Oregon County
Epidemiologist Proves The Value Of Shoe-Leather Epidemiology In
Combating Suicide
Wins 2018 Public
Health Impact Award
“Go out in the field! Do the hard, ugly fieldwork and
you will find a data goldmine.” That’s the message elicited from
Kimberly Repp, Washington county Oregon epidemiologist and winner
of the 2018 Public Health Impact Award from the National Association
of Medical Examiners. Repp competed for the prize with a manuscript
and oral presentation at the annual National Association of Medical
Examiners conference describing her work to reduce the approximately
100 annual suicide deaths in Washington county. Her manuscript is
entitled “Evaluation of a novel medico-legal death investigator based
suicide surveillance system.”
Start Up
Her decision to tackle the suicide problem followed
from the results of a community
health needs
assessment which identified suicide prevention as a priority need.
Oregon was one of the first states to participate in the National
Violent Death Reporting System (NVDRS) which collected data on five
risk factors for suicide. However, the data were 3-4 years old when
released and it was difficult to get county level data. “I wasn’t
comfortable guiding local prevention efforts using 4 year old state
data,” Repp told the Monitor.
Unique Situation
A relatively unique feature of the medical examiner
death investigators in Washington County is that they are housed in
the Public Health unit rather than with the district attorney or law
enforcement agencies. This made it easier for Repp to interact with
investigators in her agency, earn their respect and trust, and arrange
to collect additional data on each possible suicide. She accompanied
the county’s deputy medical examiners to collect new data on more than
200 investigations over a two year period.
Payoff
A feature of the data collection instrument she devised
was a blank section where investigators could note any additional
information of possible interest. In analyzing the information,
investigators noticed that a number of cases were dropping off their
pets at the animal shelter in the days before the suicide. This was
weird, said Repp, because the pets were healthy and not abused or
unloved. She called such an event a “touchpoint” where interventions
might be introduced to help prevent some of the suicides.
Interventions
Her group trained veterinarians and animal shelter
staff and volunteers to recognize these situations as missed
opportunities for prevention and encouraged them to ask clients if
they were thinking of hurting themselves. Over a six-month period, 7
persons answered yes when asked by shelter staff if they were thinking
about hurting themselves, and were put in contact with the local
suicide crisis line.
More Touchpoints
Other actionable touchpoints uncovered with the new
surveillance data include the finding that 40% of the suicide victims
had been in a health care provider’s office in the two weeks prior to
death, that evictions had taken place for 20% of cases, and that
several suicides occurred at a specific budget motel. Repp and her
group used these findings to work with the sheriff’s office
responsible for implementing evictions to put potential cases in touch
with the suicide crisis line and ensuring a trained mental health
professional was present when eviction notices were served. Also, they
trained staff at the motel in Question, Persuade, Refer (QPR)
prevention technique. Armed with the new information, individual
entities which have been identified as touchpoints are making their
own changes to help potential victims.
Impact
The overall suicide rate in Washington county has
declined but Repp told the Monitor it is too early to attribute any
changes to the interventions they have implemented. Her plans call for
collecting data from specific sites so that the effectiveness of
interventions before and after the new efforts will be ascertainable.
Challenges
Repp told the Monitor that convincing public health
professionals to undertake some of the interventions has been
relatively easy while convincing death investigators to do so has been
more challenging. However, winning the award from the Medical
Examiners Association has been useful and “it is exciting to see
buy-in at the national level from that group”.
Reactions
Asked about her reactions to participating in over 200 death
investigations, Repp told the Monitor that on the professional side
there are real parallels between how epidemiologists go about
investigating the possible causes of an outbreak and how medical
examiners investigate and rule out different potential causes of
death.
On the personal side, she said one cannot prepare for
how you are going to deal with being present at a death scene. She had
to undergo a 4 hour psychological evaluation before being allowed to
shadow the investigators. She told the Monitor that the only correct
answer that is acceptable to the question of how are you going to deal
with a violent death scene is “I don’t know.” She had to get over her
fear of what she would do in that situation. She has been very
impressed by the cultural competencies exhibited by the medical
examiners as they have to respect a very wide and rich range of death
rituals carried out by different ethnic and cultural groups in her
county.
Closing Comments
As Repp told her local newspaper, people who are at
risk for suicide will answer questions truthfully. “The take-home from
this is that anyone can save a life. You just have to have the courage
to ask the question—Are you thinking about hurting yourself? You do
not have to be a doctor or a psychologist. Anybody can ask and then
get that person on the phone with a crisis line. All this research has
shown that at the end, what saved a life was the person at the animal
shelter asking a question. Two regular people talking—that was what
saved a life.”
Repp closed her interview with the Epi Monitor by
noting that “The biggest touchpoint is the health care provider where
prevention opportunities are being handed out on a silver platter.” ■
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