Follow-up resources are key to health fairs’ success

Scenario: Health fairs are one of the most common health promotional and educational activities in the nation’s communities, and their popularity has increased in the past few decades. They offer important health screenings, but follow-up services can be critical.

Reply: The objectives of most health fairs are to provide screenings, preventive services and education at no or low cost to participants. Target audiences vary; the fair may focus on a specific disease (cardiovascular health) or demographic group (breast cancer screening for underserved women). The use of community settings and outreach materials, participation of culturally and linguistically appropriate staff and nominal cost of services eliminate many of the common financial, logistical, linguistic and cultural barriers to screening and preventive services.

Representing the collaborative efforts of the community, health fairs are beneficial for all stakeholders. Many attendees have limited access to care. Several recent studies observed that nearly half of health fair participants in underserved and vulnerable communities do not have primary care health professionals or health insurance. For them, the immunizations, hypertension and blood glucose screenings and education about diet and lifestyle may be the only such services they receive. Those who conduct the screenings have an opportunity to publicize their clinical services and network with community organizations. Medical students, residents and ancillary trainees benefit from the opportunity for service education, mentoring from more senior clinicians and working in multidisciplinary teams.

A substantial body of literature exists on health fairs, most of it describing effective planning methods, documenting the demographics of specific events, explaining their educational models and reporting the number of screenings performed. A growing body of evidence describes the impact on health outcomes. Beyond concerns of limiting liability, however, the ethical obligations of physicians who participate in health fairs have not been examined adequately. Because many participants have no established primary care physician, limited access to care and inadequate or no health insurance, the ethical challenges for physician volunteers are many.

The fairs simply cannot replace the care provided in conventional clinical settings. Physicians who provide screening or health education have no therapeutic relationship with participants and no knowledge of the patients’ histories. The encounters are typically one-time interactions with no opportunities for following up or developing rapport.

At fairs that offer phlebotomy and blood work, patients must be contacted by telephone or mail to deliver results. While most fairs have guidelines for urgent follow-up in cases of markedly abnormal findings, those with elevated blood pressure or blood glucose level are merely advised to contact their primary care physicians or nurse practitioners, but what if they have none? Herein lies the principal ethical dilemma for physicians — and the profession. What service do we provide when we screen for and discover a medical risk factor that requires attention, but have no care options to offer the patient who’s at risk?

Imagine that you are a physician volunteer at a popular annual health fair held at a community center near your office. The community and health center organizers predict that 350 people will attend during the day. The event is well-organized, with numerous prevention and screening stations offering influenza vaccination, body-mass index, blood pressure, blood glucose, mobility screening and medication review. You and five colleagues are volunteering at the final “Ask the Doctor” station, where you will review the health fair participants’ self-reported medical histories, medication lists and results of the screening sessions. A line forms at your station soon after the fair begins.

One participant, Mrs. W., walks up to your table. She is 56 and appears worried. Her main concern is that she lost her job two years ago. She is uninsured and has depleted her savings. She moved into her mother’s home after losing her own house. Her car broke down, so she takes public transportation. She walked about a mile to the venue from the bus stop. “I saw the list of free screening tests, so I didn’t mind the walk.”

Mrs. W. lists hypertension in her past medical history, but no medications for it appear on her list. When you ask her about that, she explains that she ran out of refills more than a year ago. She could not afford the drugs even when she had prescriptions, and there’s no clinic for uninsured patients near her mother’s home. She has tried to limit her sodium intake and remain physically active, but her blood pressure readings at the local pharmacy have been consistently elevated. Today it was 162/86; she is asymptomatic. She asks about her insomnia, crying spells and low mood; she asks if there is a social worker and where she can find a free primary care clinic. When you ask about physical activity, she explains that there’s no place to exercise around her mother’s home — no sidewalks, busy streets and a park that’s no longer safe. She knows of no free physical activity programs in her area.

What can be done to help Mrs. W.? Her needs exceed the capacity of a health fair. You realize that you have received no guide to local resources such as free or low-cost clinics and social services. After confirming the absence of suicidal ideations, you express to Mrs. W. your concern for her well-being and advise her to call the local information and referral services number.

But imagine, again, that before the fair you and your colleagues discussed the need for referral resources, follow-up and social services. You said, “These are the only conditions under which we can ethically participate.” Therefore, the health fair planners invited organizations that provide supportive care services. You introduce Mrs. W. to staff from a free clinic, including a nurse, a clinic scheduler and a social worker who are hosting a booth at the health fair. She receives a new patient appointment and a resource guide. “Thanks, Doc,” she says. “You cannot imagine how much you have helped me.”

Despite their time constraints and resource limitations, health fairs can be powerful outreach activities at which physicians and trainees reduce health disparities and improve access to relevant screening and preventive care. Physicians who volunteer should collaborate with colleagues and use their power in planning fairs with resource guides to key health services. Physicians should further insist that representatives from supportive services and free clinics are invited and present. Including resources relevant to the social determinants of health, especially addressing socioeconomic and geographic barriers access, is a viable solution for addressing some of the challenges confronted by the physician volunteer.

Given the ethical considerations of health fair participation, physicians must be involved in the early planning phase to ensure that the needs of vulnerable, underserved individuals are met — as a moral imperative. Physicians should take the stance that their participation is contingent upon the provision of community resources and referral access to health care follow-up and supportive services.

Monique Williams, MD, director of community outreach and assistant professor of medicine and psychiatry, Division of Geriatrics and Nutritional Science, Washington University School of Medicine, St. Louis