Projects
Typically, rural communities have limited access to health services and experience worse health outcomes than people living in urban areas. As such, living in rural or isolated communities is a social determinant of health. Puerto Rico (PR) is a US territory that includes particularly isolated communities. The Centers for Disease Control and Prevention (CDC) report that chronic disease is the leading cause of death among adults in the US and PR. Healthcare responses to the COVID-19 pandemic have demonstrated that Telehealth services (THS) and deployment of community health workers (CHWs) increase access to care and improve health, particularly in rural areas that were previously underserved. Telehealth has not been equitably available, and rural communities such as those in PR have not yet benefited from this increased access. Although the CHW model of care was replaced in PR during health care reforms, there has been an awakening to re-establish the CHW model after the 2017 Hurricane María. Capitalizing upon our extensive expertise and longstanding relationships with the Puerto Rican communities, an innovative community-based health care improvement study is proposed to examine the impact of integrating THS and CHWs into existing health services.
This model will address health inequities – particularly chronic disease – associated with living in isolated/rural communities within PR. The proposed study would be conducted on the island of Culebra, an isolated municipality of PR of approximately 1,700 inhabitants. Culebra is the municipality with the highest mortality rate in PR. Chronic diseases, including diabetes and cardiovascular, are the leading causes of death. Most specialty health services (e.g., Endocrinology, Cardiology) are only available on the main island. Our previous community-based research findings illustrated that access to care was a significant barrier to positive health outcomes. Study objectives are to investigate whether integrating THS, CHWs with health care facilities will improve health access and health outcomes. The proposed study would collaborate with longstanding academic partners in Culebra to establish THS facilitated by CHWs to coordinate social and health services and engagement.
It is hypothesized that an integrated approach will result in the following outcomes:
- increased access to healthcare facilities
- increased access to health care
- reduced health inequities in isolated areas
- improved chronic diseases outcomes.
Measures of satisfaction and health literacy will provide context, and contribute to our understanding of the effectiveness of THS delivery. Aims include the evaluation of:
- feasibility of THS as coordinated by CHWs
- effectiveness of THS as coordinated by CHWs (chronic disease outcomes such as BP, glucose, and MI)
- satisfaction with health services and health literacy
Study findings will inform the future use of Telehealth, and the role of CHWs to increase health equity and access to care for isolated communities throughout the US and its territories.
The lack of equitable information about COVID-19 is a public health challenge. Community gaps in COVID-19 education and social and health care services (including vaccines) should be prioritized as a critical effort to end the pandemic. Misinformation created by the politicization of COVID-19 and related public health measures has magnified the pandemic’s challenges, including access to healthcare, vaccination and testing efforts, and personal protective equipment (PPE). Communities with more significant pandemic-related risks are typically marginalized, and the lack of equitable access to information about COVID-19 has become another layer exacerbating pre-existing socio-structural determinants of health.
Information and Communication Technology (ICT) have been demonstrated to reduce the gaps of marginalization in education, and access among communities globally. These community members are also typically embedded in the use of ICT’s for their daily living. We identified regional and statewide gaps in services and education regarding COVID-19. In the context of these inequities, and understanding the importance of having widespread, accessible information to attenuate COVID-19, an ICT chatbot tool (named “Ana”) was developed.
Ana, a community collaborative ICT tool within the University of Rochester Medical Center (URMC), is funded by the United States Centers for Disease Control and Prevention (CDC) and the Association of University Centers on Disabilities (AUCD). Ana was created for the State of New York, following a theoretical framework integrating principles of Diffusion of Innovations Theory and Social Cognitive Theory. Ana interacts as a chatbot to disseminate unbiased information to the community about the COVID-19 vaccine, with a specific emphasis on outreach and accessibility to the disability community.
Ana provides her users answers to common questions about COVID-19, including vaccine options, side effects, virus variants, and public health guidelines. Users navigate a menu bar to select among various COVID-19-related themes, and Ana will create an interactive experience providing simple but scientifically proven answers with a friendly and engaging spin. Ana’s repository of educational content is based on national and international organizations (e.g., WHO, CDC), as well as interdisciplinary experts in medicine, psychology, and public health from URMC. Content is regularly updated accordingly to new guidelines and information.
Ana was designed to not only provide COVID-19 information but to close the gaps of COVID-19 healthcare access; therefore, users can engage directly with the New York Department of Public Health hotline to schedule vaccine appointments, identify testing sites, and to explore the prevalence of the virus in their geographical locations. Currently, Ana is available in English and Spanish, and use of plain language is prioritized.
Understanding the importance of ICTs adoption, dissemination, sustainability, and usability, community members are encouraged to rate their interactions with Ana. This information helps developers to address community priorities and create a better experience for users. The development of ICTs such as Ana is an effective way to address health disparities among marginalized communities and contribute to ending the pandemic.
Ecologically, communities living in marginalized conditions face environmental health risks (EnvHR) that place them at risk for public health crises. Traditional approaches to address EnvHR do not necessarily truly engage communities. Marginalized communities, often technologically interconnected, can take control of their environmental challenges and achieve sustainable changes. Information and Communication Technology (ICT) can reduce disparity. ICTs, including mHealth, can facilitate the process of community engagement.
Within a technology and behavioral theoretical model, this study aimed to stimulate collective action among community members to reduce EnvHR. An inclusive mixed-methods multi-phase approach will be conducted, engaging community members from Culebra, Puerto Rico in the design, development, pilot test, and evaluation of an mhealth tool termed ¡mZAP! (Zonas, Acción y Protección). Semi-structured interviews following Rapid Qualitative Inquiry (RQI), and user-centered design will guide the development of ¡mZAP!.
¡mZAP! is a mobile application with the capacity of mapping, crowdsourcing, and simple way that will allow community members to alert “hot-zone” locations to the stakeholders interested in creating ecological action in their community. This multi-theoretical (Social Cognitive and Diffusion of Innovations Theories) concept integrates explanatory and prospective approaches and will generate systematic short-term solutions for ecological challenges and long-term solutions providing the necessary tools for reducing environmental health risks and the promotion of community ecological and health equity.