West Piedmont Health District
Fight the Bite: Zika Door Hanger Canvassing
The Henry-Martinsville Health Department serves the City of Martinsville and the counties of Franklin, Henry, and Patrick. This program took place in the City of Martinsville during mosquito season 2016. Martinsville has a population of 13,800. Approximately 27.2% of the City's residents live in poverty; Virginia's average is 11.3%. For over a decade, Martinsville has had one of the highest unemployment rates in Virginia. U.S. Census estimates from 2015 indicated a population of: 50.9% Caucasian, 45.4% African American, and 4.9% Hispanic or Latino.
Describe the public health issue:
Mosquito-borne diseases have always posed a public health threat. This year, Zika generated the headlines that grabbed the general public's attention about mosquitoes and the diseases they carry including a very serious threat to infants. The City of Martinsville does not have a mosquito control program; therefore, residents were at higher risk of exposure unless awareness could be increased in another way.
Goals and objectives of the proposed practice:
The goal of the Fight the Bite: Zika Door Hanger Canvassingâ€ was to educate residents of Martinsville about Zika risks and preventative measures through a door-to-door campaign. Using English and Spanish door hanger cards provided to the HMHD by the Virginia Department of Health State Office, NSMRC volunteers and police officers on their regular beats spent weekend days walking the neighborhoods, knocking on doors, and distributing the hangers. Tip, Toss and Coverâ€ instructions on the door hangers are easy to understand, and in some cases the MRC volunteers pointed out areas on a person's property that could attract mosquitos.
Objectives targeted by this practice:
1. Get information about Zika prevention to residents of Martinsville in a timely manner.
2. Operate in a manner that would not interrupt normal services or add undue financial burden.
3. Demonstrate how unique partnerships can support the work of health departments in addressing public health concerns.
How was practice implemented/activities:
The City of Martinsville Police Department has a Neighborhood Resource Officer (NRO) program that is a part of its community policing program. The city is separated into 20 individual neighborhoods. A large part of the NRO program is for the officers to meet each of the residents in their assigned neighborhoods. NRO's go door-to-door, hand out business cards, and speak to the residents about their concerns.
1. The Health Department would supply the training for the officers and NSMRC volunteers on the Zika hanger program, as well as education about mosquito-borne diseases. The Health Department would serve as the point of contact for any specific questions concerning Zika.
2. NSMRC-supplied volunteers would ride along with officers and conduct the door-to-door canvassing. Volunteers would work only on Saturday and Sunday mornings when the Police Department had prime availability of officers.
Results/Outcomes (list process milestones and intended/actual outcomes and impacts.
Were all of the objectives met?
What specific factors led to the success of this practice?
The objectives of the Fight the Bite: Zika Door Hanger Canvassingâ€ project were met and the partnership was, in fact, expanded for the remainder of mosquito season. The program was successful due to an existing partnership between law enforcement and the health department, as well as because adequate and effective training was offered. Police offers were trained at shift changes, and NSMRC volunteers received just-in-time training on canvassing day.
Everyone had an important role. Neighborhood Resource Officers supplied knowledge of areas within the City where there might be a higher risk of mosquito problems. The NSMRC providing volunteer staffing that minimized the impact on the health department personnel and eliminated the need for overtime pay or reduction of normal operating programs.
Public Health Impact of Practice:
The canvassing project introduced residents to NSMRC and police personnel, as well as illustrated that teams were acting on their behalf to keep them safe and free of a potentially serious disease. Together, officers and volunteers demonstrated on a citizen's property what might be at risk for mosquito breeding. The face-to-face connection with the citizens allowed the health department to further emphasize the importance of vector control and the prevention of infectious diseases. Citizens interacted with health department and policing staffs in new ways. As a result of these efforts, Martinsville reported no mosquito-borne illnesses during mosquito season 2016.
Health District website: http://www.vdh.virginia.gov/LHD/westpied/index.htm
In May 2015, the Pan American Health Organization (PAHO) issued an alert regarding the first confirmed Zika virus infection in Brazil. On February 1, 2016, the World Health Organization (WHO) declared Zika virus a Public Health Emergency of International Concern (PHEIC). Local transmission had been reported in many other countries and territories. Zika virus was expected to continue to spread to new areas. In 2016, Zika was found in the United States, with Florida experiencing cases of local transmission. It was critical for public health personnel to get out in front of the problem before Zika reached Virginia.
What target population is affected by problem (please include relevant demographics)
o What is target population size? Targeted neighborhoods, 5,000 estimated residents
o What percentage did you reach? 40%
What has been done in the past to address the problem?
o Local transmission of Zika is a relatively new threat to Virginia, so this is the first effort in the City of Martinsville, West Piedmont Health District, and Virginia.
Why is current/proposed practice better?
o The partnership was successful for both the Health Department and the Police Department. The Chief of Police reported that the practice strengthened police relationships and acceptance in the neighborhoods canvassed. The health department reached its objective of educating people in high-risk neighborhoods of the potential threat of Zika infections and how to avoid them.
Is current practice innovative? How so/explain?
o Is it new to the field of public health OR
o Is it a creative use of existing tool or practice: What tool or practice did you use in an original way to create your practice? (e.g., APC development tool, The Guide to Community Preventive Services, HP 2020, MAPP, PACE EH, a tool from NACCHO's Toolbox etc.)
Program innovation was achieved by a unique partnership between police and public health staff focusing on public safety in a way that minimized resources and maximized impact. Cross training police officers on this public health issue â€“ and then expanding the partnership beyond the initial period of 6 weeks at the request of the police department â€“ clearly indicates the effectiveness of the partnership to satisfy the needs of all parties.
Partnership is the key work in this collaboration. At the core of any collaborative initiative is the relationship between public health departments and community residents, organizations, agencies, etc. A key mission should be to invest in building the partnerships between health departments and local communitiesâ€”encouraging them to work together, agree on community health priorities, and jointly develop strategies to address them.
But forming partnerships can be difficult. In many cases, partners have to overcome legacies of mistrust between each other, and especially between communities and government agencies. Local public health departments are seen as the governmental presence of public health. There are also power differentials that characterize interactions in the past. These must also be overcome. Communities, other partners, and public health departments often have little understanding and appreciation of their respective resources, roles, and responsibilities. It is important that as strong partnerships emerge, organizational models, success factors, and strategies that enable public health departments to work productively with local communities and other agencies are identified.
Strong leadership is the crucial variable that enables some public health departments to go beyond traditional practice and institutionalize community-based public health practices. According to a report by the Center for Community Health & Evaluation, strong agency leaders are able to persuasively articulate the benefits of working with the community and influence organizational culture and decision making.
Just as important is resident engagement. Productive, sustained resident engagement, however, is challenging to achieve. If residents are not paid or provided incentives to be involved, it can be difficult to maintain their interest.
Is the current practice evidence-based? If yes, provide references (Examples of evidence-based guidelines include the Guide to Community Preventive Services, MMWR Recommendations and Reports, National Guideline Clearinghouses, and the USPSTF Recommendations.)
The Turning Point Initiative,â€ a program of the Robert Wood Johnson Foundation and the W.K. Kellogg Foundation, concluded that unique collaborations, giving up concern about who gets credit for the success, and having dedicated staff and volunteers are key components of successful public health outreach practices. These practices were put into place as part of the Zika door hanger program. (Hann, Neil E. Transforming Public Health through Community Partnerships. Preventing Chronic Disease (2005): n. pag. Web.)
Goal(s) and objectives of practice
The overall goal of Fight the Bite: Zika Door Hanger Canvassingâ€ was to educate the public on the health risks that Zika and mosquitoes pose to the citizens of the City of Martinsville. One primary objective of the door-to-door canvassing was to specifically target areas and populations within Martinsville that might be at a greater risk.
What did you do to achieve the goals and objectives? Steps taken to implement the program
The Henry-Martinsville Health Department (HMHD) needed a way to better reach the citizens of the City of Martinsville and try to educate and demonstrate what the public could do around their own homes to reduce the threat of Zika and other mosquito-borne illnesses. Door-to-door canvassing was an option that could allow for this specialized educational effort. HMHD also needed a way to accomplish this safely and to reduce the impact on its staffing and programs. The City was separated into 20 individual neighborhoods. A large part of the NRO program is for the officers to meet each of the residents. NROs conduct door-to-door meetings, the officers hand out business cards that include contact information, and speak to the residents about their concerns.
The City of Martinsville Police Department handles property maintenance code enforcement. All NROs have received training on how to conduct property inspections. A couple of items that they inspect for are trash build-up and grass/weed overgrowth. With this type of training in place, the NROs have a better understanding of the at-risk areas of the City.
The Near Southwest Medical Reserve Corps supplied volunteers to support the door-to-door canvassing. Volunteers were coordinated between the NSMRC Coordinator and WPHD's Local Health Emergency Coordinator weekly. Names and contact information were shared with the City of Martinsville Police Department point of contact for the project.
The Henry-Martinsville Health Department supplied the project with bilingual door hangers (supplied by the State health department) and the staff to perform the training. The Environmental Health Supervisor, Epidemiologist, and Local Health Emergency Coordinator created a 10 minute presentation for the resource officers that covered Zika, the specific at-risk mosquitoes in the area, basic safety tips, and the door hangers. The Tip, Toss and Coverâ€ door hangers were covered in detail so that the officers would be comfortable in answering questions from the public.
NSMRC volunteers arrived at the police department on Saturday and Sunday mornings and received the same training. They would also be given specific instructions for avoiding animal bites since they would be on foot in residential areas where dogs and other animals are present. NROs were instructed that in the case of an urgent police matter to bring the volunteers back to the station. Officers would serve as guides as well for no-goâ€ homes.
The team canvassed the neighborhoods in two-hour shifts. Volunteers were responsible for tracking where and how many door hangers were distributed. The NROs initially were asked to visit areas where homes might be more susceptible to having mosquito breeding issues. Afterwards, they would expand to lesser risk areas of the community. The NROs were able to use the door hanger canvassing as an opportunity to make connections with citizens in a less formal police capacity.
Each Monday after a canvassing weekend, the Local Health Emergency Coordinator compiled data from the tracking sheets that the NSMRC volunteers documented. A spreadsheet was created to keep up with locations canvassed and by whom. The data included:
Street names with high and low house numbers
Number of actual hangers put out on each street
Notes on vacant homes, apartments canvassed, and if police calls interrupted the process
The spreadsheet was updated every Monday with printouts of the streets covered put in the Zika hanger supply kit at the police department.
Any criteria for who was selected to receive the practice (if applicable)?
The Henry-Martinsville Health Department and the City of Martinsville Police Department have partnered on a number of important community issues â€“ from domestic violence prevention to opioid abuse campaigns. Addition of the Zika door hanger program to the partnership was facilitated by the positive effects of this ongoing partnership by the Chief of Police and the District Director of the health department.
What was the timeframe for the practice
The Zika door hanger canvassing started in the first weekend in August 2016 and continued until the third weekend in October 2016.
Were other stakeholders involved? What was their role in the planning and implementation process?
What does the LHD do to foster collaboration with community stakeholders? Describe the relationship(s) and how it furthers the practice goal(s)
The Henry-Martinsville Health Department, the City of Martinsville Police Department, and the Near Southwest Medical Reserve Corps were the partners for this event. Health department and police personnel worked together to plan the activity. Coordination and training of volunteers was conducted by the health department, while the police department determined which at-risk areas to target at any given time Implementation of the partnership was a joint effort as well. The HMHD requested volunteers from the MRC and managed just-in-time training. The supplied 1-2 volunteers each Saturday and Sunday. One officer was available each Saturday and Sunday to accompany the volunteers to specific areas and accompany them during canvassing.
The HMHD continually tries to reach out to non-traditional partners in its efforts to improve the overall health of the community. The HMHD and the police department participate in other community support and safety efforts. Zika hanger canvassing afforded the opportunity to again join forces for the benefit of the community. It has been suggested that health department and police team up in the future to take similar information to at-risk neighborhoods about the opioid epidemic.
Any start up or in-kind costs and funding services associated with this practice? Please provide actual data, if possible. Otherwise, provide an estimate of start-up costs/ budget breakdown.
Zika hangers were provided free of charge to the Henry-Martinsville Health Department by Virginia Department of Health State Office. NSMRC volunteers donated 83.7 hours (26.7 hours of travel and 57 hours of canvassing) with a monetary support value rated at $26.09 per hour for a total contribution of $2,183.70.
The City of Martinsville had an in-kind donation of officer hours of approximately $1,995. This is considered in-kind because the officers conducted the canvassing during their regular shifts.
The Henry-Martinsville Health Department supplied approximately 12 hours of training for law enforcement and volunteers, 12 hours of canvassing support coverage and 40 hours of event coordination for a total contribution of $1,832.09.
From a qualitative standpoint, it was clear that most of the residents canvassed by the teams were unaware of Zika and how to prevent it. Many expressed gratitude for the officers and volunteers taking the time to meet with them. 2,161 surveys were distributed with a 47% return rate. Residents were asked two questions:
Has your knowledge of what causes mosquito-borne illnesses increased, and
Will you use any of the advice received to reduce mosquito breeding areas in your surroundings?
Nearly 100% answered affirmatively on the first question, whiled 92% said they would take steps to avoid mosquito breeding in their surroundings.
Officers and NSMRC volunteers completed brief surveys about their experiences with the following results:
Do you feel the partnership was effective? 100%
Is it your opinion that residents of the selected neighborhoods received real value from the exercise? 89%
Would you be willing to conduct canvassing for additional public health needs? 100%
Is it your belief that mosquito control measures were enhanced by your efforts? 85%
Would you recommend additional canvassing for other public health issues in the future, and (if so) please suggest topics. 92% yes. Opioid addiction was the most prevalent response.
What did you find out? To what extent were your objectives achieved? Please re-state your objectives.
The goal of the Fight the Bite: Zika Door Hanger Canvassingâ€ was to place mosquito prevention and safety information into the hands of residents most at-risk of mosquito borne illness. Objectives targeted by this practice were:
1. Provide information about Zika prevention to residents of Martinsville in a timely manner.
2. Operate in a manner that would not interrupt normal services or add undue financial burden.
3. Demonstrate how unique partnerships can support the work of health departments in addressing public health concerns.
Identifying and creating a partnership came out of a pre-existing connection between the Henry-Martinsville Health Department and the City of Martinsville Police Department. The Health Director and the Chief of Police had a conversation about Zika and a door-to-door canvassing project that the HMHD wanted to do. The Chief of Police suggested using the Neighborhood Resource program. The Zika hanger canvassing would give the HMHD access to the City with safety, and the NROs would have the opportunity to meet the citizens in an unofficial visit.
In developing a plan of operation that did not interrupt normal services, both entities designated a coordinator for the effort. The designated coordinators met and discussed the most appropriate timing for the canvassing, as well as scheduling the training for the officers. For the Police Department, Saturday and Sunday mornings afforded the best times to canvass with minimal impact on patrolling responsibilities. Training of the police officers and the NSMRC volunteers was a two-part process. Officers would receive Zika and mosquito safety training at shift changes. Training covered Zika, the Tip, Toss and Coverâ€ door hanger campaign, and guidance for keeping volunteers safe. Should the Police Department have an emergency, the NSMRC volunteer would be returned to police headquarters, and the canvassing would be canceled for the day. Also, volunteers would follow the assisting officer's guidance on any home not to approach and to avoid aggressive animals. During the first two months of canvassing, volunteers and officers were reminded to keep properly hydrated in the higher summer temperatures.
The second part of the training was for NSMRC volunteers. Their training would take place on the first morning that they volunteered to help. A Health Department representative would meet the volunteer at the police department and cover the same information that the officers had received, plus training on documenting which residences they visited and how many hangers were placed. The tracking document contained columns for street name, starting house number, finishing house number, and total number of hangers placed for each street. The form also had a comments section for noting any issues like vacant homes or apartment buildings. The sheet also had a documentation spot for the name of the volunteer and the assisting officer.
Did you evaluate your practice?
o List any primary data sources, who collected the data, and how (if applicable)
o List any secondary data sources used (if applicable)
o List performance measures used. Include process and outcome measures as appropriate.
o Describe how results were analyzed
o Were any modifications made to the practice as a result of the data findings?
A spreadsheet was created to evaluate the programs progress. The document contained two tabs. The first tab kept track of the street names alphabetically, house numbers covered, and the total number of hangers per street. This tab was printed each week and placed with the Zika hanger supplies at the police station so officers could keep track of which addresses had been covered. The second tab kept track by date of the assisting officers, NSMRC volunteers, and the streets covered. This tab would inform the cost component for the event.
In looking at projecting a canvassing rate, items like topography, spacing between houses, public interaction, and any potential official law enforcement issues had to be factored in. Expected optimal canvassing was 75 to 100 hangers per shift. The average per canvassing shift was 120, exceeding our goal.
The City of Martinsville lies in the foothills of the Blue Ridge Mountains, so not all streets are flat. This did reduce the foot speed in some areas. Some of the Martinsville streets are over a mile long but may only have twenty occupied homes while other streets are a block or two long with 16 homes. Interaction with the public had a limited impact as most citizens only had minimal questions. Official police business during the canvassing created limited delays a few times, but no stoppage.
The only modification attempted for the canvassing was in scheduling two volunteers per shift. The modification had mixed results with little to no change or doubling the output. Again, the location impacted the results.
Lessons learned in relation to practice
Although the overall canvassing project worked well, there were a couple of weak points. One was in getting volunteers around peak summer holiday weekends. With a lot of families taking vacation around Labor Day, it was difficult to obtain volunteers at that time. The other issue was a minor breakdown in communications. Each volunteer was given a contact number for a health department representative and the NSMRC coordinator in case there was an issue with being available to volunteer or a sudden cancelation while canvassing. There were a couple of instances of non-communication by volunteers.
Lessons learned in relation to partner collaboration
The partnership worked well. Officers appreciated the Zika canvassingâ€ because it enabled them to meet with residents in the neighborhoods that they were assigned to in an unofficial capacity. Canvassing also afforded the opportunity for the officers to learn which homes that might appear lived in that were not; as neighbors advised them during the canvassing.
Did you do a cost/benefit analysis? If so, describe.
The Virginia Department of Health State Office provided the door hangers to local health districts (LHDs) at no cost to the LHDs. The in-kind total for personnel from the Henry-Martinsville Health Department, City of Martinsville Police Department, and Near Southwest Medical Reserve Corps was $6,010.79. While an official cost/benefit analysis has not been conducted, clearly the program maximized resources and minimized costs.
Is there sufficient stakeholder commitment to sustain the practice?
o Describe sustainability plans
Beyond stakeholder commitment there is stakeholder enthusiasm for continuing this and adding additional community outreach. The partners are currently considering launching a similar campaign to inform residents about opioid addiction and measures citizens can take to reduce risks in their families and neighborhoods. The relatively low cost of conducting such campaigns contributed to sustainability. It is possible that other parts of the District will consider similar partnerships in the future.