan meeting with women and children refugees
Tala Al-Rousan meeting with women and children refugees

Public health translates across borders, something Al-Rousan urges students and practitioners to remember.

“You can still do global heath inside the United Sates. It doesn’t have to be outside the U.S.,” Al-Rousan says, citing work with homeless populations as one example.

“At Iowa, I also worked with prisoners during my practicum,” she adds. “This really helped me to apply my skills in the refugee camp setting, because I think of refugees as prisoners, too.”

She also stresses the value of public scholarship and community engagement, as well as keeping in mind the human stories behind the research.

“Syrian refugees are people like us – teachers, artists, engineers – who have been forced out of their country,” says Al-Rousan. “We as public health practitioners understand how connected we all are. The Syrian crisis affects the entire world.”

 

All photos courtesy of Tala Al-Rousan and Zaker Schwabkey

See more photos at the Lown Syrian Refugees Health Study Facebook page

 

CPH researchers find HPV vaccine levels lag among certain populations

A team of researchers from the University of Iowa College of Public Health recently published a study showing lagging uptake of human papillomavirus (HPV) vaccine in men and racial/ethnic disparities among women.

A portrait of Paul Gilbert, assistant professor of community and behavioral health at the University of Iowa College of Public Health.
Paul Gilbert

The study, published in the February edition of the American Journal of Public Health, shows that only 5% of young men reported ever receiving the HPV vaccine, with no differences in uptake by race/ethnicity or sexual orientation. However 30% of young women reported receiving at least one dose of HPV vaccine, with women of color having lower odds of initiating and completing the vaccine series compared with White women.

Paul Gilbert, assistant professor in the Department of Community and Behavioral Health and co-author of the study, thinks the main reason that uptake is substantially lower among males is that the vaccines were originally licensed only for use in girls and young women.

“Now the vaccine is recommended for both boys and girls, young women and young men,” Gilbert says. “The messaging has also changed. HPV vaccine is now presented as cancer-prevention rather than STI-prevention.”

HPV vaccines have proved to be effective in preventing infection and are expected to reduce incidence of cancers caused by the virus.  The vaccines do not prevent other sexually transmitted diseases, nor do they treat existing HPV infections or HPV-related disease.

Jason Daniel-Ulloa
Jason Daniel-Ulloa

Jason Daniel-Ulloa, assistant research scientist in the Department of Community and Behavioral Health and study co-author, says the reasons for the vaccination disparities among women are more difficult to pin down and may relate to socio-economic and cultural barriers to access.

“Of course the ultimate goal is to increase uptake of the vaccine among these populations,” he says. “This means working with communities to identify unique barriers to vaccination and addressing them by building partnerships between communities, public health departments, and clinics.”

According to the researchers, this may have been the first study to generate population estimates of HPV vaccination by gender, race/ethnicity, and sexual identity. The team used data from the 2013 National Health Interview Survey, a cross-sectional survey of the noninstitutionalized US population with oversampling of racial/ethnic minorities. The analytic sample consisted of 3441 women and 3003 men aged 18 to 30 years, of whom 51% and 53% were non-Hispanic White, respectively.

Edith Parker, professor and head of community and behavioral health and director of the UI’s Prevention Research Center for Rural Health, is also co-author of the study.

You can read the full article here: http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2015.303039

 

Study evaluates racial disparity in substance abuse referrals, treatment outcomes

photo illustration of doors an arrowsWhat motivates someone to change is complex, particularly when it comes to addictive behaviors. Substance abuse programs in the U.S. reflect the disparity evident in the health care system as a whole—while Whites are twice as likely to report substance abuse problems as Blacks, Black clients are two times less likely to complete substance abuse treatment programs.

Race and referral sources

In an effort to investigate this paradox, a team of University of Iowa researchers, including Marizen Ramirez, associate professor of occupational and environmental health in the College of Public Health, considered how referral source might affect completion of treatment among racial groups. They found that Black clients were most likely to successfully complete treatment when referred by an employer, while for White clients, criminal justice referrals such as court orders were associated with the highest percentage of program completion.

The study, which was published online April 18, 2015, in the journal Addictive Behaviors, drew on the vast data sets collected by the national Substance Abuse and Mental Health Services Administration from the years 2006–2009. Clients were over 18 and had received no prior treatment; more than 2.5 million cases met these criteria. Overall, the study found a 44.2% successful treatment completion rate for all clients. The treatment completion rate was 47.1% for Whites and 34.9% for Blacks.

Referral sources included self-referral, drug abuse agency, health care professional, school, employer, community, and criminal justice agency. It was noted that several of these may include a certain amount of coercion, as failure to comply would result in consequences such as loss of freedom, employment, or education.

Although the researchers could not say definitively that this was where racial differences entered the equation, they suggest that Blacks may not have been as affected by the coercive nature of possible incarceration as Whites in that they may not have believed that their behavior would have an impact on whether or not they received jail time.

Criminal justice, employer, and student referral sources had the highest success rate for both White and Black clients. Interestingly, self-referrals and referrals from health care providers were associated with the lowest success rates for both Black and White clients.

Multicultural perspectives

The study makes a strong case for the argument that incentives for substance abuse treatment might benefit from a multicultural perspective.

“Health care providers need to learn better follow-up techniques to help their patients recover,” says corresponding author Stephan Arndt, director of the Iowa Consortium for Substance Abuse Research and Evaluation. “Making more of an effort to involve employers rather than the criminal justice system may reduce the disparities.” Arndt is also a professor in biostatistics and psychiatry.

The research team also included Ethan Sahker, graduate research assistant in the Iowa Consortium for Substance Abuse Research and Evaluation and the Department of Psychological and Quantitative Foundations; Maisha Toussaint, graduate research assistant in the Department of Epidemiology; and Saba Ali, associate professor in the Department of Psychological and Quantitative Foundations.

 

Wright studying variations in observation care

A portrait of Brad Wright of the University of Iowa College of Public Health.
Brad Wright

Each year, about 1 million Medicare beneficiaries who visit the emergency room find themselves held for observation rather than being admitted to the hospital. Researchers have found the rate of observation care—a hospital-based outpatient service used to evaluate and treat acutely ill patients for extended periods—has increased nationally over the past decade, and it has become a common alternative to full hospitalization. This outpatient care saves hospitals money, but does it benefit the patient?

According to Brad Wright, assistant professor of health management and policy in the University of Iowa College of Public Health, critics suggest observation care costs patients more and may result in reduced quality of care. Previous studies also point to racial and geographic variations in the use of observation care. In a national study funded by the National Institute on Aging, Wright and colleagues from Brown University and the University of Michigan will analyze Medicare claims data from 2007-2011 to determine the causes and consequences of racial and geographic disparities in observation care among Medicare patients.

“We want to see if the variation in who receives observation care occurs within or between hospitals,” said Wright. “Are certain hospitals more likely to use observation? Or is there an inherent racial bias no matter which hospital you go to?”

Wright will also investigate whether observation care leads to better or worse health outcomes, examining mortality rates and how many patients return to the emergency department or get readmitted within 30 or 90 days.

“Are there important quality outcome differences?” asked Wright. “Maybe they don’t get the level or intensity of services they need and end up coming back. Or are they more likely to be admitted because more observation leads to better clinical decisions?”

Wright hopes the study’s findings will help inform changes in hospital policy and Medicare coverage of observation services.