Preventative Community Health Improvement plan
Submitted by Wendy Blatchley, RN, BSN
The purpose of this paper is to identify a plan within a community in Pinellas County to reduce the number of cases of sexually transmitted diseases (STDs). The plan will focus on primary prevention and health improvement as a way of accomplishing this goal. This proposed plan has been modeled after Project RESPECT, which stresses the importance of behavioral counseling as a way to reduce occurrence of STDs. The following discussion includes background information, identification of a target population, related Healthy People 2020 goals, objectives, and implementation and evaluation of a purposed community health improvement plan to reduce the number of STDs within Pinellas County.
The population that will be focused on is women between the ages of 15-24. The purposed intervention of providing this target population with education, counseling and access to screening for sexually transmitted diseases (STDs) will help reduce the incidence of STDs within the county. Studies show education is an important key to the prevention of this health issue and by increasing the public's exposure regarding access to screening, treatment and prevention could help address this issue (Friedman, Kachur, Noar, & McFarlane, 2016).
One of the prominent health issues in Pinellas County is the occurrence ofSTDs. Total cases of gonorrhea, Chlamydia, and infectious syphilis were 16,608 between the years of 2013- 2015, with 594.8 cases per year compared to the state numbers of 555.0 per year. STDs are a health issue because they are highly preventable, but continue to be an issue amongst the population (Florida Health CHARTS website, 2017). Testing and treatment is crucial to prevent the spread of these diseases and reduce morbidity. Per findings cited by Healthy People 2020, there arc many factors that arc associated with the spread and complications associated with STDs. Women tend to suffer from more complications from STDs including ectopic pregnancy, infertility and pelvic inflammatory disease, etc., young people age 15-24 account for half of newly reported STD cases, while other issues such as poverty and limited access to health care are associated with higher incidence of STDs (Healthy People website, 2014).
Healthy People 2020 Goals
There are several objectives that relate to STDs with reduction of occurrence being the primary goal. Goals that relate closely to the above mentioned target population, are as follows: Reduce the proportion of adolescents and young adults diagnosed with Chlamydia infections, reduce occurrence of gonorrhea, and reduce transmission of primary and secondary syphilis (Healthy People website, 2014). The U.S. Preventative Services Task Force (USPSTF) recommends behavioral counseling as a way to reduce the occurrence of STDs and has cited project RESPECT as an effective, evidence based practice that has been shown to help accomplish this goal (U.S. Preventative Services Task Force, 2014).
Evidence Based Plan
Project RESPECT is an example of a behavioral counseling intervention listed by the USPSTF. This randomized controlled trial study consisted of 5758 heterosexual Hlv-negative patients age 14 and older. It's objective was to compare the effects of two HIV/STD behavioral counseling interventions with prevention messages typical of current practice (Kamb ct aI., 1998). It focused on a population of heterosexual, HIV -negative patients with the goals of eliminating and reducing risky sexual behaviors and reducing STDs. Trained HIV and STD behavioral counseling, exercises and goal setting with patients in the setting of public clinics. They provide patients with printed materials for reference as well as riskreduction supplies such as condoms. Counseling interventions were executed in one of two ways: brief, which consisted of two 20-min sessions, or enhanced, which totals 200 minutes delivered over three to four weeks (U.S. Preventative Services Task Force, 2014). This intervention focuses on education and counseling and therefore would be an appropriate intervention for this paper's target population and related goals of reducing the occurrence of STDs.
Main outcome measures of RESPECT were use of condoms reported by the individual people and new cases of STDs, including gonorrhea, Chlamydia and syphilis. Results include: At the three and six month follow-up visits, reports of individuals using condoms 100 percent of the time was higher (P<.05) in both the enhanced as well as brief counseling groups compared with those whom were part of the didactic messages group. Through the six month interval, 30 percent fewer of those involved in the study had new STDs in both the enhanced (7.2%; P =.002) and brief counseling (7.3%; P=.005) groups compared with those in the didactic messages group (10.4%). at the 12 month mark, 20 percent fewer people in each counseling intervention had new STDs compared with those in the didactic messages group (P =.008). STD incidence was consistently lower at each of the five study sites in the counseling intervention group than in the didactic intervention group. STD reduction rate was comparable in both men and women and greater for those with an STD diagnosed at enrollment (Kamb et al., 1998).
Although this study originated in 1998, it provided a foundation for future prevention programs and showed that counseling interventions with a risk reduction plan can increase condom use and help prevent new STD diagnoses. The USPSTF reviewed the evidence on behavioral counseling and published an update of the 2008 recommendations regarding the effectiveness of behavioral counseling in 2014. This update again demonstrated that behavioral counseling reduced the likelihood of STDs, reduced risky sexual behaviors and increased condom use and other safe sexual practices (LeFevre, 2014). According to Healthy People evidence based resources, behavioral counseling rated a four out of four in strength of evidence, which is the highest rating that an intervention can receive. Resources with a rating of four have significant evidence to support them and include systematic reviews of the intervention evaluations and/or studies that demonstrate effectiveness with supporting evidence as well as feasibility, sustainability, and transferability (Healthy People website, 2014).
By July of2027, 60 percent of women aged 15-24 will receive behavioral counseling and outpatient education on STDs at least twice a year from Pinellas County Health clinics. This counseling will include but will not be limited to, information on low risk sexual behaviors, consistent condom use, and the importance of routine screenings for STDs such as Chlamydia
and gonorrhea and avoiding multiple sex partners. By July of 2027, total cases of gonorrhea, Chlamydia, and infectious syphilis in Pinellas county will decrease from 594.8 cases per year to 535.3. This will result in a 10 percent decrease in Pinellas county by implementation of behavioral counseling and education performed at Pinellas county health clinics.
Level of Prevention
The intervention mainly focuses on incidence and the prevention of STDs. Incidence is defined as the number of people in a population who develop the condition during a specified period of time. Education and behavioral counseling can be considered a preventative health promotion measure used to reduce the occurrence of STDs in the target population. Health promotion is considered to be primary prevention. While primary prevention of a disease or health condition is difficult to measure, it is ultimately less costly than secondary and tertiary prevention, which deal with crisis intervention and treatment of disease/disability, in both terms of human suffering as well as in monetary terms (Anderson & McFarlane, 2015).
Initiation of Intervention
These interventions will take place in Pinellas county. Collaborators will include the Pinellas County Health Department, the Center for Disease Control and Prevention (CDC) to review and analyze data, trained STD counselors/health care professionals to educate patients on the importance of safe sex practices, condom use, prevention of risky behavior and the dangers or STDs and Healthy People 2020 to assist in organizing and predicting outcomes. Sources of funding will come from the Pinellas Health Department, local health clinics and donations from the community. As previously mentioned, primary prevention methods such as education and screening to promote health promotion, is more cost effective than secondary and tertiary prevention methods (Anderson & Mcf'arlane, 2015).
Currently there are no known similar project goals in Pinellas County. Total cases ofgonorrhea, Chlamydia, and infectious syphilis were 16,608 between the years of2013~20] 5 (Florida Health CHARTS website, 2017). This is an alarming number of STDs that were entirely preventable. The Florida Department of Health in Pinellas County, local health clinics and the community can come together and make it possible to fund this program rooted in evidence based practice.
Method of Evaluation
Evaluation of this proposed intervention 'will involve reviewing current STO rates in Pinellas County prior to initiation of any intervention. Once a baseline is established and interventions started, baseline rates can be compared to previous years prior to initiation and then measured in the future. Data can be measured against state and national levels as well to determine the effectiveness of the intervention and whether there have been any notable changes in the rate of STD contraction.
In addition to the proposed intervention of behavioral counseling in an effort to prevent and reduce the rate of STDs, there are other similar recommendations cited by the USPSTF that was mentioned in their update of 2008 recommendations: The CDC recommendations suggest that all healthcare providers make it a standard routine to not only obtain a sexual history from patients, but also educate them on and encourage risk reduction. This can be accomplished through strategies sueh as prevention and behavioral counseling. Another recommendation from The Institute for Clinical Systems Improvement states that counseling on sexual behaviors to prevent STDs could begin at age 12 years and for higher-risk adults (LeFevre, 2014). To further increase chances of success, combining behavioral counseling with other prevention efforts could help lower costs and increase overall prevention effectiveness (Brockmeyer, Hogben, & Kinsey, 2016). While behavioral counseling is considered a promising practice, gaps in research remains. CDC's Division of STD Prevention is working on closing this gap by developing and integrating sustainable behavioral counseling interventions for community health centers with minimal change to current practice. The Division of STD Prevention is also working towards a plan that allows behavioral counseling to meet reimbursement requirements, whieh will only further increase sustainability of a behavioral counseling intervention as a means of prevention
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