Assigment 6 modules reflexion 2-3 pages.Apa seven . All instructions attached.

Module 6: Population Health During a Pandemic

Slide 1: Population Health During A Pandemic

Hello, and welcome to population health during a pandemic. This is a course for public health professionals and this education module has been made possible through a cooperative agreement. Between the centers for disease control and prevention and the Association for prevention teaching and research, this is module six and I’m Lori Thuente with Rosalind Franklin University of medicine and science.

Slide 2: Population Health Modules

So, as I said, this is module six. By now, you may have gone through some, if not all of the previous modules and hopefully this will be the culminating one for you.

Slide 3: Overall Learning Objective

As you know by now, we're hoping that you will gain a foundational knowledge and population health science and best practices in health and in the effective design, implementation, and evaluation of population health activities.

Slide 4: Module 6 Objectives

After completing this module you'll be able to assess the social and racial inequities and the root causes with the COVID-19 prevalence treatment and you'll be able to apply population health approaches to the management COVID-19 and future pandemics. Hopefully you will be able to implement effective communication strategies for developing action and facilitating trust when physical distancing and other risk mitigation strategies in place. And you will be able to identify linguistically and culturally appropriate messaging that reaches individuals, where they are.

Slide 5: Connections to Other Modules

This module is connected to all five of the other modules.

Slide 6: Other Module Connections Continued…

And you will see bits and pieces of those in in this one as well.

Slide 7: Objective 1

So let's take our first objective apply population health approaches to the management of COVID-19 and future pandemics.

Slide 8: Pandemics on Vulnerable and Minority Populations

We want to make sure that when we are considering the impact of pandemics and vulnerable and minority populations that we are ensuring access to care for those with increased social determinants of health. Through communication relationship building and knowledge that we identified methods of appropriate vacation to ensure correct information in multiple languages

Module 6 Transcript | 10

distributed to the Community members. In that way, involve community leaders when we're developing the mitigation strategies for the vulnerable populations, while we're maintaining treatment for chronic conditions.

Slide 9: H1N1 Pandemic: Federal Response and Deaths

It's important to look at how previous pandemics, have been handled United States in order to think about how we should go forward with future ones let's take the H1N1 or swine flu pandemic that occurred in 2009. It originated in Mexico and again it started in March of 2009 and all federal agencies were involved, from the beginning. Our first case was put into place, or our first case took place on 4/15 of ‘09 and contract tracing immediately went into effect through the federal government. On 4/23 the CDC had their first announcement, the next day they uploaded the viral sequence to an international database in order to compare it to other ones around the world. We were reporting to the World Health Organization per the guidelines as were other countries. We checked our supplies from the national stockpile and release them to states. On 4/27, so all of this happened within a week, the CDC warned of travel to and from Mexico and then the next day, the CDC approved a national test. We also then purchased an additional 13 million courses of antiviral medications and distributed them across the US and world and also distributed recommendations for the antiviral regimes. By 5/18, 40 states were conducting testing and that surveillance continued throughout the summer by October 5 we were able to give the first dose the vaccine here in the US. And by December of ‘09 the vaccine was available to everyone, so the result was that in a in one year there were about 60.8 million cases, about 270,400 people were hospitalized, and about 12,500 deaths occurred in the United States due to H1N1.

Slide 10: Ebola Pandemic: Federal Response and Deaths

The next pandemic we're going to look at is Ebola and Ebola actually originated many, many years ago in the Democratic Republic of Congo. However, the first us case happened on September 25 of 2014 that first case was in Texas, and on September 30 the CDC arrived on the scene and began to identify potentially exposed context of the Ebola patient, monitored those contacts, made plans for triaging and testing suspected Ebola patients, and reviewed infection control practices. By October 1, many federal agencies were involved there were 48 possible contacts, who were quarantine and monitored on October 8, Patient 1, the first patient who had the confirmed case died. On 10/15, Patients 2 and 3, healthcare workers of Patient 1, were confirmed. And then, by 10/20 of 2014, the CDC already put in place new infection control guidelines and new guidance for assessing the risk of potential Ebola patients that were implemented nationwide so the result of all of this action was four cases total, and only one death.

Slide 11: SARS-CoV-2 (COVID-19) Pandemic: Federal Response and Deaths

Now let's look at the SARS-COVID-19 pandemic in terms of the federal response and deaths. So the original first case was in China on 11/17 of 2019. The first US case was January 21, 2020.

By January 14 of 2020 the World Health Organization had announced the virus. And before our first case, the CDC held its first briefing and implemented screenings for three airports. By

February 23rd, we already had 14 cases reported in the US. It, we had a public emergency declared. We started with the CDC-initiated testing kits the Federal Drug Administration agency was trying to validate them, but we found that those kids were flawed. States began creating their own tests that the Federal the FDA approval left behind. The CDC then created a hospital preparedness tool which it rolled out across the country. The White House requested

$2.5 billion for vaccine development and at that point we had 57 cases. The Health and Human Services stated that we had 30 million N95 masks in the national stockpile but at that point we already needed 300 million, and there was no plan for distribution of these 30 million or purchase for more. By February 29 the FDA was allowing states to create their own test, but they required notification back to the FDA. In March, the states started requesting their own personal protective equipment supplies from the national stockpile. By mid-March, the World Health Organization declared COVID-19 to be a pandemic. Two days later, a national emergency was declared in the same day, the first testing kit was approved. By March 15, the HIPAA sanctions and penalties were waived for hospitals, so that the hospitals could report cases to a national database. However, this was very unevenly done. By March 18 there were more than 10,000 positive cases. Many were symptomatic but were unable to be tested because testing was severely limited and required a doctor's order at that point. By March 21 we'd already lost about 680 people and there were almost 100,000 positive cases. There became a bidding war between the States and the Federal Government for personal protective equipment and supplies. By April, New Jersey was the first state to require masks and make them mandatory. By the first of May, the CDC issued recommendations for contract tracing but they these were not mandatory, and by October 30th, only 33 states still had some kind of mask requirement. There was no mandatory federal mask requirement. There was also knows national testing strategy implemented. So as of the recording of this module, which is September 2nd, we now have about 650,000 deaths and many millions of cases.

Slide 12: Summary of Key Differences in Federal Response to H1N1 & Ebola v. SARS-COV-2: So what are the key differences in the federal response to H1N1, Ebola, and COVID? Well, in

H1N1 and Ebola there were key federal agencies involved prior to the first case being reported in the United States. Ebola tests had already been created the H1N1 test was created and approved than two weeks, we had national testing strategies, we had national contract tracing, beginning with the first case, and supplies and medications have been made readily available to those who needed them. For COVID-19, the CDC was the only federal agency involved with start. There were only recommendations made limiting community spread, there were no mandatory requirements. There were significant limitations and barriers and challenges for the test creation and distribution, and we had no national testing strategy. There was no national contract tracing plan. The supplies and medications were unevenly distributed, and there was no back national vaccination strategy.

Slide 13: Objective 2

Objective 2: to assess social and racial inequities and the root causes within the COVID-19 prevalence, treatment, and outcomes.

Slide 14: Population Health Surveillance During COVID-19:

Population health surveillance during COVID-19 and you learned about population health surveillance in module three. The goals for this, where do I identify vulnerable populations and to predict and track outbreaks for resource allocation. There were several challenges to that the current electronic health record system lacked the ability to connect healthcare systems and to aggregate the data into one national database. There was no infrastructure for large scale national coordination for identifying, testing, tracking, and/or counting cases. The individual states were made responsible for reporting to the national agency, and some States reported cases differently than others, or some did not at all. And that ended up prohibiting a very quick response.

Slide 15: COVID-19 Cases by Race:

So, if we look at code cases by race you'll see that the minority sized race groups were greatly affected by COVID-19 at a much higher magnitude. The Orange is the percent of COVID-19 cases and the blue is the percent of the US population. Okay, so you'll see that specifically black, African American, non-Hispanic and Hispanic Latinos had much greater populations of COVID-19 cases first versus their percentage of the US population.

Slide 16: COVID-19 Deaths by Race:

Here's another way to look at it, because it was all across the age ranges of the lifespan.

Slide 17: COVID-19 impacts and exacerbates several domains of life:

And what we found is really that COVID-19 impacts and exacerbates almost all the social determinants of health. It impacts education, food, economic stability, healthcare, neighborhood, and social context.

Slide 18: Social Determinants of Health & SARS-CoV-2:

So the COVID-19 pandemic, as we said, affected all US citizens, however, those with increased social determinants of health were impacted at significantly greater rates. And this is really because of economic stability, which is both a key driver and social determinants of health and, as it turns out COVID-19. Because without a steady sufficient income people cannot afford to obtain education food or healthcare. It resulted in poor housing and unsafe community, so the neighborhood and physical environment was not what it needed to be. We're going to talk about the education impacts, the impacts on food and Community and also on the health care system, where we're going to talk about these individually now.

Slide 19: Economic Instability

So economic instability. Unemployment rose during the pandemic from 6.2 million in February of 2020 to 20.5 million just three months later. States were overwhelmed with claims and assistance was delayed because not only did they have so many more people submitting claims, but people were trying to work from home in order to process these claims. The unemployment resulted in an increase in multi-generational households, so people began to live in more crowded living conditions in order to try to save money. Minorities who may

remain employed in essential occupations we know are paid less than a living wage. And up to 15 million people lost their healthcare coverage. So the medical bills from COVID-19 or other illnesses have contributed to significant debt and is a, medical bills are about 80% of the reasons why people file for bankruptcy.

Slide 20: Unemployment by Race:

If we look at the unemployment by race, we will see that there are higher rates of unemployment for women and for black people. So you can see that here depicted graphically. We can talk about that in just a little bit more.

Slide 21: Wealth Inequality:

We're also going to talk about wealth inequality. So black and Latino families are twice as likely to have zero wealth, and wealth is basically having any sort of savings or assets on which to fall back on. So you'll see that in 1983 15.5% of all US families have zero or net wealth, negative net wealth, and it's disproportionate again by racial groups and that increased 6% by 2016, increased across all demographic groups, except for Latino families who started faring better.

Slide 22: Federal and Local Population Health Interventions to Address Economic Instability: There were federal and local population health interventions to help address the economic instability. There were federally funded stimulus checks, there was a national moratorium on evictions, a utility cut off moratorium, so people did not lose their electricity or their heat in place in most states. Many places started to give hazard pay increases. And federal student loan payments were suspended until September of 2021 at the interest rates. Interest did not increase during that time. And by providing financial assistance and allowing people to remain in their homes, it allowed them to quarantine and thereby lessened the burden of illness.

Slide 23: Opportunities to Address Economic Instability for Future Pandemics:

So opportunity zones are disadvantaged areas in which people can invest for significant tax benefits. And these opportunity zones are places where the average median family income is lower, okay it's about 2/3 of the national median family income. Poverty rate is double the national poverty rate. There’s about a third of prime age adults who are unemployed. About 21% of the adults in an opportunity zone lack a high school diploma, and the average life expectancy is much below the national average. And again, these are places where investors can invest in businesses, in other sectors of commerce, in which they can hopefully improve the conditions in those areas and receive significant tax benefits. And this is one of the ways these opportunities zones were increased during the pandemic, and this is one way for people to try to maximize their environments.

Slide 24: Neighborhood and Physical Environment:

So, within the neighborhood and physical environment, we know that minority women are a large portion of the essential worker population. They hold roles in retail, service, manufacturing, and agriculture, and by being an essential worker to increase their likelihood of infection, because they were now increasingly exposed to the general population. Minorities,

especially Asians and Hispanics, are more likely to be living in multi-generational households, which again leads to crowded conditions, so more people in a smaller place and having more infections. In the first quarter of 2020 nationwide 44% of black families own their own home versus about 74% of whites, and that increased the instability of their housing. And low-income neighborhoods we know from previous modules they have fewer places to obtain health care.

Slide 25: Federal and Local Actions Taken to Improve Neighborhoods & Physical Environments: So some federal and local actions taken to improve neighborhoods and physical environments, so the CARES Act went into effect in March of 2020 and it was to help economically develop and support the population basically of the United States. The funding was to help economically distressed communities to help establish job growth, develop regional economic activities and collaborations, and to stimulate commercial and industrial developments through a range of investment programs. We learned about community health workers in previous modules, and community health workers were employed to help increase awareness and access to the local health care practices, and now we know that they have been used to help educate on vaccines. Initial research via population health assessments has uncovered unfortunately very few initiatives, other than the opportunity zones to improve low-income neighborhoods.

Slide 26: Education Impacts during COVID-19:

Education was perhaps the biggest sector impacted during COVID-19 because the majority of schools, colleges and universities had to shut their doors and go to online learning. Millions of children, adolescents and adults began learning at home in front of their computers. Children from low-income households, who we already know from previous modules are less likely to be educated well are now 10 times less likely to be participating in online learning, which then leaves them farther behind. Over 4.4 million children lack consistent computer access, and about 3.7 million lack consistent Internet access. So, unfortunately, nearly 70% of essential workers lack a college degree, which limits their job opportunities and impacts their ability to help their children learn at home.

Slide 27: Federal, State, and Local Actions to Address Education Barriers:

But there were federal, state, and local actions to address these education barriers. Again, the CARES Act included increased included money for increased purchases of computer technology for students. It included money for assistive and adaptive technology for students’ use at home. Universities were able to provide emergency funds, food, shelter, and healthcare to students in need. And many companies partnered together with school districts to offer free computers to marginalize children during the pandemic, either low cost or no cost Internet access for low-income residents, and this helped to ultimately provide households with computers and Internet access, which allowed them to attend school and find additional resources. Food security was an issue is still an issue during COVID-19. Food insecurity doubled or tripled depending on where one lives, and it impacted again Hispanic and black individuals more than whites. By June of 2020 almost 14 million children lived in households that reported food insecurity, and again disproportionate by race. Many children received breakfast and

lunch at school, did not get to do so and went hungry. College students on scholarships had to leave when the College is closed and therefore lost their housing and food. And food banks had to turn people away.

Slide 28: Food Insecurity:

So this is a graphic representation of food insecurity. About 17% of all American households have children and are food insecure.

Slide 29: Federal, State, and Local Actions to Address Food Insecurity:

So some federal, state, and local actions to adjust food insecurity. There was an increase in Community Meals on Wheels, and again that helps to impact the elderly and improve their access to food. There were many bills introduced by legislators and past that address college food insecurity, you can go to this link at the bottom and watch a video on innovations and nutrition programs that addressed food insecurity, and it's really a good video and gives some excellent examples that people can follow. Healthcare organizations partnered with food pantries to provide prescriptions for healthy food, so that people were able to access it a little bit easier. And again, the CARES Act provided increased funding to school to continue to provide meals for pickup or delivery in some areas of the country because of the rural locations to families of school children.

Slide 30: Community and Social Context Impacts:

In terms of community and social context impacts, social distancing required to minimize the spread of resulted in increased levels of social isolation. We have almost 38 million people who live alone, and therefore they often did not see anyone. We have 4 in 10 adults who have two or more chronic illnesses, which significantly increased their more morbidity and mortality rates to COVID-19 or from COVID-19, and that required them to be even more isolated from the public. And what we know now is this social isolation resulted in increased physical and mental health issues. It may have resulted in 26% increased risk of all-cause mortality and was more evident in rural areas and the elderly population.

Slide 31: Federal Policy and Programs to Address Social Isolation:

There were limited federal policies and programs to address social isolation. CMS expanded coverage from mental health telehealth appointments, so that was definitely an advantage. And the National Institute on Aging implemented a campaign to increase socialization among the elderly during COVID-19.

Slide 32: Healthcare Impacts during COVID-19:

Healthcare was also impacted during COVID-19 because about 40% of adults deleted seeking medical care. So things that might have been caught early were not. Elective surgeries were postponed, as were necessary treatments, such as chemotherapy. There was a sharp decline in childhood vaccinations during COVID-19 because children are not going and getting their Well- Child visits at their pediatrician. Poverty increased and exacerbated chronic illness which then again turns around and increases the level of poverty in a vicious cycle. People impacted by

social determinants of health face higher rates of diabetes, heart disease and other chronic conditions and again, we know that that has worsened their COVID-19 prognosis should they get it. And a lack of a national free COVID-19 testing program delayed people in getting the care that they needed.

Slide 33: Actions to Impact Healthcare

So some actions to impact health care. Although we talked about how many lost their private insurance, the Affordable Care Act increased their numbers of insured individuals, and I’ll show you a slide on that in just a minute. There was increased access to Telehealth, which is what we said, via Medicare and other insurance companies. Federal laws extended the licensing coverage to include mental health across state lines. So providers in say Illinois were able to use telehealth to treat patients in Indiana, for example. And there's an example of pediatricians in Boston. They created a mobile vaccine clinic and went out to their patients in their patient database and vaccinated their patients.

Slide 34: Percentage of uninsured people in the US by ethnicity 2010-2020

So this shows the percentage of uninsured people by race from 2010 to 2020. So you can see that again, as a general rule, white people are more insured than other races. And that in 2020, which is the gray bar on each of these vertical columns, the dark green one on the right, that even though people were losing their private insurance in some cases, they certainly didn't lose it as much due to the Affordable Care Act.

Slide 35: Reflection Question #1:

So reflection question number one, and you can stop in the video if you want to stop and think about this, but in what ways did your community or health department apply population health approaches to address the COVID-19 pandemic? If you want to stop your slide you can, and then I’m going to go to the next slide which contains some possible answers.

Slide 36: Reflection Question #1: ANSWERS:

So you can find out that maybe your county health department utilized healthcare providers students to conduct contract tracing, local clinics may have offered Telehealth appointments. Perhaps your county health department created free mass testing sites. Your local schools created meal pickup and delivery services and food banks increased the availability of food.

Slide 37: Objective 3:

Objective three, to implement effective communication strategies for developing connection and facilitating trust when physical distance in or other risk mitigation strategies are in place.

Slide 38: What Other Countries Did Well:

Well we're going to talk for just a second about what other countries did well, because this is important. They were prepared from previous pandemics, and we know that countries such as New Zealand, they were able to get their case numbers to be very, very low by closing the borders right away, by deferring to scientists, by having a coordinated communication plan.

Some countries implemented immediate contract tracing and they used apps in order to trace people's whereabouts, in order to figure out who they came in contact with. Other countries developed and manufactured test very quickly. Many countries and forced quarantines from the start, implemented mandatory test taking or temperature taking, and mask enforcement in public buildings. Several countries had nationwide, national widespread testing, and many countries implemented multiple stimulus packages.

Slide 39: Communication Plans are Essential During a Crisis Such as a Pandemic:

So we know that a crisis plan is essential, a communication plan is essential, during a crisis such as a pandemic, and it's important to have that in place prior to the start of the crisis. So you'll want to know what is the line of communication, for example. Does it go federal, state, local? And you'll want to identify and partner with agencies that might be specific to an individual crisis. For example, for hurricane Katrina, what they learned was that they needed to have a coordinated effort between healthcare, transportation, and real estate because they ended up putting so many people, for example in the super bowl stadium, and they didn't really have a way to get them there or way to care for them, once they were there. So they learned a lot from that crisis. We’ll want to identify specific contacts at each location, as well as backups in case that person is unavailable, update these communication plans, at least the contact, information every year. And really when we're working with a minority communities, we want to make sure that we are engaging through neighborhood organizations through churches, salons, and barbershops; places where people are.

Slide 40: Crisis Communication Plan Examples:

These are some crisis communication plan examples, you can use any of these links, and they're very well laid out plans that talk about the structures that I just discussed.

Slide 41: Effective Communication Strategies:

Having an effective communication strategy is vital, and you'll want to begin by identifying who is going to communicate these messages. You'll want to have a spokesperson, someone that people recognize when the message is delivered. So if you can have a local influencer or experts, as we all know, Doctor Fauci became a spokesperson, for example. And that spokesperson should always have training. There are multiple training videos and how to be a spokesperson on YouTube and easily accessible to everyone.

Slide 42: Communication Strategies:

The communication strategies need to be clear and consistent messages early, frequently, and through different channels to reach all the constituents. You'll need to identify what are the languages most spoken in your area, including American Sign Language, so that the messages that you are trying to convey are conveyed in those languages as well. You'll want to make sure that all cultural contexts are considered. You want to think about how the message is getting communicated, so using the regular channels of communication such as radio, TV, billboards etc. As well as atypical ones, going through social media going through churches and schools.

Try to identify potential areas of controversy and plan accordingly for those have backup plans

and ensure that all the information being communicated the websites the phone numbers, the addresses, etc., are correct and true.

Slide 43: Additional Effective Communication Strategies:

It's very important to get feedback on the communication that you are giving. So we want to make sure that there's a safe route to give this feedback and to receive this feedback, because if your message isn't getting through or it's getting through and not being taken in the way that you intended, you're going to want to get that feedback quickly and make changes as needed. Make sure that you're demonstrating empathy towards the problem and a commitment towards the solution. It's vital to be transparent and honest with your message, and it's also vital to treat everyone the same there's no one with special privileges, who gets to bypass rules or not follow the policies. It's important to develop trust by being accountable for the message and whatever the corresponding actions may be. And then you'll want to debrief with the team following each communication. You want to know what went well, what didn't, what can we do better than next time.

Slide 44: Examples of Excellent COVID-19 Communication:

There are some examples of coven of excellent COVID-19 communication and the links are available on slide 65. Many counties use text messaging alert systems to keep their populations updated, cities employ a variety of strategies to communicate with their constituents. So for example during initial assessments, they surveyed residents as to what they needed and how they wanted the information. They obtained TV and radio spots, hopefully donated by other local businesses, etc., and social media in order to convey their message on a broad scale. A couple cities hired local artists to create messages in public areas. Many promoted bicycling as a socially distance method of travel. And they created and distributed service guides for the homeless and underserved population, because these two populations were very much at risk for illness and obtaining COVID-19. And it's also vital to dispel any cultural misinformation.

Slide 45: Web Examples:

You can go, there are more references in the slides at the end, but you can see, six examples of effective COVID-19 communication here, you can also see for a specific example, what happened in Lake County, Illinois and how they did their COVID-19 updates.

Slide 46: Objective 4:

Objective four, to identify linguistically and culturally appropriate messaging there we just individuals, where they are.

Slide 47: Consider Culture:

You have to consider culture and an iceberg, is a great metaphor to describe the culture. Okay, most people only see the tip of the iceberg, okay, which is really only about 10%. The remaining 90% is much more meaningful and can result in longer lasting changes.

Slide 48: How to Provide Culturally Appropriate Communication:

Here are a couple examples of culturally appropriate communication, okay. So this one was the three tenants of cross cultural communication. And it's to help cultivate strong relationships and to counteract fears and encouraging safe behaviors during the pandemic so demonstrating empathy; it's not a feeling, it's an action. Okay, demonstrate curiosity and demonstrating respect, so making sure that all of these are within the messages that you are sending.

Slide 49: Examples of Culturally Appropriate Communication:

So, for example, COVID-19 and hospitality in South Asian culture. So they talked about having solutions, okay, so be honest and clearly communicate why not. Phrase your request as your collective duty towards society, because that is something that is culturally appropriate.

Understand that it's okay to be seen going against cultural norms, that you're indirectly saving lives by reducing the spread and offering alternative, such as video calling to ask about people's well-being. These are all done through a health department and making sure that the information is clearly communicated in the languages of their local community.

Slide 50: Final Takeaways:

And final takeaways. The COVID-19 pandemic has disproportionately affected those with social determinants of health. It is exacerbated the disparities and the inequities. We know now that there's a need for a federally coordinated program to identify test, track, and treat cases from the first day, and that is essential to controlling the spread of the disease. We need to make sure that we offer alternate approaches to access healthcare, such as telehealth. But they only work if people can access them. Communication during a pandemic will have to be customized for each specific group in order to have the maximum impact. And lastly, use population health assessments and surveillance data to demonstrate policy and, I'm sorry, to develop policy and program level interventions.

Slide 51: Reflection Question #2:

Reflection question number two. What are some effective communication strategies that you can use during a crisis such as the pandemic? If you'd like to pause and think about this just stop the video otherwise I’m going to move on.

Slide 52: Reflection Question #2 – ANSWERS:

Some possible answers are having a communication plan in place prior to the crisis, identifying potential areas of controversy and addressing those, delivering the information in multiple ways, providing a safe way for your audience provide feedback, and being respectful and empathic with your audience.

Slide 53-end:

Here are the references by slide. So if you need a reference that pertains to a specific slide you can go here and look for these. And then further down, we have other references just in order so you can see those. I hope you enjoyed this module, and I hope that you have learned the things that we were hoping that you would learn.