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City Collaboration Strategy

State: CA Type: Model Practice Year: 2019

Los Angeles County (LAC) covers over 4,000 square miles, comprises 88 cities, and, with 10 million residents, is the most populous county in the US. Accordingly, a central challenge that the Los Angeles County Department of Public Health (LAC DPH) must overcome is adapting our public health activities to account for the county's enormous size. Additionally, LAC is extensively diverse and experiences a high rate of immigration and foreign travel. Nearly half of our residents are Hispanic (49%), around one-third white (29%), and around one in ten are Asian (14%) or black (8%). Residents report over 90 languages as their primary spoken language. LAC is also a major port of entry for immigrants to the US. According to the 2011 Los Angeles County Health Survey, 46% of adult respondents stated they were born outside of the US. LAC's population is also highly mobile (frequently traveling to areas prone to emerging diseases). In terms of air travel alone, each year roughly 55 million travelers come through the Los Angeles International airport (over 40 million domestic and 14 million international travelers yearly)—making it the nation's 3rd busiest airport. Due to these characteristics, LAC was heavily impacted by the emergence of Zika in 2015, a mosquito-borne viral disease. By July 2017, 113 cases of travel-associated Zika in LAC residents had been reported to DPH, among the highest in the country. Although no mosquito-borne Zika transmission has occurred in California, conditions sufficient for a local outbreak (e.g., introduction of the virus by travelers and the presence of Aedes mosquitoes that transmit infection) are present. The most effective prevention is to practice behaviors that minimize mosquito breeding or protect oneself from mosquito bites. To increase preventive practices, DPH must effectively reach, connect to and engage the different communities across the county. The goal of the City Collaboration Strategy is to reduce the risk of Zika among LAC residents in the highest risk populations. The objectives were to 1) assess risk of Zika in each city within LAC; 2) engage leadership of two high risk cities to partner with LAC DPH in conducting enhanced outreach and prevention activities during the 2017 mosquito season, and 3) reach the highest risk communities to ensure awareness and knowledge on preventive measures among those most vulnerable. At the same time as the City Collaboration Strategy was being conducted, general education and outreach was provided to all cities and communities county-wide. The steps taken to implement the City Collaboration Strategy include development of criteria and methodology to assess risk by city, collection of data to calculate a rank value for each city, connecting with leadership in the highest risk cities, establishing partnerships in the two cities selected to pilot the City Collaboration Strategy, and conducting enhanced outreach and other prevention activities in partnership with the pilot cities. DPH met with city managers and planners who provided opportunities for collaboration and outreach. DPH and the local mosquito abatement district (MAD) collaborated with the pilot cities to participate in outreach activities. Additionally, at the completion of the project in November 2017, effectiveness of the City Collaboration Strategy was evaluated through a face-to-face community survey. To assist with survey administration, LAC DPH recruited student volunteers and Spanish-speaking community health educators). Using demographic and epidemiologic data to characterize risk, DPH ranked risk of Zika for all 88 cities in LAC. Two of the highest risk cities were selected to pilot the City Collaboration Strategy. Enhanced outreach activities in these cities included distribution of educational materials at community events, organizing community waste tire recycling events, and coordinating door-to-door educational outreaches. Overall, there was increased awareness and knowledge of Zika and a trend toward increased knowledge of mosquito reduction and risk perception associated with exposure to public health campaign materials, which was 16% higher in pilot cities than in cities that received standard county-wide outreach. LAC DPH met all objectives, as shown by the evaluation conducted at the completion of the project. Factors that led to the success of the City Collaboration Strategy was the commitment, organization, and collaboration of a coalition of DPH programs and the MADs to plan and execute intensive outreach in a short period of time. It is a testament to the close partnerships of these agencies. Based on the results of the City Collaboration Strategy, LAC DPH modified its outreach campaign in 2018 for West Nile virus (WNV), an endemic mosquito-borne virus endemic in the region. The strategy may be a successful model for other county health departments in the country that struggle with effective outreach to populous or diverse communities. Website for LHD: http://ph.lacounty.gov/
By July 2017, 113 cases of travel-associated Zika in LAC residents had been reported to DPH, among the highest in the country. Twenty-six of these cases occurred in pregnant women. Zika virus is primarily spread by the bite of infected Aedes mosquitoes. Most cases of Zika are asymptomatic and when symptomatic, clinical illness is usually mild with symptoms lasting for several days to a week. However, infection with Zika during pregnancy can result in severe fetal defects. Although no mosquito-borne Zika transmission has occurred in California, conditions sufficient for a local outbreak (e.g., introduction of the virus by travelers and the presence of Aedes mosquitoes that transmit infection) are present. The Centers for Disease Control and Prevention (CDC) identified LAC as one of seven jurisdictions in the nation with the highest risk of local Zika transmission based on its population density, high-volume of travel to Zika-affected areas and the increasing presence of Aedes mosquitoes. Thus, LAC residents are at risk of Zika in primarily two ways: 1) An individual, particularly a pregnant woman, can acquire Zika infection through travel to an endemic part of the world; and 2) Zika can infect local Aedes mosquitoes and initiate a local outbreak in a community. There are no vaccines or treatments for Zika. The most effective prevention is to practice behaviors that minimize mosquito breeding or protect oneself from mosquito bites. As it only takes one effective mosquito breeding source to introduce risk of MBD into a neighborhood, elimination of breeding sources must be practiced at the individual level as well as by the community as a whole. During 2017, only one in five cases of West Nile virus (WNV), an endemic MBD in LAC, reported taking action to prevent MBDs such as draining standing water to prevent mosquito breeding or using repellent to protect themselves from mosquito bites. To increase preventive practices, DPH must effectively reach, connect to and engage the different communities across the county. This is especially challenging as LAC is one of the most populous counties in the US with extensive racial, cultural, linguistic, and socioeconomic diversity. Though all residents are at risk of Zika through travel or a local outbreak event, specific populations within LAC are more likely to be at higher risk. The Hispanic/Latino population, particularly those who are foreign-born, are more likely to travel to Zika endemic regions of the world and stay for extended periods of time, prolonging exposure. This is evidenced by DPH Zika human surveillance data. Sixty percent of Zika cases in LAC in 2016 were Hispanic/Latino, the majority of which acquired infection while traveling to Mexico or Central America to visit friends and family. Additionally, 20% of the female cases were pregnant, all of whom were Hispanic/Latino with a travel history to Latin America. Most of these women had traveled for 2-3 weeks and many reported having a secondary residence in their country of travel. Approximately half of the LAC population is Hispanic/Latino, representing 4.7 million residents. Furthermore, 34% of residents are foreign-born, the majority from Latin America. In order for a local outbreak of Zika to occur in LAC, the virus must be introduced into the region by an infected traveler who is then bit by an Aedes mosquito, which bites and transmits the virus to another individual. This scenario is most likely to occur in the areas of LAC where the Aedes mosquito has been detected. Infestations of Aedes mosquitoes have spread rapidly throughout LAC since it was introduced into LAC in 2011 in a city located in the eastern part of the county. By July 2017, Aedes mosquitoes had been identified in 67 of the 88 cities in LAC, radiating outward from the initial detections. Given the size and demographic characteristics of LAC, these high-risk populations still represent a large proportion of the county that would require substantial resources for enhanced outreach and education. One of the objectives of the City Collaboration Strategy is to develop a systematic methodology to further evaluate risk so that smaller communities that are most at risk can be targeted. Bell and Hawaiian Gardens, the two cities selected to piloted the City Collaboration Strategy, both had among the highest proportions of foreign-born residents from Mexico or Central American (39% and 31%, respectively) and detections of Aedes mosquitoes. Though Zika is a new public health threat that emerged in the Western Hemisphere in 2015, LAC DPH has had extensive experience spanning decades in fighting other MBDs already endemic in the region including Saint Louis Encephalitis virus and WNV. DPH and the five local MADs that serve LAC have worked closely together to support key activities throughout LAC including disease surveillance; case detection and follow-up; healthcare provider education; public education and outreach; and vector control through inspection, abatement, and reduction of mosquito breeding sources. Specifically, informational webpages have been developed for the public to access; print materials have been developed and made available for distribution; provider notifications have been routinely distributed electronically, and press releases are issued on an annual basis. This foundation enabled LAC DPH to quickly adapt to the new challenges that Zika posed, such as targeting messages to pregnant women and promoting safe sex practices. The initial response to Zika as the first cases were reported to LAC DPH primarily included strengthening the existing approaches and avenues for countywide outreach and education to providers and residents. To reach out and connect with ten million residents across LAC to promote Zika awareness and prevention behaviors is a task that DPH and the local MADs could not effectively accomplish alone. Each program or agency is limited by financial resources, workforce capacity, subject matter expertise, and/or close knowledge of local neighborhoods and communities. The City Collaboration Strategy targeted outreach and prevention activities to those areas at highest risk and leveraged partnerships with governments and agencies in these local jurisdictions. In this approach, resources can be pooled and directed to communities that are most vulnerable so that the greatest increase in preventive practices among residents can be achieved. The Guidance for Surveillance and Response to Invasive Aedes Mosquitoes and Dengue, Chikungunya, and Zika in California disseminated by the California Department of Public Health provides local health departments and their partner MADs with recommendations for public education and outreach such as displaying billboards and conducting workshops and meetings. However, there is no guidance or suggestion for resources and logistics to accomplish this. To our knowledge, no other jurisdiction has systematically approached local governments to partner and collaborate in accomplishing outreach and education activities in targeted communities. In the development of a systematic methodology to evaluate and rank risk among cities, unincorporated areas, and neighborhoods in the City of Los Angeles, DPH achieved an evidence-based approach to translating environmental and social risk into risk defined by political boundaries. This was an important factor in increasing the political will for accomplishing prevention and control of Zika. Many of the indicators used to evaluate the risk of Zika, such as population density and low socioeconomic status, are well-known environmental and demographic risk factors that have been published in the literature.
The goal of the City Collaboration Strategy is to reduce the risk of Zika among LAC residents in the highest risk populations. The objectives were to 1) assess risk of Zika in each city within LAC; 2) engage leadership of two high risk cities to partner with LAC DPH in conducting enhanced outreach and prevention activities during the 2017 mosquito season, and 3) reach the highest risk communities to ensure awareness and knowledge on preventive measures among those most vulnerable. The steps taken to implement the City Collaboration Strategy include development of criteria and methodology to assess the risk of each city, collection of data from seven sources to calculate a rank value for each city, connecting with t leadership in the highest risk cities, establishing partnerships with the two cities that selected to pilot the City Collaboration Strategy, and conducting enhanced outreach and other prevention activities in partnership with these locales between September and November of 2017. In July 2017, DPH proposed to assess and rank the risk of Zika for each cityneighborhood LAC in order to identify the highest risk communities for enhanced outreach in collaboration with the local governments. Subject matter experts from DPH and the MADs were consulted to identify data variables and sources that contribute to Zika transmission and Aedes mosquito proliferation. Indicators of risk identified included the proportion of the population born in Mexico or Central America, the fertility rate, the number of local Zika cases, the presence of Aedes mosquitoes, the rate of vector control service requests per 1,000 population of the locale, the median income, and population density. Data was collected for all 88 cities in LACfrom a total of seven sources including three independent MADs and the US census website. Indicator values were ranked and summed to calculate an overall risk for each city. DPH engaged leaders of cities that ranked the highest in Zika risk to assess interest in collaboration and willingness to commit time and resources to this effort. In the City Collaboration Strategy, city leaders would commit to facilitate dissemination of materials to city residents, assist in engaging with local media, and ensure support of city departments (at minimum sanitation, public works, and public information) while support would be provided by DPH, other county departments, and local MADs. The aim was to leverage local city resources to amplify public health messaging and establish partnerships to reach the most vulnerable communities. Two cities, Bell and Hawaiian Gardens, were selected for pilot testing of the approach. DPH met with city managers and planners who provided opportunities for collaboration and outreach. DPH and MAD staff also participated in events, gave presentations and distributed educational materials at venues targeting a range of audiences throughout these cities. DPH staff presented at City Council meetings to elected officials, local leaders and city residents; presented and distributed materials to neighborhood associations, such as neighborhood watch and safety meetings; hosted informational stalls and distributed materials at community events, including Bell's 90th anniversary celebration, Bell's Community Halloween event, and a 3K Fun Run/Health Fair in Hawaiian Gardens; met with supervisory staff to establish partnerships and distribute material at local churches, libraries, police stations, and health and nutrition centers; engaged young families more likely to get pregnant by presenting and distributing materials at various school events; worked with cities to organize community waste tire recycling events in Hawaiian Gardens and Huntington Park (adjoining Bell) which drew 83 participants and collected 8.4 tons of used tires for refurbishing, resale and recycling; and coordinated door-to-door outreach in Bell and Hawaiian Gardens to talk with residents about MBDs and distribute educational information and prevention kits that included flyers and mosquito repellents, reaching almost 500 homes in each city. Initial development and planning of the City Collaboration Strategy occurred in late July 2017. Data collection, ranking, and final selection of the two high risk cities to pilot the approach was completed through the following month so that outreach activities could be conducted during the remainder of mosquito season in LAC, September through November 2017. A survey evaluation study of the uptake of prevention messaging disseminated in LAC, including outreach conducted through the City Collaboration Strategy, was conducted in November 2017. Analysis and a report were completed by January 31, 2018. The City Collaboration Strategy was developed by DPH in collaboration with the two MADs with detected Aedes mosquito infestations within their jurisdictions. The MADs provided subject matter expertise in mosquito ecology and offered their support and assistance in community outreach activities. Due to ongoing MBD threats that are endemic in LAC, DPH has longstanding relationships with the five local MADs. DPH and the MADs routinely collaborate to share human and environmental surveillance data, to develop and implement public outreach strategies, to conduct regional meetings, and to formulate comprehensive plans for prevention and control of MBDs. In addition to the MADs, there was strong participation from other stakeholders to carry out the outreach and prevention activities including the city governments of Bell and Hawaiian Gardens and Spanish-speaking community health liaisons called promotores”, who are contract employees of the LAC Department of Mental Health. Multiple programs within DPH worked closely to plan and/or implement the outreach including Acute Communicable Disease Control, Emergency Preparedness and Response Division, the Office of Communications & Public Affairs, Community Health Services, and Environmental Health. DPH also recruited student volunteers from local universities to conduct face-to-face interviews in the subsequent survey evaluation of the City Collaboration Strategy. Participating students included public health students from the University of California Los Angeles Fielding School of Public Health, California State University Northridge, and University of Southern California. The emergence of Zika was recognized by multiple health agencies nationally and internationally as a public health emergency. Emergency funding was made available to local health jurisdictions in the form of several grants to conduct surveillance and control of Zika. Several programs within DPH were awarded federal grants to respond to the Zika threat in LAC including Acute Communicable Disease Control and the Emergency Preparedness and Response Division. Though no funding was directly earmarked for targeted outreach with city governments, the City Collaboration Strategy relied on important staff resources that were funded by these grants.
In 2017, LAC DPH piloted the City Collaboration Strategy to leverage local government support and resources to amplify Zika messaging in two-high risk cities for Zika outbreak. The objectives were to 1) assess risk of Zika in each city within LAC; 2) engage leadership of two high risk cities to partner with LAC DPH in conducting enhanced outreach and prevention activities during the 2017 mosquito season, and 3) reach the highest risk communities to ensure awareness and knowledge on preventive measures among those most vulnerable. At the same time as this intensive outreach was being conducted in the two high-risk pilot cities, general education and outreach was provided to all cities and communities county-wide. A follow-up community survey showed that the City Collaboration Strategy of engaging local governments resulted in significantly greater exposure to Zika messaging among residents of the pilot cities compared to residents in cities that received general outreach alone. The effectiveness of the City Collaboration Strategy was conducted through a 27-question community survey tool which was developed to assess exposure to the Zika campaign, and to measure respondents' knowledge, attitudes, risk perception and behaviors regarding MBDs. The survey was conducted in the two high-risk cities where the City Collaboration Strategy was piloted and two comparison cities, chosen based on similar demographics and presence of Zika mosquito vector, exposed to the general county-wide outreach alone. A random sample of participants from each city was selected based on a two-stage cluster sampling design modeled after the CDC Community Assessment for Public Health Emergency Response (CASPER) survey design. To assist with survey administration, LAC DPH reached out to the three local universities with public health graduate programs to recruit student volunteers. Over 100 students responded with interest in voluntarily participating in the evaluation study. Recruitment of public health students not only increased staffing capacity for the evaluation study but also provided interested students with on-the-field public health experience and was a unique partnership not previously utilized at the health department. Each student volunteer was paired with a promotora (a bilingual Spanish/English community health educator) to conduct face-to-face interviews according to the two-stage cluster protocol. A total of 464 surveys were completed; 219 in pilot and 245 in comparison cities. Exposure to public health Zika messaging was significantly higher (16%) in pilot compared to standard cities (66% vs. 50%; p-value < 0.001). Zika awareness was higher in those directly exposed to public health messages compared to unexposed (79% vs. 60%, p-value <0.001). Zika knowledge i.e. being at least somewhat knowledgeable about Zika (defined as answering at least 2 out of 5 knowledge-based questions correctly) was also significantly higher in those exposed to the public health messaging compared to those unexposed (79% vs. 61%, p-value < 0.001). Those who reported exposure to campaign through posters, social media, or news articles had increased Zika awareness and/or knowledge. However, exposure to flyers or community meetings was not found to be associated with a similar increase. The data did not reveal an increase in mosquito prevention behavior linked to the campaign in those surveyed. Multiple interventions sustained over time, particularly in specific types of materials, may be required to change habits and actions regarding prevention of MBDs. Nonetheless, we found that compared to general outreach, the pilot approach to enhance relationships and communications with city governments appears to be more effective at reaching residents and increasing awareness and knowledge in these areas. The data were analyzed using SAS statistical software. To test for significant differences between proportions chi-square test was used and to obtain odds ratios for additional variables, logistic regression analyses was performed. Based on the promising results of the 2017 Zika city-collaboration approach at reaching high-risk communities, LAC DPH modified its public health outreach for WNV, another mosquito-borne virus endemic in the region, by incorporating city-collaboration and prioritizing more effective modes of outreach. In 2018, LAC DPH chose five cities and/or communities at highest risk of WNV based on WNV human case numbers from the previous 6 years and has been working closely with their local governments to increase spread of mosquito prevention messages in these areas. As the 2017 evaluation study showed that social media, posters and news articles were most effective at increasing awareness and/or knowledge, LAC DPH has prioritized these modes of outreach to increase awareness and knowledge of WNV. The partnership with local public health schools and use of public health student volunteers to increase staffing is another unique aspect of the evaluation study that can be utilized by LAC DPH for other special projects. The participating volunteer students were provided access to de-identified data to use to practice statistical analysis and for class projects. One of the students ended up volunteering for 8 months with the vector-borne team at LAC DPH after participation as a volunteer in the survey evaluation study.
Lessons learnt in relation to practice: It can be difficult to reach vulnerable populations in emerging disease events such as Zika. We learnt that using a systematic approach to characterize and quantify risk in different communities was an effective strategy at prioritizing response and that engaging local governments was effective at amplifying public health messages on the ground. Identifying one staff person from public health to be the point of contact for one staff person from the pilot city was helpful in maintaining communication and establishing a strong working relationship. Lessons learnt in relation to partner collaboration: In relation to partner collaboration, DPH staff learnt that local governments are very receptive to learning about new or increased disease threats in their communities and are eager to partner with public health to protect their residents. We learnt that communicating expectations to city partners and clarifying role of public health staff is essential for a successful collaboration. The cities may have variable resources and staff availability to participate in public health response and the expectations may have to be modified dependent on these factors. Is there sufficient stakeholder commitment to sustain the practice? Both DPH and MADs are committed to sustain the practice of engaging local governments in highest risk communities to decrease the threat of endemic and emerging MBDs. The MADs were very appreciative of this project as this allowed them not only to prioritize their own activities but also helped establish relationships with local government officials and brought political attention to the overlooked burden of MBDs in the county. City officials reported that they enjoyed working with public health and would partner with DPH in the future as well. In 2018, we have extended the practice of risk stratification and city collaboration with highest risk communities to WNV outreach.
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