PHE 500 Module 6 Determinants Short Paper Example

Exposed and Underprotected: Social Determinants of Rabies Risk and Vaccine Access in a Rural County

[Student Name]

Southern New Hampshire University

PHE 500: Principles of Public Health

Module Six Short Paper

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

Exposed and Underprotected: Social Determinants of Rabies Risk and Vaccine Access in a Rural County

Rabies seems to have a simple cause: a bite from an infected animal. Yet who gets bitten, and who receives vaccine in time, depends on conditions far from the bite. Braveman and Gottlieb (2014) urged public health to look upstream, to the social and economic conditions that decide who meets a risk and who can get protection. This paper applies that view to rabies in a composite central Pennsylvania county, treating exposure and access as separate questions with different determinants.

Determinants of Exposure

Work is the strongest driver of exposure. Farmers, farm workers, veterinarians, animal control officers and wildlife rehabilitators handle animals daily, and dairy and livestock farms attract raccoons and feral cats. Housing matters too. Older farmhouses and cabins, common in the county's lower-income townships, often have gaps where bats roost, and families without money for repairs live with them. Recreation brings children into contact with bats at camps and in cabins.

Pet vaccination links animal and human risk. Barn cats on farms are rarely vaccinated because they are not seen as pets, and low-income households may skip pet vaccines because of cost or distance to a veterinarian. An unvaccinated cat that fights a rabid raccoon becomes a bridge to the family. Pieracci et al. (2019) noted that vaccinating pets is among the most effective ways to prevent human rabies, which makes pet vaccine access a human health issue.

Determinants of Access

Once exposed, a resident must recognize the risk, contact a provider and complete a schedule of immune globulin and four vaccine doses over two weeks. Each step depends on social conditions. Insurance comes first. A full course costs several thousand dollars (Pieracci et al., 2019), so uninsured residents and those with high deductibles may delay or refuse care. Language is next: information about bat exposures and vaccine is published mainly in English. Fear is a third barrier. Some farm workers avoid contact with any agency that might ask about immigration status, and some Amish families prefer to handle problems within their community. Distance and time are a fourth. The two hospitals that stock immune globulin are in the county seat, up to forty minutes away, and each dose can mean a lost half day of work.

These access barriers are not evenly spread. They concentrate among the same residents whose work and housing raise their exposure, so risk and barriers to protection stack on the same households.

Summary of Determinants

Table 1 brings the analysis together.

Table 1. Determinants of rabies exposure and access

Note. Effects are drawn from department records and partner interviews.

Equity-Focused Changes

Three changes follow from the analysis. First, high-risk workers could receive pre-exposure vaccine, which simplifies treatment after an exposure by removing the need for immune globulin. Federal recommendations adopted in 2022 shortened pre-exposure vaccination to two doses for most people at elevated risk (Rao et al., 2022), making a workplace program more practical. The county could partner with the regional farm worker clinic and large farms to offer it. Second, the department could negotiate a fund or payment plan with the hospitals so no exposed resident is billed before treatment begins, and could publish clearly that the department does not ask about immigration status. Third, the spring partner meeting should add the farm worker outreach program and Amish community leaders, and materials on bat exposures should be issued in Spanish and shared through trusted community channels.

None of these changes requires a new law. Each moves resources toward the residents who carry the most exposure and the most barriers.

Measuring Equity in the Response

The department cannot improve what it does not measure. Today its records show how many people started vaccine but not who they were. Adding a few fields to the exposure record, such as township, insurance status, preferred language and occupation, would let the department compare groups: how long each waited between exposure and first dose, and how many completed all doses. If uninsured or Spanish-speaking residents wait longer or complete fewer doses, the gap becomes visible and can be tracked as changes are made. These fields must be optional and kept confidential, or they will deepen the mistrust they are meant to address.

Upstream Roots

Some determinants have deep roots. The county's dairy farms rely on seasonal and immigrant labor with few benefits, a pattern set by farm economics and federal labor law rather than local choice. Much of its older housing dates from a time when farms were more prosperous, and repairs have lagged as incomes fell. Public health cannot change these conditions alone, but naming them helps explain why the same townships appear again and again in the county's records.

Limits of This Analysis

Its evidence comes from department records and a handful of interviews rather than a population survey, so the size of each barrier is uncertain. It also cannot measure exposures that were never reported, which may be the most important gap. A short survey of farm workers and Amish families, done with trusted partners, would test whether the barriers described here are the ones that matter most.

Findings should be shared back with the groups surveyed.

Conclusion

Rabies risk in the county is shaped by work, housing, pets, insurance, language, trust and distance, and those conditions cluster among the same residents. Looking upstream turns a disease that seems to be about animals into a question of who the public health system protects, and points to changes that would protect the residents now served least.

The next milestone will weigh interventions with that question in mind.

References

Braveman, P., & Gottlieb, L. (2014). The social determinants of health: It's time to consider the causes of the causes. Public Health Reports, 129(Suppl. 2), 19-31. https://doi.org/10.1177/00333549141291S206

Pieracci, E. G., Pearson, C. M., Wallace, R. M., Blanton, J. D., Whitehouse, E. R., Ma, X., Stauffer, K., Chipman, R. B., & Olson, V. (2019). Vital signs: Trends in human rabies deaths and exposures, United States, 1938-2018. MMWR Morbidity and Mortality Weekly Report, 68(23), 524-528. https://doi.org/10.15585/mmwr.mm6823e1

Rao, A. K., Briggs, D., Moore, S. M., Whitehill, F., Campos-Outcalt, D., Morgan, R. L., Wallace, R. M., Romero, J. R., Bahta, L., Frey, S. E., & Blanton, J. D. (2022). Use of a modified preexposure prophylaxis vaccination schedule to prevent human rabies: Recommendations of the Advisory Committee on Immunization Practices, United States, 2022. MMWR Morbidity and Mortality Weekly Report, 71(18), 619-627. https://doi.org/10.15585/mmwr.mm7118a2