As with Ebola Outbreak, Social Determinants of Health Crucial in Recent Rural U.S. HIV Outbreak

Rachel Parrill, PhD, RN, APHN-BC, is an associate professor of nursing at Cedarville University in Ohio

by banditob/flickr creative commons

by banditob/flickr creative commons

This past fall, with the world watching, a crisis unfolded in West Africa that challenged our understanding of sociocultural environments, epidemiology, and health. The spread of Ebola and the intercontinental transmission of the disease exposed weaknesses in our epidemiological defense system. It also drew attention to the powerful role that cultural beliefs and practices can have on disease transmission during outbreaks.

In that same time frame, and with similar cultural etiologies, another infectious crisis played out much closer to home. The setting: the rural Midwest, in and around the small town of Austin, Indiana. The disease: HIV. The crisis: an unprecedented outbreak—one with incidence rates (up to 22 new cases a day at the height of the outbreak) estimated to be higher than those in many sub-Saharan African nations and transmission rates through injection drug use higher than in New York City. Contributing to this “perfect storm” were socioeconomic factors characteristic of many rural settings, including poverty, low education levels, limited access to health care, and few recreational or employment opportunities.

In my work as a faculty member in a rural Midwest setting, I introduce undergraduate and graduate nursing students to concepts of public health nursing and try to provide opportunities for them to engage in local health initiatives. However, I often encounter an unconcerned or unengaged attitude towards the health risks associated with rural life—both on the part of my students and the community members that we serve.

Our local rural community seems mostly untouched by notable urban problems such as injection drug use, prostitution, sexually transmitted infections, and rampant violence, and issues seen in surrounding larger metropolitan communities like homelessness and human trafficking typically capture the interest of my nursing students far more than the run-of-the-mill comorbidities they often see in rural community members, such as heart disease, diabetes, cancer, and unintentional injury.

So I was captivated by the story that unfolded this past year in nearby Austin, Indiana, just a three-hour drive from our university. The devastation experienced by this community so similar to the one I call home provided a poignant learning opportunity for my nursing students, and for the broader nursing community.

In my role as a faculty member, I challenge nursing students to consider a broad range of social determinants of health when examining the health of a community. For example, I invite students to examine the income and educational levels of a community in light of important health indicators. We discuss the fact that health is too often connected with wealth, educational opportunities, neighborhood characteristics, race and gender inequalities, and social policy.

Similar to the West African Ebola outbreak, the HIV outbreak in Austin reveals the effects of sociocultural environments on health. The outbreak occurred among a network of injection drug users, mostly within multiple generations of a small group of families. In terms of context, Austin suffered from not only a high rate of prescription drug use, but also a lack of medical and drug rehabilitation services, inadequate public health infrastructure, a knowledge deficit regarding HIV risk, and a strong community-fed stigma surrounding HIV infection very similar to the one that played a role during efforts to combat the Ebola crisis.

Alarmingly, these same factors are present in other rural, vulnerable communities throughout the United States, many of which have experienced a dangerous mix of cultural and economic setbacks along with a continuing lack of health care access. Addressing the outbreak in the Austin community depended upon identifying and remedying the roots of factors fueling the wildfire of HIV transmission. Unfortunately, initial public health interventions there faltered in the presence of beliefs surrounding disease transmission, stigma associated with HIV testing and treatment, and community resistance to needle exchange programs.

As with the Ebola outbreak in West Africa, nurses in Austin have been key players in successfully reaching those most affected. Often, their healing came through direct outreach and ad hoc support. The NY Times shared the story of a public health nurse, Brittany Combs, who took HIV testing services, HIV/AIDS education, and the needle exchange program “to the streets” in a mobile van in Austin. Hoping to decrease barriers for citizens who were reluctant to access traditional public health services, Ms. Combs faced the raw realities of injection drug use and the suffering of the small, rural community that had been shaken to the core by a problem they never expected to visit such a place.

Nurses like Ms. Combs filled an essential role in caring for the community of Austin. The strategies she used mirrored those undertaken by health care workers throughout West Africa during the recent Ebola outbreak. Her example is one I plan to share with my nursing students as we engage the topics of rural health, social determinants of health, and culturally responsive nursing interventions. I will continue to provide opportunities for nursing students to apply these principles in our local communities, working through churches and parish nursing programs, grade schools, homeless shelters, and local health departments.

For me, the future of nursing involves advocacy on the part of nurse leaders to strengthen the sociocultural fabric of communities. Nurses have a unique opportunity to understand and intervene in the spaces where health and illness occur—neighborhoods, homes, faith communities, educational settings, and workplaces. For the broader nursing community, I hope that the lessons of Austin are not ignored as we construct a future where nurses are vital participants in addressing the diverse and complex determinants of health in all communities.

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Senior editor/social media strategy, American Journal of Nursing, and editor of AJN Off the Charts.

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