UCHD is a dynamic organization serving the Union County General Health District. The Health Department’s main functions are to prevent the spread of infectious diseases, to promote health and well-being and to assist in healthy development. UCHD is comprised of five divisions including Nursing, Environmental Health, Help Me Grow, Health Education and Vital Statistics. These divisions provide a comprehensive array of services to individuals and businesses. Further information regarding these services can be found at UCHD’s website: www.uchd.net .
Union County is composed of an estimated 53,306 residents (U.S. Census, quickfacts, 2013 estimate) including 2,516 inmates residing at the Ohio Reformatory for Women (population as of 7/2014). The majority of county residents are White (92.9%), non-Hispanic (91.7%) with a high school education (91.6%) However, Union County has a significant working poor population as evidenced by the county’s adult poverty level (7.3%), child poverty level (9.8%) and both the child (5.5%) and adult (14.3%) percentage of uninsured. Though the county seat of Union County, Marysville, is considered suburban, the majority of the county is still classified as a predominately rural with difficulty in accessing services of any kind.
As UCHD continues to work towards its mission of protecting its resident’s health, addressing causes of health disparities is a necessity. When providing local public health services, understanding inequities within the community strengthens quality of services and informs strategic public health initiatives. During a public health emergency, within a limited time frame, health inequities between population groups are clearly evident.
In December 2013, UCHD conducted an interactive emergency preparedness activity through the use of a board game (PODville) with the goal of promoting health inequity awareness among its staff. The scenario utilized the specific emergency preparedness capability of dispensing medical countermeasures through points of dispensing (PODs) to the Union County population within a restricted time frame. In such case, the ability for a population to receive messaging about the opening of PODs and the necessity to report to a POD to receive countermeasures can be paramount in ensuring the prevention of morbidity and ultimately mortality. Additional factors including the ability for a population to procure transportation to arrive at a POD in a timely manner, the ability to effectively receive appropriate services at a POD site and the subsequent efficacy of populations in adhering to the recommended use of medical countermeasures, are all checkpoints along the continuum of care delivery during which there can be success or failure.
The objective of PODville is to examine to what extent factors of health equity impact the success or failure along these checkpoints. These questions are explored first hand by players who take on the role of someone who may be facing health disparities as a result of these unpreventable social determinants of health. Through this unique game scenario, UCHD staff that would comprise part of the public health emergency response delivery system, took on the roles of individuals in the community who they would encounter and serve in a POD situation. The goal is that the game will stimulate empathy among staff that is trained to provide the critical public health service delivery to these diverse populations both during times of emergency and non-emergency.
Feedback received from UCHD staff participants indicated that this game was beneficial in opening up dialogue about better understanding the challenges that different county residents face that impact health outcomes. All respondents expressed a “somewhat” or “great” improvement in performance of everyday work activities and emergency preparedness functions as a result of the health inequity aspects addressed in this exercise, supporting the impetus for staff training on reducing health inequities through increased awareness.
Based on the positive responses received from the survey of the population, game play revisions are being made to further explore how far we can impact public health staff awareness, empathy, and motivation to address issues of health equity. UCHD’s game development team will complete PODville revisions, package, market and disseminate to other local health departments as a real world emergency preparedness interactive scenario with a health equity lens.
Healthy People 2020 defines social determinants of health as, “conditions in the environments in which people are born, live, learn, work, play, worship and age that affect a wide range of health, functioning and quality of life outcomes and risks”( www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-health). UCHD knows that due to these social determinants of health, the approximately 53,000 residents of Union County are affected differently, both positively and negatively, than their peers in urban, suburban and even other rural counties. The majority of Union County residents live in outlying areas without access to public transportation. As a result of Union County’s high manufacturing demands, temporary workers through staffing agencies are a high proportion of the county workforce. However, this group is underinsured and without job security as a temporary or seasonal worker. In an emergency, POD based situation differences are highlighted as these vulnerable individuals likely face exponential challenges navigating the emergency response system; which might lead to life threatening consequences. UCHD’s intent through developing and exercising PODville is to provide its staff and workforce a first-hand experience, awareness of and empathy to the challenges that its residents might encounter while attempting to navigate through a POD situation.
Emergency preparedness exercises and drills are a routine occurrence for UCHD staff members and for local health departments (LHDs) across the nation. However, this was the first attempt to bring attention to health equity in Union County to all UCHD staff members through an emergency preparedness scenario. Initially when the phrase health disparity is used, it’s often thought of racial/ethnic disparity. This is not the case for Union County as its residents are fairly homogenous (93% White). Union County’s health disparities are oftentimes manifested through lack of access to health care, a rural community without a public transportation system and a high, vulnerable working poor population having to decide between paying the rent, buying food or paying a premium for health insurance. It is crucial for LHD staff to take these considerations into account not just for emergency planning purposes, but for everyday client interactions within their community.
The creation of PODville, an interactive emergency preparedness and health inequity simulation board game, is new to the field of public health. The UCHD staff that conceptualized and developed PODville referenced the NACCHO Tool- Maternal Child Health, Life Course Perspective Game (developed by CityMatCH and Contra Costa Health Services Family Maternal and Child Health Programs) as a starting framework for the health equity concepts found throughout PODville. However, these health inequities were specifically tailored to meet the potential challenges, barriers and injustices found throughout the navigation of a POD in a life threatening, community emergency response. For example, how does a citizen's status as a non-English speaker impact his/her ability to gain access to medications being distributed at the POD? How would this be different for someone in poverty, for someone with functional needs, for someone of a particular race/ethnicity? To emphasize these observed disparities, the layout of the game allowed for “winners” who advanced the farthest along the game board through and “losers” who advanced the least and potentially died while trying to obtain medical countermeasures.
The UCHD PODville development team had representation and expertise from each of the health department’s five divisions. The core team included: health commissioner, director of nursing, emergency preparedness coordinator, epidemiologist, communicable disease nurse and several CDC Public Health Associates. Each of these members brought a set of expertise and past historical experiences which were crucial to PODville’s development. Throughout the initial emergency preparedness simulation exercise executed in December 2013 and during the many revisions to the game design itself, nearly all of UCHD’s 34 full time employees directly participated and influenced the final PODville product.
The primary goal of the UCHD PODville development team had in the creation of the interactive game model was to raise awareness and interest of health inequity in Union County among all of its staff members. This was the kick off to the formation of a yearlong, Roots of Health Inequity group which was comprised of interdisciplinary staff meeting over the course of six months having meaningful conversations utilizing the NACCHO Roots of Health Inequity interactive online modules as a framework. In early 2015, the Roots group will reconvene to create a UCHD health equity position statement to be used across the entire agency. The secondary goal of the PODville design team was to create an easily adaptable and replicable game that other LHDs could use within their own organizations. After bimonthly design/implementation meetings from January 2014-October 2014, revisions to the game board design, player profiles and injections, the team is in the final stages of collating PODville and having it available for distribution. PODville is meant to be translatable to any LHD; however, the initial production of the game was tailored to a LHD serving smaller rurally located populations.
This project was low in material and indirect costs, but fairly labor intensive with the use of personnel time. Approximately 75 working hours were spent on the initial creation of PODville, making adaptions based on feedback to all aspects of the game design and finally completing test play of the final product. A rough estimated personnel cost in game development is $15,250.
After exercising the game among all staff during the annual December 2013 training, a brief twelve question weighted Likert scale survey was distributed via Survey Monkey to the 34 staff participants. 21 staff members responded for a 62% overall completion rate. Both process and outcome evaluation questions were posed to participants. Within the survey outcome questions were asked as they related to the primary goal of utilizing PODville to create an awareness of health inequity in Union County, specifically as it relates to an emergency POD situation. Prior to playing PODville, overall respondents self-reported an average rating of 6.71 out of 10 as the highest of an awareness of health inequity issues in Union County. Survey results also indicated that participation in the exercise increased awareness of health inequity issues in Union County with an average 7.76 rating out of 10 being the highest increase in awareness. 74% of participants reported that the exercise was “very beneficial” or “highly beneficial” in understanding their work involving interaction with a diverse community during a stressful emergency situation at a POD site. Additional feedback received from UCHD staff participants indicated that this exercise was beneficial in opening up dialogue about better understanding the challenges that county residents face that impact health outcomes. All respondents expressed a “somewhat” or “great” improvement in performance of everyday work activities and emergency preparedness functions as a result of the health inequity aspects addressed in this exercise. These results directly support the impetus for staff training on reducing health inequities through increased awareness activities.
Process evaluation questions were asked of participants in regards to the PODville game design. When asked about what participants liked most about the game nearly 80% indicated the range and types of inequities and functional needs included in game play. Respondents noted that the amount of detail put into the character/player biographies was crucial as it made the character relatable within game play. Several respondents felt that injects were not severe enough in terms of outcomes for selected players. Many comments were made around the differences between certain mental health diagnoses, comorbidities and medication compliance. Also, in the initial version of PODville, only forward progress was directed by the injections. As a result of survey feedback, both forward and backwards progress is now an option. During initial game play staff was split into five groups with approximately 5-8 people playing per group and having 45 minutes to make it through game play. Several comments were made regarding group size as it relates to having enough time for meaningful conversation of what the players experience while playing PODville. Therefore, the final version of PODville recommends 5 players per board (though it can accommodate up to 8 participants) with one hour dedicated to game play with at least 15 minutes to debrief as a group on the game experience.
Additional process evaluation questions asked for suggestions for modification to our existing POD as work is made to eliminate health disparities/inequities. Many comments were received regarding the need for staff members to “walk a mile in their (clients) shoes” and working with individuals who are experiencing adversity directly in order to be more empathetic towards the resident’s unique needs. An area that was lacking in our current POD design was the need for onsite personnel who have been trained in administering disaster mental health services.
The creation of PODville was intended to not only raise awareness of health inequities and begin meaningful conversations among staff, but to also be easily replicable and adaptable to other LHDs across the nation. Currently, UCHD is exploring disseminating the game in a self-serve manner for LHDs. Meaning, any LHD who is interested in utilizing PODville for their health equity and emergency preparedness exercise purposes could simply download and adapt materials from UCHD’s website. In Therefore, LHDs can, if they so choose, custom fit their community make up and dynamics within PODville in both the player profiles and inject scenarios. Several low cost additional game play items are required for PODville including: one twelve sided die and individual character game pieces to be used on the board for place markers. This would create sustainability and capacity of a LHDs ability to employ PODville at minimal cost or on a “shoestring” budget.
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