Clinical Commentary, System Change and Community Development
Health Equity
Within this article by Hauenstein, Clark, Merwin (2019), health systems within disadvantaged populations are critically evaluated as it relates to population health and health equity. A model is developed to show how health status, person-centered health goals and health outcomes are all effected by micro, mezzo and macro influences. Hauenstein, etc. (2019) describes disenfranchised populations as having multiple disadvantages to good health, mentally and physically. The article utilizes patients with severe mental illness and who live in rural areas as an example and describes the generalizability to other vulnerable populations as well. This specific population has community influences that affect accessibility and autonomy, that would describe the mezzo. On a macro level, rural areas have very little resources to work with as far as treatment, quality of services, and little financial resources. The micro is also described as family conflict, little education, and low social support can all have negative influences. The health outcomes recorded from these populations will vary depending on the negative influences of the community, the health care accessible, and the individual. The intersectionality and the multi-level approach to mental and physical health care is vital for not only social workers to be aware of but also for social workers to educate others on. I have worked in a rural community hospital for the past several years and have seen many influences and obstacles on a system and community level that impact my patient’s ability to access appropriate care. On of the points that is brought up is that rural areas have difficulty with being HIPPA compliant and even common word of mouth to be a community influence that prevents or discourages a patient from seeking or continuing with mental health services. The model describes person-centered health goals as the center of the model. I relate this to motivational interviewing as well that has been studied within physical health goals being used in healthcare systems only recently. Within rural areas, providers have little opportunity for new trainings and education for best-practices. Therefore, reaching providers in rural areas with this model of care many be an obstacle. Many social workers wear multiple hats in rural areas and cannot support a vast number of responsibilities and roles within health goals of the region. It is vital that instead of doing everything we can give the tools for other health care professionals and create an integrated model of care. Keeping a multi-system model in mind, we also can elevate some of the pressure that other professionals feel when working with seemingly impossible obstacles to health outcomes.
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Hauenstein, E. J., Clark, R. S., & Merwin, E. I. (2019). Modeling Health Disparities and Outcomes in Disenfranchised Populations. Community Mental Health Journal, 55(1), 9. https://doi.org/10.1007/s10597-018-0326-9
Social Work within a Global Context
Within my work I am passionate about underserved communities and the systems that keep the cycle of oppression in place. This article, Benjamin (2020), describes how the pandemic of Covid-19 served as an example of one of many global disasters that health systems are vulnerable to, and therefore the communities of underserved populations are disproportionally affected by. The following quote exemplifies this concept, “The current pandemic demonstrates the challenges that we must overcome as a global community to ensure equitable health care access, economic security, and public health protections for vulnerable communities” (Benjamin, 2020, p. 44.) The author describes that nations within the global context are now interconnected so much that every nation is affected if one is affected. As the pandemic developed and traveled, healthcare systems across the globe were resource deficient and underserved communities within those nations had little access to reliable information, physical access to public services, and were already at risk with disproportional health outcomes pre-pandemic. The author calls for a robust public health system that emphasizes appropriate resources for our global challenges. It is noted that vaping has come back, we have preventable diseases on the rise and we have environmental health concerns that are worsening with climate change. Health systems all over the globe are without adequate resources to support their population and are therefore vulnerable to the challenges we are already facing. As a social worker I am always advocating and serving clients who are right on the forefront of major issues without any buffer. The more privileged populations are affected as well, however disadvantaged persons are more vulnerable to challenges as they may be living without much social, financial, emotional, physical support. When that support net is not there and the healthcare system, or other publicly regulated support net, is not able to support the population as a whole then large portions of communities are harmed. Many social workers attempt to support their clients through resource allocation, networking, and community solutions when they are up against a global challenge. As I support my colleagues and my community, I educate myself and promote awareness of the importance of strong support systems that will increase health equity where I am able.
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Benjamin, G. C. (2020). Ensuring health equity during the covid-19 pandemic: the role of public health infrastructure. Revista Panamericana De Salud Pública, 44. https://doi.org/10.26633/rpsp.2020.70
Harm Reduction Framework within Rural America
Within this article, it describes an underserved population and the challenges that are working against the solution (Childs, Biello, Valente, Salhaney, Biancarelli, Olson, Earlywine, Marshall & Bazzi, 2021.) The underserved population is the community of people who use substances and reside in rural areas. Within health equity, health outcomes of continued use is not discussed enough. Many who use suffer from continued infections, heart conditions, organ damage, cognitive defects, brain injuries, chronic instability that causes injury, etc. As persons who use are going through recovery and return to use, their health is often overlooked until recovery is chronic. However, harm reduction efforts are becoming more and more utilized within communities of high use, mainly urban areas. Childs, etc. (2021) notes that although many more communities are being receptive to harm reduction strategies and prevention efforts, rural areas have increased stigma surrounding harm reduction at it’s theoretical foundation.
From my practice and research, it is known that rural areas around the country are disproportionally affected by the crisis. This in combination with increased stigma of harm reduction strategies, are causing various obstacles to better health outcomes and decrease overdose rates within these communities. Childs, etc. (2021) relays that efforts to engage in communities with diverse voices and major stakeholders have found to be promising and resulted in more acceptance of the evidence-based harm reduction strategies. Though the strategies may be more accepting, the stigma and moral judgement toward people who use substances is still prevalent. Social workers that are passionate about harm reduction for vulnerable populations need to work closely with the community and not only with users. It is vital that the community supports these individuals in syringe exchanges, supervised use and Narcan distribution, in order to save lives and improve quality of life. There is a decrease of services, and healthcare professionals as a whole within rural communities and outreach efforts may need to change the area served in order to impact the crisis more equitably.
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Childs, E., Biello, K. B., Valente, P. K., Salhaney, P., Biancarelli, D. L., Olson, J., Earlywine, J. J., Marshall, B. D. L., & Bazzi, A. R. (2021). Implementing harm reduction in non-urban communities affected by opioids and polysubstance use: a qualitative study exploring challenges and mitigating strategies. International Journal of Drug Policy, 90. https://doi.org/10.1016/j.drugpo.2020.103080
Environmental Discrimination
The above meta-analysis (Hunter, Cleland, Cleary, Droomers, Wheeler, Sinnett, Nieuwenhuijsen, Braubach, 2019) notes various sources to determine the impact of urban green spaces on population health. The article noted various green spaces that are utilized by city planners and development such as, parks, street trees, trees and plants to aid in storm water levels, greenways, etc. These spaces impacted health, wellbeing, social, environmental benefits and community equity. Sources were evaluated and described as impacting a few to all of the outcomes. The results were that dual use of the green spaces were very effective when park-based green spaces and greenways/trails were combined in an environment. The article goes on to say that within the meta-analysis there was certain emphasis on social equity increasing when urban green spaces were utilized. Social equity can impact many vulnerable populations such as racial minorities, migrants, low socioeconomic individuals, and housing insecure persons. The authors note that a holistic approach has not been used in many of the studies, as they measure the positive outcomes however did not measure the unintended impacts of the green spaces. They call for more research within this to see if this is a sustainable impact on marginalized communities.
I have been involved in green projects for a long time as my family as been very involved with gardens and volunteer work, as well as an emphasis on being outside for increased wellness. I chose this article specifically because it was a meta-analysis and I appreciate the critical review of what may need to be added to the table when evaluating the efforts of green space programs. As a social worker I am trained to be hopeful and solution-focused however I believe that critical review and program evaluation can prevent unintended harm to populations. I have also looked into how green programs can be publicly implemented though community implementation within vulnerable populations is common as well. There is argument that community-base approach has greater positive impact on communities than other agencies/organizations implementing change. This may need to be accounted for when looking at collective decision making at a city or county level. Green spaces seem to have positive impacts when done effectively, as described above, and when it is coming from the community itself it may be even more impactful. My practice in social work should always be evidence-based and this article is a clear reminder of that. A green space sounds nice and positive though implementation and evaluation are strong components to community health.
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Hunter, R. F., Cleland, C., Cleary, A., Droomers, M., Wheeler, B. W., Sinnett, D., Nieuwenhuijsen, M. J., & Braubach, M. (2019). Environmental, health, wellbeing, social and equity effects of urban green space interventions: a meta-narrative evidence synthesis. Environment International, 130. https://doi.org/10.1016/j.envint.2019.104923
Health Outcomes and Racial Identities
NeMoyer, A., Cruz-Gonzalez, M., Alvarez, K., Kessler, R. C., Sampson, N. A., Green, J. G., Alegría, M. (2022) take several large national surveys and interpret their data related to ethnic minority use of mental health resources within the community. They describe several community-based mental health treatment options that may not be as accessible to the diverse populations that they aim to serve. The study describes mental health care in several settings such as hospitals, emergency rooms, inpatient and outpatient mental health services, community mental health centers, etc. They look at not only the number of the services within a defined community, mostly at the county level, but also the culturally sensitive aspects of the services. They specifically look at emerging young adults as they describe this time of life as having many difficult changes happening very quickly and thus more at risk for developing maladaptive coping strategies and experiencing more mental health symptoms. Within the article, it is also theorized that this age group is less likely to engage with people around them for fear of having a perceived mental health issue. The writers noted differences in mental health service utilization for Black, Latino, and Asian populations in an array of settings and communities, and the age range that is at the most risk of needing mental health services. Based on the tables shown there was a lot of correlating data, though the writers discussed findings that were only statistically significant. They found that mental health outcomes were higher for Black communities when there was a hospital-based child wellness program, as well as better mental health outcomes were identified within the Latino population when there were hospital-based services that had linguistic and translation services available. This is significant for policy change and the social workers that work within the community, as it identifies specific programs that empirically benefit the underserved persons within our communities that we serve. Ethnic minorities across the country have higher rates of mental health symptoms and also have lower rates of utilization of mental health services. These findings exemplify that with the appropriate infrastructure, racial and ethnic minorities are able to have better mental health outcomes. This informs the social work profession through advocating for the infrastructure and knowledge when working within the infrastructure.
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NeMoyer, A., Cruz-Gonzalez, M., Alvarez, K., Kessler, R. C., Sampson, N. A., Green, J. G., Alegría, M. (2022). Reducing racial/ethnic disparities in mental health service use among emerging adults: community-level supply factors. Ethnicity & Health, 27(4), 749–769. https://doi.org/10.1080/13557858.2020.1814999
Covid, Mental Health Challenges, Ethnic and Racial Identities
Within the work, “The Mental Health Burden of Racial and Ethnic Minorities during the Covid-19 Pandemic” (Nguyen, L. H., Anyane-Yeboa, A., Klaser, K., Merino, J., Drew, D. A., Ma, W., Mehta, R. S., Kim, D. Y., Warner, E. T., Joshi, A. D., Graham, M. S., Sudre, C. H., Thompson, E. J., May, A., Hu, C., Jørgensen, S., Selvachandran, S., Berry, S. E., David, S. P., … Laws, M. B., 2022), racial and ethnic minorities during the pandemic self-reported through an app their mental health symptoms. The data was collected for thousands of people in both the US and UK and was broken down by ethnicity and racial identities. The self-reporting revealed that Hispanic self-reported participants that had reported anxiety-related symptoms were higher within the ethnicity when English proficiency was higher. From my own professional experience, I am curious if this is correlated with not having interpretation or language services that would reach participants more effectively. They evaluated the data and non-white participants reported more mental health symptoms, specifically anxiety and depressive symptoms, during the pandemic than white participants who utilize the app. The writers highlight the need to have more conversations surrounding mental health for ethnic minorities. As a social work professional, the need for destigmatization and conversations surrounding mental health challenges is needed and with the addition that our current system needs to address health disparities on a national level. Our current healthcare system emphasizes what is able to make money within our economic system, however the writers call for a standardized and national system for mental health services. Within a national system, the quality standards for community mental health, hospital-based mental health services, and crisis services would be cohesive.
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Nguyen, L. H., Anyane-Yeboa, A., Klaser, K., Merino, J., Drew, D. A., Ma, W., Mehta, R. S., Kim, D. Y., Warner, E. T., Joshi, A. D., Graham, M. S., Sudre, C. H., Thompson, E. J., May, A., Hu, C., Jørgensen, S., Selvachandran, S., Berry, S. E., David, S. P., … Laws, M. B. (2022). The mental health burden of racial and ethnic minorities during the covid-19 pandemic. Plos One, 17(8). https://doi.org/10.1371/journal.pone.0271661