Delaware Journal of Public Health - Data to Decision Making

Delaware Journal of

Volume 5 | Issue 1

February 2019

Public Health A publication of the Delaware Academy of Medicine / Delaware Public Health Association

Data to Decision Making

www.delamed.org | www.delawarepha.org

Delaware Academy of Medicine Board of Directors: OFFICERS Omar A. Khan, M.D., M.H.S. President S. John Swanson, M.D. Vice President Sandra P. Medinilla, M.D., M.P.H. Secretary

Delaware Journal of

Public Health

Timothy E. Gibbs, M.P.H., N.P.Mc. Executive Director, Ex-officio DIRECTORS Stephen C. Eppes, M.D. Eric T. Johnson, M.D. Joseph F. Kestner, Jr, M.D. Professor Rita Landgraf Brian W. Little, M.D., Ph.D. Arun V. Malhotra, M.D. Joseph A. Napoli, M.D., D.D.S. John P. Piper, M.D. Albert A. Rizzo, M.D. EMERITUS Robert B. Flinn, M.D. Barry S. Kayne, D.D.S. Leslie W. Whitney, M.D.

Delaware Public Health Association

Advisory Council:

Omar Khan, M.D., M.H.S. President Timothy E. Gibbs, M.P.H., N.P.Mc. Executive Director Louis E. Bartoshesky, M.D., M.P.H. Gerard Gallucci, M.D., M.H.S. Richard E. Killingsworth, M.P.H. Erin K. Knight, Ph.D., M.P.H. Melissa K. Melby, Ph.D. Mia A. Papas, Ph.D. Karyl T. Rattay, M.D., M.S. Margot L. Savoy, M.D., M.P.H. William J. Swiatek, M.A., A.I.C.P.

Delaware Journal of Public Health Timothy E. Gibbs, M.P.H., N.P.Mc. Publisher Omar Khan, M.D., M.H.S. Editor-in-Chief Rita Landgraf Guest Editor Liz Healy, M.P.H. Managing Editor Kate Smith, M.D., M.P.H. Copy Editor Suzanne Fields Image Director ISSN 2639-6378

Volume 5 | Issue 1

A publication of the Delaware Academy of Medicine / Delaware Public Health Association

David M. Bercaw, M.D. Treasurer Daniel J. Meara, M.D., D.M.D. Immediate Past President

February 2019

www.delamed.org | www.delawarepha.org 3 | In this Issue

Omar A. Khan, M.D., M.H.S., Timothy E. Gibbs, M.P.H., N.P.Mc.

4 | Guest Editor Rita Landgraf

6 | Social Determinants of Health 101 for Health Care: Five Plus Five Sanne Magnan, M.D., Ph.D.

16 | Holding Course for Health Impact: All Aboard Delaware’s State Health Improvement Plan (SHIP) Cassandra Codes-Johnson, M.P.A. Noël Duckworth, D.V.S. Timothy Gibbs, M.P.H., N.P.Mc. Lucy Luta, M.D., M.P.H. Karen E. McGloughlin Katherine Smith, M.D., M.P.H.

20 | UD Partnership for Healthy Communities: Expanding Campus-Community Channels for Delaware’s SHIP Rita Landgraf Erin K. Knight, Ph.D., M.P.H. Noël Duckworth, D.V.S.

24 | Statewide Alignment: Coordinated Efforts for Delaware’s Behavioral Health Needs Bethany A. Hall-Long, Ph.D., R.N., Lieutenant Governor Chair, Behavioral Health Consortium

26 | Mapping the Burden of Chronic Diseases in Delaware for Public Health Decision Making Russell K. McIntire, Ph.D., M.P.H. Madeline Brooks, M.P.H. Scott D. Siegel, Ph.D., M.H.C.D.S. Mia Papas, Ph.D., M.S.

30 | Geographic Patterns of Asthma Rates and Air Quality in Delaware Rachel Vecchione, M.P.H. Caleb Dafilou, M.P.H. Violetta Gerzen-Feshchenko, M.P.Hc. Nicole LaRatta, M.P.H. Madeline Brooks, M.P.H.

40 | Smoking and Tobacco Retail Density Among Neighborhoods in Delaware

76 | Global Health Matters Fogarty International Center

88 | Chronic Disease in Delaware Helen Arthur, M.H.A.

96 | The Division of Public Health Adopts New Population Health Approach Lisa M.G. Henry, M.S. Cassandra Codes-Johnson, M.P.A.

Margaret Pearce Robert Zucker Crystal Lee, M.P.H. Opinderjit Kaur, M.P.H. Russell K. McIntire, Ph.D., M.P.H.

102 | The Data of Disease: How Data Collection Leads to Healthy Populations

50 | Geographic Relationships Between Smoking and Chronic Lower Respiratory Disease in Delaware

105 | Social Determinants of Health: Life Expectancy and the Relationship with Race, Education and Poverty in Delaware

Arielle Horowitz, M.P.H. Danny Cheong, M.P.H. Robert Martin, M.P.H. Russell K. McIntire, Ph.D., M.P.H.

58 | Food Access in Delaware: Examining the Relationship of SNAP Retailers, Food Deserts, Obesity, and Food Insecurity Alex Fossi, M.P.H. Desmond McCaffery Courtney Riseborough Niharika Vedherey, M.P.H. Lisa Armstrong Madeline Brooks, M.P.H.

66 | Using Geographic Information Systems (GIS) to Display Spatial Patterns of Diabetes in Delaware Saheedat Sulaimon, M.P.H. Rashida Smith, B.S. Ariel Paz, M.P.H. Madeline Brooks, M.P.H.

COVER The stylized eye on the cover was chosen to represent this issue of the Journal because as how we look for, and analyze data is fundamental to the data to decision making model. Also, known as data-driven decision management (DDDM), the success of the data-driven approach is reliant upon the quality of the data gathered and the effectiveness of its analysis and interpretation.

Katherine Smith, M.D., M.P.H.

Kalyn McDonough, Ph.D.

110 | Trust for America’s Health Wellness and Prevention Digest 116 | Data To Decision Making Lexicon of Terms 117 | Data To Decision Making Resources 118 | In Memoriam: LTG William H. Duncan M.D. Joseph Kestner M.D.

119 | Index of Advertisers 120 | From the history and archives collection

The Delaware Journal of Public Health (DJPH), first published in 2015, is the official journal of the Delaware Academy of Medicine / Delaware Public Health Association (Academy/DPHA).

only the opinions of the authors and do not necessarily reflect the official policy of the Delaware Public Health Association or the institution with which the author(s) is (are) affiliated, unless so specified.

Submissions: Contributions of original unpublished research, social science analysis, scholarly essays, critical commentaries, departments, and letters to the editor are welcome. Questions? Write ehealy@delamed. org or call Liz Healy at 302-733-3989.

Any report, article, or paper prepared by employees of the U.S. government as part of their official duties is, under Copyright Act, a “work of United States Government” for which copyright protection under Title 17 of the U.S. Code is not available. However, the journal format is copyrighted and pages may not be photocopied, except in limited quantities, or posted online, without permission of the Academy/ DPHA. Copying done for other than personal or internal reference use-such as copying for general distribution, for advertising or promotional purposes, for creating new collective works, or for resale- without the expressed permission of the Academy/DPHA is prohibited. Requests for special permission should be sent to ehealy@delamed.org.

Advertising: Please write to ehealy@delamed.org or call 302-733-3989 for other advertising opportunities. Ask about special exhibit packages and sponsorships. Acceptance of advertising by the Journal does not imply endorsement of products.

Copyright © 2019 by the Delaware Academy of Medicine / Delaware Public Health Association.

Opinions expressed by authors of articles summarized, quoted, or published in full in this journal represent

I N T H I S I S SU E “If we have data, let’s look at data.

If all we have are opinions, let’s go with mine.”

– Jim Barksdale, former Netscape CEO Our very existence is predicated on observation and interpretation of our environment. In the past, as now, a missed observation or incorrect interpretation can spell the difference between thriving – or merely surviving, and between surviving or dying.

Omar A. Khan, M.D., M.H.S. President

One could argue that the practice of public and population health is the practice of gathering data, turning it into useful information, displaying it in understandable formats, and using the resulting understanding to develop predictive and responsive solutions that move us toward thriving.

Historically there have been significant barriers to gathering and interpreting data – a major one being that data, by definition, is observed at a point in time. When we add observer bias, correlation/causation mistakes, sample size issues, and not asking the correct questions for the answer we are seeking – reasonable people can make erroneous judgments.

In spite of this, the news is good, and getting better every day as our society takes leaps forward in computer assisted processing of “big data.” In addition, our own understanding of how to better collect and understand data improves every day.

Timothy E. Gibbs, M.P.H., N.P.Mc. Executive Director

In part, that “getting better every day” is what this issue on “From Data to Decision Making” is all about….drawing more accurate conclusions and creating better interventions and policies.

The Delaware Academy of Medicine / Delaware Public Health Association is dedicated to science-based discipline and solutions, and is honored to work with the Division of Public Health, University of Delaware – Partnership for Healthy Communities, and many others. Specifically, we are engaged in the work of the State Health Improvement Plan, a focus of this issue. Also, in late March we will be rolling out the latest County Health Rankings for the State in partnership with the Public Health Management Corporation.

The guest editor for this issue of the Journal is former cabinet secretary, and current University of Delaware Professor Rita Landgraf, and we thank her for her role in making this issue a reality.

As always, we hope you enjoy this issue, and find it thought-provoking and engaging.

3

Data to Decision Making “Show me the Data” is a common theme for many sectors, inclusive of researchers, educators, policy makers, program implementers, consumers, entrepreneurs, big business, non-profits, hospitals … well you get the idea! We all rely on data that drives our decisions. The intent of this edition of the Delaware Journal of Public Health is to share some meaningful data that will inform you on the overall health and wellbeing of our state population. Several authors will also share how sectors are using data to align efforts for collective impact to produce healthier outcomes.

As former Cabinet Secretary of the Delaware Department of Health and Social Services (DHSS), I saw firsthand the value of data mining, data trending, and utilizing data to support the prioritization of issues affecting Delaware’s citizens. Data was also utilized to monitor the performance of DHSS and the achievement of meaningful outcomes relative to its mission. I was proud of the use of data to inform and direct our decisions, but was also keenly aware that we were merely scratching the surface: the promise of embedded data analytics in concert with translation is clearly not yet fully achieved.

We, as a society, rely on the integrity of data, and value scientists for ensuring data validity. Even in data driven environments, many times data is collected without the benefit of translation; it is not applied to real life practice across the multitude of sectors. Collecting data for data’s sake is a mere exercise of process, with limited to no return on the investment. However, the translation of data - for a greater appreciation and understanding of trends and outcomes across audiences - will produce better universal decision-making and factual interpretations, gain a greater return on investment, advance evidence based practices and known outcomes, and create a culture of health. Through data, we can create predictability models that lead to real time preventative solutions and/or solid intervention actions that truly promote positive health outcomes at both the individual and community level.

Now that would be truly transformative.

Rita M. Landgraf Director UD Partnership for Healthy Communities Professor of Practice and Distinguished Health & Social Services Administrator in Residence College of Health Sciences

Rita Landgraf is the director of the UD Partnership for Healthy Communities, and professor of practice and distinguished health and social services administrator in residence with the College of Health Sciences at the University of Delaware. Prior to joining the faculty at UD, Rita served as Cabinet Secretary of the Delaware Department of Health and Social Services from Jan. 22, 2009 through Feb 6, 2017, under Governor Jack Markell’s administration. As Secretary, she led the principal agency charged with keeping Delawareans healthy, ensuring they get the health care they need, and providing children, families, individuals with disabilities and seniors with the essential services they depend on.

4 Delaware Journal of Public Health – February 2019

SAVE THE DATE/TIME May 2, 2019 - 8:00 am to 1:30 pm

Focus on Hypertension • Accurate Blood Pressure Measurements and new/non-conventional ways to measure blood pressure • Controlling the Hormone Basis of HTN • Unusual Case Presentations • Treatments for Resistant HTN • Obesity and Hypertension • New AHA Guidelines on HTN

John H. Ammon Medical Education Center at Christiana Hospital in Newark, Delaware.

Visit www.delamed.org for more information and to register onine.

5

DISCUSSION DISCUSSION DISCUSSION PAPER PAPER PAPER

Reprinted with permission from the National Academy of Medicine DISCUSSION PAPER

Social Social Social Determinants Determinants Determinants of of of Health Health Health 101 101 101 for for for Health Health Health Care: Care: Care: Five Five Five Plus Plus Plus Five Five Five Sanne Sanne Sanne Magnan, Magnan, Magnan, MD, MD, MD, PhD, PhD, PhD, HealthPartners HealthPartners HealthPartners Institute; Institute; Institute; University University University ofof Minnesota ofMinnesota Minnesota

October October October 9,9,2017 9,2017 2017

Introduction Introduction Introduction

play play play a role a role a role in in effin eff orts eff orts orts to to mitigate to mitigate mitigate or or improve or improve improve thethe SDoH. the SDoH. SDoH. Third, Third, Third, they they they express express express concern concern concern about about about thethe limited the limited limited evidence evidence evidence Social Social Social determinants determinants determinants of of health of health health (SDoH) (SDoH) (SDoH) is ais relatively is a relatively a relatively new new new Figure 1 | County Health Rankings & Roadmaps of of effof eff ectiveness eff ectiveness ectiveness of of interventions of interventions interventions byby health by health health care care care onon the on the the term term term in health in in health health care. care. care.

AsAs de As de ned de ned by ned by the by the World the World World Health Health Health Or-OrOrSOURCE: Reprinted with permission from CountySDoH Health Rankings &isRoadmaps, http://www.countyhealthrankings.

SDoH SDoH [2].

[2].

There [2].

There There is a is viewpoint, a a viewpoint, viewpoint, however, however, however, forfor health for health health ganization ganization ganization (WHO), (WHO), (WHO), SDoH SDoH SDoH areare “the are “the “the conditions conditions conditions in which in which which org/our-approach (accessed July 18, in 2017). care care care to to nd to nd its nd its role its role role in in population in population population health health health [3],[3], and [3], and some and some some people people people areare born, are born, born, grow, grow, grow, live, live, live, work work work and and and age. age. age.

These These These cir-cir-cirproviders providers providers believe believe believe there there there is is enough is enough enough science science science to to support to support support SDoH are greatly in uenced by policies, systems, and behaviors, socioeconomic factors, and environmencumstances cumstances cumstances areare shaped are shaped shaped byby the by the distribution the distribution distribution of of money, of money, money, integration integration integration of of SDoH of SDoH SDoH into into into health health health care care care and and and are are pursuare pursupursutalresources factors. we as aand country spend a higher environments (PSE). A diagram used by County Based power power power and and resources and resources atAlthough at global, at global, global, national national national and local and local local levlevleving ing evidence-informed ing evidence-informed evidence-informed interventions interventions interventions with with with community community community percentage of our gross domestic product on els” els” [1]. els” [1].

The [1].

The social The social social determinants determinants determinants of of health of health health also also also deterdeterdeter-medical Health Rankings and Roadmaps (Figure 1) shows the partners partners partners [4,5].

[4,5]. interaction between health outcomes, the SDoH, and care expenditures than other developed countries, it is [4,5]. mine mine mine access access access and and and quality quality quality of of medical of medical medical care—sometimes care—sometimes care—sometimes Lest Lest Lest wewe think we think think SDoH SDoH SDoH areare the are the next the next next panacea panacea panacea in in health in health health policies and programs.

For example, tobacco is a more diffi cult to compare spending on the SDoH. We referred referred referred to to asto as medical as medical medical social social social determinants determinants determinants of of health of health health care, care, care, let let us let us consider us consider consider what what what we we know we know know and and what and what what we we need we need need (e.g., leading determinant of many health outcomes that many developed countries (see (see (see Figure Figure Figure 1do for 1 know for 1the for the County the County County Health Health Health Rankings Rankings Rankings model model model of proportionof of to to learn to learn learn about about about SDoH SDoH SDoH to to achieve to achieve achieve the the national the national national quality quality quality ately spend more on social services than the factors factors factors shaping shaping shaping health). health). health).

Future Future Future opportunities opportunities opportunities may may may ex-exex- United mortality, quality of life), and decreasing tobacco strategy strategy strategy of of better of better better care, care, care, healthy healthy healthy people/healthy people/healthy comcomcomuse is more in uenced bypeople/healthy the price of cigarettes and States [8].

Although social services do not correspond istist inist in genetics in genetics genetics and and and biological biological biological determinants; determinants; determinants; however, however, however, munities, munities, munities, and and aff and aff ordable aff ordable ordable care care care [6].[6].[6]. in the community than by smoke-free environments directly to the SDoH, this comparison gives one view of whether whether whether modifying modifying modifying these these these willwill be will be asbe as feasible as feasible feasible as as modifyas modifymodifythe availability of cessation clinics or quitlines. proportional expenditures country. inging the ing the social the social social determinants determinants determinants of of health of health health isin unknown. isour unknown. is unknown.

Five Five Five Things Things Things We We Know We Know Know About About About (Social) (Social) (Social)

Although Although Although the the SDoH theSDoH SDoH easily easily easily resonate resonate resonate for for clinicians, forclinicians, clinicians, Corollary: Community partnerships Corollary: Despite our signi cant spending, our outDeterminants Determinants Determinants ofof Health of Health Health in in Health in Health Health Care Care Care that synergize given given given their their their intuitive intuitive intuitive recognition recognition recognition that that that health health health outcomes outcomes outcomes medical interventions and PSE changes produce a more comes are among the lowest for developed countries, 1.

1.

As1.

As athe As determinant a determinant a determinant of of health, of health, health, medical medical medical care care is is change. is areare aff are aff ected aff ected ected by by patients’ by patients’ patients’ conditions conditions conditions outside outside outside the clinithe cliniclinicomprehensive approach to care behavior For exincluding signi cant inequities [9].the For health care, insuffi insuffi insuffi cient cient cient for for ensuring for ensuring ensuring better better better health health health outcomes. outcomes. outcomes. calcal walls, cal walls, walls, clinicians clinicians clinicians may may may raise raise raise several several several concerns concerns concerns about about about ample, walking prescriptions for patients can be comhope is that addressing the more upstream social deterinvolvement involvement involvement in in the in the SDoH. the SDoH. SDoH. First, First, First, they they they realize realize realize that that that this this this plemented by community changes toonly increase availabilminants will improve health outcomes, reduce inequiMedical Medical Medical care care care is is estimated is estimated estimated to to account to account account forfor only for only 10-20 10-20 10-20 is is not is not their not their their domain domain domain of expertise of expertise expertise or or current or current current accountaccountity of safe walking spaces.

Such partnerships ties, andoflower costs.

What can weaccountlearn from percent other napercent percent of of the of the modi the modi modi able able able contributors contributors contributors to to healthy to healthy healthy outoutout-can also ability. ability. ability.

Second, Second, Second, some some some are are worried are worried worried that that that health health health care care care syssyssysproviders’ concerns about being held responsible tions’ medical and nonmedical system effortscomes that are comes comes forfor afor population aallay population a population [7].[7].

The [7].

The other The other other 80 80 to80 to 90 to 90 percent 90 percent percent tems tems tems already already already have have have enough enough enough tohealth to address to address address and and should and should should notnot not for problems outside their clinical domain, and the achieving better outcomes? areare sometimes are sometimes sometimes broadly broadly broadly called called called thethe SDoH: the SDoH: SDoH: health-related health-related health-related 2. SDoH Are Inuenced by Policies and Programs, and Associated with Better Health Outcomes.

partnerships can bring expertise, allies, and resources to address complex issues such as tobacco use, physical activity, alcohol use, housing, and so on.

Perspectives Perspectives Perspectives | Expert | Expert | Expert Voices Voices Voices in in Health in Health Health & Health && Health Health Care Care Care Page 2

6 Delaware Journal of Public Health – February 2019

Published October 9, 2017

DISCUSSION PAPER DISCUSSION PAPER

3. New Payment Models Are Prompting Interest in the SDoH. New value-based payment models such as alternative payment models, accountable care models such as accountable care organizations (ACOs) and patient-centered medical homes, and Medicare Shared Savings are moving toward payment for outcomes rather than process measures, as well as benchmarks for “total cost of care.” Since better results on the SDoH are associated with better health outcomes, will payment models evolve to jointly reward health care organizations and communities for outcomes such as lower tobacco, obesity and/or diabetes prevalence , or improved high school graduation rates?

Social Determinants of Health 101 for Health Care

cludes community-driven and individual data for use in primary care, recognizing that there are still questions about the effect on outcomes [13]. The framework, however, does not include how the data might be used with community partnerships to expand the effect of collecting the data.

Screening tools have been developed, e.g., for an accountable health community initiative [14], and one for a pediatric emergency department with a low-income population [15]. Models are emerging for how to follow up screening data, e.g., “clinic-to-community treatment models” for children living in food-insecure households [16].

For the EHR, the Institute of Medicine (IOM) has recommended that social and behavioral health domains be captured [17]. The incentive, training, and privacy barriers for feasibility of incorporating SDoH into EHRs have been discussed [18]. Interestingly, electronic screening produced higher rates of self-disclosure of some sensitive determinants (violence and substance abuse) than in-person screening [15]. Most recently, the feasibility, reliability, and validity of the IOM-recommended domains (except for income) were evaluated, and clinical trials were recommended [19, 20].

Corollary: The Population-based Payment Model Workgroup of the Health Care Learning and Action Network (LAN) recently recommended that “Big(ger) Dot” measures increasingly be used in new payment models. For example, measures of cardiac care are ideally outcome measures (e.g., 30-day mortality, health-related quality of life or well-being), not individual process measures (e.g., aspirin at arrival) [10]. However, process measures continue to be important for quality improvement and for some payment programs. New summary measures Corollary: Integrating the SDoH into health care should for population well-being for use by health Figure 1 | Countyhealth Healthand Rankings & Roadmaps not&fall primarilyhttp://www.countyhealthrankings. on primary care clinicians. Although SOURCE: Reprinted with permission from County Health Rankings Roadmaps, plans1 and accountable care organizations have been Figure | County Health Rankings & Roadmaps front-line clinicians can see patterns of key determiorg/our-approach (accessed July 18, 2017). proposed [11,12], with and frameworks for rewarding healthRankings & Roadmaps, http://www.countyhealthrankings.

SOURCE: Reprinted permission from County Health nants for populations, leadership within health care org/our-approach (accessed July 18, 2017). outcomes are being developed. are greatlymust inuenced bythis policies, and behaviors, socioeconomic factors, and environmen- SDoH organizations advance work systems, by alignment environments (PSE).

A diagram used by County Based tal factors.

Although we as a country spend a higher SDoH are greatly in uenced by policies, systems, and behaviors, socioeconomic factors, and environmenwith strategic directions, board support for community 4. Frameworks for Integrating SDoH Are Emerging.

Health Rankings and Roadmaps (Figure 1) shows the percentage of our gross domestic product on medical A diagram used County tal factors. Although we as a country spend a higher environments partnerships,(PSE). adopting a culture thatby values theBased SDoH Data frameworks have been proposed for integrating interaction between health outcomes, the SDoH, and care expenditures developed countries, it is Health Rankings and Roadmaps (Figure 1) shows the percentage of ourthan grossother domestic product on medical in addition to quality and affordable health care, meaSDoH into primary care and capturing SDoH domains policies and programs. For example, tobacco is a more difficult to compare spending on the SDoH. We between health outcomes, the SDoH, and care expenditures than other developed countries, it is interaction surement/evaluation, role clarication, creation of new in electronic health records (EHRs). One framework in- leading determinant of many health outcomes (e.g., do know developed countries proportionmore diffithat cult many to compare spending on the SDoH. We policies and programs. For example, tobacco is a quality of of life), andhealth decreasing tobacco ately spend more ondeveloped social services than proportionthe United mortality, leading determinant many outcomes (e.g., do know that many countries is morequality inuenced by the price of cigarettes and States [8]. Although social services do than not correspond mortality, of life), and decreasing tobacco ately spend more on social services the United use the community thanand by directly to the SDoH, this comparison gives view of smoke-free use is moreenvironments inuenced by in the price of cigarettes States [8].

Although social services do not one correspond availability of cessation clinics quitlines. than by proportional in our country. smoke-free environments in the or community directly to theexpenditures SDoH, this comparison gives one view of the proportional expenditures in our Corollary: Despite our signi cantcountry. spending, our outcomes are among Corollary: Despite the ourlowest signifor cantdeveloped spending,countries, our outincluding signi cantthe inequities [9]. developed For health countries, care, the comes are among lowest for hope is that addressing the more[9]. upstream social deterincluding signi cant inequities For health care, the minants will addressing improve health outcomes, reduce hope is that the more upstream socialinequideterties, and lower costs. What canoutcomes, we learn from other naminants will improve health reduce inequitions’ medical nonmedical system orts other that are ties, and lowerand costs.

What can we learneff from naachieving better health outcomes? tions’ medical and nonmedical system efforts that are achieving better health outcomes?

2. SDoH Are Inuenced by Policies and Programs, and Associated with Better 2. SDoH Are In uenced

by Health PoliciesOutcomes. and Programs, and Associated with Better Health Outcomes.

the availability of cessation clinics or quitlines.

Corollary: Community partnerships that synergize medical interventions andpartnerships PSE changes produce a more Corollary: Community that synergize comprehensive approach exmedical interventions and to PSEbehavior changes change. produceFor a more ample, walking prescriptions for patients can be comcomprehensive approach to behavior change. For explemented by community changes to increase ample, walking prescriptions for patients canavailabilbe comity of safe walking spaces.changes Such partnerships can also plemented by community to increase availabilallay concerns about held responsible ity ofproviders’ safe walking spaces.

Suchbeing partnerships can also for problems outside their clinical domain, and the allay providers’ concerns about being held responsible partnerships bring their expertise, allies, and resources for problemscan outside clinical domain, and the to address complex issues such as tobacco use,resources physical partnerships can bring expertise, allies, and activity, alcohol use, issues housing, and on. use, physical to address complex such asso tobacco activity, alcohol use, housing, and so on.

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NAM.edu/Perspectives Page 2

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Social Determinants of Health 101 for Health Care

DISCUSSION PAPER 3. New Payment Models Are Prompting Interest in the SDoH. 3. New Payment Models Are Prompting Interest in the SDoH. New value-based payment models such as alternative payment models, accountable careasmodels New value-based payment models such altersuch as accountable care organizations (ACOs) and native payment models, accountable care models patient-centered medical homes, and Medicare Shared such as accountable care organizations (ACOs) and Savings are moving toward payment for outcomes patient-centered medical homes, and Medicare Shared rather than as well asfor benchmarks Savings are process movingmeasures, toward payment outcomes for “total cost of care.”

Since better results on the SDoH rather than process measures, as well as benchmarks are “total associated better outcomes, willSDoH payfor cost ofwith care.”

Sincehealth better results on the ment models evolve to jointly reward health will carepayorare associated with better health outcomes, ganizations communities for outcomes such oras ment modelsand evolve to jointly reward health care lower tobacco, obesity and/or diabetes prevalence , or ganizations and communities for outcomes such as improved high school rates?prevalence , or lower tobacco, obesitygraduation and/or diabetes

Social Determinants of Health 101 for Health Care

cludes community-driven and individual data for use in primary care, recognizing and thatindividual there are data still questions cludes community-driven for use in about the effect on outcomes [13].are The framework, primary care, recognizing that there still questions however, noton include how the data might be used about thedoes effect outcomes [13].

The framework, with community partnerships expand the eff of however, does not include howto the data might beect used collecting the data. with community partnerships to expand the effect of Screening collecting thetools data.have been developed, e.g., for an accountable community initiative [14], Screening health tools have been developed, e.g.,and forone an for a pediatric emergency department low-inaccountable health community initiativewith [14], aand one come population [15]. Models are emerging how for a pediatric emergency department with afor low-into follow up screening e.g., “clinic-to-community come population [15]. data, Models are emerging for how treatment models” for children in food-insecure to follow up screening data, e.g.,living “clinic-to-community householdsmodels” [16]. for children living in food-insecure treatment For the EHR, the Institute of Medicine (IOM) has rechouseholds [16]. ommended that social and behavioral For the EHR, the Institute of Medicinehealth (IOM)domains has recbe capturedthat [17].social The incentive, training, anddomains privacy ommended and behavioral health barriers for feasibility incorporating SDoH into EHRs be captured [17]. Theofincentive, training, and privacy have been discussed [18].

Interestingly, electronic barriers for feasibility of incorporating SDoH into EHRs screening higher of self-disclosure of have beenproduced discussed [18].rates Interestingly, electronic some sensitive determinants (violence and substance screening produced higher rates of self-disclosure of abuse)sensitive than in-person screening [15]. and Mostsubstance recently, some determinants (violence the feasibility, reliability,screening and validity the IOM-recabuse) than in-person [15].ofMost recently, ommended domains (except income) were evaluthe feasibility, reliability, and for validity of the IOM-recated, and clinical trials(except were recommended [19, 20]. ommended domains for income) were evalu-

improved high graduation Payment rates? Model WorkCorollary: Theschool Population-based group of the Care Learning and Action Network Corollary: TheHealth Population-based Payment Model Work(LAN) recently recommended that “Big(ger) Dot” meagroup of the Health Care Learning and Action Network sures increasingly be used in new For (LAN) recently recommended thatpayment “Big(ger)models.

Dot” meaexample, measuresbeofused cardiac carepayment are ideally outcome sures increasingly in new models.

For measuresmeasures (e.g., 30-day mortality, health-related quality example, of cardiac care are ideally outcome of life or well-being), individual process measures measures (e.g., 30-daynot mortality, health-related quality (e.g., at arrival)not [10].individual However, process process measures of lifeaspirin or well-being), continue to be important for quality improvement and (e.g., aspirin at arrival) [10].

However, process measures for some to payment programs.

New summary measures continue be important for quality improvement and ated, and clinical trials were recommended [19, 20].

Corollary: Integrating the SDoH into health care should for some population health and well-being for use by health payment programs. New summary measures not fall primarily on primary Although Corollary: Integrating the SDoHcare intoclinicians. health care should plans and accountable care organizations been for population health and well-being for usehave by health front-line clinicians can see patterns of key Although determinot fall primarily on primary care clinicians. proposed [11,12], frameworks for rewarding health plans and accountable care organizations have been Figure 1 | and County Health Rankings & Roadmaps nants for clinicians populations, within health care front-line can leadership see patterns of key determioutcomes are being developed. proposed [11,12], and frameworks for rewarding health SOURCE: Reprinted with permission from County Health Rankings & Roadmaps, http://www.countyhealthrankings. organizations must advance this work by alignment nants for populations, leadership within health care org/our-approach (accessed July 18, 2017). outcomes are being developed. with strategic directions, board support for community 4. Frameworks for Integrating SDoH Are Emerging. organizations must advance this work by alignment SDoH adopting are greatly inuenced policies, systems, and behaviors, socioeconomic factors, and environmenpartnerships, aboard culture that by values the SDoH with strategic directions, support for community 4.

Frameworks for Integrating SDoH Are Emerging.

Data frameworks have been proposed for integrating environments (PSE).

A diagram used

by SDoH County Based tal factors. Although we as a country spend a higher in addition to adopting quality and affordable care, meapartnerships, a culture thathealth values the SDoH into primaryhave carebeen and capturing domains Data frameworks proposed SDoH for integrating Health Rankings Roadmaps (Figure 1) shows the percentage of our gross domestic product on medical surement/evaluation, roleand clari cation, creation ofmeanew in addition to quality and aff ordable health care, in electronic health care records OneSDoH framework inSDoH into primary and(EHRs). capturing domains health outcomes, the SDoH, and care expenditures than other developed countries,surement/evaluation, it is interaction between role clarication, creation of new in electronic health records (EHRs). One framework inmore difficult to compare spending on the SDoH. We policies and programs. For example, tobacco is a do know that many developed countries proportion- leading determinant of many health outcomes (e.g., ately spend more on social services than the United mortality, quality of life), and decreasing tobacco States [8]. Although social services do not correspond use is more inuenced by the price of cigarettes and directly to the SDoH, this comparison gives one view of smoke-free environments in the community than by the availability of cessation clinics or quitlines. proportional expenditures in our country.

Corollary: Despite our signicant spending, our outcomes are among the lowest for developed countries, including signicant inequities [9]. For health care, the hope is that addressing the more upstream social determinants will improve health outcomes, reduce inequities, and lower costs. What can we learn from other nations’ medical and nonmedical system efforts that are achieving better health outcomes?

2. SDoH Are Inuenced by Policies and Programs, and Associated with Better Health Outcomes.

Corollary: Community partnerships that synergize medical interventions and PSE changes produce a more comprehensive approach to behavior change. For example, walking prescriptions for patients can be complemented by community changes to increase availability of safe walking spaces. Such partnerships can also allay providers’ concerns about being held responsible for problems outside their clinical domain, and the partnerships can bring expertise, allies, and resources to address complex issues such as tobacco use, physical activity, alcohol use, housing, and so on.

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DISCUSSION PAPER DISCUSSION PAPER

3. New Payment Models Are Prompting Interest in the SDoH. New value-based payment models such as alternative payment models, accountable care models such as accountable care organizations (ACOs) and patient-centered medical homes, and Medicare Shared Savings are moving toward payment for outcomes rather than process measures, as well as benchmarks for “total cost of care.” Since better results on the SDoH are associated with better health outcomes, will payment models evolve to jointly reward health care organizations and communities for outcomes such as lower tobacco, obesity and/or diabetes prevalence , or improved high school graduation rates?

Social Determinants of Health 101 for Health Care

cludes community-driven and individual data for use in primary care, recognizing that there are still questions about the effect on outcomes [13]. The framework, however, does not include how the data might be used with community partnerships to expand the effect of collecting the data.

Screening tools have been developed, e.g., for an accountable health community initiative [14], and one for a pediatric emergency department with a low-income population [15]. Models are emerging for how to follow up screening data, e.g., “clinic-to-community treatment models” for children living in food-insecure households [16].

For the EHR, the Institute of Medicine (IOM) has recommended that social and behavioral health domains be captured [17]. The incentive, training, and privacy barriers for feasibility of incorporating SDoH into EHRs have been discussed [18]. Interestingly, electronic screening produced higher rates of self-disclosure of some sensitive determinants (violence and substance abuse) than in-person screening [15]. Most recently, the feasibility, reliability, and validity of the IOM-recommended domains (except for income) were evaluated, and clinical trials were recommended [19, 20].

Corollary: The Population-based Payment Model Workgroup of the Health Care Learning and Action Network (LAN) recently recommended that “Big(ger) Dot” measures increasingly be used in new payment models. For example, measures of cardiac care are ideally outcome measures (e.g., 30-day mortality, health-related quality of life or well-being), not individual process measures (e.g., aspirin at arrival) [10]. However, process measures continue to be important for quality improvement and for some payment programs. New summary measures Corollary: Integrating the SDoH into health care should for population well-being for use by health Figure 1 | Countyhealth Healthand Rankings & Roadmaps not&fall primarilyhttp://www.countyhealthrankings. on primary care clinicians. Although SOURCE: Reprinted with permission from County Health Rankings Roadmaps, plans and accountable care organizations have been front-line clinicians can see patterns of key determiorg/our-approach (accessed July 18, 2017). proposed [11,12], and frameworks for rewarding health nants for populations, leadership within health care outcomes are being developed. are greatlymust inuenced bythis policies, and behaviors, socioeconomic factors, and environmen- SDoH organizations advance work systems, by alignment environments (PSE).

A diagram used by County Based tal factors.

Although we as a country spend a higher with strategic directions, board support for community 4. Frameworks for Integrating SDoH Are Emerging.

Rankingsadopting and Roadmaps 1) shows the percentage of our gross domestic product on medical Health partnerships, a culture(Figure that values the SDoH Data frameworks have been proposed for integrating interaction between health outcomes, the SDoH, and care expenditures than other developed countries, it is in addition to quality and affordable health care, meaSDoH into primary care and capturing SDoH domains and programs.role For example, tobaccoofisnew a more difficult to compare spending on the SDoH. We policies surement/evaluation, clari cation, creation in electronic health records (EHRs). One framework indo know that many developed countries proportion- leading determinant of many health outcomes (e.g., qualityneeds of life), and decreasing tobacco ately more on socialofservices than families’ social demonstrated a decrease in the skillspend sets, and realignment resources [21],the i.e.,United building mortality, use is more in uenced by the price of cigarettes and States [8].

Although social services do not correspond a system approach to integration. These leadership ac- families’ report of social needs and better reported chilenvironments in [23], the community thanrecomby directly the front-line SDoH, this comparison onechampions view of smoke-free dren’s overall health status and the authors tions to allow clinicians to begives natural the availability of cessation clinics or quitlines. proportional expenditures in our country. for the SDoH within the organization and the community mend more experiments to determine investments in without being responsible forcant all the necessary Corollary: Despite our signi spending, ourcompooutnents of a systems approach. comes are among the lowest for developed countries, including signicant inequities [9]. For health care, the 5. Experiments Are Occurring at the Local and hope is that addressing the more upstream social deterFederal Level. minants will improve health outcomes, reduce inequiState innovation models arewe exploring ties, and lower costs.

What can learn fromconnections other naamong health care, services, and eff some [22]. tions’ medical and social nonmedical system ortsSDoH that are ACOs are responding nonmedical needs of patients achieving better healthtooutcomes? such as transportation, housing, and food with the as2.

SDoH Are In uenced by Programs, sumption that outcomes andPolicies cost willand improve [4]. One and Associated with Better Health Outcomes. randomized pediatric intervention of in-person navigation services in two safety-net hospitals to address

interventions.

The Centers for Medicare & Medicaid Corollary: Community partnerships that synergizeServices (CMS) launchedand accountable health communities medical interventions PSE changes produce a more (ACH)—the rstapproach innovation-center model to test comprehensive to behavior change.

For matchexing the walking needs of a population (i.e., CMS bene ciaries) ample, prescriptions for patients can be comwith community resources [24,25].

With a robust evaluplemented by community changes to increase availabilation the ve-year ACH model tests twocan tracks: ity of plan, safe walking spaces.

Such partnerships also assistance track -concerns provide about community service navigation allay providers’ being held responsible assistance, alignment track - domain, encourage for problemsand outside their clinical andpartner the alignment to ensure services are available and responpartnerships can bring expertise, allies, and resources sive.

These experiments willasprovide evidence to address complex issues such tobacco more use, physical about ectiveness in achieving activity,eff alcohol use, housing, and better so on. outcomes, better experience, and lower costs.

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Social Determinants of Health 101 for Health Care

DISCUSSION PAPER 3. New Payment Models Are Prompting Interest in the SDoH.

Five Things We Need to Learn about Social New value-based paymentinmodels Determinants of Health Healthsuch Care as alternative payment models, accountable care models 1.

Howasdoaccountable we prioritize SDoH for individual patients such care organizations (ACOs) and and for communities? patient-centered medical homes, and Medicare Shared Savings are requires moving toward paymentoffor outcomes Prioritization an assessment readiness to rather than process measures, as well as benchmarks address proven or testable interventions, and return for investment. “total cost of Which care.” Since better results on on patients will bene t the SDoH most are associated health outcomes, willWhich payfrom addressingwith theirbetter SDoH, and which SDoH? ment models evolve to for jointly reward health care orpatients are most ready these interventions?

Which ganizations and outcomes such as interventions will communities decrease per for capita spending?

From lower tobacco, obesity and/or diabetes prevalence , or a community perspective, which SDoH are of most conimproved high school graduation and rates? cern to community stakeholders, which SDoH will have the greatest effect on total population health and Corollary: The Population-based Payment Model Workwell-being, health equity, and health care expenditures? group of the Health Care Learning and Action Network

Social Determinants of Health 101 for Health Care

cludes community-driven and individual data for use in primary care, that there are still questions 2. How do werecognizing intervene without medicalizing SDoH? about the effect on outcomes [13]. The framework, There is a danger that a how medical approach to used these however, does not include the data might be nonmedical factors will lead to more health care with community partnerships to expand the effectverof sus morethe cost-eff collecting data.ective and community-based interventions.

Fortools example, social worker sees patient Screening have abeen developed, e.g.,a for an with schizophrenia once a week in northern Minnesoaccountable health community initiative [14], and one ta, but she says, “What thisdepartment patient needs friend.” for a pediatric emergency withis aa low-inHow do we avoid “re-creating the wheel” inside come population [15]. Models are emerging forhealth how care and increasing costs?

How do we listen to comto follow up screening data, e.g., “clinic-to-community munities, identify and delineate health care’s role, treatment models” for children living in food-insecure and collaborate appropriately with existing commuhouseholds [16]. nity andInstitute increase health care Forresources the EHR, the of capacity?

Medicine As (IOM) has recprofessionals, need huge doses health of humility and ommended thatwe social and behavioral domains openness to authentically address SDoH and form or be captured [17]. The incentive, training, and privacy join community partnerships.

A recent infographic barriers for feasibility of incorporating SDoH into EHRsillustrates an discussed emerging path community electronic collaborahave been [18]. for Interestingly, screening produced higher rates of self-disclosure of some sensitive determinants (violence and substance abuse) than in-person screening [15]. Most recently, the feasibility, reliability, and validity of the IOM-recommended domains (except for income) were evaluated, and clinical trials were recommended [19, 20].

(LAN) recently recommended that “Big(ger) Dot” measures increasingly be used in new payment models. For example, measures of cardiac care are ideally outcome measures (e.g., 30-day mortality, health-related quality of life or well-being), not individual process measures (e.g., aspirin at arrival) [10]. However, process measures continue to be important for quality improvement and for some payment programs. New summary measures Corollary: Integrating the SDoH into health care should for population health and well-being for use by health not fall primarily on primary care clinicians. Although plans and accountable care organizations have been front-line clinicians can see patterns of key determiproposed [11,12], frameworks for rewarding health Figure 1 | and County Health Rankings & Roadmaps nants for populations, leadership within health care outcomes are being developed.

SOURCE: Reprinted with permission from County Health Rankings & Roadmaps, http://www.countyhealthrankings. organizations must advance this work by alignment org/our-approach (accessed July 18, 2017). with strategic directions, board support for community 4. Frameworks for Integrating SDoH Are Emerging.

SDoH adopting are greatly inuenced policies, systems, and behaviors, socioeconomic factors, and environmenpartnerships, a culture that by values the SDoH Data frameworks have been proposed for integrating environments (PSE).

A diagram used by meaCounty Based tal factors. Although we as a country spend a higher in addition to quality and affordable health care, SDoH into primary care and capturing SDoH domains Health Rankings Roadmaps (Figure shows the percentage of our gross domestic product on medical surement/evaluation, roleand clari cation, creation of 1) new in electronic health records (EHRs). One framework incare expenditures than other developed countries, it is interaction between health outcomes, the SDoH, and more difficult to compare spending on the SDoH. We policies and programs. For example, tobacco is a do know that many developed countries proportion- leading determinant of many health outcomes (e.g., ately spend more on social services than the United mortality, quality of life), and decreasing tobacco States [8]. Although social services do not correspond use is more inuenced by the price of cigarettes and directly to the SDoH, this comparison gives one view of smoke-free environments in the community than by the availability of cessation clinics or quitlines. proportional expenditures in our country.

Corollary: Despite our signicant spending, our outcomes are among the lowest for developed countries, including signicant inequities [9]. For health care, the hope is that addressing the more upstream social determinants will improve health outcomes, reduce inequities, and lower costs. What can we learn from other nations’ medical and nonmedical system efforts that are achieving better health outcomes?

2. SDoH Are Inuenced by Policies and Programs, and Associated with Better Health Outcomes.

Corollary: Community partnerships that synergize medical interventions and PSE changes produce a more comprehensive approach to behavior change. For example, walking prescriptions for patients can be complemented by community changes to increase availability of safe walking spaces. Such partnerships can also allay providers’ concerns about being held responsible for problems outside their clinical domain, and the partnerships can bring expertise, allies, and resources to address complex issues such as tobacco use, physical activity, alcohol use, housing, and so on.

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DISCUSSION PAPER DISCUSSION PAPER

Social Determinants of Health 101 for Health Care

3. New Payment Models Are Prompting Interest in cludes community-driven and individual data for use in nershipscare, requires trust for not onlyare sharing data but tion—from recognizing that there still questions the SDoH. the “aha moments” to feedback and course primary also for sharing resources and money.

What factors are correction to new dialogue with the community [34]. about the effect on outcomes [13]. The framework, New value-based payment models such as alter- most important for building trust between health care Corollary: We often speak ofaccountable the SDoH, butcare whatmodels are the however, does not include how the data might be used native payment models, organizations and community partners, where there is “social well-being”?

Well-being “the with community partnerships to expand the effect of such as determinants accountable of care organizations (ACOs)is and often a power differential? A recent workshop from the collecting the data. sense of life satisfaction the individual” as introduced patient-centered medicalof homes, and Medicare Shared National Academies of Sciences, Engineering, and MedScreening tools have been developed, e.g., for an

by Evans and Stoddart in theirpayment classic paper on the deSavings are moving toward for outcomes icine (NASEM) explores the infrastructure of successful accountable health community initiative [14], and one terminants of health, in which they postulate that wellrather than process measures, as well as benchmarks multisector partnerships, including examples of health being is cost the ultimate of health [35].

Ad- for a pediatric emergency department with a low-infor “total of care.” objective Since better resultspolicy on the SDoH sector and community collaboration [38].

For example, come population [15]. Models are emerging for how vancing “socialwith determinants of well-being” versus are associated better health outcomes, willhealth pay- a leader from Bellin Health identied ve “domains of to follow up screening data, e.g., “clinic-to-community does not have the automatic association with hospitals, ment models evolve to jointly reward health care or- transformation”: (1) understand the system, (2) social treatment models” for children living in food-insecure clinics, visits, tests, procedures, for and outcomes medicationsuch that the ganizations and communities as change, (3) critical conversations, (4) co-creation, and households [16]. termtobacco, health has.

This concept promoted

by Kottke, ,Stilower obesity and/or isdiabetes prevalence or (5) spread and scale.

For the EHR, the Institute of Medicine (IOM) has recefel, and Pronk who suggest we engage others and avoid improved high school graduation rates? that social and behavioral health domainsof Corollary: What level of integration (e.g., in continuity medicalizing by focusing on “well-being in all policies” ommended Corollary: The Population-based Payment Model Workbe captured [17].

The incentive, training, and care, responsibility for quality and costs for a privacy popularather than health in all policies [36,37]. group of the Health Care Learning and Action Network barriers for feasibility of incorporating into EHRs tion, hospital affiliation, etc.) betweenSDoH health care or(LAN) recently recommended that “Big(ger) Dot” mea- have 3. What (new) data are needed? been discussed Interestingly, electronic ganizations and service[18]. organizations is needed or not sures increasingly be used in new payment models. For produced higher ratesSDoH of self-disclosure of needed to successfully address with community A third question is what SDoH data should be col- screening example, measures of cardiac care are ideally outcome some sensitive determinants (violence and substance partners?

Does it depend on the SDoH being addressed? lected—for what purpose, and by whom? Recently, measures (e.g., 30-day mortality, health-related quality in-person[4] screening Mostofrecently, Fraze than and colleagues describe a[15]. typology ACOs reHealthDoers, a Robert Wood Johnson Foundation– abuse) of life or well-being), not individual process measures feasibility, reliability, of and validitynon-medical of the IOM-recthe integration patients’ needs funded network with the Network for Regional Health- thegarding (e.g., aspirin at arrival) [10]. However, process measures domains (except for income) were evaluwith medical care—from noncoordinated to fully intecare Improvement, held a Peer-to-Peer (P2P) event ommended continue to be important for quality improvement and ated, and clinical trials were recommended [19, 20]. grated—with most ACOs being in the noncoordinated focused on the intersection of clinical, multisector, for some payment programs. New summary measures quadrant Integrating (“neither services norinto organizations inand SDoH data. Nial Brennan, former Chief Data Corollary: the SDoH health carewere should for population health and well-being for use by health Figure | County & Roadmaps tegrated”).

More importantly, what speci c system comOfficer 1 at CMS, Health asked Rankings how SDoH data fared on not&fall primarilyhttp://www.countyhealthrankings. on primary care clinicians. Although SOURCE: Reprinted with permission from County Health Rankings Roadmaps, plans and accountable care organizations have been ponents (e.g., global can budgets, board leadership, quality four key questions(accessed he says he always asks about collectfront-line clinicians see patterns of key determiorg/our-approach July 18, 2017). proposed [11,12], and frameworks for rewarding health improvement culture, data systems, care managers or ing new data [27]: nants for populations, leadership within health care outcomes are being developed. community health experience are greatly inworkers, uenced by policies, systems, and behaviors, socioeconomic factors, environmenorganizations must advance this workwith by community alignment 1.

“How much will it cost to collect?and Is the juice worth SDoH partnerships) are needed to create eff ective intervenenvironments (PSE).

A diagram used by County Based tal factors.

Although we as a country spend a higher with strategic directions, board support for community 4. Frameworks the squeeze?for Integrating SDoH Are Emerging. tions?Rankingsadopting and Roadmaps 1) shows the percentage of our gross domestic product on medical Health partnerships, a culture(Figure that values the SDoH 2.

“How good [are] the data?

Is it standardized?

Data frameworks have been proposed for integrating interaction between health outcomes, the SDoH, and care“How expenditures than other developed countries, it is in addition to quality and affordable health care, mea3. [are] the data?SDoH Are we getting 5. What else?

SDoH intocomprehensive primary care and capturing domains policies and programs.role For example, tobaccoofisnew a more diffi cult to compare spending on the SDoH. We surement/evaluation, clari cation, creation it for 5%, health 10%, 50%, 100%of people? in electronic records (EHRs).

One framework in- leading The lastdeterminant question is “What else?”

For outcomes example, discusof many health (e.g., do know that many developed countries proportion4. “What level of granularity does the data need to be sions about population health its measurement quality of life), and and decreasing tobacco atelyat?” spend more on social services than the United mortality, often centerin onuenced the leading ofcigarettes death andand not is more by thecauses price of States [8]. Although social services do not correspond use Theseto questions back to issues prioritizawell-being or the “leading in causes of life,” such as purenvironments the community than by directly the SDoH,lead thisus comparison gives of one view of smoke-free tion, the opportunity index,in and ective interventions. the pose, connection, agency, clinics blessing, and hope [39]. In availability of cessation or quitlines. proportional expenditures oureff country.

With so many unknowns about the use of SDoH in addition, health care mental models are frequently Corollary: Community partnerships that synergize Corollary: our signi cant spending,and ourevaluoutclinical care, Despite having data for measurement built from a decit perspective—addressing what is medical interventions and PSE changes produce a more comes are among the lowest for developed countries, ation of interventions is essential. Monitoring for wrong with an individual and/or a community. How do comprehensive approach to behavior change. For exincluding signi cant inequities [9].

For health care, the unintended consequences of well-designed and/or we focus on assets, starting with what is right with paample, walking prescriptions for patients can be comhope is that addressing the more upstreamissocial deterwell-intentioned programs and policies important, tients, families, and/or communities so we can build on plemented by community changes to increase availabilminants to willensure improve health outcomes, reduce inequiespecially that disparities do not worsen. strengths? Building on strengths and working with mulity of safe walking spaces. Such partnerships can also ties, and lower costs. What can we learn from other natisector collaborations are two ways to minimize any allay providers’ concerns about being held responsible medical and nonmedical efforts that are 4. tions’ How do we build multisectorsystem partnerships? unintended consequences of screening for the SDoH in for problems outside their clinical domain, and the achieving better health outcomes?

What partnerships should be built to address the SDoH clinical settings [40]. partnerships can bring expertise, allies, and resources for individuals and for communities?

What sectors 2. SDoH Are In uenced

by Policies and Programs, to address complex issues such as tobacco use, physical need to be involved achieve the desired outcomes? Conclusion and Associated withtoBetter Health Outcomes. activity, alcohol use, housing, and so on.

What are the roles of people and organizations in these This paper articulates ve things we know and ve different partnerships? Building these multisector partPage 2

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DISCUSSION PAPER

Social Determinants of Health 101 for Health Care Social Determinants of Health 101 for Health Care

3. New Payment Models Are Prompting Interest in cludes community-driven and individual data for use in forcare, better U.S. health things health care organizations need to learn to ad- primary recognizing thatcare. thereThe are Commonwealth still questions the SDoH. July 2017. http://www.commonwealthfund. dress SDoH for the national quality strategy [6]. Critics aboutFund, the effect on outcomes [13]. The framework, New value-based payment models such as alterorg/publications/fund-reports/2017/jul/mirrorare right to question how we address yet another is- however, does not include how the data might be used native payment models, accountable care models mirror-international-comparisons-2017 (accessed sue in health care. However, organizations can dene with community partnerships to expand the eff ect of such as accountable care organizations (ACOs) and July 29, (and circumscribe) their roles [41], and join or form collecting the 2017). data. patient-centered medical homes, and Medicare Shared 10.

Health Care Learning and Action new community partnerships to prioritize, develop, and Screening tools Payment have been developed, e.g., Network for an Savings are moving toward payment for outcomes (LAN).

2016.

Population-based Payment Work implement proven and/or testable interventions. With accountable health community initiative [14], and one rather than process measures, as well as benchmarks Group. Accelerating aligning population-based the failure of our current health care system to deliv- for a pediatric emergencyand department with a low-infor “total cost of care.” Since better results on the SDoH models: er better health and well-being at an affordable cost, come payment population [15]. performance Models are measurement. emerging for http:// how are associated with better health outcomes, will payhcp-lan.org/workproducts/pm-whitepaper-final. exploring opportunities in the other determinants of to follow up screening data, e.g., “clinic-to-community ment models evolve to jointly reward health care orpdf (accessed June 8, 2017). health seems wise, if not imperative. treatment models” for children living in food-insecure ganizations and communities for outcomes such as 11. Kottke,[16].

T. E., J. M. Gallagher, S. Rauri , J. O. Tillema, households lower tobacco, obesity and/or diabetes prevalence , or References Pronk, S. M.ofKnudson. sumFor N. theP.EHR, the and Institute Medicine2016.

(IOM) New has recimproved high school graduation rates? mary that measures of population health and well1. WHO (World Health Organization). 2012. What are ommended social and behavioral domains Corollary: The Population-based Payment Model Workbeing for implementation by health plans and the social determinants of health? http://www. be captured [17]. The incentive, training, and privacyacgroup of the Health Care Learning and Action Network barriers countable care of organizations. who.int/social_determinants/sdh_definition/en/ for feasibility incorporatingPreventing SDoH into Chronic EHRs (LAN) recently recommended 13:160224. (accessed June 8, 2017). that “Big(ger) Dot” mea- have Disease been discussed [18].https://www.cdc.gov/pcd/isInterestingly, electronic increasingly be used in new sues/2016/16_0224.htm (accessed June 11, 2017).

2. sures Solberg, L. I. 2016.

Theory vs payment practice: models.

Should For pri- screening produced higher rates of self-disclosure of example, measures of cardiac care are ideally outcome 12.

Kottke, T. E., J. M. Gallagher, S. Rauri, J. O. Tillema, N. mary care practice take on social determinants of some sensitive determinants (violence and substance measures (e.g., 30-day mortality, health-related quality abuse)P.than Pronk, and S. M.screening Knudson.[15].

2016.

Newrecently, summary health now?

No. Annals of Family Medicine 14:102in-person Most of 103. life or well-being), not individual process measures the feasibility, measuresreliability, of population health and well-being and validity of the IOM-rec-for aspirin atE.arrival) [10]. process measures implementation by health andwere accountable 3. (e.g., Eggleston, M., and J. A.However, Finkelstein.

2014.

Finding ommended domains (except for plans income) evalucontinue to be important for quality improvement and care organizations.

National Academy of Medicine, the role of health care in population health. Journal ated, and clinical trials were recommended [19, 20]. forofsome payment Medical programs.

New summary measures Washington, DC. https://nam.edu/new-summarythe American Association 311(8):797-798.

Corollary: Integrating the SDoH into health care should for population health and well-being for use measures-of-population-health-and-well-being4. Fraze, T., V. A. Lewis, H. P. Rodriquez, by andhealth E. S. not fall primarily on primary care clinicians. Although plans and 2016. accountable caretransportation, organizations have been for-implementation-by-health-plans-and-accountFisher.

Housing, and food: front-line clinicians can see patterns of key determiproposed [11,12], and frameworks for rewarding health able-care-organizations/ (accessed June 11, 2017).

How Figure ACOs 1 seek to improve by | County Healthpopulation Rankings &health Roadmaps nants for populations, leadership within health care outcomes are being developed.

SOURCE: Reprinted with permission from Health County Health Roadmaps, http://www.countyhealthrankings.

13. Rankings DeVoe, J.&E., A. W. Bazemore, E. K. Cottrell, S. Liaddressing nonmedical needs of patients. organizations must advance this work by alignment org/our-approach (accessed July 18, 2017). kumahuwa-Ackman , J. Grandmont, N. Spach, and Affairs (Millwood) 35(11):2109-2115. with strategic directions, board support for community 4. Frameworks for Integrating SDoH Are Emerging.

R. Gold. 2016. Perspectives in primary care: A con5. Baciu, A., and socioeconomic J. M. Sharfstein.

2016.and PopulaSDoH adopting are greatly inuenced policies, systems, and behaviors, factors, environmenpartnerships, a culture that by values the SDoH Datation frameworks have been proposed for integrating ceptual framework and path for integrating social health case reports from clinic to commuenvironments (PSE).

A diagram used by meaCounty Based tal factors. Although we as a country spend a higher in addition to quality and affordable health care, SDoH intoJournal primaryofcare and capturing SDoHAssociation domains determinants of health into primary care practice. nity. theour American Medical Health Rankings Roadmaps (Figure shows the percentage of gross domestic product on medical surement/evaluation, roleand clari cation, creation of 1) new in electronic health records (EHRs). One framework inAnnals of Family Medicine 14(2):104-108.

315(24):2663-2664. care expenditures than other developed countries, it is interaction between health outcomes, the SDoH, and 14. Billioux, A., K. Verlander, S. Anthony, and D. Al6. Agency Research and onQuality morefor diffiHealthcare cult to compare spending the SDoH. We policies and programs. For example, tobacco is a ley. 2017. Standardized screening for health(AHRQ).

2017.that About thedeveloped National Quality Stratdo know many countries proportion- leading determinant of many health outcomes (e.g., related social needs in clinical settings: The acegy. Content last reviewed Agency ately spend more on March social 2017. services than for the United mortality, quality of life), and decreasing tobacco countable health communities screening tool.

Healthcare Research and Quality, Rockville, MD. States [8]. Although social services do not correspond use is more inuenced by the price of cigarettes and Discussion Paper, National Academy of Medicine, http://www.ahrq.gov/workingforquality/about/indirectly to the SDoH, this comparison gives one view of smoke-free environments in the community than by Washington, DC. https://nam.edu/wp-content/ dex.html (accessed June 11, 2017). the availability of cessation clinics or quitlines. proportional expenditures in our country. uploads/2017/05/Standardized-Screening-for7. Hood, C. M., K. P. Gennuso, G. R. Swain, and B. Corollary: Community partnerships that synergize Corollary: Despite health our signi cant spending, B. Catlin.

2016. County rankings: Relation- our out-Health-Related-Social-Needs-in-Clinical-Settings. medical interventions and PSE changes produce a more comes are among the lowest for developed countries, pdf (accessed June 11, 2017). ships between determinant factors and health comprehensive approach behavior including signiJournal cant inequities [9]. For health care,15. theGottlieb, L., D. Hessler, D. Longto, A. Amaya,change. and N. For exoutcomes.

American of Preventive Medicine ample, walking prescriptions for patients hope is that addressing the more upstream social deterAdler. 2014. A randomized trial on screeningcan forbe com50(2):129-135. plemented by community changes to increase availabilminants will improve health outcomes, reduce inequisocial determinants of health: The iScreen study.

8. Bradley, E. H., B. R. Elkins, J. Herrin, and B. Elbel. ity of safe walking spaces.

Such partnerships ties, and lower costs.

What can we learn from other naPediatrics 134(6):e1611-e1618. www.pediatrics.can also 2011. Health and social services expenditures: Asallay providers’ concerns about being held responsible tions’with medical and nonmedical effand orts that areorg/cgi/doi/10.1542/peds.2014-1439. sociations health outcomes.

BMJsystem Quality for problems outside and theirH.clinical domain, achieving better health outcomes?

16. Barnidge, E., S. Stenmark, Seligman.

2017.and the Safety in Health Care 20(10):826-831. partnerships can bring expertise, allies, and resources Clinic-to-community models to address food inse9. Schneider, E. C., D. O. Sarnak, D. Squires, A. Shah, 2. SDoH Are Inuenced by Policies and Programs, to address complex issues such as tobacco use, curity. Journal of the American Medical Associationphysical and M. M. Doty. 2017. Mirror, mirror 2017: Internaand Associated with Better Health Outcomes. activity, alcohol use, housing, and so on.

Pediatrics 171(6):507-508. tional comparison reects aws and opportunities NAM.edu/Perspectives

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12 Delaware Journal of Public Health – February 2019

DISCUSSION PAPER DISCUSSION PAPER

Social Determinants of Health 101 for Health Care

3. New Payment Models Are Prompting Interest in 17. Institute of Medicine (IOM). 2014. Capturing social the SDoH. and behavioral domains and measures in elecNew tronic value-based paymentPhase models such as alterhealth records: 2. Washington, DC. nativeThe payment accountable care models Nationalmodels, Academies Press. such as accountable organizations (ACOs) A. and 18. Gottlieb, L. M., K.care J. Tirozzi, R. Manchanda, R. patient-centered medical homes, and Medicare Shared Burns, and M. T. Sandel. 2015. Moving electronic Savings are moving payment for outcomes medical recordstoward upstream: Incorporating social ratherdeterminants than processof measures, as well asJournal benchmarks health. American of Prefor “total costMedicine of care.”48(2):215-218.

Since better results on the SDoH ventive are associated with better health S. outcomes, will A. pay19. Giuse, N. B., T. Y. Koonce, V. Kusnoor, A. mentPrather, models L. evolve to jointly reward health care M. Gottlieb, L. Huang, S. E. Phillips,orY. ganizations communities forStead. outcomes as Shyr, N.and E. Adler, and W. W. 2017. such Institute lowerof tobacco, obesity and/or diabetes or Medicine measures of social andprevalence behavioral,deimproved high school graduation rates? terminants of health: A feasibility study. American

cludes community-driven and individual data for use in (accessed June 8, 2017). primary care, recognizing that there are still questions 26. Lee, V. S., K. Kawamoto, R. Hess, C. Park, J. Young, about the effect on outcomes [13]. The framework, C. Hunter, S. Johnson, S. Gulbransen, C. E. Pelt, D. however, does not include how the data might be used J. Horton, K. K. Graves, T. H. Greene, Y. Anzai, and with community partnerships to expand the effect of R. C. Pendleton. 2016. Implementation of a valuecollecting the data. driven outcomes program to identify high variabilScreening tools have been developed, e.g., for an ity in clinical costs and outcomes and association accountable health community initiative [14], and one with reduced cost and improved quality. Journal for a pediatric emergency department with a low-inof the American Medical Association 316(10):1061come population [15]. Models are emerging for how 1072. to follow up screening data, e.g., “clinic-to-community 27. HealthDoers Network. HealthDoers network peertreatment models” for children living in food-insecure to-peer summary: The intersection of clinical data, households [16]. claims and the social determinants of health: inteFor the EHR, the Institute of Medicine (IOM) has recgrating multi-sector data to create health out of ommended that social and behavioral health domains health care. 2017. http://www.nrhi.org/uploads/ JournalThe of Preventive MedicinePayment 52(2):199-206.

Corollary: Population-based Model Work- be captured [17]. The incentive, training, and privacy hdpeer-to-peer-event_jan17_summary_nal.pdf; 20.

Prather, A. A., L. M. Gottlieb, N. B. Giuse, T. Y. group of the Health Care Learning and Action Network barriers for feasibility of incorporating SDoH into EHRs https://vimeo.com/201783081 (accessed June 8, Koonce, S. recommended V. Kusnoor, W. Stead, Dot” and meaN. E. (LAN) recently thatW.“Big(ger) have been discussed [18]. Interestingly, electronic 2017).

Adler.

2017. National of Medicine sosures increasingly be used inAcademy new payment models. For screening produced higher rates of self-disclosure of 28. Centers for Disease Control and Prevention (CDC). cial and behavioral measures: Associations with example, measures of cardiac care are ideally outcome some sensitive determinants (violence and substance guide to working with health-care systems self-reported health.

American Journal of Prevenmeasures (e.g., 30-day mortality, health-related quality abuse)A practical than in-person screening [15]. Most recently, on tobacco-use treatment. 2006. Atlanta, GA: U.S. tive Medicine Mar 21. pii: S0749-3797(17)30157-5. of life or well-being), not individual process measures the feasibility, reliability, and validity of the IOM-recDepartment of Health and Human Services, Cendoi: 10.1016/j.amepre.2017.02.010.

[Epub ahead (e.g., aspirin at arrival) [10]. However, process measures ommended domains (except for income) were evaluters for Disease Control and Prevention, National of print] continue to be important for quality improvement and ated, and clinical trials were recommended [19, 20].

Center for Chronic Disease Prevention and Health 21.

Institute for Clinical Systems Improvement for some payment programs. New summary measures Corollary: Integrating into and health care should Promotion, Officethe onSDoH Smoking Health. https:// 2015.health Goingand beyond clinical for (ICSI). population well-being forwalls: use byLessons health Figure 1 | County Health Rankings & Roadmaps not fall primarily on primary care clinicians.

Although learned: Leaders outfrom to transform health SOURCE: Reprinted withstepping permission County Health Rankings &www.cdc.gov/tobacco/quit_smoking/cessation/ Roadmaps, http://www.countyhealthrankings. plans and accountable care organizations have been front-line clinicians can see patterns key 11, determiorg/our-approach (accessed July 18, 2017). pdfs/practical_guide.pdf (accessedofJune 2017). and health care. https://www.icsi.org/_asset/pvproposed [11,12], and frameworks for rewarding health nants for populations, leadership within health care 29.

National Collaborative on Childhood Obesity Rer9ot/lessonslearned.pdf (accessed June 8, 2017). outcomes are being developed. are greatly in uenced by policies, systems, and behaviors, socioeconomic factors, and environmen- SDoH organizations must 2015. advance this workcommunity-clinby alignment search (NCCO).

Evaluating 22. Hester, J. A., J. Auerbach, D. I. Chang, S. Mag(PSE).

A diagram used

by County Based tal factors. Although we as a country spend a higher environments withical strategic directions, support for community 4. Frameworks Integrating SDoH Are Emerging. engagement toboard address childhood obesity: nan, and J. for A. Monroe.

2015.

Opportunity knocks Rankings and Roadmaps (Figure 1) shows the percentage of our gross domestic product on medical Health partnerships, adopting a culture that values Implications and recommendations forthe theSDoH eld. for population health: Round in state Data again frameworks have been proposed fortwo integrating between health outcomes, the SDoH, and care expenditures than other developed countries, it is interaction in addition to quality and aff ordable health care, meahttp://nccor.org/downloads/NCCOR-Communityinnovation models.

Discussion Paper, Institute SDoH into primary care and capturing SDoH domains and programs.role For example, tobaccoofisnew a more difficult to compare spending on the SDoH. We policies surement/evaluation, clari cation, creation Engagement-Workshop-Summary.pdf (accessed of Medicine, DC. https://nam.edu/ in electronic health Washington, records (EHRs).

One framework indo know that many developed countries proportion- leading determinant of many health outcomes (e.g., June 11, 2017). perspectives-2015-opportunity-knocks-again-forately spend more on social services than the United mortality, quality of life), and decreasing tobacco 30. Larimer, M. E., D. K. Malone, M. D. Garner, D. C. population-health-round-two-in-state-innovationStates [8]. Although social services do not correspond use is more inuenced by the price of cigarettes and Atkins, B. Burlingham, H. S. Lonczak, K. Tanzer, J. models/ (accessed June 8, 2017). directly to the SDoH, this comparison gives one view of smoke-free environments in the community than by Ginzler, S. L. Clifase, W. G. Hobson, and G. A. Mar23. Gottlieb, L. M., D. Hessler, D. Long, E. Laves, A. R. the availability of cessation clinics or quitlines. proportional expenditures in our country. latt. 2009. Health care and public service use and Burns, A. Amaya, P. Sweeney, C. Schudel, and N. Corollary: Community partnerships synergize Corollary: Despite signi spending, our outcosts before and after provisionthat of housing for E. Adler.

2016.our Effects ofcant social needs screening medical interventions and PSE changes produce more comes among the lowest for developed countries, chronically homeless persons with severeaalcohol andare in-person service navigation on child health: comprehensive approach to behavior exincluding signicantclinical inequities For health the problems. Journal of the Americanchange.

MedicalFor AssociaA randomized trial.[9].

Journal of the care, American ample, walking prescriptions for patients can be comhope is that addressing the more upstream social detertion 301(13):1349-1357.

Medical Association Pediatrics 170(11):e162521. plemented by community changesR.toOwen, increase availabilminants will improve health outcomes, reduce inequi31.

Sandberg, S. F., C. Erikson, K. D. Vickery, doi: 10.1001/jamapediatrics.2016.2521. ity ofS.safe walking spaces.

SuchN.partnerships can ties,Alley, and lower can we learn otherD.naT. Shimotsu, M. Linzer, A. Garrett, K. A. also John24.

D. E.,costs.

C. N.What Asomugha, P. H. from Conway, M. allaysrud, providers’ aboutand being held responsible tions’ medical and nonmedical system effortscommunithat are D. M.concerns Soderlund, J. DeCubellis.

2014.

Sanghavi.

2016.

Accountable health for problems clinical domain, and the achieving better healthsocial outcomes?

Hennepinoutside Health:their A safety-net accountable care ties—addressing needs through Medicare partnerships can bring expertise, allies, and resources organization for the expanded Medicaid populaand Medicaid. New England Journal of Medicine 2. SDoH Are Inuenced by Policies and Programs, to address complex issues such as tobacco use, physical tion. Health Affairs (Millwood) 33(11):1975–1984.

374(1):8-11. and Associated with Better Health Outcomes. activity, alcohol use, and so on. C. Ndumele, E. 32.

Taylor, L. A., A. housing, X. Tan, C. E. Coyle, 25. Centers for Medicare & Medicaid Services (CMS).

2017 https://innovation.cms.gov/initiatives/ahcm/

Rogan, M. Canavan, L. A. Curry, and E. H. Brad-

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13

DISCUSSION PAPER DISCUSSION PAPER 3. New Payment Models Are Prompting Interest in the SDoH. ley. 2016. Leveraging the social determinants of New health: value-based payment models as alterWhat works?

Public Librarysuch of Science One native11(8):e0160217. payment models, accountable care models http://journals.plos.org/plosone/ such article?id=10.1371/journal.pone.0160217 as accountable care organizations (ACOs) and (acpatient-centered cessed Junemedical 8, 2017).homes, and Medicare Shared Savings are moving for outcomes 33. Bickerdike, L., A.toward Booth, payment P. M. Wilson, K. Farley, ratherand than process measures, as well as benchmarks K. Wright. 2017. Social prescribing: Less rhetfor “total care.”

Since A better resultsreview on the of SDoH oriccost andof more reality. systematic the are associated withOpen better health outcomes, will payevidence. BMJ 2017;7:e013384. doi:10.1136/ ment bmjopen-2016-013384. models evolve to jointly reward health care organizations and for Improvement outcomes such as 34. Institute forcommunities Clinical Systems (ICSI). lower2015. tobacco, obesity and/or diabetes prevalence , or Going beyond clinical walls: Pioneering lesimproved school graduation rates? sons:high An emerging health care path for commu-

Social Determinants of Health 101 for Health Care Social Determinants of Health 101 for Health Care

cludes community-driven and individual data for use in primary care, recognizing that there are still questions munity business model to deepen focus on nonabout the effect on outcomes [13]. The framework, clinical factors of health outcomes. Health Affairs however, does not include how the data might be used (Millwood) 32(8):1446-1452. with community partnerships to expand the effect of collecting theCitation data.

Suggested Screening tools have been developed, e.g., for an Magnan, S. 2017. Social determinants of health 101 for accountable health community initiative [14], and one health care: ve plus ve. NAM Perspectives. Discussion for a pediatric emergency department with a low-inPaper, National Academy of Medicine, Washington, come population [15]. Models are emerging for how DC. https://nam.edu/social-determinants-of-healthto follow up screening data, e.g., “clinic-to-community 101-for-health-care-ve-plus-ve. treatment models” for children living in food-insecure households [16].

Author Information For the EHR, the Institute of Medicine (IOM) has recSanne Magnan a senior at HealthPartners Inommended that is social and fellow behavioral health domains stitute, adjunct assistant professor of medicine at the be captured [17]. The incentive, training, and privacy University Minnesota, and a co-chairSDoH of theinto Roundtabarriers foroffeasibility of incorporating EHRs ble on Population Health Improvement at the National have been discussed [18]. Interestingly, electronic Academiesproduced of Sciences, Engineering, Medicine. of screening higher rates of and self-disclosure some sensitive determinants (violence and substance Acknowledgments abuse) than in-person screening [15]. Most recently, The feasibility, author wishes to acknowledge conthe reliability, and validitythe of valuable the IOM-rectributions todomains this paper of David George ommended (except forKindig, income) were Isham, evaluEllen Gagnon, Tom Kottke, and Alina Baciu. ated, and clinical trials were recommended [19, 20].

nity collaborations. https://www.icsi.org/_asset/ Corollary: The Population-based Payment Model Workw7vd0v/pathinfographicweb.pdf June group of the Health Care Learning and(accessed Action Network 8, 2017).

(LAN) recently recommended that “Big(ger) Dot” mea35.

Evans, R. G., and G. L.in Stoddart.

1990.models.

Producing sures increasingly be used new payment For health,measures consuming healthcare care. & example, of cardiac areSocial ideallyScience outcome Medicine 31(12):1347-1363. measures (e.g., 30-day mortality, health-related quality 36.

Kottke, T. E., M. Stiefel, and N.process P. Pronk.

2016. of life or well-being), not individual measures “Well-being in all policies”: Promoting cross-sec(e.g., aspirin at arrival) [10]. However, process measures toral collaboration to for improve lives. and Precontinue to be important qualitypeople’s improvement Chronicprograms.

Disease 13:160155. https://www. for venting some payment New summary measures Corollary: Integrating the SDoH into health care should for cdc.gov/pcd/issues/2016/16_0155.htm population health and well-being for use (accessed by health Conict-of-Interest Disclosures not fall primarily on primary care clinicians. Although June 8, 2017). plans accountable care organizations have been Magnan is a consultant with the Network for ReFigure 1 and | County Health Rankings & Roadmaps front-line clinicians can see patterns of key determi37.

Kottke, T. E., with M. Stiefel, and for N. rewarding P.County Pronk.

2016.Rankings proposed [11,12], frameworks health SOURCE: Reprinted permission Health Roadmaps, http://www.countyhealthrankings. gional& Healthcare Improvement for the HealthDoers Figure 1 | and County Health from Rankings & Roadmaps nants for populations, leadership within health care org/our-approach (accessed July 18, 2017).

“Well-being in all policies”: Promoting crossoutcomes are being developed.

Peer-to-Peer (P2P) event, the Intersection of Clinical SOURCE: Reprinted with permission from County Health Rankings & Roadmaps, http://www.countyhealthrankings. organizations must advance this work by alignment org/our-approach July 18, 2017). lives. Data, sectoral collaboration(accessed to improve people’s Claims, and the Social Determinants of Health: SDoH greatly inuenced by support policies,for systems, and behaviors, socioeconomic factors, and environmenwith are strategic directions, board community 4. Frameworks for Integrating SDoH Are Emerging.

National Academy of Medicine, Washington, DC. Integrating Multi-Sector Data to Create Health out of environments (PSE).

A diagram used by County Based tal factors.

Although socioeconomic we as a countryfactors, spend and a higher SDoH are greatly in uenced by policies, systems, and behaviors, environmenpartnerships, adopting a culture that values the SDoH Data https://nam.edu/wp-content/uploads/2016/05/ frameworks have been proposed for integrating Health Care, January 23-24, 2017; the concept of this Health Rankings and Roadmaps (Figure 1) shows the percentage of our gross domestic product on medical environments (PSE).

A diagram used by meaCounty Based tal factors. Although we as a country spend a higher in addition to quality and affordable health care, SDoHWell-Being-in-All-Policies-Promoting-Cross-Secinto primary care and capturing SDoH domains paper was presented as part of the conference. She is interaction between health outcomes, the SDoH, and care expenditures than other developed countries, it on is medical Health Rankings and Roadmaps (Figure 1) shows the percentage of our gross domestic product surement/evaluation, role clari cation, creation of new toral-Collaboration-to-Improve-Peoples-Lives.pdf in electronic health records (EHRs). One framework in- a nonpaid member of Epic’s Population Health Steerand programs.

For health example, tobaccothe is SDoH, a more difficare cult expenditures to compare spending ondeveloped the SDoH.countries, We policies interaction between outcomes, and than other it is (accessed June 8, 2017). ing Board. leading determinant ofprograms. many health outcomes (e.g., do know more that many developed countries proportionpolicies and For example, tobacco is a diffi cult to compare spending on the SDoH. We 38. National Academies of Sciences, Education and mortality, quality of life), and decreasing tobacco ately spend more on social services than the United leading determinant of many health outcomes (e.g., do know that many developed countries proportionCorrespondence Medicine (NASEM).

2016.

Exploring the infrause is more inuenced by the cigarettes and tobacco States [8].ately Although social services do services not correspond mortality, quality of price life), of and decreasing spend more on social than the United structure of multisector community health part- Questions or comments should be directed to Sanne environments in the by community than by directly toStates the SDoH, this comparison gives one view of smoke-free use is more in uenced the price of cigarettes and [8].

Although social services do not correspond nerships: a workshop. http://www.nationalacad- Magnan at sanne.magnan@gmail.com. the availability of cessation clinics or in quitlines. proportional expenditures in our country. smoke-free environments the community than by directly to the SDoH, this comparison gives one view of emies.org/hmd/Activities/PublicHealth/Populati the availability cessation clinics quitlines. proportional expenditures in our country.

Corollary: Communityofpartnerships thator synergize Corollary: Despite our signicant spending, our outonHealthImprovementRT/2016-DEC-08.aspx (ac- Disclaimer medical and changes produce a that more comes areCorollary: among lowestour for signi developed countries, our cessed June 11,the 2017).

Corollary: inCommunity partnerships Despite cant spending, outThe views interventions expressed thisPSE paper are those of the au- synergize comprehensive approach to behavior change.

For ex- a more including signicant inequities For Leading health care, thecountries, 39.

Gundersen, G., L. Pray.

2009. causes medical interventions and PSE changes produce comes areand among the[9]. lowest for developed thors and not necessarily of the authors’ organizations, ample, walking prescriptions for patients can be comhope is that addressing the more upstream social deterof life:including Five fundamentals to change[9]. theFor way you care, comprehensive approach (NAM), to behavior change. signicant inequities health thethe National Academy of Medicine or the Na- For explemented by community changes to increase availabilminants will improve healthPress, outcomes, reduce inequilive your life.

Abingdon Nashville, TN. ample, walking prescriptions for patients can be comhope is that addressing the more upstream socialtional deterAcademies of Sciences, Engineering, and Mediity of safe walking spaces.

Such partnerships can also ties,Garg, and lower can we learnoutcomes, otherreduce na- inequi40.

A., R.costs.

Boynton-Jarrett, and P.from H. Dworkin. plemented by community changes to increase minants willWhat improve health cine (the National Academies). The paper is intended to availabilallay providers’ concerns about beingSuch held responsible tions’ medical and lower nonmedical system eff orts thatfrom are 2016.

Avoiding the unintended consequences of other ity of stimulate safe walking spaces. partnerships ties, and costs. What can we learn nahelp inform and discussion.

It is not a report can also for problems outside their clinical domain, and achieving better health outcomes? screening social and determinants ofsystem health.eff Jourproviders’ concerns about Copyright being heldthe responsible tions’for medical nonmedical orts that are NAMallay of the or the National Academies. by partnerships can bring expertise, allies, and resources nal of the American Medical for problems outside their clinical domain, achieving better healthAssociation outcomes?316(8):813- the National Academy of Sciences. All rights reserved. and the 2. SDoH Are Inuenced by Policies and Programs, to addresspartnerships complex issues as expertise, tobacco use, physical 814. cansuch bring allies, and resources and Associated with Better Health Outcomes.

2. SDoH Are Inuenced by Policies Programs, activity, alcohol use, housing, and sosuch on. as tobacco use, physical 41. Isham, G. J., D. J. Zimmerman, D. A. Kindig, and and G. to address complex issues and Associated with Better Health Outcomes.

W. Hornseth.

2013. HealthPartners adopts comactivity, alcohol use, housing, and so on.

NAM.edu/Perspectives Page 2 NAM.edu/Perspectives Page 2

14 Delaware Journal of Public Health – February 2019

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9 PublishedPage October 9, 2017

The DPH Bulletin

From the Delaware Division of Public Health Men and women: prevent colorectal cancer by getting a colonoscopy During Colorectal Cancer Awareness Month in March, the Division of Public Health (DPH) reminds men and women to get a colonoscopy, a screening that painlessly finds polyps that can lead to colorectal cancer.

Men and women age 50 and older should get a colonoscopy once every 10 years.

Health care providers may recommend more frequent colonoscopies, at a younger age, for those with a personal or family history of colorectal cancer, colon cancer, colorectal adenomatous polyps, inflammatory bowel disease (IBD), ulcerative colitis, or Crohn’s disease. The Delaware Cancer Consortium names colorectal cancer as the third most commonly diagnosed cancer in men and women, and the third most common cause of cancer death in Delaware and the U.S. Hospitals statewide have nurse navigators who can schedule cancer screenings and provide follow-up help for any Delawarean, including those without health insurance. To connect with a nurse navigator, visit HealthyDelaware.org/ to complete the online form or call any of these hospitals: • Bayhealth Medical Center, 302-566-1202 • Beebe Healthcare, 302-297-8342 • Christiana Care Health System, 302-261-8719 • Nanticoke Health Services, 302-604-5243, ext.

3765 • Saint Francis Hospital, 302-504-6732 Prevent colon cancer by avoiding or limiting red and processed meats, keeping a healthy weight, not smoking, and limiting or avoiding heavy alcohol consumption. Individuals have a greater risk of being diagnosed with colon cancer at a younger age if they have a close relative who was diagnosed with colon cancer, if they have IBD or diabetes, are African American, or are 20 pounds or more overweight.

February 2019 Free naloxone kits available at DPH distribution events in March In an ongoing effort to prevent losing lives to overdoses, DPH will distribute free naloxone kits at three events in March.

The first Community Naloxone Distribution Initiative event will be Saturday, March 2 from 8:00 a.m. to 11:00 a.m. at St. Peter’s Church, located at 515 Harmony St. in New Castle, Delaware. It is being held at the same time as the atTAcK 5K Run/Walk.

Each kit will contain two doses of naloxone, and those who attend these events will receive one-on-one training on how to administer the overdose-reversing medication. The goal is to equip family and friends of those struggling with substance use, with the medication in the event of an overdose.

Naloxone distribution events are planned for Kent and Sussex counties. Information will be posted to www.helpisherede.com as details become available.

Vehicles need a preparedness kit

Having a preparedness kit in each vehicle might keep you safe – and alive – if your vehicle becomes stuck in a snowdrift or in a lengthy traffic jam. These items are recommended: cell phone charger jumper cables and a spare tire ice scraper, snow brush, and snow shovel a white cloth and flares or roadside reflectors a bag of sand or kitty litter and a tow rope flashlight with working (and extra) batteries extra set of winter clothes, hat, and gloves Survival blanket or sleeping bag bottled water and non-perishable snacks such as dried fruit and protein bars. first aid kit and essential medications Keep gas tanks at least half full. Have a mechanic check antifreeze levels, the battery and ignition system, oil, tires, brakes, windshield wipers and fluid, lights (including hazard lights); and the heater, defroster, and thermostat.

It is also important to check for leaks in the exhaust system because carbon monoxide is deadly. For more information, visit PrepareDE.org.

15

Holding Course for Health Impact: All Aboard Delaware’s State Health Improvement Plan (SHIP)

www.delawareship.org Cassandra Codes-Johnson, M.P.A Noël Duckworth, D.V.S. Timothy Gibbs, M.P.H.

Lucy Luta, M.D., M.P.H. Karen E. McGloughlin Katherine Smith, M.D., M.P.H.

The year 2019 marks an exciting leg of Delaware’s voyage to health improvement. The Delaware Division of Public Health (DPH) recently released a summary of the Delaware State Health Needs Assessment (DSHNA) and Delaware State Health Improvement Plan (DE SHIP) Recommendations Report (2018). This iteration of the DE SHIP charts four priority areas for Delaware’s health needs, and launches fourteen recommendations for addressing them. These points were collectively charted by SHIP stakeholders, key informants, and community residents and leaders across Delaware through community The DSHNA identified meetings, four areas of priority focus: brainstorming • Chronic Disease sessions, telephone • Maternal and Child Health interviews, • Substance Use/Misuse surveys, • Mental Health and other

assessment activities (Delaware Division of Public Health, 2017). Inclusiveness is a critical and ongoing part of the SHIP process (Association of State and Territorial Health Officials, 2015). While government public health agencies such as the DPH are the backbone of a state public health system, they do not and must not work alone. To effectively shape health outcomes, they must build and maintain partnerships with other organizations and sectors, including communities and community based organizations, faith-based organizations, the health care delivery system, the education sector and academia, business, the media, housing, criminal justice, planning and land use, public safety, transportation agencies, and more (ASTHO, 2015). According to the Association of State and Territorial Health Officials (2015), a SHIP is not designed to assess the performance of any one agency or program, but the state’s overall health system performance with the goal of quality improvement. The National Public Health Accreditation Board explains

16 Delaware Journal of Public Health – February 2019

Fourteen recommendations were provided in the DSHNA to address priority areas: • Reduce obesity by promoting healthy diet and exercise • Increase access to healthy foods • Improve the built environment • Promote access to remote patient monitoring for those with chronic conditions • Increase access to community health workers and care coordination • Reduce lung disease (e.g. asthma, lung cancer, chronic obstructive pulmonary disorder) • Increase the number of primary care physicians in underserved areas • Increase the number of Medicaid dental providers in underserved areas • Develop a focused effort to “make the healthy choice the easy choice” • Embed education for pre- and inter-conception care in schools • Reduce tobacco and tobacco-substitute use • Reduce substance use • Improve access to behavioral and mental health services

Kronstadt,, Robin, & Leep, 2018). In a recent survey of accredited health departments, 90% said that accreditation stimulated greater accountability and transparency (Beitsch et al, 2018). Kaye Bender, PHAB President & CEO, refers to these as, “progressive, futuristic health departments” that “strive to use national performance standards and measures and peer review to hold themselves accountable for that journey toward excellence” (Bender, 2018, p.1). The first DE SHIP was published in 2014, and was a key component and required prerequisite for Delaware’s successful application for National Public Health Department accreditation in 2016 (Delaware Division of Public Health, 2014).

During a March 2016 site visit, PHAB noted in their report that Delaware had an increased focus on evidence-based practices and the widespread involvement of senior managers in learning collaboratives; partnerships that include universities and community partners, and robust quality improvement projects.

PHAB summarized that, “these efforts hold great promise for Delaware affecting the health outcomes for the citizens of the state” (PHAB, 2014, p. 2).

• Adopt a Policy, Systems, and Environmental (PSE) change approach to promoting health in all policies, incorporating a social marketing approach, and addressing the social determinants of health Source: Delaware Division of Public Health, 2018

that the purpose of a state health improvement plan is to “describe how the health department and the community it serves will work together to improve the health of the population of the jurisdiction that the health department serves. The community, stakeholders, and partners can use a solid SHIP to set priorities, direct the use of resources, and develop and implement projects, programs, and policies” (2013, p.123). Therefore, the DE SHIP is not only a plan for DPH implementation, planning, and evaluation, but a system-wide guide for how organizations and sectors working across the state can partner to strengthen system capacity, align and move in common directions, and ultimately improve the health of the state’s population.

In 2013, the first cohort of health departments were accredited by the Public Health Accreditation Board (PHAB), a group formed in 2007 for the purpose of “improving the quality and performance of state, county, tribal, and territorial health departments in the United States.” Some evidence suggests PHAB’s mission has helped affect positive change (Beitsch,

In terms of healthy system planning, Delaware aims to produce a SHIP at least every five years, incorporating stakeholder input at every phase. The identification phase included a statewide health needs assessment, and was followed by a planning phase (Delaware Division of Public Health, 2017). With the recent dissemination of the 2018-2023 Delaware State Health Assessment and State Health Improvement Plan, Delaware has now fully moved into the action cycle, and is beginning to address the objectives laid out in the planning phase. Toward this effort, DPH contracted with the Partnership for Healthy Communities at the University of Delaware, working in collaboration with the Delaware Academy of Medicine/Delaware Public Health Association, to assess and communicate SHIP implementation progress to date, help identify and address gaps, and participate in engagement and assessment activities. Current emphasis includes dissemination of the plan, deliberate communication around the priority areas, and an effort to further engage stakeholders. Success requires the continued engagement of people and groups across disciplines, sectors, communities and organizations at every level across the state (ASTHO, 2015). Several stakeholders highlighted in this issue of the Delaware Journal of Public Health have begun to share how their respective organizations 17

What’s Your Role in Delaware’s SHIP? Some of the organizations and sectors involved in a state’s health system include: • Healthcare providers such as hospitals, community health centers, mental health organizations, nursing homes and rehabilitation centers • Public safety organizations such as police, fire and emergency medical services.

• Human service and community-based organizations such as food banks, community gardens, public assistance agencies, and transportation providers, which assist people to access healthcare and receive other healthenhancing services • Educational and youth development organizations such as schools, faith institutions, youth centers, and other youth-serving groups and organizations.

• Recreational and arts-related organizations that contribute to the physical and mental well-being of the community and those who live, work, and play in it.

• Economic and philanthropic organizations such as employers, community development organizations, zoning boards, and community and business foundations that provide resources necessary for individuals and organizations to survive and thrive in the community.

• Environmental, violence-prevention, social justice and advocacy agencies or organizations which contribute to, enforce laws related to, or advocate for a safe and healthy environment Source: National Association of County and City Health Officials, 2013.

or coalitions have aligned with the DE SHIP’s statewide goals and objectives. Articles in this issue highlight progress and milestones achieved in helping improve population health, explore shared SHIP priorities and objectives among diverse stakeholders, discuss gaps and opportunities for improvement, and describe plans and considerations for the future.

While we have just embarked on our latest SHIP journey, it is without question that having “all hands on deck” and working in a coordinated and unified fashion will help us collectively sail in the right direction. That said, Delaware’s SHIP is also a dynamic document and is expected to be updated and refined over the next five years. Annual reports will be issued, and stakeholder input will be solicited at SHIP statewide meetings and through regular communications between such events.

As the work continues, the SHIP team will continue to invite and involve partners to come aboard, encourage all partners to make a clear commitment to improving the health of Delaware residents through engagement and alignment with the SHIP, and work collaboratively to stay the course for improved health outcomes. To learn more or share information about the role your community or agency plays in helping Delaware get in “shipshape,” please go to www.delawareship.org or contact Noel Duckworth, SHIP Project Manager, noel@udel.edu.

18 Delaware Journal of Public Health – February 2019

References Association of State and Territorial Health Officials (2015). Developing a State Health Improvement Plan: Guidance and Resources. Retrieved from http://www.astho.org/ Accreditation-and-Performance/Developing-a-State-Health-Improvement-Plan-Guidance-andResources/Home/ Beitsch, L. M., Kronstadt, J., Robin, N., & Leep, C. (2018, May 1). Has Voluntary Public Health Accreditation Impacted Health... : Journal of Public Health Management and Practice.

Retrieved from https://journals.lww.com/jphmp/Fulltext/2018/05001/Has_Voluntary_Public_ Health_Accreditation_Impacted.3.aspx Bender, K (2018, November). Greetings from PHAB. Public Health Accreditation Board E-Newsletter. Retrieved from https://myemail.constantcontact.com/PHAB-E-Newsletter-October-November-2018.html?soid=1102084465533&aid=zaMaMPHNeSc Delaware Division of Public Health. (2017). Delaware State Health Needs Assessment. Retrieved from https://dhss.delaware.gov/dhss/dph/files/shna.pdf Delaware Division of Public Health. (2014, June). The First Delaware State Health Improvement Plan: Assessing and Improving Community Health in Delaware. Retrieved from https://dhss. delaware.gov/dhss/dph/files/shaship.pdf Delaware Division of Public Health (2018, November 26). Summary of Delaware State Health Needs Assessment and Delaware State Health Improvement Plan: Recommendations Report 2017. Retrieved from https://dhss.delaware.gov/dhss/dph/files/shipaandrsummary2017.pdf Institute of Medicine (2003). The future of the public’s health in the 21st century. Washington, D.C: The National Academies Press. DOI: https://doi.org/10.17226/10548 National Association of County and City Health Officials (2013). National Public Health Performance Standards: Local Implementation Guide. Retrieved from https://www.naccho. org/uploads/card-images/public-health-infrastructure-and-systems/2013_1209_NPHPS_ LocalImplementationGuide.pdf Public Health Accreditation Board site visit report from e-PHAB. (2016, March 8). vRetrieved from https://dhss.delaware.gov/dhss/dph/files/phabsitevisitreport.pdf Public Health Accreditation Board (2013, December). Standards and Measures, Version 1.5.

Retrieved from https://chfs.ky.gov/agencies/dph/Documents/PHABVersion15.pdf

Authors Cassandra Codes-Johnson, M.P.A., Lean Six Sigma Greenbelt, is a public health and organizational management professional with over twenty years of experience in health care. Cassandra has over a decade of experience working at the community level engaged in initiatives to improve the health status and economic status of vulnerable populations.

Cassandra is currently the Associate Deputy Director for the Delaware Division of Public Health and provides oversight for over 500 dedicated public health staff who work daily to promote and protect the health of Delawareans.

Lucy Luta, M.D., M.P.H., is currently the Chief of the Bureau of Health Equity for the Division of Public Health. The Bureau’s mission is to eliminate health disparities across Delaware. Lucy also has background working in DPH’s Communicable Disease section, she was previously in charge of Delaware’s HIV/AIDS treatment program. Lucy received her medical degree from the University of Nairobi. She subsequently received a masters in public health from the University of Dundee in Scotland.

Noël Duckworth, D.V.S., has been working alongside communities and building coalitions for over twenty-six years as a social justice advocate and public health practitioner. She has managed statewide policy, practice and research grants, including serving more than a decade as the Principal Investigator for a CDC program to build state, organizational and local-level public health prevention capacity. In her current role, Noël coordinates the University of Delaware’s Partnership for Healthy Communities and serves as Project Manager for Delaware’s State Health Improvement Plan.

Karen E. McGloughlin, U.S.A.F. Retired, has over 35 years’ experience working in the public healthcare field, more recently focused on community health engagement, violence prevention, and women’s issues. Karen brings a social justice, health equity and veteran’s perspective to her work as the Director for the Office of Women’s Health and the Rape Prevention and Education Program under the Division of Public Health, Department of Health and Social Services.

Timothy Gibbs, M.P.H., is the Executive Director of the Delaware Academy of Medicine/Delaware Public Health Association, a position he has held since 2007. Mr. Gibbs has overseen the transformation of the Academy (founded in 1930) from a medical library system to Delaware’s affiliate to the American Public Health Association. As a part of the new organizational scope of services, the work on the State Health Improvement Plan is an excellent fit for the dual role the Academy/DPHA plays at the intersection of individual, population, and public health.

Kate Smith, M.D., M.P.H., has led research projects on foreign and domestic immunization practices, the role of women and sexism in American society, and the use of advance directives in Delaware.

Her dual degrees allow her a unique take on medical and public health issues, and her dual citizenship adds an international perspective, allowing her to act in ways that truly benefit citizens and society.

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The Healthy Communities program incorporates a system-wide “Health in all Policies” approach to address the social determinants of health. In this way, it is able to focus on all four of the Delaware SHIP priority areas.

UD Partnership for Healthy Communities:

Expanding Campus-Community Channels for Delaware’s SHIP Rita Landgraf, Erin K. Knight, Ph.D., M.P.H., Noël Duckworth, D.V.S.

About the UD Partnership for Healthy Communities In the fall of 2017, the University of Delaware (UD) launched the Partnership for Healthy Communities (PHC) as part of UD’s Community Engagement Initiative, which is designed to strengthen the contributions of UD as an engaged research university. Our mission at the Partnership for Healthy Communities is to align and strengthen UD research, educational and service capabilities to improve the health and well-being of Delaware communities and beyond through effective community partnerships.

This strategic focus on healthy communities underscores growing evidence that health is affected by more than what happens in the doctor’s office, and is reflected in the social factors and physical conditions of the environment in which people are born, live, learn, play, work, and age. We seek to improve the health and well-being of Delaware residents, especially those 20 Delaware Journal of Public Health – February 2019

What is a Healthy Community?

living in communities A healthy community goes that experience beyond quality medical care social, environmental and is reflected in the social and economic and environmental factors that disadvantages. We promote well-being. It is a place know that many of free from discrimination and our residents live in oppression and where there is communities that equitable access to the resources lack the resources needed for optimal health. needed for good health and often shoulder a disproportionate share of threats or risks to health (Knight, Ransford, Gugerty, Dugan & Codes-Johnson, 2015). PHC Graduate Research Assistant, Kalyn McDonough, conducted research on life expectancy and the relationship with race, education and poverty in Delaware that is further highlighted in this journal issue. We also know that thriving communities with affordable, high quality housing, well-paying jobs, good schools, safe parks and welcoming community spaces, as well as affordable and high-quality healthcare, translate into positive health outcomes for their residents (Marmot, Friel, Bell, Houweling, & Taylor, 2010).

We are inspired by the possibility of this reality for all Delaware communities, as well as being inspired by a vision of equity in health where everyone has the opportunity to reach optimal health and well-being.

The focus on how the university engages in this work is also vital. PHC seeks to do this work in authentic partnership by facilitating and enhancing connections between UD (i.e. Colleges of Health Sciences, Agriculture, Arts and Sciences, Business and Economics, Earth, Ocean and Environment, Education and Human Development, and Engineering) and the community (i.e. community-based organizations, state and local agencies and communities themselves, including those impacted

first hand by inequities). We consider partnerships to be long-term, two-way mutually beneficial collaborations (with potential for scale); designed to leverage collective resources toward a shared goal; and, guided by jointly defined vision, roles and strategies for achieving that goal. We seek out collective, inter-disciplinary, multisector efforts with partners dedicated to learning from each other, embracing strengths and assets, aligning around shared impact, and advancing collaboration in place of unnecessary duplication.

A UD campus-wide survey in fall 2017 that focused on assessing health-related partnerships confirmed that there is much work to build upon. Seventythree respondents reported that they were currently engaged in 91 health-related partnerships, with some active for over 25 years. Some of the top focus areas of such partnerships included inequities, health care transformation, population health, and health policy. PHC aims to support, sustain and strengthen these efforts in a collective framework that cultivates meaningful engagement to promote equity and drive healthier outcomes.

Alignment with SHIP System-wide Recommendations PHC’s work in advancing “upstream” thinking for building healthy communities and addressing the social determinants of health is fundamental for improving global and national health, and is a priority for Delaware stakeholders (Delaware Division of Public Health, 2018). Specifically, PHC’s mission and goals

aim to align with the Delaware Division of Public Health’s 2018-2023 Delaware State Health Assessment and State Health Improvement Plan, which emphasizes a system-wide approach that promotes health in all policies, incorporates a social marketing approach, and addresses the social determinants of health. For example, PHC connected public policy students in the Biden School to work alongside a local Blueprints Community who wanted to understand not only how their neighborhood redevelopment plans might impact the environment, but also have an impact on residents’ health. Students conducted a literature review, assessed existing conditions, and predicted the health impact of the community’s plan across 12 social determinants of health (Fuzayl et al., 2018). For more information on Health Impact Assessments, see UD’s Institute for Public Administration’s Complete Communities Toolkit (www. completecommunitiesde.org).

To guide and inform the work of PHC, and potentially support Delaware’s SHIP in addressing gaps and opportunities for improvement, another group of students conducted research this fall to provide an overview of the current state of Health in All Policies (HiAP) approaches taken by various cities, states, and countries. Based on findings from a comprehensive, semester-long literature review, this report mapped out what HiAP might look like in Delaware, including recommendations for a policy alternative to a Delawarespecific HiAP approach (Dorsey et al., 2018).

Through multi-year, donor-funded projects initiated in the summer of 2018, PHC began placing students in a federally-qualified healthcare centers (FQHC) to support clinics in addressing the social determinants of health impacting their patients. Students conducted research on food access initiatives that could help identify and advance potential models for Delaware and developed resource guides to support each clinic in making referrals tailored to their community and patients. The student fellows also worked extensively to plan, coordinate and implement community outreach events in Wilmington and Dover that yielded the highest participation rates since the event’s inception.

Alignment with SHIP Priority Areas PHC’s alignment with Delaware SHIP system-wide goals has also facilitated our work on Delaware SHIP priority focus areas: chronic disease, maternal and child health, substance use/misuse, and mental health (Delaware Division of Public Health, 2018). One example is PHC’s 21

Open Streets Dover – Children get active during Open Streets Dover as part of the Healthy Neighborhoods strategy

support of Delaware’s Healthy Neighborhood strategies.

As part of Delaware’s healthcare transformation efforts through the federal State Innovation Model program, the Healthy Neighborhoods population health strategy has helped establish local-level councils and task forces across the state that integrate community and health system efforts and target parallel priority focus areas (Delaware Center for Health Innovation, 2017).

PHC has been working extensively with Healthy Neighborhoods, and has helped mobilize several teams of cross-college faculty and students from our Wilmington, Newark and Dover campuses to assist with implementation and evaluation. Internally, PHC also coordinated with UD’s Cooperative Extension leadership and staff, who have been supporting Healthy Neighborhoods across the state with planning and logistics since their inception. These plans are laying the groundwork for systems to work across sectors and engage in more “upstream” strategies as part of healthcare transformation’s shift to value-based care and greater return on investments. Moving ahead, PHC is excited to play a role in helping sustain efforts to align for better health in DE. These efforts are now being led by Healthy Communities Delaware, a consortium of public, nonprofit and private organizations aligning efforts and investing in projects, programs and policies aimed at improving the health of people in low-wealth communities in the state.

community partners, planned and hosted 15 events as part of National Public Health Week. The week culminated in a presentation from Joseph Telfair, DrPH, MSW, MPH, President of the American Public Health Association (APHA). Dr. Telfair underscored the need to build infrastructure and develop our workforce as essential means to assuring the public's health (Telfair, 2018). Dr. Telfair outlined gaps in training, stressed the need for skill development among workers to better understand and influence policy, and described looming workforce capacity challenges. It is estimated that 250,000 more public health workers will be needed by 2020 to maintain capacity (Rosenstock et al., 2008). These remarks further bolstered PHC goals to expand public health-related educational opportunities through new and expanded instructional programs and enhanced experiential learning. In addition to a new “Public Health in Practice” course taught in 2018 by PHC Director, Rita Landgraf, Professor of Practice and Distinguished Health & Social Services Administrator in Residence, PHC is working to develop and advance a Masters of Public Health program. While UD’s current Public Health minor continues to generate interest with student enrollment over 180, an MPH would help DE provide the educational and training capital needed to support public health professionals in gaining accredited, innovative and rigorous public health workforce development.

Dr. Telfair also focused on the role policies played in

Plans and Considerations for the Future In spring 2018, PHC, in partnership with the Delaware Academy of Medicine/Delaware Public Health Association and 12 campus and 22 Delaware Journal of Public Health – February 2019

Group Photo – Dr. Joseph Telfair (center), President, American Public Health Association, meets students in Rita Landgraf ’s (left) Public Health in Practice course during National Public Health Week

some of the greatest public health achievements of the 20th century, where the results had an outsize impact over time (i.e, fluoridating our water, mandating seatbelts, and improving access to family planning services). In the 2017 Public Health Workforce Interests and Needs Survey (PH WINS), three quarters of respondents agreed that it is important to have the skills to influence policy and understand the relationship between public health policy and public health problems. However, one-third of that group reported either beginner-level ability or no ability at all in these areas.

This April, PHC will launch our first Policy Academy for faculty, students, staff, state and local government leaders and representatives, advocates, community partners and residents. This inaugural academy, “Reducing Health Inequities by Addressing Structural Racism,” will cultivate awareness of how policy and resource allocation often create or perpetuate health inequities and racial injustice. We are working to ensure that participants leave with new and deepened insights, grounded in the best possible evidence, to evoke compassion and shared responsibility for dismantling structural racism and promoting equitable policies and practices. As a longterm strategy, PHC Policy Academies will have several aims: increase our collective understanding of key issues that impact the health of communities, give voice and clarity to why certain communities are most impacted by health inequities, facilitate authentic partnerships, and advance informed decision-making related to the complex nature of health inequities and the policies that impact them.

As PHC progresses through its second year, we are excited to advance research and policy, expand educational opportunities, and enhance our service capabilities. Ensuring that our goals are aligned with Delaware’s SHIP is not only an ironclad strategy to improve and protect the health of Delawareans, it is a partnership we are honored and proud to be a part of with the Delaware Division of Public Health and our partners across the First State.

References Delaware Center for Health Innovation (2017, April). Healthy Neighborhoods Program Overview. Retrieved from https://pages.dehealthinnovation.org/healthy-neighborhoods-overview Delaware Division of Public Health. (2017). Delaware State Health Needs Assessment. Retrieved from https://dhss.delaware.gov/dhss/dph/files/shna.pdf Delaware Division of Public Health (2018, November 26). Summary of Delaware State Health Needs Assessment and Delaware State Health Improvement Plan: Recommendations Report 2017. Retrieved from https://dhss.delaware.gov/dhss/dph/files/shipaandrsummary2017.pdf Dorsey, S., Hinson, M., James, K., Marks, R., Richardson, R., & Rogal, L. (2018, December 12).

The Road to Health in All Policies: An overview of literature review and recommendations for Delaware. Retrieved from https://udcapture.udel.edu/2018f/uapp440-review/?t=a22e9032254d0 8cb130aa5b0eafa6482

Fuzayl, E., Hurd, T., Lawler, L., Monslave, V., Sorge, J., & Poole, C. (2018). Northeast Wilmington Health Impact Assessment. Retrieved from https://sites.google.com/udel.edu/ uapp440/previous/18s-health-ne-wilm-hia?authuser=0 Knight, E. K., Ransford, G., Gugerty, P., Dugan, E., & Codes-Johnson, C. (2015, June). Health Equity - Guide for Public Health Practitioners and Partners. Retrieved from https://dhss. delaware.gov/dhss/dph/mh/healthequityguide.html Marmot, M., Friel, S., Bell, R., Houweling, T. A., & Taylor, S. (2010). Closing the gap in a generation: Health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health, 10(3). doi:10.11606/issn.2316-9044. v10i3p253-266 Rosenstock, L., Silver, G. B., Helsing, K., Evashwick, C., Katz, R., Klag, M., … Sumaya, C. (2008). On Linkages: Confronting the Public Health Workforce Crisis: ASPH Statement on the Public Health Workforce. Public Health Reports, 123(3), 395–398. https://doi. org/10.1177/003335490812300322 Telfair, J. (April 2018). Affiliates responding to and shaping Public Health in the US through Partnerships and Workforce Development. American Public Health Association. Retrieved 2018, from http://hawaiipublichealth.org/resources/Documents/HPHA Key Note PPT (Telfair).pdf

Student Research – UD graduate students Abigail Heath (left) and Andrew Castillant (right) work in community with PHC and partners to evaluate community health interventions 2017 National Findings. (2017). Public Health Workforce Interests and Needs Survey. Retrieved 2018, from https://www.debeaumont.org/phwins/

Authors Rita Landgraf is the director of the UD Partnership for Healthy Communities, and professor of practice and distinguished health and social services administrator in residence with the College of Health Sciences at the University of Delaware. Prior to joining the faculty at UD, Rita served as Cabinet Secretary of the Delaware Department of Health and Social Services from Jan. 22, 2009 through Feb 6, 2017, under Governor Jack Markell’s administration. As Secretary, she led the principal agency charged with keeping Delawareans healthy, ensuring they get the health care they need, and providing children, families, individuals with disabilities and seniors with the essential services they depend on.

Erin K. Knight, Ph.D., M.P.H., is the associate director of the UD Partnership for Healthy Communities, associate director of the Center for Community Research and Service, and an assistant professor in the Biden School of Public Policy and Administration at the University of Delaware. Her research focuses on improving policy and practice to address social determinants of health and advance health equity.

Noël Duckworth, D.V.S., has been working alongside communities and building coalitions for over twenty-six years as a social justice advocate and public health practitioner. She has managed statewide policy, practice and research grants, including serving more than a decade as the Principal Investigator for a CDC program to build state, organizational and local-level public health prevention capacity. In her current role, Noël coordinates the University of Delaware’s Partnership for Healthy Communities and serves as Project Manager for Delaware’s State Health Improvement Plan.

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Behavioral health is one of the four Delaware SHIP priority areas. It closely aligns with substance abuse, another priority area.

Statewide Alignment:

Coordinated Efforts for Delaware’s Behavioral Health Needs Bethany A. Hall-Long, Ph.D., R.N., Lieutenant Governor Chair, Behavioral Health Consortium

As Delaware’s Lieutenant Governor, I regularly travel up and down the state, speaking with Delawareans from Brandywine to Blades, and I’m often asked about the most pressing issues facing our communities. The topics range from education funding to job growth and public safety concerns, but the singular issue that has been felt by everyone is the impact of the opioid and heroin epidemic. It has been felt throughout every town and community in our state.

In 2017, overdose deaths claimed the lives of 345 Delawareans (Delaware Division of Forensic Science, 2017). We will likely exceed that number for 2018. The opioid epidemic has become the public health crisis of our generation. As a public health nurse, I see the incredible devastation the loss of life has on families and communities. The need for swift action from policymakers, advocates and the medical community has never been more urgent. This public health crisis affects the entire spectrum of health care from the cradle to the grave and includes steadily rising costs, lost wages, and disability payments estimated at nearly $467 billion a year (Council of Economic Advisors, 2017).

Over the past year and a half, the Behavioral Health Consortium has hosted four statewide community forums engaging more than 600 stakeholders, including physicians, first responders, school nurses, families and so many others involved in this fight. There are six committees ranging from Access and Treatment to Corrections and Law Enforcement. The dedicated members of the Consortium are now hard at work executing the 117 point action plan, and we have had quite a bit of success. Delaware became the first state in the nation to implement an Overdose System of Care, which will model our more traditional systems of care like trauma and stroke. The Overdose System of Care will better align first responders, health systems and critical rehabilitation services in order to save lives and mobilize individuals into a path to recovery.

Meanwhile, physicians and other health care workers have lead Narcan distribution and other harm reduction measures throughout our communities. Taking action to break down barriers, get individuals into treatment, and provide prevention measures will save lives.

Implementing the Consortium’s Three Year Action Plan is crucial to this mission.

Since its formation, the Behavioral Health Consortium has sought to address not only the enormous impacts of the opioid and heroin epidemic, but also to identify the gaps within our entire continuum of care. I receive calls and emails every day from Delawareans desperately looking for help, many of whom don’t know where else to turn. These families often seek guidance on ways to navigate a fractured system that is full of hurdles and gaps. Their calls are often the same: pleas to help their child, sibling or parent who is struggling with addiction and mental illness. Many are in active crisis.

This is why I was so thrilled to see the Delaware State Health Needs Assessment and Delaware State Health Improvement Plan’s Recommendations Report (Division of Public Health, 2018). The report calls for a statewide media campaign with the goal of reducing stigma, integrating the work of the healthy neighborhoods, school based mental health screenings, and educational and payment reform opportunities for the practitioner community. These recommendations align with not only the Consortium’s roadmap, but also the work of its committees.

24 Delaware Journal of Public Health – February 2019

Specifically, the Changing Perceptions and Stigma Committee are aggressively working with stakeholders on a comprehensive, statewide campaign that will reduce the stigma around behavioral health. Our Education and Prevention Committee has convened educators and mental health professionals from across the state to discuss evidence-based curriculum and mental health screenings starting in our highest need and at-risk schools.

In short, the Recommendations Report calls to attention the much-needed work in the critical area that is behavioral health. Although we have made improvements, we continue to identify additional gaps that need to be addressed quickly. As I have often said, this work cannot be addressed by piecemeal proposals.

We must coordinate committed efforts and encourage those who might be interested to reach out to my office.

We all know that it will take this type of collaboration to properly remove barriers that currently exist including stigma, lack of awareness, and inadequate access to care and prevention. We need dedicated leaders to step forward and get involved in order to achieve our goal of a stronger, healthier Delaware.

The First Delaware State Health Improvement Plan

Assessing and Improving Community Health in Delaware

References Council of Economic Advisers (U.S.),. (2017). The underestimated cost of the opioid crisis.

Retrieved from https://www.whitehouse.gov/sites/whitehouse.gov/files/images/The%20 Underestimated%20Cost%20of%20the%20Opioid%20Crisis.pdf Delaware Division of Forensic Science (2017). 2017 Annual Report. Retrieved from https://dshs. delaware.gov/forensics/pdf/2017%20DFS%20Annual%20Report.pdf Delaware Division of Public Health (2018, November 26). Summary of Delaware State Health Needs Assessment and Delaware State Health Improvement Plan: Recommendations Report 2017.

Retrieved from https://dhss.delaware.gov/dhss/dph/files/shipaandrsummary2017.pdf

Author Bethany A. Hall-Long, Ph.D., R.N., For the last 14 years, Bethany has served as a member of Delaware’s legislature. First as a Representative, then as a Senator. She serves as the chair of the Health and Social Services committee where her efforts are aimed at ensuring a stronger, healthier Delaware by combating addiction, focusing on a stronger mental health system, and fighting cancer. She also serves as a member of the capital budget Bond Committee where Bethany focuses on building Delaware’s infrastructure, modernizing our schools, repairing our highways, and protecting our environment and open space.

Behavioral Health Consortium

THREE-YEAR ACTION PLAN

May 2018

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Data mapping is used to analyze how populations differ based on their geography. Disease surveillance, risk analysis, and health care planning all utilize data mapping to efficiently view and transmit information to audiences.

Mapping the Burden of Chronic Diseases in Delaware for Public Health Decision Making

Russell K. McIntire, Ph.D., M.P.H. 1 Madeline Brooks, M.P.H.2 Scott D. Siegel, Ph.D., M.H.C.D.S. 2 Mia Papas, Ph.D., M.S. 2 1 Jefferson College of Population Health, Thomas Jefferson University 2 Christiana Care Value Institute

Abstract: Public health decision-makers need to consider geographic differences in rates of chronic disease risk factors and outcomes in order to focus intervention efforts on populations exhibiting the greatest burden of disease. Increasingly, public health agencies are using geographic information systems (GIS) to analyze area-based variation and identify geographic priority areas for health promoting interventions. The articles in this issue are descriptive studies presenting the geographic distribution of select chronic disease risk factors and outcomes among Delaware communities. These studies emerged from a collaboration between the Christiana Care Value Institute and the Jefferson College of Population Health. These studies show that the burden of chronic diseases is not distributed evenly among communities in Delaware. The results of these studies add to the evidence base about public health in Delaware, and should inform public health practitioners working to improve the health of Delaware communities.

26 Delaware Journal of Public Health – February 2019

Data is Important in Decision Making

Public health practitioners need to make decisions about the distribution of resources to focus on services that best utilize the skills and training of the public health workforce, are evidence-based, meet the health needs of populations, and ultimately reduce the burden of disease and increase the quality of life for members of populations. Ideally, public health practitioners should make programmatic, policy, and budgetary decisions by considering the best evidence available and the comparative effectiveness of interventions. A main process of evidence-based public health is to quantify the impact of public health issues by measuring the associated burden of disease among populations (Brownson, Gurney & Land, 1999). This process utilizes data from a variety of sources, including electronic medical records, birth and death records, demographic and health surveys, community input, expert opinion, and many others.

Public health practitioners carefully analyze this data in order to highlight health issues that should be addressed, identify sub-populations disproportionately affected, monitor and evaluate intervention efforts, and generate hypotheses about the causes of negative health outcomes.

Place Affects Health

Studies have consistently found that characteristics about where individuals live predict their length and quality of life, even after controlling for genetics, demographics, and health behaviors. The distribution of health is not equal in every community. There are vast and dramatic health disparities based on geography, at the state level and at smaller geographies such as counties, zip codes, and neighborhoods. These differences are due to historical, social, and cultural factors that have provided unequal opportunities for groups of the U.S. population. Segregation, employment inequality, and unequal access to adequate housing have produced vast differences in health behaviors such as physical activity, diet and other risk factors such as stress. Smoking, substance use, and health seeking behavior are very much influenced by the normative social environment- the people you encounter most, including family, friends, coworkers and neighbors. All of these factors have fostered the extensive differences in length and quality of life between geographic areas in the U.S.

Prioritizing Areas of Greatest Health Burden using GIS Mapping

Because of resource constraints, public health practitioners are constantly tasked with implementing programs and policies that are the most efficient.

Prioritizing which interventions and activities to focus on is a major effort among local, state, and national public health organizations of all sectors. Due to shrinking budgets, it is very important that local health departments and other organizations tasked to improve the health of communities focus on efforts that could maximize the population health impact among communities and minimize resources expended.

Increasingly, public health agencies are using geographic information systems (GIS) to analyze geographical variation and identify geographic priority areas of focus for health promoting interventions. GIS mapping is used in a number of ways to strengthen the public’s health, including disease surveillance, environmental risk analysis, health access and planning, and community health profiling (Nykiforuk & Flaman, 2011). Health mapping is a powerful way of efficiently transmitting information to the reader or viewer, and has been influential in health-related decision making. Maps can communicate geographic relationships that may not be possible with tabular data or other presentation formats (Mullner, Chung, Croke & Mensah, 2004). When planning communitybased health interventions, GIS mapping can help public health practitioners identify the populations that are experiencing the greatest burden of disease. An application of this approach is the Camden Coalition of Healthcare Providers in New Jersey’s hotspotting process, which identifies geographic clusters of patients with poorly coordinated care, and implements programs to meet their health needs. In this case, the Camden Coalition’s efforts reduced the utilization of healthcare services and cost of these patients’ care by almost half (Kaufman, Ali, Craig & Brenner, 2014).

A focused analysis of geographically linked data is important when deciding where evidence-based interventions would address the greatest public health needs.

Mapping the Burden of Chronic Diseases in Delaware

This collection of articles emerged from a collaboration between the Christiana Care Value Institute and the Jefferson College of Population Health (JCPH).

27

Students in the GIS Mapping class at JCPH mapped and analyzed publically accessible data about risk factors and chronic diseases identified by the Christiana Care Value Institute. Students used innovative and rigorous methods to describe and analyze geographic relationships about chronic disease risk factors and outcomes experienced within and among Delaware communities.

The first paper in the Data to Decision-Making Issue identifies that asthma rates vary dramatically by neighborhood in Delaware, and that urban areas such as Wilmington have a greater burden of disease compared to rural areas. The second paper focuses on relationships between smoking rates and tobaccoretail density among Delaware neighborhoods, and quantifies the high number of tobacco-retail outlets in close proximity to schools in Wilmington. The third article identifies the geographic distribution of the third greatest cause of death in Delaware, chronic lung diseases, with a particular focus on chronic obstructive pulmonary disease. The fourth article characterizes the food environment among Delaware communities, and explores relationships between SNAP-retail locations, food deserts, food insecurity, and obesity. The final article in the issue identifies and analyzes the differences in prevalence and mortality due to diabetes by geography and race.

These descriptive studies reinforce what is increasingly becoming apparent to public and population health practitioners; demographics and the social determinants of health matter for risk of disease. Where you live truly does impact your length and quality of life. Zip code is, by far, a better predictor of individual’s longterm health outcomes than blood pressure, cholesterol level, or any ICD-10 code in the manual. Overall, these studies show that the burden of chronic diseases is not distributed evenly among communities in Delaware.

The maps and analyses included in this edition are valuable for upstream hypothesis generation about the causes of health disparities, and serve as a “gateway” to consideration of other related data including demographic, socioeconomic, and health factors within the same geographic unit of interest. As all evidencebased decision-making should consider the breadth of knowledge about public health topics, no individual study or finding should solely initiate public health action. The results identified in these studies are just the beginning of further, more in-depth, inquiries to quantify the distribution and determinants of geographic health disparities in Delaware. The results of these studies add to the evidence base about public health in Delaware, and hopefully, will inform public health practitioners working to improve the health of Delaware communities.

28 Delaware Journal of Public Health – February 2019

References Brownson, R. C., Gurney, J. G., & Land, G. H. (1999). Evidence-based decision making in public health. Journal of Public Health Management and Practice, 5, 86-97.

Kaufman, S., Ali, N., DeFiglio, V., Craig, K., & Brenner, J. (2014). Early efforts to target and enroll high-risk diabetic patients into urban community-based programs. Health promotion practice, 15(2_suppl), 62S-70S. Mullner, R. M., Chung, K., Croke, K. G., & Mensah, E. K. (2004). Introduction: geographic information systems in public health and medicine.

Nykiforuk, C. I., & Flaman, L. M. (2011). Geographic information systems (GIS) for health promotion and public health: a review. Health promotion practice, 12(1), 63-73.

Authors Russell K. McIntire, Ph.D., M.P.H., is an Assistant Professor and epidemiologist in the Jefferson College of Population Health (JCPH) at Thomas Jefferson University. Dr. McIntire teaches epidemiology and geographic information systems (GIS) mapping at JCPH. His major research interests include identifying and analyzing the social, behavioral, and geographic risk factors of chronic diseases among vulnerable populations.

Madeline Brooks, M.P.H., is a research associate in the Value Institute at Christiana Care Health System in Newark, DE. Her work focuses on the use of geographic information systems (GIS) to study population health and health services delivery. She holds a Master of Public Health from Thomas Jefferson University.

Scott D. Siegel, Ph.D., M.H.C.D.S., is a licensed psychologist and Director of Population Health & Community Based-Research within the Value Institute at the Christiana Care Health System in Newark, DE. In this role, Dr. Siegel works collaboratively with multidisciplinary teams in the health system and across sectors, including local and state governments, academic partners, and community-based organizations, to address the social and behavioral determinants of the health in our local communities.

Mia Papas, Ph.D., M.S., current research projects focus on understanding the determinants of obesity among vulnerable populations. Her expertise includes experimental and observational study designs, the assessment of validity and reliability of screening tools, sample size and statistical power, the analysis of longitudinal data, hierarchical linear modeling, the use of GIS in understanding the effect of place on health and health behaviors, factor analysis, survival analysis, and multivariate logistic and linear regression.

Dr. Kara Odom Walker, Secretary Jill Fredel, Director of Communications 302-255-9047, Cell 302-357-7498 Email: jill.fredel@state.de.us

Date: February 13, 2019 DHSS-2-2019

DPH TO DISTRIBUTE OVERDOSE REVERSING MEDICATION NALOXONE MARCH 2, 2019 AT ATTACK ADDICTION 5K First event in DPH Community Naloxone Distribution Initiative NEW CASTLE (Feb. 13, 2019) – In an effort to reduce the number of individuals overdosing, and dying from drug overdoses in Delaware, the Division of Public Health (DPH) is announcing the Community Naloxone Distribution Initiative. DPH will distribute free naloxone kits to members of the general public, at events in each county in March. The first event will be held on Saturday, March 2, 2019, in conjunction with the annual atTAcK addiction 5K race starting at St. Peter’s Church 515 Harmony St., New Castle, DE 19720. The remaining dates and event locations will be announced as details are finalized.

Each naloxone kit will contain two doses of naloxone, and members of the community who attend these events will receive one-onone training on how to administer the overdose-reversing medication. The Division of Substance Abuse and Mental Health (DSAMH) also will have representatives on hand to answer any questions about access to treatment for those struggling with substance use disorder.

“It is critically important for family and friends of loved ones struggling with addiction to have access to naloxone,” said DPH Director Dr. Karyl Rattay. “The data are telling us that 80 percent of overdoses happen in a residence. If family or friends of someone overdosing have naloxone immediately accessible, it can mean the difference between life or death for that person.”

Within three to five minutes after administration, naloxone can counteract the life-threatening respiratory depression of an opioidrelated overdose and stabilize a person’s breathing, which buys time for emergency medical help to arrive. DPH recommends calling 9-1-1 immediately if you find someone in the midst of a suspected overdose, starting rescue breathing, and then administering naloxone. Naloxone is not a replacement for emergency medical care and seeking immediate help and follow-up care is still vital.

There were at least 291 deaths last year in Delaware from suspected overdoses. Tragically, the final number is expected to exceed 400 after all toxicology screens are finished (they take six-eight weeks) and final death determinations are made on outstanding cases by the Division of Forensic Science. The Centers for Disease Control and Prevention ranked Delaware as number six in the nation for overdose deaths in 2017.

“We are incredibly excited to partner with DPH to provide them with a host site for their first Community Naloxone Distribution event,” said David Humes, a board member of atTAcK addiction. “It seems like a natural extension of the event’s purpose. I made a vow after losing my son Greg six years ago to a heroin overdose that I would save a life in his name. By partnering with DPH and expanding access to naloxone in the community this way, atTAcK addiction continues to save lives and keep the memory of all of our loved ones alive.” Individuals who would like a naloxone kit on March 2, do not have to be a 5K participant.

In 2018, first responders administered 3,728 doses of naloxone, compared to 2,861 in 2017, a 30 percent increase.

Funding for the Community Naloxone Distribution Initiative comes from state funding built into DPH’s budget for the fi rst time in state fi scal year 2019, thanks to the advocacy of Lt. Governor Bethany Hall-Long and the Behavioral Health Consortium. In October, DPH also announced the agency was awarded federal funds to support the purchase of naloxone and other programs for fi rst responders.

“This is about saving lives,” said Lt. Governor Hall-Long. “The more naloxone we have in our communities the more lives we can save, allowing us to connect people with the resources to begin their road to recovery. I applaud the work of the Behavioral Health Consortium, the Division of Public Health and our community advocates to help expand access to this life saving medication.”

Community access to naloxone has increased significantly since 2014 when legislation was enacted making it available to the public.

In 2017, Governor John Carney signed additional legislation ensuring pharmacists had the same legal protections as doctors, peace officers and good Samaritans when dispensing the medicine without a prescription.

Information on community training and pharmacy access to naloxone, along with resources regarding prevention, treatment and recovery are available on www.HelpIsHereDE.com.

29

Data mapping is used to analyze how populations differ based on their geography. Disease surveillance, risk analysis, and health care planning all utilize data mapping to efficiently view and transmit information to audiences.

Geographic Patterns of Asthma Rates and Air Quality in Delaware

Rachel Vecchione, M.P.H., Caleb Dafilou, M.P.H., Violetta Gerzen-Feshchenko, M.P.Hc, Nicole LaRatta, M.P.H., Madeline Brooks, M.P.H.

Abstract: Objectives: This study will describe the geographic distribution of asthma prevalence, measures of air quality, asthma-related hospitalizations, and sociodemographic characteristics in the state of Delaware.

Methods: Maps displaying asthma prevalence, ozone levels, atmospheric particulate matter (PM2.5) levels, traffic counts, rates of asthma-related hospitalization, poverty rates, and White and Black populations were created using data from the U.S. Census(2010), the CDC BRFSS, the Delaware Division of Public Health, the Delaware Division of Air Quality, and FirstMap Delaware.

Results: Ozone levels averaged .075 particles per million(ppm) across the state. PM2.5 levels averaged 8.4µg/m3 in middle and southern Delaware and 9.6µg/m3 in northern Delaware. Rates of hospital discharge due to asthma per 10,000 were disproportionately high among Black individuals (27.3 vs. 7.4 among White individuals) and females (15.1 vs. 10.6 for males). High rates of poverty and high traffic counts were shown to correspond geographically with high rates of asthma.

Conclusion: Our findings support the body of evidence showing correlations between measures of poor air quality and increased rates of asthma. Asthma and its environmental triggers disproportionately affect minority and lowincome populations in Delaware. These findings can inform policy discussions to improve air quality and reduce the burden of asthma across the state.

30 Delaware Journal of Public Health – February 2019

Introduction Asthma is a chronic disease that causes the bronchial tubes (passageways that allow air to enter and exit the lungs) to become narrow and inflamed, making it difficult to breathe. Certain substances can act as triggers that worsen asthma symptoms and alter regular breathing patterns (American College of Allergy, Asthma, and Immunology, 2014).

Allergic asthma occurs when exposure to allergens occurs, and non-allergic asthma occurs due to stress, exercise, illness, irritants in the air, extreme weather, and even some medications (American College of Allergy, Asthma, and Immunology, 2014). Currently, there is no cure for asthma and means of prevention are unclear (Akinbami et al., 2012). Awareness of asthma triggers, particularly those occurring outside the home environment, can offer the greatest public health impact in terms of reducing harmful exposures at the population level.

Asthma prevalence increased from 7.3% to 8.4% from 2000 to 2010, at which time a total of 25.7 million people had asthma (Akinbami et al., 2012). Prevalence appears to have plateaued and remained at 8.3% through 2016 (Centers for Disease Control and Prevention, 2016). Asthma is more prevalent among females (9.7%) than males (6.9%). Asthma also disproportionately affects African-American individuals, with 11.6% of AfricanAmerican individuals experiencing asthma compared to 8.3% of Caucasian individuals (CDC, 2016).

Asthma attacks can result in missed work, school absenteeism, emergency room visits, health care expenditures, and mortality, the associated costs of which exceeded $81 billion in the United States in 2013.

A person with asthma spends approximately $3,266

annually on medical care, and prescription medications account for more than half of these costs. The estimated annual cost burden of asthma for individuals living below the poverty line is more than $300 greater (Nurmagambetov, et.al., 2018).

In the state of Delaware, the geographic area of focus for these maps, the Division of Public Health published “The Burden of Asthma in Delaware” in 2005 and an update to this report in 2016. From the initial report in 2005 to the update in 2016, the state saw a slight increase in the prevalence of adults with asthma from about 7.5% to 9.2%. This was not found to be a statistically significant difference, with some of the increase in asthma diagnoses due to the population increase in Delaware during this time (Delaware Division of Public Health, 2016). It was reported that adult women had a higher rate of “current asthma” diagnoses (meaning people who currently have an asthma diagnosis) than men did, and those with a disability were 2.75 times more likely to have asthma as well (Delaware Division of Public Health, 2016).

Overweight or obese adults were also found more likely to currently have asthma, and African-American rates of hospitalizations and deaths due to asthma were disproportionately high (Delaware Division of Public Health, 2016). With the cost of asthma per person per year estimated to be about $3,300, asthma is costing Delaware over $200 million each year (Delaware Division of Public Health, 2017).

The Delaware Department of Public Health has also released data that indicate socioeconomic disparities in asthma prevalence, with higher rates of asthma among minorities and those with lower levels of education (Delaware Division of Public Health, 2016). Asthma prevalence in Delaware differs based on gender, race/ ethnicity, and education. In 2015, adult asthma prevalence was 4.4% for males and 13.7% for females, 9.6% for Non-Hispanic White individuals, 8.3% for Black/ African American individuals, 8.7% for Hispanic/ Latino individuals, 13.1% among individuals with less than a high school diploma or GED and 8.9% and 8.8% for individuals with a high school diploma /GED or college degree, respectively. Hospitalizations due to asthma were found to be disproportionately high among Black/African-American individuals. Women with asthma were found to utilize hospital inpatient services more than men (Delaware Division of Public Health, 2017).

Current asthma prevalence does not differ significantly by county. In 2015, the prevalence in New Castle 31

County was 9.5%, the prevalence in Kent County was 10.2%, and the prevalence in Sussex County was 7.5%.

There are, however, significantly higher rates of asthma in the City of Wilmington. In 2013-2014 the rate of “current asthma” prevalence in Wilmington was 13.6% compared to 9.3% in suburban New Castle County, 9.9% in Kent County, and 8.9% in Sussex County (Delaware Division of Public Health, 2017).

Air pollution is a known asthma trigger. The Delaware Department of Natural Resources and Environmental Control monitors carbon monoxide, nitrogen oxides, sulfur dioxide, ozone, particles smaller than 10 micrometers and particles smaller than 2.5 microns.

(Delaware.gov, 2009) Ground-level ozone is a byproduct of reactions involving Volatile Organic Chemicals (VOCs) and nitrogen oxides (Etzel, 2003).

Increased ozone exposure has been shown to worsen the effects of asthma, leading to increased school absences and hospitalizations when it is high (Trasande et al., 2005). Ground-level ozone continues to be a problem in Delaware due to the high amounts of (VOCs) and nitrogen oxides from in-state industrial facilities, vehicle exhaust, and upwind pollution from Baltimore and Washington, D.C. (Delaware.gov, 2018). Asthma is monitored in Delaware, as is ground-level ozone.

Ground-level ozone is one of only two air pollutants which are documented to be at “unhealthy” levels in Delaware (Delaware.gov, 2018).

One asthma trigger gaining recent attention is that of exposure to particulate matter. The Environmental Protection Agency (EPA) defines particulate matter as “a mixture of solid particles and liquid droplets found in the air” (United States Environmental Protection Agency, 2016). Particulate matter is generally classified by those between 2.5-10 micrometers in diameter (PM10) and those less than 2.5 micrometers in diameter (PM2.5) and thus cannot be seen by the naked eye.

32 Delaware Journal of Public Health – February 2019

They come from sources such as construction sights, roads, fields, pests, mold, and smoke and commonly result from chemical reactions of air pollutants produced by factories and machines (United States Environmental Protection Agency, 2016). Many studies have shown that combined exposure to chemical air pollution and allergies have a synergistic effect on the exacerbation of asthma, further validating previous findings (Baldacci et al., 2015). Particulate matter has been found to trigger asthma and increase wheezing severity. Studies have also showed that this association is magnified by geographic location, leading to socioeconomic disparities in exposure to particulate matter and thus asthma and asthma severity (Grineski, Collins, & Olvera, 2015).

Studies have also shown that while the number of days each year that Delaware residents are exposed to an Air Quality Index (AQI) of unhealthy levels according to the CDC has fluctuated greatly, air quality has continued to worsen over the past few decades. The AQI accounts for carbon monoxide, nitrogen oxides, ozone, sulfur dioxide, PM10, and PM2.5; however, levels of each chemical have shown different fluctuations in surveillance data (Delaware Division of Public Health, 2017). By mapping asthma prevalence and particulate matter levels across Delaware, we can generate hypotheses about the relationships between these and other variables.

Some evidence suggests that asthma symptoms might be affected by air pollutants resulting from traffic. One potential trigger of asthma is carbon monoxide (CO), which is a result of vehicle emissions in traffic (Delaware Health and Social Services (DHHS), 2016).

Pollutants attributable to traffic-related air pollution (TRAP) include sulfur dioxide and nitrogen dioxide (NO) which increase cell membrane permeability, decrease ciliary beat frequency and induce airway inflammation and airway hyper-responsiveness (Guarnieri et al., 2014). Traffic-related air pollution induces asthma, exacerbates symptoms, and increases susceptibility to other irritants by increasing permeability of airways. European studies have found that traffic-

related air pollution is associated with increased emergency room attendance (Ferguson et al., 2004).

Research suggests that traffic-related air pollution causes exacerbations of asthma through airway remodeling and increased susceptibility to other triggers, as opposed to new onset of asthma. (Guarnieri et al., 2014).

Higher traffic counts could result in higher emissions of CO and other pollutants. One study, which looked at effects of traffic air pollution on children, found that a relationship existed between higher rates of traffic air pollution and hospital readmission rates for white, but not African American, pediatric patients (Chung et.al., 2014). Another study found a relationship between gender and asthma onset due to traffic air pollution, where female pediatric patients were affected more than male patients (Newman, 2014). Since genders and races are affected differently, it is important to further examine these disparities to direct interventions, policies, and resources more effectively.

This study aims to describe the state of asthma in Delaware as it relates to air quality. This study will describe the geographic distribution of asthma and analyze related environmental and socioeconomic variables. Specifically, we will seek to describe correlations between asthma rates and traffic counts, fine particle matter, and ozone as well as the ways in which these relationships are mediated by race, gender, and poverty.

We hypothesize that increased levels of fine particle matter and ozone, high traffic counts, having a lower income, being female and being African-American will all be positively correlated with higher rates of asthma.

Our findings may be used to inform policymakers about decisions regarding emissions regulations and asthmarelated health programming.

Methods Data were collected from one of four sources: the U.S. Census 2010, the Centers for Disease Control and Prevention Behavioral Risk Factor Surveillance System

(CDC BRFSS), the Delaware Division of Air Quality, and FirstMap Delaware (First Map Delaware, 2017; First Map Delaware, 2018; PolicyMap, 2018; US Census Bureau 2017). Each layer is composed of a shapefile and tabular data joined by Object ID. The Division of Air Quality collects ozone and PM2.5 levels from seven different sites across Delaware and report three-year average levels for each of these measures (Division of Air Quality, 2013). The Delaware Division of Air Quality ozone and PM2.5 monitoring sites show average levels from 2011-2013. These data were imported into Excel 2010 and geocoded in ArcMap. Based on the World Population Review, the four cities in Delaware with populations greater the 20,000 were extracted as a new layer (World Population Review, 2018). All maps use the Delaware State Plane NAD 1983 (meters) Coordinate System and are scaled at 1:750,000 meters. A summary of each layer and its use is included in Table 1.

Data [S]= shapefile [T] = Table

Downloaded

Source

Census Tracts [S]

US Census Tiger Line

US Census, 2010

Poverty Rates [T]

PolicyMap

US Census, 2010

Census Tracts [S]

US Census Tiger Line

US Census, 2010

Adult Asthma Prevalence [T]

PolicyMap

CDC BRFSS, 2012-2016

US Places [S]

US Census Tiger Line

US Census, 2010

US Places [S]

US Census Tiger Line

US Census, 2010

Average Ozone Levels [T]

Entered Manually from 2013 Report

DE Division of Air Quality

US Places [S]

US Census Tiger Line

US Census, 2010

Average PM2.5 Levels [T]

Entered Manually from 2013 Report

DE Division of Air Quality, 2013

County (Hollow Contour)

US Counties [S]

US Census Tiger Line

US Census, 2010

White Population (Chloropleth)

White Population [S]

First Map DE

Census 2010

Black Population (Chloropleth)

Black Population [S]

First Map DE

Census 2010

Traffic Count (Graduated Line)

Traffic Count [S]

First Map DE

Census 2010

Layer (Type)

Poverty Rates (Graduated Circles)

Adult Asthma Prevalence (Chloropleth) Largest DE Cities (Triangles)

Ozone Monitoring Site (Graduated Circles)

PM2.5 Monitoring Site (Graduated Circles)

Table 1: A summary of all the layers created and used to create Figures 1-4

33

Figure 1: Adult Asthma Prevalence (2013) and Poverty Rates (2012-2016)

Figure 2: Adult Asthma Prevalence (2013) and Ozone Levels (2011-2013)

Figure 2: Adult Asthma Prevalence (2013) and Ozone Levels (2011-2013)

Traffic Counts and Race Distribution in Delaware

25 or under 26-75 - 76-150 - 151-300

Annual Average Daily Traffic

25 and under

500 or less

-26-75

-- 501-4500

- 76-150

-- 4501 or more

- 151 -300

ďż˝.,.._ 301 and over

,.

Sources: County Shapefiles, Census 2010 Race Shapefiles, Census 2010 Average Annual Traffic Count Shapefile, FirstMap DE

Map by Violetta Feshchenko and Caleb Dafilou

Figure 4: White Population Count (left), Annual Average Daily Traffic (center), Black Population Count (right)

Figure 3: Adult Asthma Prevalence (2013) and PM2.5 Levels (2011-2013)

34 Delaware Journal of Public Health – February 2019

Results Though there is no statistically significant difference in adult asthma prevalence by county (Delaware Division of Public Health, 2017), there are census tracts throughout the state which have higher rates of asthma than the surrounding census tracts. A visual review of these maps shows that Kent County has the greatest number of census tracts with higher rates of asthma (i.e., rates exceeding 10%), followed by Sussex and then New Castle Counties. The census tracts with the highest rates are spread across the state. There are spikes in adult asthma prevalence around the four largest cities (Wilmington, Newark, Middletown, Dover) in the state.

The census tracts around Wilmington, Newark and Dover have some of the highest levels of adult asthma prevalence. The census tract east of Middletown also has a higher prevalence of asthma than the census tracts surrounding it, but this still represents low to moderate tiers of asthma prevalence compared to the rest of the state.

Poverty rates vary across the state, with the largest clusters of increased poverty being in the northernmost part of Delaware and the central part of the state west of Dover. Certain census tracts throughout the state, such as two in the central region of the state, one in the most northeastern region of the state and one neighboring Newark to the east, show both higher rates of poverty and asthma than surrounding census tracts.

Average Ozone levels are fairly consistent across the state at an average value of .075 ppm with no station showing disproportionately high levels compared to other stations. In the middle and southern regions of the state PM2.5 levels are fairly consistent at an average value of 8.4 µg/m3. The PM2.5 values in the northernmost part of the state are much higher at an average value of 9.6 µg/m3. The three stations in the northernmost part of the state which have the highest PM2.5 levels in the state surround the cities of Newark and Wilmington.

These two cities are surrounded by census tracts with some of the highest rates of asthma in the state. The northernmost part of the state (around and to the north of Newark and Wilmington) has increased rates of poverty, PM2.5 levels, and traffic counts.

The traffic counts represented in Figure 4 are Annual Average Daily Traffic counts. Delaware has a network of Automatic Traffic Recorder (ATR) Stations which “count the number of vehicles passing through each location, continuously throughout the year” (Delaware Department of Transportation, 2016). Traffic counts

vary across the state with the highest levels concentrated in the northernmost part of the state. Distributions of African American and Caucasian populations also vary across the state. While the state’s population is predominantly white, census tracts with higher proportions African Americans are found primarily in the northern half of New Castle County, with smaller areas in the middle of Kent County and eastern Sussex County. Areas with higher numbers of black residents correspond to roadways with the highest annual traffic counts. Areas with higher numbers of black residents also correspond to areas with higher rates of asthma and poverty, such as the area around Wilmington in New Castle County, the area around Dover in Kent County and the area in eastern Sussex County (figures 1 and 4).

We examined maps displaying the distribution of black and white residents per census tract combined with average traffic count. Roads with light traffic had an AADT count of 500 or less, those with medium traffic had an AADT count between 501 and 4500, and roads with high traffic had an AADT count of 4501 or greater.

The greatest concentration of high-traffic roadways is in the northern half of New Castle County. Areas of high traffic correspond to the presence of large cities such as Wilmington, Newark, and Dover.

We also examined hospital discharges due to asthma by county, sex, and race. Data were obtained from the Division of Public Health (2016) and crude rates per 10,000 were calculated.

County

Population

Hospital Discharges

Rate per 10,000

Kent

162,349

210

12.9

New Castle

538,477

799

14.8

Sussex

197,110

149

7.6

Male

434,601

462

10.6

Female

463,335

698

15.1

White

625,861

464

7.4

Black

204,729

559

27.3

Total Delaware Population

897,936

1160

12.9

Gender

Race

Table 2: Hospital discharge rates in Delaware due to asthma in 2012 per 10,000. Population estimates based on 2010 Census. (U.S. Census Bureau, 2010) (Delaware Division of Public Health, 2017)

Table 2 shows that female individuals have a much higher rate of hospital discharge (and thus hospitalization) due to asthma at 15.1 per 10,000 compared to the male 35

rate of asthma-related discharge at 10.6 per 10,000.

Additionally, Black individuals also have a rate of hospital discharge due to asthma that is almost four times higher than that of White individuals (27.3 per 10,000 vs. 7.4 per 10,000, respectively). These values are consistent with national rates. The national rate of asthma hospital inpatient discharges in 2010 was 13.0 per 10,000 among adults, 8.7 per 10,000 among White individuals, and 29.9 per 10,000 among Black individuals (CDC, 2010).

Table 2 also shows that New Castle County has the highest rates of hospital discharge at 14.8 per 10,000, whereas Kent County has a rate of 12.9 per 10,000 and Sussex County has a rate of 7.6 per 10,000.

Discussion Asthma rates are high in Delaware, particularly in the central region of the state and around major urban centers. The high rates of asthma around Wilmington are consistent with the previous reports showing that Wilmington has a higher prevalence of adults with asthma than did suburban Kent, New Castle, and Sussex counties (Delaware Health and Social Services, 2016).

While excessive ozone levels are known to exacerbate asthma, these levels did not vary greatly across the state and we could not identify clear correlations between ozone and asthma prevalence in this study. However, since ozone levels in Delaware near the U.S. National Ambient Air Quality Standards (NAAQS) of 0.075 36 Delaware Journal of Public Health – February 2019

ppm, small fluctuations could be harmful to health (Division of Air Quality, 2013).

PM2.5 levels are highest in the northern-most part of the state around Newark and Wilmington, two cities which also have increased rates of asthma. Higher particle matter may indicate worse air quality in this part of the state. This is consistent with reports indicating that air quality in New Castle County is worse than the rest of the state. Based on the AQI, New Castle County had the most categorized “unhealthy� days compared to the rest of the state (Delaware Health and Social Services, 2016). Furthermore, the finding that higher levels of particulate matter are correlated with higher rates of asthma is consistent with existing literature (Baldacci et al., 2015). Each state monitoring site recorded average PM2.5 levels below the U.S. NAAQS of 15 ug/m3, which indicates that it is unlikely PM2.5 levels alone are unlikely to result in increased rates of asthma (Division of Air Quality, 2013).

Areas around the most heavily trafficked roadways were more likely to also be areas with higher numbers of Black individuals. Black individuals were also found to experience disproportionately high rates of asthma and associated hospitalization. This correlation between traffic counts and higher asthma rates is supported by existing literature. (Guarnieri et al., 2014). The area in the northern half of New Castle County encompassing Wilmington has the highest concentration of heavily

trafficked roads. This area also has the largest cluster of high poverty rates, pockets of high adult asthma prevalence. These results are all consistent with the findings that New Castle has the highest hospital discharge rates due to asthma and Wilmington has statistically significant higher rates of asthma prevalence than surrounding areas. (Delaware Division of Public Health, 2017) Our findings support existing literature showing significant correlations between contributors to poor air quality and increased rates of asthma, findings which have significant policy implications. These findings can be used to target interventions to people who need them most by showing, for example, that people living in urban centers and high-poverty areas, are at greater risk for asthma. The results of this study would support policies to improve asthma outcomes by reducing PM2.5 levels or reducing and redirecting traffic. More research must be done on the effects of socioeconomic and demographic factors on asthma rates as well as the effect of ground-level ozone on asthma rates.

This study has several strengths. The maps incorporate multiple indicators of air quality (ozone, particulate matter, traffic counts) that provide a more comprehensive picture of environmental factors Asthma’s Impact on the Nation Data from the CDC National Asthma Control Program What is asthma?

Asthma is a chronic disease that affects the airways in the lungs. During an asthma attack, airways become inflamed, making it hard to breathe. Asthma attacks can be mild, moderate, or serious — and even life threatening.

Symptoms of an asthma attack include: • Coughing • Shortness of breath or trouble breathing • Wheezing • Tightness or pain in the chest

We don’t know for sure what causes asthma, but we do know that attacks are sometimes triggered by: • Allergens (like pollen, mold, animal dander, and dust mites) • Exercise • Occupational hazards • Tobacco smoke This material is provided for historical reference.

Some of the data in this fact sheet is no longer current. For up to date asthma surveillance statistics, please visit http://www.cdc.gov/asthma/asthmadata.htm.

1 in 11

children has asthma

• Air pollution • Airway infections There’s no cure for asthma. People with asthma can manage their disease with medical care and prevent attacks by avoiding triggers.

Is asthma really a problem?

Yes. Asthma is a serious health and economic concern in the United States. It’s expensive.

• Asthma costs the United States $56 billion each year.

• The average yearly cost of care for a child with asthma was $1,039 in 2009.

In 2008, asthma caused: • 10.5 million missed days of school • 14.2 million missed days of work

1 in 12 adults

has asthma

It’s common.

In 2010: • 18.7 million adults had asthma. That’s equal to 1 in 12 adults.

• 7 million children had asthma. That’s equal to 1 in 11 children.

It’s deadly.

• About 9 people die from asthma each day.

• In 2009, 3,388 people died from asthma.

influencing asthma. These data, combined with poverty rates and adult asthma prevalence, show clear trends that are easy to visualize on the maps. These maps can be used to demonstrate geographic differences in asthma adult prevalence and air quality measures presented in this study.

This study also has several limitations. The data reviewed shows only asthma prevalence, not severity.

Information about variations in asthma severity would better describe the true disease burden across the state.

Another limitation is that asthma by age group is not described. Viewing the disease burden of asthma by age group would be valuable in informing and encouraging local policymakers to increase regulations in the vicinity of schools. A final limitation is that this study does not consider indoor air quality. Components of indoor air quality, such as mold, can trigger and exacerbate asthma (CDC, 2009). The concentration of substandard housing in low-resource areas and housing discrimination create racial, ethnic and socioeconomic disparities in access to good quality housing, which has an impact on health (Robert Wood Johnson Foundation, 2011).

Conclusion In this study, we examined rates of asthma, air quality measures, and sociodemographic characteristics across the state of Delaware This study showed clear associations between air pollutants and asthma rates, which were especially pronounced among Delaware’s low-income and minority populations. Asthma, which affects large numbers of people across the United States and in Delaware, has an outsized impact on quality of life and health care spending. The information presented in this study can be valuable in informing policymakers of pathways where regulation could prevent and reduce the burden of asthma among populations at greatest risk.

References Akinbami, L.J., Moorman, J.E., Baily, C., Zahran, H.S., King, M., Johnson, C. A., & Liu, X. (2012). Trends in asthma prevalence, health care use, and mortality in the United States, 20012010. NCHS Data Brief, (94), 1-8.

American College of Allergy, Asthma, and Immunology (2014). Asthma Information. Retrieved from https://acaai.org/asthma/about American College of Allergy, Asthma and Immunology. 2014. Who has asthma and why. https:// acaai.org/asthma/who-has-asthma Baldacci, S., Maio, S., Cerrai, S., Sarno, G., Baïz, N., Simoni, M., …HEALS Study. (2015).

Allergy and asthma: Effects of the exposure to particulate matter and biological allergens.

Respiratory Medicine, 109(9), 1089-1104. doi:10.1016/j.rmed.2015.05.017 CDC. (2015). Adult Self-Reported Current Asthma Prevalence Rate (Percent) and Prevalence (Number) by State or Territory, BRFSS 2015. Retrieved from https://www.cdc.gov/asthma/ brfss/2015/current_508.PDF CDC. (2018). Asthma. Retrieved from https://www.cdc.gov/asthma/default.htm CDC. (2016). Asthma: Data, Statistics and Surveillance. Retrieved from https://www.cdc.gov/ asthma/asthmadata.htm

National Center for Environmental Health Division of Environmental Hazards and Health Effects CS232840

37

CDC. (2010). Asthma: Most Recent Asthma Data: National Asthma Hospital Inpatient Discharges (2010). Retrieved from https://www.cdc.gov/asthma/most_recent_data.htm CDC. (2009). Asthma: Triggers Indoors.

Retrieved from https://www.cdc.gov/asthma/triggers_indoor.html CDC. (2009). Impact on the Nation:Data from the CDC National Asthma Control Program.

Retrieved from https://www.cdc.gov/asthma/impacts_nation/asthmafactsheet.pdf Centers for Disease Control and Prevention (2015). 2015 National Health Interview Survey (NHIS) Data. Retrieved from https://www.cdc.gov/asthma/nhis/2015/table3-1.htm Centers for Disease Control and Prevention. (2016). Most Recent Asthma Data. Retrieved June 5, 2018, from https:www.cdc.gov/asthma/most_recent_data.htm Chung C.S., Hathaway D. , Lew, D. (2014). Risk Factors Associated With Hospital Readmission in Pediatric Asthma. Journal of Pediatric Nursing. (30) 364-384.

Delaware Department of Transportation. (2016). 2016 Vehicle Volume Summary Book Introduction. Retrieved from https://deldot.gov/Publications/manuals/traffic_counts/pdfs/2016/ Introduction.pdf?042517 Delaware Division of Public Health (2016). Burden of Asthma in Delaware: 2016 Update Reviews Data from Last Decade. Division of Public Health.

Retrieved from http://dhss.delaware.gov/dhss/dph/dpc/asthma2.html Delaware Division of Public Health. (2017). The Burden of Asthma in Delaware: Update May 2016, Revised March 2017.

Retrived from: https://dhss.delaware.gov/dhss/dph/dpc/files/asthmaburdenupdate16.pdf Delaware Health and Social Services. (2016). The Burden of Asthma in Delaware. www.Dhhs.Delaware.gov Delaware.gov. (2005). Report Details Asthma Prevalence and Burden in Delaware.

Retrieved from http://dhss.delaware.gov/dhss/dph/dpc/asthma.html Delaware.gov. (2018). Division of Waste and Hazardous Substance.

Retrieved from http://www.dnrec.delaware.gov/dwhs/info/Pages/Ozone.aspx Department of Natural Resources and Environmental Control Division of Air Quality. (2013).

Delaware Annual Air Quality Report. Retrieved from http://www.dnrec.delaware.gov/Air/ Documents/Ann%20Rpt%2013%20final%20wi th%20corrected%20graph.pdf Esri. February 19, 2012. http://www.arcgis.com/home/item.html?id=30e5fe3149c34df1ba922e6f5bbf808f Etzel, R.A. (2003, July). How Environmental Exposures Influence the Development and Exacerbation of Asthma. Retrieved from http://pediatrics.aappublications.org/content/112/Supplement_1/233.short Ferguson, E. C., Maheswaran, R., & Daly, M. (2004). Road-traffic pollution and asthma – using modelled exposure assessment for routine public health surveillance. International Journal of Health Geographics, 3, 24. http://doi.org/10.1186/1476-072X-3-24 FirstMap Delaware. (2017). Delaware Census Race. Firstmap.gis.delaware.gov Retrieved from https://regionaldelaware.opendata.arcgis.com/datasets/b9e2068e378848b79296ad2ea9f5b 508_4 FirstMap Delaware. (2018). Traffic Count 2012. Firstmap.gis.delaware.gov Retrieved from https://regionaldelaware.opendata.arcgis.com/datasets/b9e2068e378848b79296ad2ea9f5b 508_4 FirstMap Delaware. (2003). Delaware Boundaries County State. Firstmap.gis.delaware.gov Retrieved from : https://regional-delaware.opendata.arcgis.com/datasets/ b9e2068e378848b79296ad2ea9f5b508_4 Friedman, M.S., Powell, K.E., Hutwagner, L., Graham, L.M. & Teaque, W.G. (2001, February 21). Impact of Changes in Transportaiton and Commuting Behaviors During the 1996 Summer Olympic Games in Atlanta on Air Quality and Childhood Asthma.

Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/11180733 Grineski, S.E., Collins, T.W., & Olvera, H. A. (2015). Local variability in the impacts of residential particulate matter and pest exposure on children’s wheezing severity: A geographically wighted regression analysis of environmental health justice. Population and Environment, 37(1), 22-43. doi:10.1007/s11111-015-0230-7 Guarnieri, M., & Balmes, J. R. (2014). Outdoor air pollution and asthma. Lancet, 383(9928), McConnell R., Islam, T Ketan Shankardass, K., Jerrett , M., Fred Lurman, F., Frank Gilliland, F ., Gauderman, J., Avol, E., Künzli, N., Yao, L., Peters, J., and Berhane, K. (2010). Childhood Incident Asthma and Traffic-Related Air Pollution at Home and School. Environmental Health Perspectives .(18) 1021-1026.

Newman, N., Ryan, P., Bin Huang, B., Beck, A., Sauers, H., Kahn, R. (2014). Traffic-Related Air Pollution and Asthma Hospital Readmission in Children: A Longitudinal Cohort Study. The Journal of Pediatrics. 164(6), 1396-1402.

Nurmagambetov T., Kuwahara R., Garbe P. (2018). The Economic Burden of Asthma in the United States, 2008-2013. Ann Am Thorac Soc. doi: 10.1513/AnnalsATS.201703-259OC PolicyMap. (2013). Estimated Percent of Adults Reporting to Have Asthma in 2013. Retrieved from https://tju.policymap.com/maps PolicyMap. (2016). Estimated Percent of All People That Are Living In Poverty as of 2012- 2016.

Retrieved from https://tju.policymap.com/maps PolicyMap. (2018). GIS Mapping and Geographic Information System Data. Retrieved June 5, 2018, from http://www.policymap.com/ Population facts. Delaware Community Foundation. Retrieved from https://delawarefocus.org/demographics/population-facts/population-by-gender/data-tables Rakowska, Agata & Wong, Ka Chun & Townsend, Thomas & Chan, Ka Lok & Westerdahl, Dane & Ng, Simon & Močnik, Griša & Drinovec, Luka & Ning, Zhi. (2014). Impact of traffic volume and composition on the air quality and pedestrian exposure in urban street canyon.

Atmospheric Environment. 98. 260–270. 10.1016/j.atmosenv.2014.08.073.

Robert Wood Johnson Foundaiton. (2011, May). Housing and Health. Retrieved from https://dhss.delaware.gov/dhss/dph/mh/files/housingandhealth.pdf

38 Delaware Journal of Public Health – February 2019

Trasande, L. and Thurston, G.D. (2005, April 3). The Role of Air Pollution in Asthma and Other Pediatric Morbidities. Retrieved from https://www.sciencedirect.com/science/article/pii/ S0091674905003064?via%3Dihub United States Environmental Protection Agency. (2016, September 12). Particulate Matter (PM) Basics. Retrieved June 5, 2018, from https://www.epa.gov/pm-pollution/particulate-matterpmbasics#PM1581–1592. http://doi.org/10.1016/S0140-6736(14)60617-6 United States Census Bureau. (2010). Quickfacts. Retrieved from https://www.census.gov/ quickfacts/fact/table/sussexcountydelaware,kentcountydelaware,newcastlecountydelaware,de/ PST045218 United States Census Bureau. (2017). 2017 TigerLine Shapefiles: Census Tracts. Retrieved from https://www.census.gov/cgibin/geo/shapefiles/index.php?year=2017&layergroup= Census+Tracts World Population Review. (2018). Population of Cities in Delaware (2018). Retrieved from http://worldpopulationreview.com/states/delaware-population/cities/

Arthors Rachel Vecchione, M.P.H., holds a Master of Public Health from Thomas Jefferson University and is currently pursuing further graduate work in public health.

Caleb Dafilou, M.P.H., is a research fellow at Jefferson University’s Center for Urban Health and the Philadelphia Collaborative for Health Equity. His work focuses on integrating qualitative and quantitative research while conducting a community health needs assessment in Eastern North Philadelphia. He holds a Master of Public Health from Thomas Jefferson University.

Violetta Gerzen-Feshchenko, M.P.Hc., is a Master of Public Health candidate at Thomas Jefferson University class of 2019 Nicole LaRatta, M.P.H., is a research coordinator at the University of Pennsylvania’s Abramson Cancer Center in Philadelphia, PA. As part of the Lymphoma research team, Nicole helps coordinate clinical trials that utilize both chemotherapies and personalized cellular therapies. She holds a Master of Public Health from Thomas Jefferson University.

Madeline Brooks, M.P.H., is a research associate in the Value Institute at Christiana Care Health System in Newark, DE. Her work focuses on the use of geographic information systems (GIS) to study population health and health services delivery. She holds a Master of Public Health from Thomas Jefferson University.

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Data mapping is used to analyze how populations differ based on their geography. Disease surveillance, risk analysis, and health care planning all utilize data mapping to efficiently view and transmit information to audiences.

SMOKING AND TOBACCO RETAIL DENSITY AMONG NEIGHBORHOODS IN DELAWARE Margaret Pearce, Robert Zucker, Crystal Lee, M.P.H, Opinderjit Kaur, M.P.H., and Russell K. McIntire, Ph.D., M.P.H.

Introduction Tobacco use exerts a large burden on the health of Delawareans and on the economy in Delaware. While cigarette smoking in Delaware has hit an all-time low of 17.8% in 2016, this is still higher than the national average of 15.5% in 2016 (IMPACT Tobacco Prevention Coalition (IMPACT), 2016; Jamal et al., 2016). The 2014 Surgeon General’s Report estimated that 480,000 people die from cigarette smoke-related causes in the United States per year; in Delaware, an estimated 1,400 people die annually from cigarette smoke-related causes, including lung cancer (Centers for Disease Control and Prevention, 2015; US Department of Health and Human Services, 2014). Delaware, a relatively small state with a population of less than 1 million people, is burdened with a high rate of lung cancer (Delaware Comprehensive Cancer Program, 2017). In 2014, lung and bronchus cancers had the third highest incidence of all cancers in Delaware (58.3 cancer diagnoses per 100,000 people) and the highest death rate (42.2 deaths per 100,000 people) among all 40 Delaware Journal of Public Health – February 2019

cancers in Delaware (U.S. Cancer Statistics Working Group, 2017). IMPACT Tobacco Prevention Coalition of Delaware estimates that the tobacco-related workplace productivity losses are $391 million per year. Further, Delawareans spend $532 million per year on tobaccorelated direct medical services, of which $95 million per year is on tobacco-related medical expenditures that are covered by Medicaid (2016).

State and local tobacco control efforts have increasingly focused on limiting access to tobacco products within communities. Tobacco retailer density is a measure of the number of retailers selling tobacco products per population in a given geographic area. Neighborhoods with high tobacco retail density have been associated with increased rates of cigarette smoking initiation among adults age 25-34 and for non-cigarette combustible product (such as little cigars)-initiation among adults 18-24 (Cantrell et al., 2016). Living in an area with higher tobacco retailer density has been associated with nicotine dependence among adults living with severe mental illness (Young-Wolff, Henriksen,

Delucchi, & Prochaska, 2014). Additionally, living in areas with a higher density of tobacco retailers has been associated with higher odds of ever smoking among teens (Schleicher, Johnson, Fortmann, & Henriksen, 2016).

Retailer density might also impact those who wish to quit smoking, as studies show that individuals living in low-income areas who live further from a tobacco retail outlet were more likely to abstain from smoking than those living closer to a tobacco retailer (Cantrell et al., 2015). Studies focused on the school environment have shown that with more tobacco retailers surrounding a school, there was higher prevalence of occasional and daily smoking among students, higher prevalence of ever smoking among students, and higher susceptibility for students to become smokers (Adams, Jason, Pokorny, & Hunt, 2013; Chan & Leatherdale, 2011; McCarthy et al., 2009).

Behavioral Risk Factor Surveillance System

Tobacco retailer density should be used to monitor the neighborhood-smoking environment due to the potential for retailers to sell to minors, foster smoking initiation in young people, deter quitting behavior, and creating a smoking-friendly environment within communities. Researchers have already used tobacco retailer density in Philadelphia and Illinois to assess the relationship between tobacco retailer density and proximity to schools (Adams et al., 2013; Philadelphia Department of Public Health, 2016). However, no studies have explored tobacco retailer density in the state of Delaware.

Tobacco Retail Location

The primary purpose of our study is to describe the geographic distribution of adult smoking prevalence and tobacco retailer density in Delaware in order to identify areas of burden and potential areas of focus for public health interventions. Additionally, we provide a more focused analysis of the geographic proximity of tobacco retail outlets to schools in the city of Wilmington.

Methods Data Sets

We performed a descriptive study using publicly accessible datasets describing adult smoking prevalence from the CDC’s Behavioral Risk Factor Surveillance System (BRFSS) and tobacco retailer locations from the Delaware Department of Finance, Division of Revenue in the state of Delaware. We used Policy Map to download BRFSS data by census tract, which was the smallest geographic unit available (Policy Map, 2017).

Census tracts are the census-derived geographic unit that corresponds to neighborhood.

BRFSS is a nation-wide telephone survey conducted by the CDC that collects data about health risk behaviors (CDC, 2018). We used this data to identify the estimated percent of adults reporting to smoke cigarettes in the most current data available to us in 2013. In Delaware, 5,052 people participated in the 2013 BRFSS (CDC, 2015). Participants were considered current smokers if they responded, "every day" or "some days" to the question, "Do you now smoke cigarettes every day, some days, or not at all?" Estimates at the census tract level were derived using the BRFSS data, weighted

by Census Metropolitan delineation files and the 2009-2013 American Community Survey 5-year estimates for the adult population and household income by age and race (Policy Map, 2017).

Tobacco retailer location is collected as part of the list of Delaware Business Licenses by the Department of Finance, Division of Revenue (State of Delaware, 2018). According to state laws, a person or entity that is conducting business in the State of Delaware must have a Delaware business license from the Delaware Division of Revenue (Division of Revenue, 2018). We determined that a tobacco retailer was labeled as either “tobacco products retailer” or “retailer-tobacco” and found 1353 tobacco retailers.

Geographic Analysis

Maps throughout this study were created using ArcGIS® software by ESRI (ESRI, 2014). Additionally, all maps were displayed with the Delaware State Plane (NAD 1983 State Plane Delaware FIPS 0700 (Meters)) projected coordinate system.

Prevalence of smoking by census tract

We linked the 2013 BRFSS/Policy Map data to 2017 TIGER/Line Shapefiles (U.S. Census Bureau, 2017) in order to map current smoking rates by census tract in Delaware (CDC, 2018). We displayed the data using a choropleth map with graduated colors corresponding to the rates of smoking in census tracts. In addition, we mapped Delaware cities stratified by population size using graduated symbols.

Location of Tobacco Retailers

Tobacco retailers were geocoded by address using the geocoder provided by FirstMap in ArcGIS to obtain the location of the retailers (FirstMap, n.d.). Of 1353 41

addresses, 1196 were automatically matched. Thirteen unmatched addresses were manually matched when the address had a match score of at least 75%, and was agreed upon by two individual investigators. This resulted in a final match rate of 89.4%.

Proximity of Schools and Tobacco Retailers in Wilmington

We performed a proximity analysis to assess tobacco retailer distance from schools in the most populous city in Delaware: Wilmington. We used FirstMap Delaware to find both private and public school locations in Wilmington (FirstMap@De, 2018). We used ArcGIS to identify the number of tobacco retailers contained within 500 and 1,000 feet of each school.

Density of tobacco retailers by census tract

We identified tobacco retailer density per 1,000 people by census tract in Delaware. We aggregated the number of tobacco retailers by census tract and divided by the total the census tract population to get the density of tobacco retailers per 1,000 people by census tract. Data for the population per census tract was obtained from the 2016 American Community Survey from the U.S. Census Bureau (U.S. Census Bureau, 2016).

Results Prevalence of smoking by census tract

Upon visually inspecting the map of smoking prevalence in Delaware (Figure 1), we observed census tracts with high smoking prevalence near Dover, Newark, and Wilmington that ranged from the highest smoking rates in Delaware (23.1-28.7%) to areas of lower, but still comparatively high smoking rates (20.1-23.0%).

In addition, the census tracts with relatively low smoking rates were clustered in northern (northwest of Wilmington) and the southeastern coast of Delaware.

In general, the census tracts with the highest smoking prevalence clustered around the largest cities, and those in suburban, rural, or coastal areas had lower smoking prevalence.

Figure 1: Prevalence of current smoking among adults by census tract in Delaware. Source: U.S. Center for Disease Control and Prevention (2013) and U.S. Census Bureau (2017).

Statistical analysis

We conducted a simple linear regression to investigate the correlation of tobacco retailer density and the prevalence of adult smoking by census tract. We first conducted the analysis among all census tracts in Delaware, then limited the analysis only to urbanized areas as defined by the 2010 U.S. Census (U.S. Census Bureau, 2015). We conducted all statistical analyses using SPSS (IBM, 2017).

Delaware Cities (Population Size)

Less than 20,000 20,001 – 40,000 40,001 – 73,0270

Delaware Smoking Rates

by Census Tract (%)

Less than 15%

15.1 - 17.0%

17.1 - 20.0%

20.1 - 23.0%

Prevelance of Smoking (%) in Delaware Mean 17.984 (SD 2.352) Median 18.05

42 Delaware Journal of Public Health – February 2019

23.1 - 28.7%

Point data for tobacco retailers and school proximity analysis

A visual inspection of the tobacco retailer point data shows clusters of tobacco retailers in larger cities and around the major highways (Figure 2). Few tobacco retailers have established themselves away from the main highways. One of the largest clusters of tobacco retailers is in Wilmington. For this reason, we took a closer look at Wilmington to examine the relationship between tobacco retailers and public and private schools.

Figure 2: Point data for tobacco retailers in Delaware. Source: State of Delaware, Delaware Department of Finance, Department of Revenue (2018); FirstMap Delaware (2017).

Delaware Cities (Population Size)

We mapped the locations of public and private schools and tobacco retailers to understand the number of public and private schools in Wilmington that are located within 500 and 1000 feet of a tobacco retailer and, vice versa, the number of tobacco retailers in close proximity to schools (Figure 3). The results of this proximity analysis are summarized in Table 1. We found that there were 25 tobacco retailers within 500 feet of the schools and 86 retailers within 1000 feet.

There were 16 Wilmington schools out of 48 (33.3%) with at least one tobacco retailer within 500 feet. Two schools had as many as four retailers within 500 feet.

There were 37 schools (77.1%) with at least one retailer within 1000 feet. Amazingly, one school had eighteen tobacco retailers within 1000 feet. Of the 202 tobacco retailers in Wilmington, 11.4% were within 500 feet of a Wilmington school and 38.6% were within 1000 feet. In addition, there were an additional eight retailers outside of the Wilmington city limits that were within 1000 feet of a school and two within 500 feet.

Table 1: Count of Schools within N tobacco retailers

Less than 20,000 20,001 – 40,000 40,001 – 73,0270 Tobacco Retailers Major Roads Delaware Counties

Count of schools with N tobacco retailers within 500 ft

Count of schools with N tobacco retailers within 1000 ft

N

Schools

N

Schools

0

32

0

11

1

11

1

7

2

1

2

8

3

2

3

6

4

2

4

6

5

3

6

3

9

1

10

1

13

1

18

1

Total number of tobacco retailers

(Percent of Wilmington tobacco retailers [%])

25 (11.4)

86 (38.6)

43

Figure 3: Proximity analysis for tobacco retailers and K-12 schools in Wilmington, DE. Source: State of Delaware, Delaware Department of Finance, Department of Revenue (2018); FirstMap Delaware (2017).

Figure 4b

Retailer Density (per 1,000 people) 9.01 - 18.32 6.01 - 9.00 3.01 - 6.00 1.01 - 3.00 0.01 - 1.00 0 No Data

Density of tobacco retailers by census tract

The map of tobacco retailer density reveals that much of the state has between zero and one tobacco retailers per 1000 people (Figure 4). However, there are two areas with notable exceptions, the Wilmington area has several of the highest densities of retailers (including the highest at 18.32 retailers per 1000 people) as does the southeastern shoreline census tracts (including the second highest of 12.36 retailers per 1000 people). The Dover region has several census tracts in the 3.10-6.00 retailers per 1000 people-range but none as high as the southeastern shore or Wilmington.

Figures 4a & 4b: Density of tobacco retailers by census tract. Source: U.S. Census Bureau (2017), State of Delaware, Delaware Department of Finance, Department of Revenue (2018) Figure 4a Delaware Cities (Population Size) Less than 20,000 20,001 – 40,000 40,001 – 73,027

44 Delaware Journal of Public Health – February 2019

Tobacco Retailer Density (per 1,000 people) in Delaware Mean 1.693 (SD 2.006) Median 1.094

Correlation between smoking prevalence and tobacco density in urban census tracts

Initially, we conducted a simple linear regression between tobacco retailer density and smoking prevalence in all census tracts in Delaware. Surprisingly, we did not find a significant correlation between our two variables (t212 =1.86 p=.06). Since we observed a higher smoking prevalence clustered around the larger cities in Delaware, such as in Dover and Wilmington, we decided to limit our statistical analysis to urbanized census tracts. In the 117 urbanized census tracts in Delaware, the average smoking prevalence was 18.3% (Standard Deviation

(SD): 2.49), and the average retailer density was 1.79 tobacco retailers per 1,000 people (SD: 2.04). This time, we found a significant correlation between smoking rates and tobacco retailer density (t115 =3.69 p<.001).

Pearsonâ&#x20AC;&#x2122;s correlation was 0.325, meaning that an increase of one tobacco retailer in an urbanized area in Delaware corresponded to an increase of smoking prevalence by 0.325%. We checked the assumptions of the linear regression and found the homogeneity of variances and normality of errors to be slightly questionable, which should be taken into account in our analysis.

We looked at nearby Philadelphia, where more adult residents smoke cigarettes (19.5%) than in any other major U.S. city, because of the methods Philadelphia employs to investigate and curtail tobacco retailers (Philadelphia Department of Public Health (PDPH), 2017). Schools in Philadelphia had an average of 1.1 retailers within 500 feet and an average of 4.9 within 1000 feet compared to Wilmingtonâ&#x20AC;&#x2122;s school averages of 0.56 and 3.08, respectively (Philadelphia Department

Discussion In this study, we analyzed smoking prevalence, and tobacco retailer location and density in Delaware.

Smoking prevalence and tobacco retailer density were observed by census tracts. Using tobacco retailer location, we also analyzed the proximity of tobacco retailers to schools in Wilmington.

Our analysis showed high density of tobacco retailers in Delaware cities. Wilmington had the census tracts with the highest tobacco retail density among all census tracts in Delaware. This was not surprising as urban areas, in general, have higher tobacco retail densities than less urbanized areas (Rodriguez, Carlos, Adachi-Mejia, Berke, & Sargent, 2013).

Our proximity analysis showed that among the 48 total schools in Wilmington, 77.1% had at least one tobacco retailer within 1000 feet and 34.3% had at least one tobacco retailer within 500 feet. Seven schools had over five tobacco retailers within 1,000 feet. This resulted in an average of 0.56 retailers within 500 feet of a school and an average of 3.08 retailers within 1000 feet. The proximity of tobacco retailers to schools means that students are exposed to tobacco advertising and environments that portray smoking as a normal behavior. Studies have shown that as the number of tobacco retailers located in close proximity to schools increases, youth smoking increases (Chan & Leatherdale, 2011; McCarthy et al., 2009). Another study linked the density of tobacco retailers within one half-mile radius from a school to the prevalence of smoking among students (Adams et al., 2013). Our study is the first that explores tobacco retail density in Delaware. This information can be used as an area of focus for local tobacco control efforts to limit the density of tobacco retail establishments, especially in dense urban areas such as Wilmington.

of Public Health, 2016). As a result of PDPHâ&#x20AC;&#x2122;s research, Philadelphia instituted geo-based tobacco control policies in 2016 including limits on the number of new tobacco retailer permits by city planning district so that no planning district exceeded one retailer per 1000 daytime population, and prohibiting new retailers within 500 feet of a school. As Philadelphia planning districts divide the city into 18 districts made of many census tracts, the enacted retailer density limit in Philadelphia may not be directly comparable to the individual retailer density of census tracts used in our study. Furthermore, the PDPH used a commuter-adjusted daytime population rather than residential population (as our study does) to determine tobacco retail density. Despite this, tobacco control professionals in Delaware should considering implementing similar types of geo-based tobacco control policies based on retailer locations and density in order to reduce youth and adult smoking initiation, exposure to tobacco advertising, and relapse among those who wish to quit smoking. We found several census tracts across Delaware, particularly in Wilmington, that exceed one tobacco retailer per 1,000.

This is above the national median density for census tracts of 0.43 per 1000, and higher than the median rate for urban census tracts of 0.74 per 1000 (Rodriguez, Carlos, Adachi-Mejia, Berke, & Sargent, 2013).

Reducing tobacco retailer density in Delaware has the potential to reduce smoking rates and have a lasting impact on health of Delaware residents. In the future, 45

researchers should work to understand how retailer density directly relates to health outcomes in Delaware, and explore other ways of measuring the tobacco retail density within Delaware neighborhoods.

A visual comparison of the map of tobacco retailer density with the map of smoking prevalence shows that the Wilmington area has several census tracts that have a high density of tobacco retailers and a high smoking prevalence rate. However, this relationship is not found in the census tracts near Dover which have some of the highest rates of smoking but low rates of retailer density. Furthermore, census tracts along the southeast shoreline had some of the highest rates of retailer density but the lowest rates of smoking prevalence, possibly due to tobacco retailers catering to tourists that may not be accounted for in the smoking prevalence or census data. Upon statistical analysis, we found a significant relationship between smoking prevalence and tobacco retailer density in the urbanized census tracts of Delaware, which is consistent with the current literature. Still, it was interesting to note the relationship between tobacco retailer density and smoking prevalence (Pearsonâ&#x20AC;&#x2122;s coefficient =0.325) in our simple linear regression. Although there are many other factors that contribute to smoking prevalence, such as demographics, tobacco product pricing, exposure to tobacco advertising, peer and family influence, and even second-hand smoke exposure (McIntire, 2015) tobacco product density may be a practical option for regulation of the neighborhood-tobacco environment.

Strengths & Limitations

As there has been little prior research on the geographic distribution of smoking prevalence, tobacco retailer density, and proximity of tobacco retailers to schools in Delaware, our study is important as it identifies geographic areas that could benefit from public health interventions related to smoking. We found that generally, our results were consistent with the findings from the 2017 DHSS Cancer report for general trends in smoking rate demographics, but they did not report geographic trends such as areas of high and low smoking prevalence. In addition, there were no analyses including tobacco retailer location and proximity to schools.

Another notable feature of our study was our use of census tracts to display smoking prevalence and tobacco retailer density. Census tracts are a good unit of analysis for prioritizing neighborhood-based public health interventions because publicly accessible data is available for them through the U.S. census, and census tracts are 46 Delaware Journal of Public Health â&#x20AC;&#x201C; February 2019

small enough to highlight unique historical and cultural characteristics of neighborhoods. This is important when working on community-engaged research so that community membersâ&#x20AC;&#x2122; voices and concerns can be effectively addressed.

While this study makes an important contribution to tobacco control efforts in Delaware, the study has limitations. Our unit of analysis was the census tract, which is the best geographic unit to describe neighborhoods within an area. However, our visual and statistical comparisons are limited by the ecological nature of these variables. Confounders such as age, sex, income, and other demographics may explain the variation we identified between variables or census tracts. While the tobacco retailer match rate was a respectable 89.4%, some tobacco retailers could not be geocoded because some individual retailers used P.O. boxes instead of physical addresses or colloquial stripmall names instead of street addresses. Additionally, while tobacco retail density by population is important, it may not account for fluctuating populations like at a tourist destination such as Rehoboth Beach which might explain the high tobacco retailer density compared to areas of similar demographics, but a more constant residential population.

Implications & Next Steps

The main findings from our studies indicate that there is need for future studies analyzing geo-based relationships between tobacco retailer density and smoking status among adults, or initiation among kids, which would include controlling for important confounders such as age, gender, race, education level and income in Delaware.

While the map of retailer density shows that there is a wide range in tobacco retailer density by census tract, the five highest all have populations below 1,500 people.

This means that the tobacco retailer density per 1,000 people could increase dramatically by opening a single store. Future research should investigate if there are contextual area-level characteristics that make these census tracts popular for locations of tobacco retailers.

For instance, the census tract with the second highest tobacco retail density contains Rehoboth Beach, a popular tourist location (Delaware Tourism Office, n.d.). It is likely that the full public health burden of tobacco sales in Rehoboth Beach is not counted in health statistics based on a residential address, since tourists who smoke or develop lung cancer would not be a resident in that census tract. The outcomes of our

study will be beneficial to both local and state agencies such as DHSS for future interventions. This includes current interventions pursued by the DHSS including interventions which target youth, cessation, special populations and the general population. Additionally, the DHHS has a program to fund local interventions called Mini-Grant, and our information present in this paper can point DHHS to where the need is highest (IMPACT, 2016). These interventions should be tailored to the characteristics of the area and prioritized based on the tobacco-use and cancer-related burden particular to the area.

Delaware Comprehensive Cancer Program. (2017). Cancer Incidence and Mortality in Delaware, 2009-2013. Dover, DE: Delaware Health and Social Services.

Conclusion

FirstMap@De. (2018, May 8). Delaware Road Inventory. Retrieved June 5, 2018, from http:// opendata.firstmap.delaware.gov/datasets/delaware-road-inventory

This study identified the geographic distribution of and relationship between smoking prevalence and location of tobacco retailers for geographic areas in Delaware.

We found that New Castle, Dover and Wilmington had a high prevalence of smoking while Wilmington and Rehoboth Beach had the highest tobacco retailer density. We also found that in Wilmington, over half of the private and public schools are within 1,000 feet from a tobacco retailer. This analysis is important to understanding the relationship between smoking and tobacco retailers. Additionally, this analysis will inform organizations who wish to decrease smoking rates in Delaware through public health interventions.

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Authors Margaret Pearce is currently working in the field of public health as a Research Study Interviewer at the Wake Forest School of Medicine.

She received her Masters in Public Health degree from Thomas Jefferson University in July 2018 with interest in cultural competency in the medical field with particular focus on the LGBTQ+ community.

48 Delaware Journal of Public Health – February 2019

Robert Zucker is currently a Master of Public Health Candidate at Thomas Jefferson University with an interest in applying communitybased strategies to improve health resilience in emergencies and the relationship between geography and healthcare utilization. He holds a B.Sc. in Biology from the George Washington University.

Crystal Lee, M.P.H., is currently a 1st year medical student at Sidney Kimmel Medical College with an interest in serving urban underserved populations. She earned her MPH degree at Jefferson in 2018 and hopes to apply her public health training to her medical practice in the future.

Opinderjit Kaur, M.P.H., holds a Master of Public Health degree from Thomas Jefferson University. She is currently applying to dental schools and wishes to combine her public health background with her future dental education in order to better understand and serve populations.

Russell K. McIntire, Ph.D., M.P.H., is an Assistant Professor and epidemiologist in the Jefferson College of Population Health (JCPH) at Thomas Jefferson University. Dr. McIntire teaches epidemiology and geographic information systems (GIS) mapping at JCPH. His major research interests include identifying and analyzing the social, behavioral, and geographic risk factors of chronic diseases among vulnerable populations.

Innovation and Interaction Center A new approach to the Exhibit Hall. Weâ&#x20AC;&#x2122;re inviting all conference registrants to submit a proposal to share a bold idea, a bold new program, or bold new approach to improving the health of women, men, infants and families. Grassroots, community community-based based initiatives are of particular interest. Youâ&#x20AC;&#x2122;ll get to set up a table, share information, and talk to everyone about this innovation.

The One Minute Pitch Got a program or idea that will improve health and well-being being in Delaware? Looking for networking opportunities and potential partnerships? All registrants are invited to submit a proposal to pitch their project to the entire assembly and live live-streamed. streamed. Think of the exposure and possibilities.

Community Changemakers Panel Weâ&#x20AC;&#x2122;ve done panels before, but this special panel will be just for community changemakers, grassroots leaders and community action-takers. takers. Those individuals who are registered as community delegates and working to improve the health of wo women, men, infants and families where they live work and play are invited to submit a proposal to join the panel.

You can submit your proposal for any or all of these three activities to llisitano@e-worldways.com worl ays

Nominate A Community Health Champion

Each year DHMIC honors both an individual and an organization that go the extra mile to ensure health and well-being being for everyone, regardless of race, income or social status. Do you have a person or organization from the state or your neighborhood that you would like to celebrate? You can go directly to the nomination page via this link: https://www.surveymonkey.com/r/J2NNSCQ

49

Data mapping is used to analyze how populations differ based on their geography. Disease surveillance, risk analysis, and health care planning all utilize data mapping to efficiently view and transmit information to audiences.

Geographic Relationships Between Smoking and Chronic Lower Respiratory Disease in Delaware Arielle Horowitz, M.P.H., Danny Cheong, M.P.H., Robert Martin, M.P.H., Russell K. McIntire, Ph.D., M.P.H. Thomas Jefferson University College of Population Health

Abstract: Objectives: To determine geographical relationships between smoking prevalence, COPD prevalence, and lower respiratory disease mortality in Delaware by census tract and county.

Methods: Data about Delaware residents with COPD, who are smokers, and/or have chronic lower respiratory diseases, respectively, were analyzed from publically accessible datasets posted on PolicyMap and Delaware Open Data. Data was linked to shapeďŹ les in order to map prevalence and mortality rates by Delaware census tract and county. Geo-based descriptive analysis was conducted via choropleth maps.

Results: COPD prevalence was higher in urban areas with high smoking prevalence. The highest proportion of census tracts with high COPD rates occurred in Sussex County and the lowest was in New Castle County. The highest crude and age-adjusted mortality rate due to chronic lower respiratory disease was in Sussex County and the lowest was in New Castle County. Chronic lower respiratory disease mortality was highest among white residents, increased as age increased, and occurred more frequently in females than in males.

Conclusion: Sussex County had a high proportion of census tracts with high COPD rates and the highest mortality rate due to chronic lower respiratory disease. Urban census tracts displayed high rates of COPD prevalence and smoking prevalence. Identifying geographic focus areas can be used to direct future healthcare programs and public health initiatives. Future research should test statistical relationships between risk factors, geographic areas, and chronic lung disease outcomes.

50 Delaware Journal of Public Health â&#x20AC;&#x201C; February 2019

INTRODUCTION Background Chronic lower respiratory diseases are chronic diseases of the lower lungs including chronic obstructive pulmonary disease (COPD). COPD is the disease responsible for making chronic lower respiratory disease the third leading cause of death in the nation (American Lung Association, 2018). COPD is a progressive lung disease that makes breathing difficult as it causes airways to become inflamed and thickened while destroying the tissue where oxygen is exchanged. It can lead to serious long-term disability and early death (American Lung Association, 2018). While there is no cure, COPD can be treated with medication, rehabilitation, or surgery (American Lung Association, 2018). The major cause of COPD is tobacco smoke. Other factors that cause COPD are air pollution in the home and workplace, genetic factors, and respiratory infection. In some developing countries, indoor air quality plays a larger role in COPD onset and progression, but in the United States tobacco smoke is, by far, the most prevalent risk factor (Centers for Disease Control and Prevention (CDC), 2005). Demographic subgroups with higher prevalence of COPD are people ages 6574, American Indian/Alaskan Natives and multiracial non-Hispanics, women, current or former smokers, and people with history of asthma (Mannino, Gagnon, Petty, & Lydick, 2000).

Impact on Delaware As of 2017, 16 million Americans were diagnosed with COPD - 46,700 of whom live in Delaware (DE) (National Heart, Lung, and Blood Institute, 2017). This means that nearly 5% of Delawareâ&#x20AC;&#x2122;s population has a current diagnosis of COPD. While this rate is similar to the national rate, the disease exerts a large public health burden in Delaware, especially since almost 40% of adults in Delaware suffer from multiple chronic conditions (Gupta, 2016).

COPD is more prevalent among women compared to men and much more common among people as they age (Ward, Nugent, Blumberg, & Vahratian, 2017). In 2014, 10.7% of the Medicare population in Delaware were diagnosed with COPD. According to the Kaiser Family Foundation (KFF), in 2014, 19% of Delawareâ&#x20AC;&#x2122;s population were Medicare beneficiaries (KFF, 2014). The American Lung Association stratified COPD morbidity by county in Delaware and found that Kent County had the highest percentage of Medicare patients with COPD (13.4%) followed by Sussex (11.5%) and finally New Castle (9.1%) (American Lung Association, 2017).

According to the CDC, in 2017, the overall mortality rate in the U.S. of chronic lower respiratory disease was 44.7 deaths per 100,000 when not age-adjusted, and 40.6 deaths per 100,000 when age-adjusted. The mortality rate of chronic lower respiratory disease in Delaware was 40.5 deaths per 100,000 when including all age groups (American Lung Association, 2017).

While lower than the U.S. mortality rate, the mortality burden in Delaware is higher in comparison to other states in the mid-Atlantic region, including Pennsylvania (36.8 per 100,000), Maryland (30.5 per 100,000) and New Jersey (27.9 per 100,000) (National Center for Health Statistics, 2018). In 2016, chronic lower respiratory disease was the third leading cause of death in Delaware, accounting for 6.1% of all deaths (Delaware Department of Health and Human Services, 2018).

This study will explore the geographic and demographic relationships between chronic lower respiratory diseases and smoking in Delaware using the most updated publically accessible datasets. Analyzing COPD prevalence and smoking in Delaware by census tract allows for identification of potential geographic disease patterns and reveal the areas with the greatest risk for 51

COPD and other lung illnesses. Additionally, this study will consider mortality rates of chronic lower respiratory disease by Delaware county.

A descriptive study analyzing the geographic relationships of COPD outcomes using maps provides many advantages. By analyzing COPD rates by census tract and mortality rates by county, mapping may be able to identify geographic patterns of disease in Delaware communities. In addition to informing further research into the causes of differences in geographic distribution of chronic lower respiratory disease, this analysis can direct future healthcare programs and public health initiatives to prioritize the populations most in need of lung disease prevention initiatives and treatment.

METHODS Data Sources Smoking Rates: The prevalence of adult current smoking was obtained from the 2013 Behavioral Risk Factor Surveillance System (BRFSS) for the state of Delaware.

BRFSS data alone does not have adequate sample size to produce survey estimates for census tracts in Delaware.

Policy Map obtained BRFSS data for Delaware in 2013 and used statistical models to estimate smoking prevalence by census tract by weighting BRFSS responses against U.S. census data from the American Communities Survey. These small area estimates of smoking by DE census tract were downloaded from PolicyMap (Policy Map, 2018a).

COPD Rates: Policy Map calculated small area estimates of the crude prevalence of COPD by census tract with BRFSS data using similar methods as those used to determine rates of smoking. CDC researchers have calculated small area estimates using similar methods (Zhang et al, 2014; CDC, 2018a). Small area estimates of rates of COPD by Delaware census tract were downloaded from PolicyMap (Policy Map, 2018b).

The original BRFSS item asked participants if a doctor, nurse, or other health professional has ever told them they had chronic conditions, including COPD. Chronic Lower Respiratory Disease Mortality: The source of 2013 crude and age-adjusted county-specific mortality rates of chronic lower respiratory disease was the CDC WONDER Online database from the Multiple Cause of Death Files, 1999-2017 (CDC, 2018b). The source of chronic lower respiratory disease mortality data presented in tables was death certificates compiled by Delawareâ&#x20AC;&#x2122;s Department of Health and Social Services, Division of Public Health and the Health Statistics Center between 2009 and 2016. This information is publically accessible on Delaware Open 52 Delaware Journal of Public Health â&#x20AC;&#x201C; February 2019

Data (Delaware Department of Health and Human Services, 2018b). This individual-level death data included helpful demographic information such as county of residence, age, race/ethnicity, sex, and place of death.

Sample Rate estimates of smoking and COPD were identified for 214 of the 218 census tracts in Delaware. For chronic lower respiratory disease mortality there were 3,733 total deaths due to chronic lower respiratory disease reported in Delaware between 2009 and 2016.

Measures Statistical and Geographical Analysis: Base map TIGER/ Line shapefiles were downloaded from the U.S. Census Bureau for counties and census tracts in Delaware from 2010. Risk factor and health outcome data was inspected and prepared via Microsoft Excel to import into ArcGIS version 10.3 (ESRI, 2014). The data was then joined to basemaps in ArcGIS to create choropleth maps that employed shading to display differences in smoking prevalence by census tract, differences in COPD prevalence by census tract, and differences in 2013 chronic lower respiratory disease mortality by Delaware county.

Using SPSS (IBM, 2017), we generated descriptive statistics to summarize the number and proportion of deaths related to chronic lower respiratory disease (20092016) in respective counties stratified by race, age range, and sex.

We mapped the data using choropleth maps. Choropleth maps allowed us to visually compare rates by geography between relevant variables. The projected coordinate system was Delaware State Plane (NAD 1983 StatePlane Delaware FIPS 0700 (Meters)).

RESULTS Smoking by Census Tract The choropleth map of smoking prevalence by census tract shows much variability (Figure 1). Many of the census with elevated smoking rates cluster around the urban centers of Wilmington, Newark and Dover. The majority of Delaware census tracts with the lowest smoking prevalence (15.26% or below) occurred in New Castle county north of Wilmington, and along the southeastern coast communities. By county, the highest proportion of census tracts with smoking rates in the two highest categories (orange or red; between 19.3928.71%) were in Kent County, with 33.3%.

Figure 1. Small-area estimates of the prevalence of smoking by census tract in Delaware in 2013

Figure 2. Small-area estimates of the prevalence of COPD by census tract in Delaware in 2013

COPD by Census Tract

Chronic Lower Respiratory Disease Mortality by County

The choropleth map of crude COPD prevalence by census tract (Figure 2) shows a high proportion of census tracts in the highest COPD rate category (8.53-11.1%) in Sussex county. Although, COPD rates noticeably cluster in census tracts the southeastern corner of Delaware, there is also a clear pattern of high prevalence in census tracts in the urban areas of Wilmington, Newark and Dover. The vast majority of census tracts with the lowest COPD prevalences (2.64-5.89%) were located in the New Castle County. No census tracts had a COPD prevalence below 2.65%.

The choropleth map of crude chronic lower respiratory disease mortality by county (Figure 3) displays a clear visual differentiation in mortality rates. In 2013, New Castle County had the lowest mortality rate with 44.4 deaths due to chronic lower respiratory disease per 100,000 population. Kent County had the second highest mortality rate with 47.2 deaths per 100,000, and Sussex County had the highest crude mortality rate due to chronic lower respiratory disease mortality, with 76.5 deaths per 100,000 population.

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Figure 3. Crude chronic lower respiratory disease mortality by county in Delaware in 2013

These crude rates of mortality due to chronic lower respiratory disease do not take into account differences in the age distribution of people living in the different counties in Delaware, however. Figure 4 shows the age-adjusted death rate due to chronic lower respiratory disease among Delaware counties. Figure 4 shows that the mortality rate for Sussex county dropped dramatically after age-adjustment. This suggests that Sussex County had a high proportion of older people that would be more likely to die from chronic diseases such as chronic lower respiratory disease.

54 Delaware Journal of Public Health â&#x20AC;&#x201C; February 2019

Figure 4. Age-adjusted chronic lower respiratory disease mortality by county in Delaware in 2013

Chronic Lower Respiratory Disease Mortality in Delaware 2009-2016, by Demographics Delaware Open Source Data from 2009-2016 showed that 3733 Delawareans died of chronic lower respiratory disease. Among those deaths, 88.5% were White, 10.6% were Black, and 0.9% reported a race as Other or was unknown (Delaware Department of Health and Human Services, 2018c). During this time period, there was a higher proportion of female deaths due to chronic lower respiratory disease (53.3%) than males (46.7%). The proportion of those who died of chronic lower respiratory disease increase as age increases, with the most cases occurring in people aged 75 and older (63.3%) and the fewest cases occurring in people ages 15 - 54 years old (3.8%). New Castle County has the highest proportion of deaths among all counties (50.2%) compared to Sussex (30.6%) and Kent (19.2%) counties.

Table 1. Chronic lower respiratory disease mortality (2009-2016) by race, age group, sex and county of residence in Delaware (U.S. Census, 2010; Delaware Department of Health and Human Services, 2018d)

County of Residence

Race %, (Count) Black

White

Other/Unknown

Kent (n =715)

10.8 (77)

88.2 (631)

1.0 (7)

New Castle (n=1874)

13.9 (261)

85.3 (1599)

0.80 (14)

Sussex (n=1144)

4.9 (56)

94.0 (1075)

1.1 (13)

Total n = 3733

394

3305

34

County of Residence

The purpose of this study was to examine geographical relationships between smoking prevalence, COPD prevalence, and chronic lower respiratory disease mortality in Delaware. This study analyzes health data geographically by adding data layers representing adult smoking, COPD prevalence and lower respiratory disease mortality to basemaps for Delaware census tracts and counties. Delaware Open Data describing chronic lower respiratory disease mortality was also analyzed to identify mortality proportions by race, age group, and sex.

Main Findings

Age Group %, (Count) 15-54

55-64

65-74

75+

Kent (n =715)

5.2 (37)

9.8 (70)

24.9 (178)

60.1 (430)

New Castle (n=1874)

3.9 (74)

10.1 (190)

21.1 (395)

64.8 (1215)

Sussex (n=1144)

2.7 (31)

8.7 (100)

25.7 (294)

62.8 (719)

Total n = 3733

142

360

867

2364

County of Residence

DISCUSSION

Sex %, (Count) Male

Female

Kent (n =715)

46.7 (334)

53.3 (381)

New Castle (n=1874)

41.0 (766)

59.0 (1108)

Sussex (n=1144)

46.7 (534)

53.3 (610)

Total n = 3733

1634

2099

Our study showed a visual correlation between high smoking prevalence and COPD prevalence in census tracts surrounding urban areas; however, we found no visual correlation in general between census tracts regarding smoking and COPD prevalence among all census tracts in Delaware. There are a multitude of risk factors for development of COPD that occur independently of tobacco use or exposure - including respiratory infections, genetics, occupational exposures, socio-economic status, and, perhaps most importantly, age. Our rates of COPD by census tract were not ageadjusted; therefore age distribution between census tracts cannot be discounted as a possible driver in the rate of COPD experienced by people within census tracts in Delaware. Additionally, studies using 2015 BRFSS data found that rural counties had higher rates of COPD, hospitalizations among Medicare patients, and COPD-related deaths, compared to more urban residents (Croft, Wheaton & Liu, 2015). It is possible that the smoking-urban/rural-COPD rate relationships are different in Delaware due to local contextual factors such as access to healthcare, demographics, or smoking norms, or methodological differences such as categories of urbanicity and rurality. A more in-depth study to explore these relationships is warranted.

We also found that the census tracts with the highest COPD rates were located, largely, in the counties with the highest mortality rate, which is not surprising.

Sussex County had the highest crude and age adjusted mortality rate (76.5 deaths per 100,000 and 47.5 deaths per 100,000, respectively). It is interesting to see such a dramatic reduction in mortality rate after age-adjustment in Sussex County. Age-adjustment is a common method among descriptive epidemiological studies to remove the confounding effect of age on determination of rates that describe groups (Anderson & Rosenberg, 1998).

This process allows researchers to make meaningful comparisons of rates between groups, such as counties.

After age-adjusting, Sussex, Kent, and New Castle Counties had very similar rates of chronic lung disease mortality, which suggests that a main risk factor for 55

death due to chronic lung disease in Delaware in 2013 was age, and that Sussex county had a very high proportion of older people compared to Kent and New Castle counties. Because age is not a modifiable risk factor, this finding may not change the nature of lung disease interventions, but it does identify that Sussex County has a large amount of people with increased likelihood of mortality due to chronic lower respiratory diseases.

In examining the chronic lower respiratory disease mortality from 2009 - 2016 by demographics, we found similar racial trends between counties; the highest proportion of cases were among whites, followed by blacks, and lowest among individuals in the unknown/other category. These percentages largely mirror the racial demographics contained in the counties (U.S. Census, 2019).

However, the proportion that died of chronic lower respiratory disease (by race) within each county is not the same as the racial distribution within each county.

For example, the proportion of whites that died of chronic lower respiratory disease within each county was higher than the proportion of whites that lives within each county. This suggests that whites were more likely to die of chronic lower respiratory disease, compared to other races. In previous studies, white populations were found to have both higher prevalence and higher mortality rates than African Americans and other ethnicities (Mannino, Homa, Akinbami, Ford & Redd, 2002; Ford, 2015; Kamil et al. 2013). A potential confounder for this relationship could be smoking.

However, a study by Gilkes et al. (2016), found that in London, blacks were half as likely as whites to have COPD even after adjusting for smoking, suggesting the influence of other demographic, genetic, or behavioral factors. In addition, females had a higher proportion of deaths compared to males. Previous studies have found that female smokers are about 50% more likely to develop COPD than male smokers, and have increased risk of hospitalization and death from respiratory failure and comorbidities (Barnes 2016; Han et al. 2007).

Another important risk factor for the development and exacerbation of COPD is air quality. According to the American Lung Association Air Report Card for Delaware, which rates County-level air quality on a letter scale from highest quality (A) to lowest quality (F), air quality varies by Delaware county. New Castle received a D grade in particle pollution whereas Kent and Sussex Counties both received A grades. New Castle scored an F for the number of high ozone days whereas Kent scored a C and Sussex scored D (American Lung Association, 2019). While these scores do not directly correlate with the COPD outcomes we identified in this study, poor air quality may interact with other risk factors that make 56 Delaware Journal of Public Health â&#x20AC;&#x201C; February 2019

individuals more likely to develop COPD and poor outcomes resulting from COPD, such as death.

The CDC emphasizes the importance of COPD surveillance to identify local communities that would benefit from interventions, and evaluate the effectiveness of prevention and treatment of COPD (CDC, 2012).

From the current study, it is clear that many Delaware census tracts in urban areas and in Sussex County as a whole, would benefit from targeted public health interventions related to smoking cessation and/or COPD management. Also, physicians can tailor their treatment plans to be more efficient for the people who live in Sussex County. A randomized controlled trial with over 8,000 participants found that a health management program including health lectures, counseling for smoking cessation, psychological counseling, and regular follow-up is an effective community-based strategy for COPD prevention and management (Lou et al., 2015). This study confirmed the results of previous research that found that the INTERdisciplinary COMmunity-based COPD management program (INTERCOM) is effective for patients with COPD without exercise impairment as well as for patients with COPD with exercise impairment and less advanced airflow obstruction (van Wetering et al., 2010).

While this study identified geographic areas with high burdens of chronic lung diseases on which prevention and treatment efforts should be focused, there are limitations. First, this study used only visual comparisons between variables, and did not employ statistical comparative methods. Future studies should identify if the upstream visual associations that we found are statistically significant between variables and geographic units of analysis. Second, the cross sectional nature of the data limits inferences based our results to associations only; no causal relationships can be identified based on our study results. Third, the ecological nature of the variables, as they described data at the group level not the individual level, prevents inferences from applying to individuals. Fourth, there are likely many other confounding factors that contribute to

the development of and severity of lung diseases within communities including pollution, population density, access to healthcare, socioeconomic status, and health behaviors aside from smoking such as physical activity, preventive care, and disease management.

Centers for Disease Control and Prevention. (2012). Chronic obstructive pulmonary disease among adults--United States, 2011. MMWR. Morbidity and mortality weekly report, 61(46), 938.

Next Steps for Research

Centers for Disease Control and Prevention. (2018, December 20). Chronic Obstructive Pulmonary Disease (COPD). https://www.cdc.gov/copd/data.html

In addition to future studies mentioned above, an interesting continuation of this research would be to perform a more focused geographic analysis of mortality.

Deaths could be aggregated over time by census tract to identify sub-county areas with the highest and lowest mortality. This information could be important to explore the influence of geographic proximity to healthcare services on lung disease mortality.

There are various potential risk factors related to the development of COPD; some, such as genetics, age, and sex are not modifiable. Air quality is modifiable through a number of quality control strategies (U.S. Environmental Protection Agency, 2018). There are many ways of measuring air pollution, for example, by direct air monitoring devices, or by residential proximity to pollutant sources such as manufacturing plants or major highways. Linking information on area or residential-based proximity to pollutants with patient-level data on COPD or mortality data in order to analyze relationship between air pollution and chronic lung disease outcomes in Delaware could be an important and influential study.

Centers for Disease Control and Prevention. (2018). Multiple Cause of Death Data. Retrieved January 18, 2019, from https://wonder.cdc.gov/mcd.html

CONCLUSION In the study we mapped the prevalence of smoking and COPD by census tract, and explored mortality by county, age, race, and sex in the state of Delaware. We analyzed maps for visual geographic patterns between variables and geographic units of analysis.

We found that Sussex County had a high proportion of census tracts with high COPD rates and the highest chronic lower respiratory disease mortality rate. COPD prevalence was higher in urban areas with high smoking prevalence. This study is useful to health care providers, researchers, and public health professionals working to create programs in Delaware to improve chronic lung disease prevalence and mortality.

References American Lung Association. (2018). Chronic Obstructive Pulmonary Disease (COPD).

Retrieved May 29, 2018, from http://www.lung.org/lung-health-and-diseases/lung-diseaselookup/copd/ American Lung Association (2019). State of the Air 2019. Retrieved January 22, 2019, from https://www.lung.org/our-initiatives/healthy-air/sota/city-rankings/states/delaware/ CDC Behavioral Risk Factor Surveillance System. Pct. of Adults Every Diagnosed with Chronic Obstructive Pulmonary Disease, Emphysema, or Chronic Bronchitis in 2013 Policy Map. https:// tju-policymap-com.proxy1.lib.tju.edu/maps CDC Behavioral Risk Factor Surveillance System. Pct. of Adults Reporting to Smoke Cigarettes Regularly in 2013 Policy Map. https://tju-policymap-com.proxy1.lib.tju.edu/maps CDC. Chronic Lower Respiratory Disease Deaths per 100,000 People in 2016 Policy Map. https://tju-policymap-com.proxy1.lib.tju.edu/maps

Centers for Disease Control and Prevention. (2017, August 4). Chronic Obstructive Pulmonary Disease (COPD). Retrieved May 29, 2018, from https://www.cdc.gov/copd/index.html Centers for Disease Control and Prevention. Annual smoking-attributable mortality, years of potential life lost, and productivity losses — United States, 1997–2001. MMWR Morb Mortal Wkly Rep. 2005;54(250):625–628.

Croft J.B., Wheaton AG, Liu Y, et al. Urban-Rural County and State Differences in Chronic Obstructive Pulmonary Disease — United States, 2015. MMWR Morb Mortal Wkly Rep 2018;67:205–211. DOI: http://dx.doi.org/10.15585/mmwr.mm6707a1 Delaware Department of Health and Human Services (2018) Delaware Vital Statistics Executive SUMMARY report 2016. https://www.dhss.delaware.gov/dhss/dph/hp/files/summary16.pdf Ford, E. S. (2015). Trends in mortality from COPD among adults in the United States. Chest, 148(4), 962–970. doi:10.1378/chest.14-2311 Gilkes, A., Ashworth, M., Schofield, P., Harries, T. H., Durbaba, S., Weston, C., & White, P. (2016). Does COPD risk vary by ethnicity? A retrospective cross-sectional study. International Journal of Chronic Obstructive Pulmonary Disease, 11, 739–746. doi:10.2147/COPD.S96391 Gupta S. Burden of Multiple Chronic Conditions in Delaware, 2011–2014. Prev Chronic Disease 2016;13:160264. DOI: http://dx.doi.org/10.5888/pcd13.160264 IBM. (2017). IBM SPSS Statistics for Windows (25). Computer software, Armonk, NY: IBM Corp.

Kamil, F., Pinzon, I., & Foreman, M. G. (2013). Sex and race factors in early-onset COPD. Current Opinion in Pulmonary Medicine, 19(2), 140–144. doi:10.1097/ MCP.0b013e32835d903b Lou, P., Chen, P., Zhang, P., Yu, J., Wang, Y., Chen, N., … Zhao, J. (2015). A COPD health management program in a community-based primary care setting: a randomized controlled trial.

Respiratory Care, 60(1), 102–112. doi:10.4187/respcare.03420 Mannino DM, Gagnon RC, Petty TL, Lydick E. Obstructive lung disease and low lung function in adults in the United States: data from the National Health and Nutrition Examination Survey 1988-1994. Arch Intern Med. 2000;160:1683–1689.

Mannino, D. M., Homa, D. M., Akinbami, L. J., Ford, E. S., & Redd, S. C. (2002). Chronic obstructive pulmonary disease surveillance-United States, 1971-2000. Respiratory care, 47(10), 1184-1199.

National Center for Health Statistics. (2017, May 3). Chronic Obstructive Pulmonary Disease (COPD) Includes: Chronic Bronchitis and Emphysema. Retrieved August 5, 2018, from https:// www.cdc.gov/nchs/fastats/copd.htm National Center for Health Statistics. (2018, January 8). Chronic Lower Respiratory Disease Mortality by State. Retrieved August 5, 2018, from https://www.cdc.gov/nchs/pressroom/ sosmap/lung_disease_mortality/lung_disease.htm National Heart, Lung, and Blood Institute. (2017, May 15). COPD State Prevalence Cards.

Retrieved May 29, 2018, from https://www.nhlbi.nih.gov/node/83481 United States Census Bureau. (2019). Quick Facts. Retrieved January 17, 2019, from https:// www.census.gov/quickfacts/fact/table/

Authors Arielle Horowitz, M.P.H., is a recent MPH graduate from Jefferson College of Population Health (JCPH) at Thomas Jefferson University.

Arielle hails from Long Island, N.Y. and received her Bachelors Degree in both history and neuroscience from Dartmouth College.

Danny Cheong, M.P.H., is a recent MPH graduate from Jefferson College of Population Health (JCPH) at Thomas Jefferson University.

During his studies he has worked extensively with research and data analysis. Danny has worked on asset mapping at Abington-Jefferson Health for their upcoming Community Health Needs Assessment (CHNA).

Robert Martin, M.P.H., is a recent MPH graduate from Jefferson College of Population Health (JCPH) at Thomas Jefferson University.

Robert received his Bachelors Degree in Biology: Vertebrate Physiology from the Pennsylvania State University.

Russell K. McIntire, Ph.D., M.P.H., is an Assistant Professor and epidemiologist in the Jefferson College of Population Health (JCPH) at Thomas Jefferson University. Dr. McIntire teaches epidemiology and geographic information systems (GIS) mapping at JCPH. His major research interests include identifying and analyzing the social, behavioral, and geographic risk factors of chronic diseases among vulnerable populations.

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Data mapping is used to analyze how populations differ based on their geography. Disease surveillance, risk analysis, and health care planning all utilize data mapping to efficiently view and transmit information to audiences.

Food Access in Delaware: Examining the Relationship of SNAP Retailers, Food Deserts, Obesity, and Food Insecurity

Alex Fossi, M.P.H., Desmond McCaffery, Courtney Riseborough, Niharika Vedherey, M.P.H., Lisa Armstrong, Madeline Brooks, M.P.H. Jefferson College of Population Health

Abstract: Objective: To examine the geographic variables of Delaware SNAP retail locations, food deserts, rates of food insecurity and obesity in order to identify areas in which inequalities in food access may diminish the health benefits of the SNAP program.

By identifying areas of need, this study can inform service providers and policymakers who work to address food insecurity in Delaware.

Methods: This study used geographic information systems (GIS) to examine the presence of the variables at the county- and census tract-levels in Delaware. ArcGIS was used for all mapping and analyzing. Area level data were joined to Delaware census tract or county shapefiles using their respective Federal Information Processing Standards (FIPS) codes, a set of standardized geographic identifiers used by the U.S. Census Bureau.

Results: Wilmington and its southeastern suburbs have high concentrations of low-income residents and SNAP recipients and lack enough grocery stores, suggesting a need for more SNAP-accepting retailers. South-central Delaware was found to have many rural SNAP recipients who cannot reach a SNAP retail store without driving over 20 miles. Efforts to increase SNAP retail access through mobile units or transportation assistance may be necessary here.

Policy implications: Prioritization of food access in identified areas combined with interventions to address economic and individual factors influencing obesity may provide a viable approach to improve consumption of healthy, affordable foods.

58 Delaware Journal of Public Health – February 2019

Food Insecurity

Introduction Background This study explores relationships between obesity, food insecurity, food deserts, Supplemental Nutrition Assistance Program (SNAP) participation, and SNAP retail locations among Delaware residents. By identifying areas of high need based on the co-occurrence of variables indicating poor food access, this study can inform service providers and policymakers who work to address food insecurity in the state. This study used geographic information systems (GIS) to examine the presence of the above variables at the county- and census tract-levels in Delaware.

Overweight and Obesity Body Mass Index (BMI) a measure of body fat based on height and weight, allows a person to be categorized as underweight, normal, overweight, or obese. Individuals are considered overweight with a BMI between 25.0 and 29.9 and obese with a BMI of 30 or higher, placing them at high risk for chronic diseases such as diabetes,

Food insecurity can be defined as low food security (reduced quality or variety of diet) or very low security (multiple indications of disrupted eating patterns and food intake) (Berclaw, 2017). According to Pruitt (2016), people who are food insecure are at risk for obesity, hypertension, diabetes, and limited access to health care. In Delaware, 12.9% of residents are food insecure, and 5.1% experience very low food security (Berclaw, 2017).

The Food Bank of Delaware (2016) reports that 1 in 8 adults and 1 in 6 children struggle with hunger.

Supplemental Nutrition Assistance Program (SNAP) and SNAP Retail Locations The United States Department of Agriculture (USDA) administers SNAP, the nation's leading anti-hunger program. SNAP provides supplemental nutrition support to individuals and families whose gross incomes are up to 130% of the federal poverty line, feeding over 44 million Americans in 2017 (Feeding America, 2018). SNAP assists more than 42 million people each year, serving at-risk households with children, elderly or those with disabilities (Feeding America, 2018). Nearly all SNAP-eligible recipients participate in SNAP, and it is a crucial element to preventing food insecurity in populations in need of support (Kearney & Harris, 2013). In 2017, 15% of Delawareans received SNAP benefits (Center on Budget and Policy Priorities (CBPP), 2018).

Food Deserts

cardiovascular disease, and many others (Centers for Disease Control and Prevention (CDC), 2016). The proportion of overweight adults is increasing in all 50 states and is projected to reach higher than 50% for both adult men and women by 2030 (Kapetanakis et al., 2012). Delaware's adult obesity rate is 31.8%, lower than the national obesity rate (39.8%). When broken down by race, Blacks have the highest obesity rate (37.4%), followed by Latinos (31.9%), and nonHispanic Whites (29.7%) (The State of Obesity, 2018).

Food deserts pose barriers to affordable and nutritious food, particularly in lower-income communities. As defined by the USDA (2015), food deserts are areas devoid of fresh fruit, vegetables, and other healthful whole foods, usually in impoverished communities that lack grocery stores, farmersâ&#x20AC;&#x2122; markets, and/or healthy food providers. The common indicators to measure food access and food deserts are accessibility of sources to healthy food, individual resources such as income or vehicle availability, and neighborhood resources such as average income of a neighborhood and availability of public transportation (United States Department of Agriculture (USDA) Economic Research Service (ERS), 2017).

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deserts, which may result in higher rates of overweight and obesity for those recipients. We hypothesize that food deserts and higher rates of food insecurity and overweight will exist predominantly in areas with fewer SNAP retail locations. Given that SNAP serves lowincome individuals and families, it is important to consider the disparities of access to healthy food choices, and the potential benefits of increasing SNAP retail locations.

Methods Data Sources TIGER/LINE shapefiles depicting Delaware census tracts and counties were obtained from the U.S Census Bureau (2018) and projected using the Delaware State Plane (NAD 1983 State Plane Delaware FIPS 0700 (Meters)) coordinate system (U.S. Census Bureau, 2018). PolicyMap, a repository of spatial data, was used to obtain the following variables: prevalence of overweight (BMI 24.9-29.9) adults in Delaware by Delaware census tract (Centers for Disease Control and Prevention (CDC), 2013); food insecurity rates by county (Feeding America, 2016); percentage of SNAP recipients by census tract (U.S. Census, 2016); food deserts defined using the USDA’s low-income and lowaccess measures (USDA, 2015); and Delaware SNAP retail locations (USDA, 2018).

A census tract is considered low access if at least 500 people or 33% of the population in the tract are at least one mile from a supermarket or large grocery store (or ten miles if the tract is in a rural area) (USDA ERS, 2017). An estimated 17.7% of the U.S. population live in census tracts that are low-income and low access and are more than ½ mile (urban) or 10 miles (rural) from the nearest supermarket (USDA, 2015). According to a report by the University of Delaware’s Institute for Public Administration, 61% of Delawareans live in census tracts with no grocery store, and 27% live in census tracts with only one grocery store (Jacobson, O’Hanlon, Clark, 2011).

Study Aim and Hypotheses This study examines the geographic variables of SNAP retail locations, food deserts, rates of food insecurity and obesity in order to identify areas in which inequalities in food access may diminish the health benefits of SNAP. Although SNAP is successful when serving populations faced with food insecurity; healthy food may remain out of reach for SNAP recipients who live in food 60 Delaware Journal of Public Health – February 2019

Mapping and Analysis ArcGIS (version # 10.3) was used for all mapping and analysis. Area-level data (food deserts and prevalence of overweight, food insecurity, and SNAP participation) were joined to Delaware census tract or county shapefiles using their respective Federal Information Processing Standards (FIPS) codes, a set of standardized geographic identifiers used by the U.S. Census Bureau (2015).

The attribute tables of the resulting new shapefiles were cleaned to remove unnecessary variables. The area-level variables of interest were depicted using choropleth maps, in which numeric values for polygons (e.g., prevalence of overweight, etc.) were symbolized using color ramps. Classification method and number of classes were used to symbolize each variable with natural breaks, quantiles, etc.

The point locations of SNAP retail locations were geocoded using a reference dataset of Delaware street addresses obtained from the U.S. Department of Agriculture (USDA, 2018). Unmatched addresses were compared to similarly named streets in Delaware and matched if the primary street name and ZIP code

corresponded to a physical address; for example, a location on “College Street” that matched the ZIP code for the same numbered address on “College Road” was considered a match, with an achieved match rate of 97%. These geocoded locations were joined by spatial location to shapefile of census tracts, creating a sum of SNAP locations that fall within each census tract. The sum of SNAP locations per census tract was symbolized as a proportional dot map with differently sized dots corresponding to 0, 1, 2-5, 6-10, or 11-21 SNAP retail locations existing within the census tract.

Figure 2: Location of Food Deserts in Delaware (2015)

Results Figure 1: Percent of Adults Reporting to be Overweight (BMI 25.0 to <30) by census tract in Delaware in (20092013).

Figure 2 shows food desert locations, and when compared to Figure 1, the prevalence of overweight adults and food desert locations are closely related.

Higher prevalence rates of overweight adults are located around low-income areas with little access to food (USDA ERS Food Access Research Atlas).

Figure 1 shows the proportion of adults reporting to be overweight in census tracts in Delaware using the CDC BRFSS 2009-2013 Census American Community Survey. The map clearly shows that the prevalence of adult self-reported overweight is highest in Northern Delaware and Southwest Delaware.

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Figure 3: Delaware SNAP Recipients by Percentage (20122016)

Figure 3 shows that SNAP recipients are geographically distributed across the state, with higher concentrations in the cities of Wilmington and Dover, as well as some rural Sussex County communities (Data source: Decennial Census & American Community Survey 2012-2016; U.S. Census Bureau 2015).

62 Delaware Journal of Public Health â&#x20AC;&#x201C; February 2019

Figure 4: Percent of SNAP Recipients in Relation to Food Deserts in Delaware (2012-2016)

Figure 4 shows that areas where most SNAP recipients reside, there is an overlap with food deserts. The most challenging areas are those represented by red areas with a large green dot, as these represent areas with very high numbers of SNAP recipients who live in areas considered to be food deserts and therefore likely face barriers to accessing food (Decennial Census & American Community Survey 2012-2016; U.S. Census Bureau).

Figure 5: SNAP Location Density & Low-Income Residents Living Over ½ Mile from a Grocery Store (2016)

Discussion Prevalence of Overweight Delaware’s prevalence of overweight adults is similar to the national average (31.8% and 39.8%, respectively).

Census-tract level analysis revealed smaller communities with high prevalence of overweight adults in coastal Sussex County and New Castle County, around Wilmington and Dover in particular. Lifestyle behaviors may play a part in the prevalence of overweight adults.

Along with diet and other factors, personal behaviors such as limitied physical activity can hinder individual’s ability to maintain or obtain a healthy body weight (Hruby & Hill, 2015). The Delaware Behavioral Risk Factor Surveillance Survey (BRFSS) found that 35.4% of Delawareans consume fruit less than one time per day, and 17.2% consume vegetables less than one time per day. Thirty one percent of Delawareans reported not participating in physical activities in the last month (CDC, 2017).

Figure 5 compares the number of SNAP locations in each census tract with the percentage of low-income residents of that tract who live over ½ mile from the nearest grocery store. Rural residents and residents of the southeastern outskirts of Wilmington all have limited access to SNAP locations, at least when it comes to geographic proximity to their homes (USDA ERS Food Access Research Atlas).

Aside from these lifestyle behaviors, individuals residing in neighborhoods with limited access to healthy food, or with more availability to food options such as processed or fast foods with lower nutritional value are at risk for overweight and obesity (The State of Obesity, 2018). Pan et al. (2012) found that 35.1% of food-insecure adults are overweight, compared to 25.2% of food-secure adults. Food-insecure individuals were at risk for poorer health and often came from communities with less access to SNAP retail locations. Our maps indicate a similar picture, as census tracts defined as food deserts also had high prevalence rates of overweight adults.

Food Insecurity Rates at the County Level Our analyses showed that Kent County experiences higher estimated rates of food insecurity compared to the national average (13.0% vs. 11.8%, respectively) (Feeding America, 2016). According to a survey conducted for the Delaware Plan 4 Health project, Kent County residents experience several disparities related to food insecurity. Non-Hispanic blacks were more likely than non-Hispanic whites to report food insecurity, as were WIC/SNAP recipients compared to non-recipients.

Respondents who reported food insecurity, household income <$15,000, or WIC/SNAP participation were more likely to be morbidly obese. Most Kent County residents travel at least three miles to get to their food stores, and WIC/SNAP participants were more likely than non-participants to rely on public transportation when food shopping (Delaware Plan 4 Health, 2016).

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These issues illustrate the necessity of removing barriers to healthy food access in order to make food security possible for all Kent County households.

Comparing Food Insecurity and SNAP Locations Within Census Tracts We found several census tracts south of Wilmington that appeared to be underserved by current SNAP locations.

Given that many of these census tracts were considered food deserts and had 20% or more of the population receiving SNAP benefits (U.S. Census Bureau, 2016), it appears that these would be logical areas to add new SNAP retail locations. While barriers to access are more complicated than straight-line distance to a grocery store, the co-occurrence of food deserts and SNAP participation in this region underscores the need for SNAP retailers that provide healthy food options.

A more complicated issue is approaching areas in western and southern Delaware that are considered food deserts.

In densely populated areas, it is easy to identify areas in need of additional food sources. In rural census tracts with relatively small populations, there may be very high percentages of residents experiencing food insecurity, but the actual number of these residents might still be fairly low, meaning that additional SNAP locations would not reach a large number of families and individuals in need. In these regions it may be more efficient to offer transportation assistance to existing SNAP locations, due to the feasibility of opening additional food outlets.

Food Deserts, Poverty and SNAP Of Delaware’s 197 census tracts, there are 15, primarily in the northeastern part of the state, in which 45% or more of the population receives SNAP benefits. Figure 5 shows these areas tend to overlap with USDA-defined food deserts. This mirrors nationwide trends in which 92% of SNAP benefits go to households with incomes below the poverty line, and 56% of benefits go to households below half the poverty line, enabling these households to afford more healthy foods (CBPP, 2018).

Market-driven mechanisms may contribute to the lack of quality food options in high-need communities. The city of Wilmington faced two grocery store closures in 2015 alone, due in part to bankruptcy of grocery store chains and increased competition from dollar stores and superstores such as Target and Walmart (Parra, 2015).

It is worth noting that the locally owned Kenny Family ShopRites recently opened a store in Wilmington’s developing Christina Crossing Shopping Center, and participated in a partnership with Goodwill to promote community employment (Parra, 2015).

64 Delaware Journal of Public Health – February 2019

Study Implications It is perplexing to see the number of food deserts in a state where 2,500 farms account for 39 percent of all land. Delaware’s annual value in agricultural sales is over one billion dollars, and the poultry livestock revenue is a three billion-dollar industry (USDA, 2015).

This places Delaware in a unique position to develop alternative methods of supplying healthy food options.

For example, the state could collaborate with farmers to sell locally-grown poultry and vegetables through mobile markets.

The findings of this study suggest that expansion of SNAP retail locations may help improve access to healthy food, reduce food insecurity, and in turn reduce rates of overweight and obesity. This may also increase the number of low-income residents that live within ½ mile of the nearest grocery store, addressing one component of food deserts. Transportation vouchers may also help to ensure food access for SNAP recipients living in census tracts with zero or few grocery stores.

Next Steps for Research This study raises issues worth future research. More information is needed to differentiate between barriers to food access in Delaware’s urban and rural communities.

Studies should also consider grocery store access from customers’ workplaces, schools, or childcare centers, as access need not be defined solely by distance from residence.

Another valuable study could categorize SNAP retail locations by type. A typical chain grocery store can successfully provide healthy food to large populations and serve entire neighborhoods, whereas a corner store lacks the same selection of foods and serves a much smaller population. Given that our maps indicated areas with few SNAP locations but sufficient levels of access and food security, it is possible that these areas are served by SNAP locations more capable of serving a large population. A study categorizing these retailers could create a more complete portrait of areas served (or underserved) by SNAP retailers.

Strengths & Limitations This study was strengthened by the use of high-quality, publicly available data from federal agencies including the CDC, U.S. Census Bureau, and USDA ERS. The study’s variables of food insecurity and food deserts are well-defined and covered in-depth in academic literature.

This allowed us to place our findings into context and identify explanations for visual trends in the maps.

However, the study is limited in that it only described broad geographic associations between food insecurity, SNAP participation, food deserts and obesity. Another limitation is the assumption that Delaware SNAP recipients would be limited to food shopping in the state, as some may choose to use their benefits in the bordering states of Maryland and Pennsylvania.

Although this study clearly demonstrates the coexistence of food insecurity and food deserts in Delaware, we cannot describe the nutritional value of food purchased through SNAP and its potential relationship to rates of overweight and obesity. Numerous factors – such as poverty, employment, and education – confound the relationship between food access and health outcomes and deserve further study.

Conclusion Our study identified two areas in Delaware in need of support to increase healthy food access. The first is Wilmington and its southeastern suburbs, where high concentrations of low-income residents and SNAP recipients lack a sufficient number of grocery stores.

This suggests a need for more SNAP-accepting retailers.

The second area of need is in south-central Delaware, where many rural residents who receive SNAP cannot reach a SNAP retail store without driving over 20 miles.

Efforts to increase SNAP retail access through mobile units or transportation assistance may be necessary here.

Prioritization of food access in these areas, combined with interventions to address economic and individual factors influencing obesity, may provide a viable approach to improve Delawareans’ consumption of healthy, affordable foods.

The authors declare no conflict of interest.

References Berclaw, S. (2017). Food Insecurity in Delaware. University of Delaware. Retrieved June 5, 2018 from: http://extension.udel.edu/blog/food-insecurity-in-delaware/ Centers for Disease Control and Prevention (CDC). (2017). BRFSS Prevalence & Trends Data.

Retrieved January 3, 2019, from https://www.cdc.gov/brfss/brfssprevalence/ Centers for Disease Control and Prevention. (2016). Defining Adult Overweight and Obesity.

Division of Nutrition, Physical Activity, and Obesity: National Center for Chronic Disease Prevention. Retrieved June 22, 2018 from https://www.cdc.gov/obesity/adult/defining.html Center on Budget and Policy Priorities. (2018). Delaware: Food Supplement Program. Retrieved June 10, 2018, from https://www.cbpp.org/sites/default/files/atoms/files/snap_factsheet_ delaware.pdf Delaware Plan 4 Health. (2016). Kent County Resident Survey Summary of Results. Retrieved June 24, 2018, from http://deplan4health.org/wordpress/wp-content/uploads/2016/12/ Plan4Health-Survey-Report-2016-012-7-updated.pdf Feeding America. (2016). Map the Meal Gap. Retrieved January 3, 2019 from Feeding America: http://map.feedingamerica.org/ Feeding America. (2018). Hunger in Delaware. Retrieved June 3, 2018, from https://www. feedingamerica.org/hunger-in-america/delaware FOOD STAMPS/Supplemental Nutrition Assistance Program (SNAP) 2012-2016 American Community Survey 5-Year Estimates. (2016). Retrieved January 1, 2019, from https://factfinder. census.gov/faces/tableservices/jsf/pages/productview.xhtml?src=bkmk Hruby, A., & Hu, F. (2016). The Epidemiology of Obesity: A Big Picture. Retrieved January 3, 2018, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4859313/ Jacobson, E., O’Hanlon, J., Clark, A. (2011). Access to Healthy Foods in the Built Environment.

Institute for Public Administration. Retrieved June 4, 2018, from www.ipa.udel.edu/publications/ HealthPolicyIssueBrief3.pdf

Kapetanakis, V., Brown, McPherson, K., Webber, L., Rtveladze, K., & Marsh, T. (2012). OP26 By-State Comparison of Obesity Trends in the Adult Population of the United States of America.

Diet and Obesity. Retrieved June 20, 2018 from http://jech.bmj.com.proxy1.lib.tju.edu/ content/66/Suppl_1/A10.3 Kearney, M.S. & Harris, B.H. (2013). Hunger and the Important Role of SNAP as Part of the American Safety Net. Retrieved June 23, 2018 from https://www.brookings.edu/blog/upfront/2013/11/22/hunger-and-the-important-role-of-snap-as-part-of-the-american-safety-net/ Pan, L., Sherry, B., Njai, R., & Blanck, H.M. (2012). Food insecurity is associated with obesity among US adults in 12 states. Journal of Academy of Nutrition and Dietetics. 112(9); 14031409. Retrieved June 11, 2018, from https://jandonline.org/article/S2212-2672(12)00745-9/pdf Parra, E.,. Delaware’s food deserts grow (2015). The News Journal. Retrieved June 17, 2018 from https://www.delawareonline.com/story/news/local/2015/09/13/delawares-food-desertsgrow/72213132/ Pruitt, S., Leonard, T., Xuan, L., Amory, R., Higashi, R., Nguyen, O., . . . Swales, S. (2016, October 13). Who Is Food Insecure? Implications for Targeted Recruitment and Outreach, National Health and Nutrition Examination Survey, 2005–2010. Retrieved June 6, 2018, from https://www.cdc.gov/pcd/issues/2016/16_0103.htm The State of Obesity. (2018). State Briefs. Retrieved June 5, 2018, from https://stateofobesity.org/ states/de/ United States Census. (2016). Census’ Small Area Income and Poverty Estimates. Retrieved January 3, 2019 from U.S. Census: https://www.census.gov/programs-surveys/saipe/data.html United States Census Bureau. (2018). TIGER Products. From Geography: https://www.census. gov/geo/maps-data/data/tiger.html, accessed January 3, 2019 United States Department of Agriculture (USDA). (2017). Food & Nutrition Assistance.

Retrieved June 3, 2018, from https://www.ers.usda.gov/topics/food-nutrition-assistance/foodsecurity-in-the-us/ United States Department of Agriculture (USDA). (2018). SNAP Retail Locations. Retrieved January 3, 2019 from United States Department of Agriculture (USDA), Food and Nutrition Service: http://www.fns.usda.gov/snap/retailerlocator United States Department of Agriculture (USDA). (2015). United States Department of Agriculture, Economic Research Service (ERS/USDA) Food Access Research Atlas. Retrieved January 3, 2019 from U.S. Department of Agriculture, Economic Research Service: http://www. ers.usda.gov/data-products/food-access-research-atlas/download-the-data.aspx.

Authors Alex Fossi, M.P.H., is a research coordinator at Jefferson’s Lambert Center for the Study of Medicinal Cannabis and Hemp. He received his MPH from Jefferson’s College of Population Health in 2018. His past research has focused on social dynamics and their impact on health outcomes, health equity for refugees and other at-risk populations, and the use of medical cannabis in chronic pain patients.

Desmond McCaffery is an MPH candidate at Thomas Jefferson University College of Population and a graduate of Drexel University’s LeBow College of Business. He has worked for GlaxoSmithKline (GSK) since 1998 in various roles. In his current role, he manages different aspects of GSK’s employee volunteering initiatives.

Courtney Riseborough, an MPH candidate at Thomas Jefferson University College of Population Health, is a Research Assistant at Jefferson University College of Nursing. Prior to joining the Jefferson College of Nursing, she held positions with Philadelphia Corporation for Aging, and Public Health Management Corporation’s Research and Evaluation Department.

Niharika Vedherey, M.P.H., is a research associate at the Rutgers School of Public Health, working on the Women’s Circle of Health Study for breast cancer, funded by the Cancer Institute of New Jersey. She holds a Master of Public Health from Thomas Jefferson University.

Lisa Armstrong, an MPH candidate at Thomas Jefferson University College of Population Health, is the Assistant Director of Volunteer Programs at Bryn Mawr College. Lisa holds an MSS and is a licensed staff therapist at Menergy.

Madeline Brooks, M.P.H., is a research associate in the Value Institute at Christiana Care Health System in Newark, DE. Her work focuses on the use of geographic information systems (GIS) to study population health and health services delivery. She holds a Master of Public Health from Thomas Jefferson University.

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Data mapping is used to analyze how populations differ based on their geography. Disease surveillance, risk analysis, and health care planning all utilize data mapping to efficiently view and transmit information to audiences.

Using Geographic Information Systems (GIS) to Display Spatial Patterns of Diabetes in Delaware

Saheedat Sulaimon, M.P.H., Rashida Smith, B.S., Ariel Paz, M.P.H., Madeline Brooks, M.P.H. Thomas Jefferson University, College of Population Health

Abstract: Objectives: To use geographic information systems (GIS) to identify spatial patterns of diabetes prevalence and mortality in Delaware.

Methods: ArcMap 10.3 was used to create choropleth maps depicting diabetes prevalence rates, percent of adults reporting to have a primary care physician (PCP), percent of Medicare beneficiaries with diabetes, and overall and race-specific diabetes mortality rates.

Results: Sussex County had the highest overall diabetes prevalence and mortality rates, though a majority of census tracts in the highest quintile of diabetes prevalence rates were located in New Castle County. At least 70% of adults in all census tracts reported having a PCP. Kent County had the highest percent of Medicare beneficiaries with diabetes. Age-adjusted diabetes mortality rates were consistently higher for the Black population statewide.

Conclusions: This study identified communities within New Castle County that experience high burdens of diabetes prevalence, which may be overlooked when considering only the countyâ&#x20AC;&#x2122;s much lower overall prevalence rate. No clear geographic relationships were seen between diabetes diagnosis/management, PCP access, and receipt of Medicare.

Policy Implications: This study identifies geographic areas with excessive diabetes prevalence and attributable mortality. The Delaware Division of Public Health can use GIS to inform the provision of its diabetes management/prevention programming.

66 Delaware Journal of Public Health â&#x20AC;&#x201C; February 2019

Introduction Diabetes, a chronic condition affecting how glucose is used for energy in the body, exacts a staggering toll on public health. More than 30 million people in the United States (U.S.) (9.4% of the population) have diabetes, a condition that has risen to the seventh leading cause of death in the U.S.1 Diabetes often exacerbates existing health conditions and can lead to serious chronic health problems such as heart attack, stroke, blindness, kidney failure, and lower-extremity amputations.2 In 2017, diagnosed diabetes resulted in costs of $327 billion, $90 billion of which was due to reduced productivity.3 The burden of diabetes necessitates further efforts to study, treat, and prevent this disease at the national and local levels.

Critical to these efforts is an understanding of behavioral and social risk factors for diabetes. Among U.S. adult diabetics, 15.9% were current smokers, 87.5% were overweight or obese, and 40.8% were physically inactive (participating in less than ten minutes of moderate or vigorous activity per week).4 Race and ethnicity also influence the risk for type 2 diabetes. African Americans, Hispanic/Latino Americans, and American Indians are at a higher risk for type 2 diabetes compared to their White counterparts.2 Diabetes is also very prevalent among Medicare beneficiaries. More than a quarter (28%) of Medicare beneficiaries were diagnosed with diabetes in 2010, and it was ranked the fifth most common chronic condition among this group.5 Diabetes is of particular concern in the state of Delaware. In 2016, 10.6% of Delaware adults reported being diagnosed with type 1 or type 2 diabetes, higher than the national rate of 9.4%.4,6 Sussex County had the highest prevalence of diabetes (13.1%) among Delawareâ&#x20AC;&#x2122;s three counties.6 Furthermore, diabetes was the eighth leading cause of death in the state in 2016.7 Non-Hispanic Black Delawareans are disproportionately affected by diabetes mortality, with rates twice as high as

those of their White counterparts.8 A qualitative research study of physicians in Delaware identified barriers to providing care for diabetic patients, including lack of population-based patient management, self-management education, and public health support.9 Despite the clear need for population-based management of diabetes, it remains challenging to incorporate evidence from research into clinical practice.10 Geographic information systems (GIS), used to display and analyze spatial data, offer a powerful tool for public health planning. Previous studies have used GIS to identify geographic patterns in diabetes prevalence and mortality at the national level.11,12 By studying the spatial distribution of diabetes and its risk factors, public health professionals can identify areas of high priority and develop population-based interventions. This study used GIS to investigate visual relationships of diabetes prevalence and mortality rates among Delaware residents. The spatial data presented here can provide additional insight for statewide health programming.

Three maps were created to test five hypotheses informed by state and national trends. Map 1 tested the following hypotheses: (1) a majority of census tracts in Sussex County will have higher prevalence rates of diabetes than those in New Castle and Kent Counties, mirroring county-level trends and (2) census tracts with greater prevalence rates of diabetes will also have a higher percentage of adults who report having a primary care provider. Map 2 tested the following hypothesis: (3) the percentage of Medicare beneficiaries with diagnosed diabetes in each county will be comparable to national levels. Map 3 tested the following hypotheses: (4) ageadjusted diabetes mortality rates will be higher in Sussex County compared to New Castle and Kent Counties and (5) overall age-adjusted diabetes mortality rates across counties will be higher among non-Hispanic Blacks than non-Hispanic Whites.

Methods We obtained county and census tract shapefiles for the state of Delaware from FirstMap Delaware and the U.S. Census Bureau.13,14 Delaware contains 215 census tracts, 214 of which contain people (one census tract contains only a landfill and a wastewater treatment plant). For the purposes of these analyses, there were considered to be 214 â&#x20AC;&#x153;trueâ&#x20AC;? census tracts in the state. ArcMap 10.3 was used to create choropleth maps of the prevalence rates of diabetes and percent of adults who reported having 67

a PCP by Delaware census tract in 2013. In addition, county-level choropleth maps were created to map percent of Medicare beneficiaries with diabetes, overall age-adjusted diabetes mortality rates, and age-adjusted diabetes mortality rates by race. All maps were set to Delaware’s State Plane coordinate system (NAD 1983 StatePlane Delaware FIPS 0700 (Meters)) and displayed at a scale of 1:750,000.

Map 1: Prevalence of Diabetes and Percent of Adults Reporting to Have a Primary Care Physician (PCP) by Delaware Census Tract Data source: A subset of the CDC’s 2013 Behavioral Risk Factor Surveillance System (BRFSS) was used in this study. BRFSS is an annual, health-related telephone survey conducted at the state level. This survey collects data from non-institutionalized adults in the U.S. regarding health conditions, risk behaviors, and use of preventive services.15 Data were downloaded as a Microsoft Excel file from Policy Map. Sample: Survey data collected from BRFSS apply to the non-institutionalized adult population, aged 18 years or older, who live in the U.S. These data were analyzed at the census tract level for both maps. The census tract-level data are estimated from a multilevel model with post-stratification based on metropolitan area status, race, age, and income characteristics. The multilevel model is based on state-level estimates, as well as state- and individual-level characteristics including age group, income level, racial/ethnic group, and metropolitan area status.16 Measures: To collect data for the BRFSS, home telephone numbers were obtained through randomdigit dialing, and the survey was available in both English and Spanish. In the BRFSS Section 7.12, Column 109 (Chronic Health Conditions), respondents who responded “Yes” to the question “Has a doctor ever told you that you have diabetes?” were considered to have diabetes. Women who only had diabetes during pregnancy and individuals who reported having prediabetes or borderline diabetes were not included.17 Because BRFSS does not distinguish between type 1 and type 2 diabetes, the data included a combined count. Prior to the geographic analysis, the tabular data were organized in a Microsoft Excel spreadsheet with the following column headings: (1) census tract, (2) estimated number of adults ever diagnosed with diabetes in 2013, (3) estimated adult population aged 18 and older in each census tract between 2012 and 2016, and (4) prevalence rate of diabetes in each census 68 Delaware Journal of Public Health – February 2019

tract. Column three, the estimated adult population by census tract, was obtained from the 2012-2016 U.S. Census Bureau’s American Community Survey (ACS).18 The prevalence rate of diabetes in each census tract was calculated as follows: census tract’s total # of cases of diabetes in 2013 (census tract’s adult population (2012-2016)

x 1,000.

In BRFSS Section 3.2, Column 88 (Health Care Access), respondents who responded “Yes, only one” and “More than one” to the question “Do you have one person you think of as your personal doctor or health care provider?” were included. These data were downloaded as the estimated percent of adults per census tract reporting to have a PCP.17,19 Geo-based analysis: Once data tables were imported to ArcMap, prevalence rates and percentages for outcomes of interest were joined to the census tract shapefile based on their 11-digit Federal Information Processing Standards (FIPS) codes. Prevalence rates and percentages were classified into quintiles.

Map 2: Percent of Medicare Beneficiaries with Diagnosed Diabetes by County Data source: We obtained 2015 data on the percent of Medicare beneficiaries with diagnosed diabetes by county in Delaware from CMS and Policy Map.20 Sample: Medicare beneficiaries are considered to have a chronic condition if there is a CMS claim indicating that the beneficiary received a service or treatment for the specific condition.5 The sample only includes individuals who are enrolled in Medicare Part A (hospital insurance) and Part B (medical insurance).

Medicare Part A and Part B cover individuals, ages 65 and over, who are receiving Social Security, people who have received disability benefits for at least two years, people who have amyotrophic lateral sclerosis (Lou Gehrig’s disease) and receive disability benefits, as well as people who have end-stage renal disease (permanent kidney failure) and receive maintenance dialysis or a kidney transplant.5 Information for Medicare beneficiaries who have died during the study year is also included in the dataset.

Measures: Diabetes data were collected through CMS administrative enrollment and claims data for Medicare beneficiaries. Individuals who have diabetes were identified based on CMS claims for services or treatment for diabetes.5 Geo-based analysis: Data on the percent of Medicare beneficiaries with diagnosed diabetes were downloaded

and cleaned for import into ArcMap. Medicare data were joined with county shapefiles based on county FIPS codes. The percentage of Medicare beneficiaries with diabetes was classified into three classes using manual intervals.

Map 3: Diabetes Mortality by Delaware County Data source: We obtained diabetes mortality data from 2014—the most recent year available—from Delaware Open Data which contains data collected by the DHSS, DPH, and Delaware Health Statistics Center.21 The U.S. Census Bureau’s American FactFinder website was used to obtain county adult populations for Delaware using Census 2010 population data as well as U.S. adult populations using Census 2000 population data.22-27 Sample: The sample consisted of individuals who died of diabetes in Delaware in 2014. The sample size was inclusive of all counties, genders, races, and educational levels.21 All deaths occurred in adults aged 18 or older. Deaths by age group, inclusive of the 18 and older population, were used for age-adjusted mortality rates.

Measures: Outcome data were collected from death certificates of individuals who died from diabetes in 2014 in Delaware. The Office of Vital Statistics, under the DPH and the DHSS, is responsible for collecting and storing death certificate information for the state of Delaware.21 Statistical analysis: Since each row of data represents one death attributed to diabetes, filter functions were first used to sort diabetes-attributable deaths by county and age group. County mortality data population counts were used to determine the age-adjusted diabetes cause-specific mortality rates per county. The following cause-specific mortality equation was used: county’s total # of deaths due to diabetes in 2014 per age group county population by age group in 2010

x 100,000.

Race-specific diabetes mortality rates by county were also calculated: county’s total # of (black or white) deaths due to diabetes in 2014 county (black or white) population by age group in 2010

x 100,000.

Geo-based analysis: Diabetes mortality data were cleaned and converted to an Excel spreadsheet. The Excel spreadsheet included the following column headings for each of Delaware’s three counties: county name, FIPS county code, number of deaths due to diabetes in 2014 per age group, county population by age group in 2010, and diabetes mortality rate.

Death rates were stratified by age groups and age-

adjusted using the U.S. 2000 population as a reference population. The basemap shapefile for Delaware and diabetes mortality data table were imported to ArcMap 10.3. Overall and race-specific diabetes mortality rates were manually classified into three classes.

Results Map 1: Prevalence of Diabetes and the Percent of Adults Reporting to Have a Primary Care Physician (PCP) by Delaware Census Tract Sussex County had the highest overall prevalence of diabetes with 133.37 cases per 1,000 adults, followed

by Kent County (122.14 per 1,000) and New Castle County (118.10 per 1,000). Of the 214 census tracts with diabetes prevalence data, 120 had a diabetes prevalence rate greater than the statewide rate of 122.39 cases per 1,000 adults in 2013 (Figure 1).

Those census tracts in the highest quintile of diabetes prevalence rates had rates exceeding 141 cases per 1,000 adults (n = 42 census tracts). Additionally, 24 out of the 42 census tracts in the highest quintile of diabetes prevalence rates were located in New Castle County, the northernmost county in the state.

In all census tracts in Delaware (excluding those where data were not available), more than 70% of adults reported having a PCP. Specifically, in 80% (n = 172) of census tracts, more than 84% of adults reported having a PCP. New Castle County had the greatest number of census tracts (n = 34) in the lowest quintile of percentage of adults with a PCP. Sussex County had the greatest number of census tracts (n = 23) in the highest quintile of percentage of adults with a PCP. New Castle County had the most census tracts in both the highest quintile of diabetes prevalence rates and the lowest quintile of self-reported PCP access; however, all census tracts in New Castle County had PCP access rates of 70% or greater. While Sussex County had the most census tracts (n = 23) in the highest quintile of PCP access (access rates exceeding 90%), all of these census tracts had diabetes prevalence rates exceeding 114 cases per 1,000 adults. It is challenging to visually ascertain relationships between PCP access and associated rates of diabetes diagnosis or prevention.

Map 2: Percent of Medicare Beneficiaries with Diagnosed Diabetes by County The percent of Medicare beneficiaries with diagnosed diabetes in Delaware in 2015 was mapped by county (Figure 2). Kent County had the largest percent 69

of Medicare beneficiaries with diagnosed diabetes (33.2%) compared to New Castle and Sussex Counties (29.4% and 28.2%, respectively), and therefore skewed the statewide prevalence of the disease. Values for New Castle and Sussex Counties were below the overall state value of 29.7%.

Map 3: Diabetes Mortality by Delaware County Age-adjusted diabetes mortality rates were mapped

by Delaware county for the overall adult population and the Black and White populations (Figure 3). The overall age-adjusted adult diabetes mortality rate was highest in Sussex County with 30.75 diabetes deaths per 100,000 people, compared to New Castle and Kent which had similar cause-specific mortality rates (26.53 and 25.87, respectively). Diabetes mortality rates for the Black population were highest in Sussex County with 93.73 diabetes deaths per 100,000 people, compared to New Castle and Kent Counties (82.39 and 64.11, respectively). Diabetes mortality rates for the White population were also highest in Sussex County, with 55.98 diabetes deaths per 100,000 people, compared to New Castle and Kent Counties (46.14 and 52.72, respectively).

Map 1: Prevalence of Diabetes and the Percent of Adults Reporting to Have a Primary Care Physician (PCP) by Delaware Census Tract Previous research has shown that having multiple providers of care rather than one designated PCP may have negative impacts on the health of individuals.28 A limited patient-physician connection leads to low adherence to guideline-consistent services by physicians, and continuity of care has been associated with improved diabetes prevention and management.29 Our analysis of the prevalence of diabetes and the percent of adults reporting to have a PCP among census tracts in Delaware shows that New Castle County had the greatest number of census tracts in the highest quintile of diabetes prevalence rates, contradicting our hypothesis that we would see higher diabetes prevalence rates in Sussex County census tracts. Additionally, at least 70% of adults in all census tracts in the state reported to have a PCP in 2013. The high percentage of individuals who reported having a PCP corresponds to the literature on the importance of having a consistent PCP.28 Because New Castle County appeared to have lower PCP access but higher diabetes prevalence in some census tracts, these data may be interpreted such that lower access to PCPs may result in lack of preventive care and screening that contributes to higher rates of diabetes. Prior research has shown that patients with diabetes who identified a regular PCP were more likely to receive most recommended elements of diabetes care and to have better control of this chronic condition.30

In addition to producing maps to assess visual patterns, a descriptive statistics summary table was created to reveal additional patterns that may not be evident from the spatial analysis. Comparing individual counties, the age-adjusted diabetes mortality rate per 100,000 people is consistently higher for the Black population in Delaware counties, compared to the White population. Diabetes mortality rates for the White population are more reflective of the overall diabetes mortality rates for Delaware counties.

Because the White population represents two-thirds Map 2: Percent of Medicare Beneficiaries with of Delawareâ&#x20AC;&#x2122;s population (68.9%), trends in diabetes Diagnosed Diabetes by County mortality for the White population are more likely to Visual analysis of this map shows that Kent County be similar to the trends for the entire state.24 However, has the largest percentage of Medicare beneficiaries because the Black population comprises only 21.4% of with diagnosed diabetes, whereas New Castle and the state population, diabetes mortality trends for the Sussex Counties have similar values. The percentages entire state may not be reflective of trends in the Black 24 for Medicare beneficiaries with diagnosed diabetes population. for each county are as follows: New Castle County, 29.4%, Sussex County, 28.2%, and Kent County Discussion 33.2%. These percentages closely mirror those at the Given the increasing interest in visually displaying the national level. Diabetes is a highly ranked chronic burden of chronic disease across the nation, GIS was used condition among the Medicare beneficiary population to analyze patterns of diabetes prevalence and mortality with 28% of Medicare beneficiaries diagnosed with in Delaware. Specifically, we explored the relationships diabetes in 2010.5 The high prevalence of diabetes between: (1) prevalence of diabetes by census tract; (2) among Medicare beneficiaries confirms the need for percentage of Medicare beneficiaries with diabetes by more targeted interventions in this population. county; and (3) diabetes mortality by county.

70 Delaware Journal of Public Health â&#x20AC;&#x201C; February 2019

Map 3: Diabetes Mortality by Delaware County Diabetes mortality rates were highest in Sussex County for the overall population and the Black and White populations. Comparing individual counties, the diabetes mortality rate per 100,000 people is consistently higher for the Black population in Delaware counties, in comparison to the White population.

According to the Delaware Health Statistics Center, the five-year diabetes mortality rate for 2006-2010 was 20.6 deaths per 100,000 people. The report also stated that Black Delawareans had a higher diabetes mortality rate compared to their White counterparts.8 Similarly, the findings in our study reflect these historical trends in that disparities in diabetes mortality rates persist between racial and ethnic groups. Lower levels of education and access to care may explain in part why disparities among racial and ethnic groups have continued to persist for decades.8 Diabetes mortality trends for the overall population are more reflective of diabetes mortality trends for the White population because Delaware’s three county populations are predominantly White. For this reason, it is important to look beyond overall trends when assessing where to direct diabetes mortality prevention efforts. Overall diabetes mortality trends may not accurately reflect the health of sub-populations.

In order to change the trajectory of diabetes mortality rates among Delawareans, addressing disparities should be at the forefront of chronic disease management.

Doing so can more appropriately influence county initiatives and better inform intervention and prevention programs for those populations at increased risk for diabetes mortality.

Comparative Analysis Our visual analysis of diabetes prevalence in Delaware identified geographic and demographic disparities in this condition. In comparing diabetes prevalence to diabetes mortality across counties, clear associations were not seen. Sussex County had the highest diabetes prevalence (133.37 cases per 1,000 adults) of the three counties in Delaware, yet New Castle County had a greater number of census tracts with prevalence rates exceeding 141 cases per 1,000 adults, as compared to Kent and Sussex Counties. In contrast, diabetes mortality rates do not mirror these patterns at the census tract level in that Sussex County had higher overall and race-specific diabetes mortality rates in comparison to Kent and New Castle Counties.

To continue our visual analysis, we looked at diabetes in the state’s Medicare population. There did not appear to be a close relationship between diabetes prevalence and mortality among counties’ Medicare beneficiaries.

Despite Sussex County having the highest diabetes mortality rate, it has the lowest percentage of Medicare beneficiaries diagnosed with diabetes. Similarly, because the percentage of Medicare beneficiaries diagnosed with this disease was relatively low in New Castle County, it remains unclear whether receiving Medicare impacts an individual’s diagnosis and management of diabetes.

There are likely several confounding variables not examined here that influence the relationship between diabetes diagnoses, prevalence, and mortality in the Medicare population.

Strengths and Limitations It is necessary to discuss our findings in the context of several strengths and limitations. The most recent available data were used to produce the three maps, providing us with the most current state of diabetes in Delaware. Additionally, looking at different measures of diabetes (prevalence, mortality, and Medicare beneficiaries) paints a more complete picture of this chronic disease. These maps can help display trends that may not be readily apparent in tabular data form.

It is important to note limitations that may impact the interpretation of our findings. One limitation is that some data are available only at the county level, obscuring variance within counties. This made it challenging to fully ascertain relationships between variables of interest across relatively large geographic units. Additionally, since data were collected from multiple sources and different calendar years, future map-based analyses would benefit from use of temporally consistent data covering a longer time period.

Implications and Future Directions Diabetes prevalence, mortality, and costs have farreaching implications for the healthcare system and public health. Substantial healthcare costs and suboptimal health outcomes confirm the need to transform the delivery of diabetes care. Redesign of primary care services could help a greater number of patients meet recommended targets for preventive interventions. This can ultimately improve the health of the population by reducing not only the impact of diabetes but also associated physician burnout.31 Furthermore, our findings may be used to inform policy making, targeted interventions, and future research initiatives at the census tract, county, and state levels.

71

Future studies should use more granular units of analysis (e.g. zip code-level data) to better explore the relationships between the mapped variables.

Additionally, potential confounding factors should be identified and comparatively mapped in order to expose a clearer link between outcomes of interest.

and physical burdens to both individual residents and the state as a whole, it is critical to identify specific geographic areas most affected by diabetes. Analyzing these data can help to highlight health disparities and expose other risk factors that are unevenly distributed across communities.

Conclusion

There is value in mapping these data for public health planning. Maps can be used to quickly visualize and communicate geographic disparities in diabetes.32 The rise of diabetes continues to widen health inequities and present economic and social threats to society and health systems.31 Incorporating geography into diabetes prevention and management can help us to better understand root causes and tailor interventions for unique populations.32

Despite how much money the U.S. healthcare system spends on diabetes, individuals with diabetes are not reaching target levels of optimal care that clinical experts recommend. In order to help communities in Delaware effectively prevent and manage diabetes, county and census tract-level diabetes data were mapped to identify areas with high diabetes prevalence and mortality. Given that this chronic disease poses large economic, social, References 1. Centers for Disease Control and Prevention. (2017a). About Diabetes. Retrieved June 2, 2018, from https://www.cdc.gov/diabetes/basics/diabetes.html 2. Centers for Disease Control and Prevention. (2018). About Prediabetes & Type 2 Diabetes | Diabetes | NDPP. Retrieved June 5, 2018, from https://www.cdc.gov/diabetes/prevention/ prediabetes-type2/index.html 3. American Diabetes Association. (2018). Economic costs of diabetes in the U.S. in 2017.

Diabetes Care, 41(5), 917–928. doi:10.2337/dci18-0007 4. Centers for Disease Control and Prevention. (2017b). National Diabetes Statistics Report, 2017. Retrieved from https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetesstatistics-report.pdf 5. Centers for Medicare and Medicaid Services. (2012). Chronic Conditions among Medicare beneficiaries. Retrieved from https://www.cms.gov/research-statistics-data-and-systems/ statistics-trends-and-reports/chronic-conditions/downloads/2012chartbook.pdf 6. Delaware Health and Social Services, Division of Public Health. (2016). Behavioral Risk Factor Survey (BRFS). Retrieved from http://www.dhss.delaware.gov/dph/dpc/diabetes02. html 7. National Center for Health Statistics. (2016). Stats of the State of Delaware. Retrieved from https://www.cdc.gov/nchs/pressroom/states/delaware/delaware.htm 8. Delaware Division of Public Health. (2014). The Burden of Diabetes in Delaware 2014 Update. Retrieved from https://www.dhss.delaware.gov/dhss/dph/dpc/files/de_diabetes_ burden_2014update.pdf 9. Elliott, D. J., Robinson, E. J., Sanford, M., Herrman, J. W., & Riesenberg, L. A. (2011). Systemic barriers to diabetes management in primary care: a qualitative analysis of Delaware physicians. American Journal of Medical Quality, 26(4), 284–290. doi:10.1177/1062860610383332 10. Ammerman, A., Smith, T. W., & Calancie, L. (2014). Practice-based evidence in public health: improving reach, relevance, and results. Annual Review of Public Health, 35(1), 47–63. doi:10.1146/annurev-publhealth-032013-182458 11. Barker, L. E., Kirtland, K. A., Gregg, E. W., Geiss, L. S., & Thompson, T. J. (2011).

Geographic distribution of diagnosed diabetes in the U.S.: a diabetes belt. American Journal of Preventive Medicine, 40(4), 434–439. doi:10.1016/j.amepre.2010.12.019 12. Dwyer-Lindgren, L., Bertozzi-Villa, A., Stubbs, R. W., Morozoff, C., Kutz, M. J., Huynh, C., … Murray, C. J. L. (2016). US County-Level Trends in Mortality Rates for Major Causes of Death, 1980-2014. The Journal of the American Medical Association, 316(22), 2385–2401. doi:10.1001/jama.2016.13645 13. FirstMap Delaware. (2003). Delaware Boundaries County State. Retrieved from https:// firstmap.delaware.gov 14. U.S. Census Bureau. TIGER/Line Shapefiles. (2017). Census Tracts: Delaware.

Retrieved from https://www.census.gov/cgi-bin/geo/shapefiles/index. php?year=2017&layergroup=Census+Tracts 15. Centers for Disease Control and Prevention. (2014). Behavioral Risk Factor Surveillance System. Retrieved from https://www.cdc.gov/brfss/about/index.htm 16. Policy Map (2017). Data Sources. Retrieved from https://www.policymap.com/data/our-datadirectory/ 17. Centers for Disease Control and Prevention. (2013). BRFSS 2013 Survey Data and Documentation. Retrieved from https://www.cdc.gov/brfss/annual_data/annual_2013.html

72 Delaware Journal of Public Health – February 2019

18. U.S. Census Bureau. (2016). American Factfinder, 2012-2016 American Community Survey 5-Year Estimates, Table DP05. Retrieved from https://factfinder.census.gov/faces/ tableservices/jsf/pages/productview.xhtml?src=bkmk 19. Centers for Disease Control Behavioral Risk Factor Surveillance System (2013). Percent of adults ever diagnosed with diabetes in 2013. Policy Map. Retrieved from https://www. policymap.com/maps 20. Centers for Medicare and Medicaid Services (2015). Estimated percent of all people who are medicare fee-for-service beneficiaries in 2015. Policy Map. Retrieved from https://www. policymap.com/maps 21. Delaware Open Data. (2014). Delaware Deaths [Data file]. Retrieved from https://data. delaware.gov/browse 22. U.S. Census Bureau. (2010a). American Factfinder, 2010 American Community Survey 1-Year Estimates, Table B01001A. Retrieved from https://factfinder.census.gov/faces/ tableservices/jsf/pages/productview.xhtml?pid=ACS_10_1YR_B01001A&prodType=table 23. U.S. Census Bureau. (2010b). American Factfinder, 2010 American Community Survey 1-Year Estimates, Table B01001B. Retrieved from https://factfinder.census.gov/faces/ tableservices/jsf/pages/productview.xhtml?pid=ACS_10_1YR_B01001B&prodType=table 24. U.S. Census Bureau. (2010c). American Factfinder, 2010 Demographic Profile Data, Table DP-1. Retrieved from https://factfinder.census.gov/faces/nav/jsf/pages/community_facts. xhtml 25. U.S. Census Bureau. (2000). American Factfinder, Census 2000 Summary File, Table DP1. Retrieved from https://factfinder.census.gov/faces/tableservices/jsf/pages/productview. xhtml?pid=DEC_00_SF1_DP1&prodType=table 26. U.S. Census Bureau. (2000). American Factfinder, Census 2000 Summary File, Table P012A. Retrieved from https://factfinder.census.gov/faces/tableservices/jsf/pages/productview. xhtml?pid=DEC_00_SF1_P012A&prodType=table 27. U.S. Census Bureau. (2000). American Factfinder, Census 2000 Summary File, Table P012B. Retrieved from https://factfinder.census.gov/faces/tableservices/jsf/pages/productview. xhtml?pid=DEC_00_SF1_P012B&prodType=table 28. Morrison, F., Shubina, M., Goldberg, S. I., & Turchin, A. (2013). Performance of primary care physicians and other providers on key process measures in the treatment of diabetes.

Diabetes Care, 36(5), 1147–1152. doi:10.2337/dc12-1382 29. Atlas, S. J., Grant, R. W., Ferris, T. G., Chang, Y., & Barry, M. J. (2009). Patient-physician connectedness and quality of primary care. Annals of Internal Medicine, 150(5), 325–335. doi:10.7326/0003-4819-150-5-200903030-00008 30. O’Connor, P. J., Desai, J., Rush, W. A., Cherney, L. M., Solberg, L. I., & Bishop, D. B. (1998). Is having a regular provider of diabetes care related to intensity of care and glycemic control? The Journal of Family Practice, 47(4), 290–297.

31. National Institute of Diabetes and Digestive and Kidney Diseases. (2017). Current Burden of Diabetes in the U.S. Retrieved from https://www.niddk.nih.gov/health-information/ communication-programs/ndep/health-professionals/practice-transformation-physicianshealth-care-teams/why-transform/current-burden-diabetes-us 32. Curtis, A. B., Kothari, C., Paul, R., & Connors, E. (2013). Using GIS and secondary data to target diabetes-related public health efforts. Public Health Reports (Washington, D.C. : 1974), 128(3), 212–220. doi:10.1177/003335491312800311

Figure 1. Prevalence Rates of Diabetes per 1,000 Adults Compared to the Percent of Adults Reporting to Have a Primary Care Physician Among Delaware Census Tracts, Year 2013

Authors Saheedat Sulaimon, M.P.H., has interests in health care disparities, childrenâ&#x20AC;&#x2122;s health, and health literacy, especially for minorities, and other vulnerable populations. She has experience working with underserved populations and is committed to contributing to the field of public health through her work and educational experiences.

Saheedat received her Bachelor of Science in Biological Sciences with a Minor in Psychology from Southern Methodist University and her Master of Public Health from Thomas Jefferson University, College of Population Health.

Ariel Paz, M.P.H., graduated from the University of Miami with a B.S. in Neuroscience and received her M.P.H. from Thomas Jefferson University. In the Fall of 2019, she will further her knowledge of individual and population health by pursuing a Doctor of Osteopathic Medicine degree. Her understanding of how social determinants of health evoke disease patterns will inform the way she engages in patient care, and her public health lens will help her facilitate an empathic approach to disease prevention and health promotion.

Madeline Brooks, M.P.H., is a research associate in the Value Institute at Christiana Care Health System in Newark, DE. Her work focuses on the use of geographic information systems (GIS) to study population health and health services delivery. She holds a Master of Public Health from Thomas Jefferson University.

Rashida Smith, B.S., is a current Master of Public Health student at Thomas Jefferson University, College of Population Health. She received her B.S. in Biology, minor in Chemistry from Andrews University in Michigan where her passion for public health grew.

Her areas of interest are chronic diseases, vulnerable populations, and maternal and child health.

Figure 2. Percent of Medicare Beneficiaries with Diagnosed Diabetes, Year 2015 73

Figure 3. Diabetes Mortality Rates per 100,000 Adults, by Delaware County: Overall, Black, and White Populations, Year 2014

Table 1: Age-Adjusted Diabetes Mortality Rates, per 100,000 People, by Delaware County: Overall, Black, and White Populations, Year 2014

County Name

Overall Age-Adjusted Diabetes Mortality Rate per 100,000, in 2014

Age-Adjusted Diabetes Mortality Rate per 100,000, Black Population, in 2014

Age-Adjusted Diabetes Mortality Rate per 100,000, White Population in 2014

New Castle

26.53

82.39

46.14

Kent

25.87

64.11

52.72

Sussex

30.75

93.73

55.98

74 Delaware Journal of Public Health â&#x20AC;&#x201C; February 2019

HIGHLIGHTS FROM

The

NATION’S HEALTH A P U B L I C AT I O N O F T H E A M E R I C A N P U B L I C H E A LT H A S S O C I AT I O N

February/March 2019 The Nation’s Health headlines Online-only news from The Nation’s Health newspaper Stories of note include: • APHA annual congressional record: How members of Congress supported public health See how your legislators voted on particular issues of importance to public health during the last session of Congress. Read full story >> • Suicide, opioids tied to ongoing fall in US life expectancy: Third year of drop For the third year in a row, U.S. life expectancy has dropped, mostly due to a rise in so-called “deaths of despair.”

Read full story >> • Focus on nutrition, physical activity at school level can pay off for students School-based interventions can help students reduce weight gain and cut down on unhealthy eating.

Read the story >> • LGBT patients prefer sharing sexual orientation, gender identity in writing When LGBT patients visit the doctor, they’re often more comfortable sharing orientation and gender identity information on forms than speaking about it with providers.

Read full story>> • People who skip cancer screenings more likely to die from other causes People who don’t keep up with cancer screenings may also fail to follow chronic disease prevention guidelines, suggesting behavior differences.

Read full story >> • Hawaii again takes lead spot as healthiest state in US rankings Runners-up in the latest America’s Health Rankings were Massachusetts, Connecticut, Vermont and Utah. Southern states did not fare as well.

Read full story >> • E. coli in produce shows need for better tracking, prevention Recent food poisoning outbreaks involving romaine lettuce have led to a renewed focus on U.S. produce safety.

Read full story >> • Thousands lose coverage from Medicaid work requirements Work requirements for Medicaid can cause people to lose coverage and put their health at risk.

Read full story >> 75

www.fic.nih.gov www.fic.nih.gov

Reprinted with permission from the Fogary International Center

GLOBAL GLOBAL HEALTH HEALTH M M AT AT TERS TERS

JAN/FEB 2019 JAN/FEB 2019

Inside this issue Inside this issue Former Fogarty trainee Former Fogarty trainee builds neurology research builds neurology research training in Zambia . . . p. 5 training in Zambia . . . p. 80

FOGARTY INTERNATIONAL CENTER • NATIONAL INSTITUTES OF HEALTH • DEPARTMENT OF HEALTH AND HUMAN SERVICES FOGARTY INTERNATIONAL CENTER • NATIONAL INSTITUTES OF HEALTH • DEPARTMENT OF HEALTH AND HUMAN SERVICES

New New fellowships fellowships bring bring African African scientists scientists to to train train at at NIH NIH

By Shana Potash

By Shana Potash

FOCUS FOCUS 76 Delaware Journal of Public Health – February 2019

Dr. Nana Amissah from Ghana is training with NIH senior investigator Dr. Otto asfrom partGhana of the new Africanwith Postdoctoral Initiative.

Dr. Michael Nana Amissah is training NIH seniorTraining investigator Dr. Michael Otto as part of the new African Postdoctoral Training Initiative.

that are research priorities in their respective countries, that are research priorities in their respective countries, including infectious diseases, maternal and child health, including infectious diseases, maternal and child health, and diabetes. and diabetes.

“It’s an opportunity to learn new techniques, new skills,” “It’s to learn new techniques, new skills,” said an Dr.opportunity Nana Ama Amissah, a fellow from Ghana who said Dr. Nana a fellow frominvestigator Ghana who is training withAma Dr. Amissah, Michael Otto, a senior is training Dr. Michael a senior with NIH’s with National InstituteOtto, of Allergy andinvestigator Infectious with NIH’s(NIAID), National Institute Allergy and Infectious Diseases who sharesofher research interest Diseases (NIAID), who aureus shares bacterium. her research interestS. in the Staphylococcus Because in the Staphylococcus aureus wounds, bacterium.

Because S.been aureus can reside in chronic Amissah has aureus can reside chronic wounds, hasofbeen investigating if andinhow it might delayAmissah the healing investigating if and how it might delay the healing of buruli ulcers—a potentially devastating skin and tissue buruli ulcers—a potentially devastating skin and tissue infection that is caused by a Mycobacterium ulcerans and infection that isincaused a Mycobacterium ulcerans occurs mainly tropicalbyareas including West Africa.and occurs mainly in tropical areas including West Africa. . . . continued on p. 2 ...continued on next pageon p. 2 . . . continued

Mentorship training in LMICs needs increased support Mentorship training in LMICs needs increased support • New journal supplement serves as guide for enhancing mentorship journal supplement serves guide for enhancing • New Programs must be developed foras implementation in LMICmentorship context • Programs must be developed for implementation in LMIC context Articles detail mentorship competencies, case studies, toolkits • Articles detail mentorship competencies, case studies, toolkits

81– –984 Read more on pages 6 Read more on pages 6 – 9

PhotoPhoto

by Chia-Chi

by Chia-Chi Charlie Charlie Chang Chang for Fogarty for Fogarty

A new NIH fellowship program aims to prepare future A new NIH fellowship aimswhile to prepare future generations of Africanprogram researchers establishing generations of African researchers while NIH establishing ongoing scientific partnerships between labs and ongoinginvestigators scientific partnerships between NIH labs and African and institutions.

The African African investigators institutions.

The African Postdoctoral Trainingand Initiative (APTI) is a collaboration Postdoctoral Training is a collaboration of the NIH, the AfricanInitiative Academy(APTI) of Sciences and the Bill of the NIH, the African Academy of Sciences and the Bill & Melinda Gates Foundation. Fogarty is managing the & Melinda Gates Foundation.

Fogarty is managing the partnership. partnership.

During the four-year fellowships, NIH will provide two During four-year NIH will provide two years ofthe training with fellowships, principal investigators who share years of training withinterests. principal The investigators who share the fellows’ research African scientists will the fellows’ interests.

The African scientists then returnresearch to their home institutions and receive twowill then return to their home institutions receive two years of support to help them continueand their research yearsestablish of support to help them continue their research and themselves as independent investigators. and establish themselves as independent investigators.

Ten fellows chosen for the inaugural cohort will assume Ten fellows chosen for the inaugural willcohort assume their NIH positions by early 2019 andcohort another their NIH positions by earlyin2019 and another cohort is expected to be recruited 2020.

NIH and the Gates is expected to be recruited in 2020.

NIH and the Gates Foundation together are expected to provide about $4 Foundation together are expected to provide about $4 million for the program. million for the program.

“Our goal is to equip these talented African fellows with “Our goal to is become to equipscientific these talented African fellows with the skills leaders, prepared to help the skills to become scientific leaders, prepared to help solve their country’s health challenges and train future solve their country’s health challenges and train generations of researchers,” said NIH Director Dr.future Francis generations of researchers,” NIH Director Dr. Francis S. Collins, whose intramuralsaid research lab will host one S. the Collins, whose research lab will host one of fellows.

“Byintramural designing the African Postdoctoral of the fellows.

“By designing African Postdoctoral Training Initiative to begin atthe NIH and then continue at Training Initiative to begin at NIH and then continue at their home institution, we aim to prevent ‘brain drain,’ their home institution, we aim to prevent ‘brain drain,’ build sustainable research capacity, and establish longbuild sustainable research and establish longterm collaborations betweencapacity, U.S. scientists and African term collaborations between U.S. scientists and African investigators and research institutions.” investigators and research institutions.”

The fellows chosen for the 2019 cohort come from six The fellows chosenGhana, for the Mali, 2019 Nigeria, cohort come from Kenya six African countries: Ethiopia, African countries: Ghana, Nigeria, Kenya and Egypt.

They have beenMali, matched withEthiopia, labs from seven and Egypt.atThey been matched withand labsconditions from seven institutes NIH have and will study diseases institutes at NIH and will study diseases and conditions

JANUARY/FEBRUARY JANUARY/FEBRUARY 2019 2019

New Newfellowships fellowshipsbring bringAfrican Africanscientists scientiststototrain trainatatNIH NIH ...continued from previous pagep.1 . . .. .continued . continued from from p.1

Noting Noting that that Amissah Amissah has has had had interesting interesting results results onon a specific a specific lineage lineage of of S. S. aureus, aureus, Otto Otto said said “she “she can can benefit benefit very very much much from from thethe re-research search environment environment at at thethe NIH NIH right right now now to to digdig deeper.” deeper.”

explains explains it better,” it better,” Amissah Amissah said. said.

The The fellowship fellowship program program targets targets early early career career scientists scientists who who have have doctoral doctoral degrees degrees and and less less than than five five years years of of research research experience. experience.

Candidates Candidates must must also also bebe citizens citizens of of anan African African country country and and employed employed at at one one of of thethe continent’s continent’s academic, academic, research research or or government government institutions. institutions.

During During thethe fellowship, fellowship, Amissah Amissah will will bebe learning learning and and conducting conducting basic basic science science she she couldn’t couldn’t dodo back back at at home. home. is is imperative imperative to to strengthen strengthen African African She She took took courses courses in in molecular molecular biology biology “It“It scientific leadership leadership to to advance advance and and recombinant recombinant DNA DNA technology technology to to scientific health and and development development goals goals onon prepare prepare to to work work with with Otto, Otto, who who is is chief chief health thethe continent. continent.

WeWe areare thrilled thrilled to to of of thethe Pathogen Pathogen Molecular Molecular Genetics Genetics partner partner with with thethe NIH NIH and and thethe African African Section.

Section.

“If “If there’s there’s anything anything I don’t I don’t Academy of of Sciences Sciences to to support support these these understand, understand, I go I go to to him him and and then then hehe Academy

1010 outstanding outstanding researchers researchers working working to to solve solve thethe world’s world’s greatest greatest health health challenges,” challenges,” said said Dr.Dr. Trevor Trevor Mundel, Mundel, President President of of thethe Global Global Health Health Division Division at at thethe Gates Gates Foundation.

Foundation.

“Training “Training from from NIH, NIH, one one of of thethe world’s world’s foremost foremost biomedical biomedical research research institutions, institutions, will will help help these these scientists scientists develop develop thethe transformational transformational solutions solutions thethe world world and and their their communities communities urgently urgently need.” need.”

RESOURCES RESOURCES http://bit.ly/NIHAfricanPostdoc http://bit.ly/NIHAfricanPostdoc

Fogarty’s Fogarty’sBridbord Bridbordcelebrated celebratedfor for35 35years yearsofofservice service The The Fogarty Fogarty family family assembled assembled in in December December to to toast toast Dr.Dr. Ken Ken Bridbord Bridbord and and pay pay tribute tribute to to hishis many many contricontributions butions to to global global health health research research and and training. training.

Although Although Bridbord Bridbord is is retiring retiring from from federal federal employment, employment, hehe will will remain remain at at thethe Center Center asas senior senior scientist scientist emeritus. emeritus.

tific tific leadership leadership in in LMICs, LMICs, resulted resulted in in creation creation of of scientific scientific leaders leaders who who form form thethe backbone backbone of of global global HIV/ HIV/ AIDS AIDS research research today, today, observed observed Yale Yale University’s University’s Dr.Dr. Sten Sten Vermund, Vermund, in in a video a video tribute. tribute.

In In another another taped taped message, message, Fogarty Fogarty grantees grantees in in South South Africa, Africa, Drs. Drs. Salim Salim and and Quarraisha Quarraisha Abdool Abdool Karim, Karim, echoed echoed praise praise forfor “We “We allall stand stand in in awe awe of of your your contricontriBridbord’s Bridbord’s keen keen insight insight and and forwardforwardbutions,” butions,” noted noted Fogarty Fogarty Director Director thinking thinking ideas. ideas.

“This “This legacy legacy you’ve you’ve Dr.Dr. Roger Roger I. Glass.

I. Glass.

“It“It was was anan amazing amazing created—we created—we can can already already seesee thethe fruits fruits joyjoy to to work work with with you you and and experience experience of of it in it in terms terms of of research research leadership leadership in in your your wisdom, wisdom, your your vision vision and and your your developing developing countries countries and and in in soso many many warmth.” warmth.” other other ways ways in in terms terms of of thethe quality quality and and quantity quantity of of research research emanating emanating from from A few A few years years after after joining joining Fogarty, Fogarty, Africa,” Africa,” Quarraisha Quarraisha Abdool Abdool Karim Karim said. said.

Bridbord Bridbord co-chaired co-chaired thethe 1987 1987 International International Conference Conference onon AIDS AIDS held held Speakers Speakers also also paid paid tribute tribute to to in in Washington, Washington, D.C. D.C. That That experience experience Bridbord’s Bridbord’s dedication, dedication, flexibility flexibility inspired inspired him him to to develop develop thethe Center’s Center’s and and patience. patience.

“You “You understood understood that that first first extramural extramural funding funding mechanism— mechanism— building building sustainable sustainable international international thethe AIDS AIDS International International Training Training and and research research and and public public health health capacity capacity Research Research Program Program (AITRP)—designed (AITRP)—designed required required anan investment investment measured measured in in to to help help lowlowand and middle-income middle-income decades, decades, and and notnot in in years,” years,” observed observed countries countries build build thethe capacity capacity to to Dr.Dr. Glenda Glenda Gray, Gray, President President and and CEO CEO respond respond to to HIV/AIDS. HIV/AIDS. of of thethe South South African African Medical Medical Research Research Council.

Council.

Bridbord’s Bridbord’s vision vision that that NIH NIH field field research research could could bebe advanced advanced byby AITRP AITRP provided provided thethe model model forfor investing investing in in developing developing local local sciensciennumerous numerous other other Fogarty Fogarty initiatives, initiatives,

22

resulting resulting in in a portfolio a portfolio of of programs programs that that has has supported supported training training forfor more more than than 6,000 6,000 scientists scientists globally globally and and currently currently awards awards $60 $60 million million each each year. year.

In In this this way, way, Bridbord Bridbord has has influenced influenced countless countless numbers numbers of of research research careers careers and and touched touched virtually virtually every every discovery discovery in in HIV, HIV, observed observed Dr.Dr. Mike Mike Cohen, Cohen, who who was was principal principal investigator investigator onon thethe University University of of North North Carolina’s Carolina’s AITRP AITRP grant. grant.

Earlier Earlier in in hishis career, career, Bridbord Bridbord played played a critical a critical role role in in convincing convincing thethe Environmental Environmental Protection Protection Agency Agency to to remove remove lead lead from from gasoline. gasoline.

“That “That was was a huge a huge triumph triumph forfor public public health,” health,” according according to to Dr.Dr. Phil Phil Landrigan Landrigan of of Boston Boston College, College, Bridbord’s Bridbord’s partner partner in in thethe effort. effort.

Fogarty Fogarty staff staff also also expressed expressed their their appreciation. appreciation.

AsAs a mentor, a mentor, Bridbord Bridbord saw saw thethe best best in in everyone, everyone, took took time time to to listen listen and and didn’t didn’t micromanage, micromanage, said said Dr.Dr. Josh Josh Rosenthal.

Rosenthal.

Bridbord Bridbord could could bebe summed summed upup in in a single a single word—charismatic, word—charismatic, according according to to Dr.Dr. Joel Joel Breman.

Breman.

Dr.Dr. Flora Flora Katz Katz observed observed Bridbord Bridbord takes takes great great pride pride in in hishis work work and and “believes “believes in in thethe nobility nobility of of public public service.” service.”

77

JANUARY/FEBRUARY 2019

Conference seeks to advance women in global health

By Karin Zeitvogel

A woman health worker in rural India was gang-raped “to teach her a lesson” after she promoted contraception, family planning and education for girls. Women working on polio vaccination campaigns have been abducted and killed. And one of the world’s few women health ministers was asked during congressional testimony if she was married or single. The male lawmaker asking the question said the answer would indicate to him and his colleagues if the minister had ever had “a good night.”

“ If they don’t give you a seat at the table, pull up a

folding chair. If they don’t let you pull up your folding chair, sit on the table.

”

— DR. AYOADE OL ATUNBOSUN- AL AKIJA, CHIEF HUMANITARIAN COORDINATOR, NIGERIA Change has to start at the base of the pyramid and cover every level of caregiver and recipient, conference-goers were told. “We need leaders and excellent foot soldiers,” said Dr. Wafaa el-Sadr, a professor at Columbia University and member of Fogarty’s advisory board. “Everyone within an organization needs to be transformed.” All women need access to quality health care, and organizations need to revisit their messaging about women’s health, said Dr. Joanne Liu, the international president of Médecins Sans Frontières (MSF). “If we don’t improve access to health care for women, we’re always going to be running behind a train that is moving faster,” Liu said. Three-quarters of patients who go to MSF hospitals are women seeking care for a pregnancy-related issue or to give birth, she added.

“But we never talk about that. We talk about the warwounded, about Ebola, never about women coming in to deliver and being safe and well cared for.”

All leaders, male and female, need to be able to inspire others “to pursue a common mission that’s higher than yourself and the people you’re trying to lead,” said the Bill & Melinda Gates Foundation’s Dr. Anita Zaidi, who is also the principal investigator on a Fogarty-supported project 78 Delaware Journal of Public Health – February 2019

Participants at the recent Women Leaders in Global Health conference explored barriers to progress, such as those experienced in Peru by Fogarty grantee and former health minister, Dr. Patty Garcia (on right).

David Snyder for Fogarty

Those were some of the stories heard by the 900, mainly female attendees at the second Women Leaders in Global Health (WLGH) conference, held in London in November.

Despite women making up around three-quarters of the global health workforce, often serving on the frontlines of a health crisis or providing unpaid care for a family member, they hold less than a quarter of global health leadership positions, noted former Fogarty trainee Dr. Soumya Swaminathan, who is now WHO Deputy DirectorGeneral for Programmes.

on children’s health. Women in leadership positions can have a broad impact, said former Fogarty trainee, Dr. Patty Garcia, who was health minister of Peru from 2016-17. During her 15 months in office, Garcia successfully pushed to allow contraception from the age of 14 to tackle Peru’s teen pregnancy problem, and changed the way Peru screens for cervical cancer. “We now have molecular testing and self-testing so women can be empowered taking their own samples,” Garcia told the conference. But change didn’t come without a struggle. “I got into a big fight with male physicians— they didn’t want empowerment,” said Garcia—the woman health minister who was asked about her marital status.

Women leaders need to be assertive to overcome resistance to being included in top-level conversations, said Dr. Ayoade Olatunbosun-Alakija, Nigeria’s chief humanitarian coordinator. “There’s an urgency—we don’t have time to wait around and be invited,” she said. “If they don’t give you a seat at the table, pull up a folding chair. If they don’t let you pull up your folding chair, sit on the table.”

The conference, part of the Women Leaders in Global Health Initiative, was hosted by the London School of Hygiene and Tropical Medicine. The 2019 WLGH conference is set to take place in November in Rwanda.

RESOURCE Website: www.wlghconference.org

3

PPPPRRRROOOOFFFFIII LILLLEEEE FogartyFellow Fellow studies studies Fogarty Fogarty FogartyFellow Fellowstudies studies kidney disease in India kidney kidney disease diseasein ininIndia India India kidney disease

By Shana Potash By Shana Shana Potash Potash ByBy Shana Potash Dr. Shuchi Anand, who was born in India and Dr. Dr. Shuchi Shuchi Anand, Anand, who who was was born born in in India India and and Dr. Shuchi Anand, who was born in and moved to the U.S. with her family atIndia age 12, noticed moved moved to to the the U.S. U.S. with with her her family family at at age age 12, 12, noticed noticed moved to theduring U.S. with her family at age 12,with noticed something a return visit that stuck her. “As something something during during a return a return visit visit that that stuck stuck with with her. her.

“As “As I was becoming aware of the distinctly something duringmore a return visit thatworld, stuckI with her.

“As I was I was becoming becoming more more aware aware of of the the world, world, I distinctly I distinctly remember visiting someone inthe theworld, hospital in India, in I was becoming more aware of I distinctly remember visiting visiting someone someone in thethe hospital hospital in India, in India, India, in in myremember hometown, and seeing the disparity in in care,” shein remember visiting someone ininthe hospital my my hometown, hometown, and and seeing seeing the the disparity disparity in in care,” care,” she she said.

“It was really heartbreaking.” my hometown, and seeing the disparity in care,” she said. said.

“It was was really really heartbreaking.” heartbreaking.” said.

“It“Itwas really heartbreaking.”

Years later, as she pursued a medical degree, a master’s Years later, later, asshe as she she pursued pursued medical a medical degree, degree, master’s a master’s in Years clinical epidemiology andaapostdoctoral training Years later, as pursued medical degree, aa master’s in in clinical clinical epidemiology epidemiology and and postdoctoral postdoctoral training training nephrology at U.S. institutions, Anandtraining seized inin clinical epidemiology and postdoctoral in in nephrology nephrology at at U.S. U.S. institutions, institutions, Anand Anand seized seized every opportunity she could to work in developing in nephrology at U.S. institutions, Anand seized every every opportunity opportunity she she could could to to work work in in developing developing countries and gain experience in global health. A every opportunity she could to work in developing countries countries and and gain gain experience experience in in global global health. health.

A A Fogarty fellowship took her back to India—to countries and gain experience in global health.the A Fogarty Fogarty fellowship fellowship took took her her back back to to India—to India—to the the Centrefellowship for Chronic Disease Control (CCDC), athe research Fogarty took her back to India—to Centre Centre for for Chronic Chronic Disease Disease Control Control (CCDC), (CCDC), a research a research organization in New Delhi where, the amentorship Centre for Chronic Disease Controlunder (CCDC), research organization organization in in New New Delhi Delhi where, where, under under the the mentorship mentorship of director Dr. Dorairaj Prabhakaran, Anand studied organization in New Delhi where, under the mentorship of of director director Dr. Dr. Dorairaj Dorairaj Prabhakaran, Prabhakaran, Anand studied studied prevalence and risk factors for chronicAnand kidney disease of director Dr. Dorairaj Prabhakaran, Anand studied prevalence prevalence and and risk risk factors factors for for chronic chronic kidney kidney disease disease (CKD), a condition most commonly caused by diabetes prevalence and risk most factors for chronic kidney disease (CKD), (CKD), a condition a condition most commonly commonly caused caused by by diabetes diabetes and high blood pressure.

(CKD), ahigh condition most commonly caused by diabetes and and high blood blood pressure. pressure. and high blood pressure.

“It is a significant problem in terms of chronic disease “It “It is is a significant ainsignificant problem problem in in terms terms of chronic chronic disease disease burden low-resource settings, andofin India in “Itburden isburden a significant problem in terms of in chronic disease in in low-resource low-resource settings, settings, and and in India India in in particular, where there’s a lot of diabetes,” Anand burden in low-resource settings, in India inlittle particular, particular, where where a lot a lot of and of diabetes,” diabetes,” Anand Anand noted.

At the timethere’s ofthere’s her fellowship, there was particular, where there’s a lot of diabetes,” Anand noted. noted.

At At the the time time of of her her fellowship, fellowship, there there was was little data on CKD in India and most of her time waslittle spent noted.

At the time of her fellowship, there was little data data on on CKD CKD in in India India and and most most of of her her time time was was spent spent helping to fill that gap. data on CKD in India and helping helping to to fill fill that that gap. gap. most of her time was spent helping fill that Anandto worked ongap. a large project, the Center for Anand Anand worked worked onRisk on a large a Reduction large project, project, the Center Center forfor Cardiometabolic inthe South Asia Anand worked on a large project, the Center for Cardiometabolic Cardiometabolic Risk Risk Reduction Reduction in in South South Asia Asia (CARRS) Surveillance Study, which through clinic and Cardiometabolic Risk Reduction inrelated South Asia (CARRS) (CARRS) Surveillance Surveillance Study, Study, which which through through clinic clinic and and home visits gathered information to diabetes, home home visits visits gathered gathered information information related related to to diabetes, diabetes, (CARRS) Surveillance Study, which through clinic and cardiovascular disease and CKD from thousands of cardiovascular cardiovascular disease disease and and CKD CKD from from thousands thousands of of home visits gathered information related to diabetes, people in three large South Asian cities—New Delhi people people in in three three large large South South Asian Asian cities—New cities—New Delhi Delhi cardiovascular and CKD from thousands and Chennai, disease India and Karachi, Pakistan.

Anandof and and Chennai, India India and and Karachi, Karachi, Pakistan.

Pakistan.

Anand Anand to people inChennai, three interviewers large South Asian Delhi accompanied as theycities—New went door-to-door accompanied accompanied interviewers interviewers as as they they went went door-to-door door-to-door to to and Chennai, Indiainand Karachi, Pakistan.

Anand data. conduct surveys India and then helped analyze conduct conduct surveys surveys in in India India and and then then helped helped analyze analyze data. data.

A 2015 paper on which Anand was the door-to-door lead author to accompanied interviewers as they went A 2015 A 2015 paper paper on which which Anand Anand was was the the lead lead author author estimated one on inin 12 people living in New Delhi anddata. conduct surveys India and then helped analyze estimated estimated one one in in 12 12 people people living living in in New New Delhi Delhi and and have of CKD, with mellitus, A Chennai 2015 paper onevidence which Anand was thediabetes lead author Chennai Chennai have have evidence evidence of of CKD, CKD, with with diabetes diabetes mellitus, mellitus, pre-diabetes put them risk of estimated one and in 12hypertension people livingthat in New Delhiat and pre-diabetes pre-diabetes and and hypertension hypertension that that put put them them at at risk risk of of a heart attack, end-stage renal with death or other adverse Chennai have evidence of CKD, diabetes mellitus, a heart a heart attack, attack, end-stage end-stage renal renal death death or or other other adverse adverse outcomes. and hypertension that put them at risk of pre-diabetes outcomes. a outcomes. heart attack, end-stage renal death or other adverse “I sort of grew with Dr. Prabhakaran’s center because outcomes.

“I sort “I sort of of grew grew with Dr. Dr. Prabhakaran’s Prabhakaran’s center center because because this was one ofwith their major population-based surveys, this this was was one one of of their their major major population-based population-based surveys, surveys, “I sort of grew with Dr. Prabhakaran’s center because 4 this 4 4was one of their major population-based surveys,

4

Shuchi Anand, M.D., M.S. Shuchi Shuchi Anand, Anand, M.D., M.D., M.S. M.S. Anand, M.D., M.S. Fogarty Fellow: 2012-2013 Fogarty Fogarty Fellow: Fellow: Fogarty Fellow: Fellowship at: Fellowship Fellowship at: Fellowship at:at: U.S. partners: U.S. U.S. partners: partners: U.S. partners: Research focus: Research Research focus: focus: Research focus:

2012-2013 2012-2013 2012-2013 Centre for Chronic Disease Control, India Centre Centre for for Chronic Chronic Disease Disease Control, Control, India India Centre Chronic Disease Control, India Stanfordfor University and University of California, Berkeley Stanford Stanford University University and and University University ofofCalifornia, ofCalifornia, California, Berkeley Berkeley Stanford University and University Berkeley Chronic kidney disease in developing regions Chronic Chronic kidney kidney disease disease inindeveloping indeveloping developing regions regions Chronic kidney disease regions

their first one. And it’s the first one that has been their their first first one. one.

And And it’son it’s the the first first one one that that has has been been rigorously conducted chronic diseases in India,” their first one.

And it’s the first one that has been Anand rigorously rigorously conducted conducted on on chronic chronic diseases diseases in in India,” India,” Anand Anand said of the conducted exposure the provided. was able rigorously onfellowship chronic diseases inShe India,” Anand said said of of the the exposure exposure the the fellowship fellowship provided. provided.

She She was was able able to watch and learn how team trained interviewers said of the exposure thethe fellowship provided.

She was able to to watch watch and and learn learn how how the the team team trained trained interviewers interviewers to interact with study participants and pose survey to watch and learn how the team trained interviewers to to interact interact with with study study participants participants and and pose pose survey survey questions, and she learned how to manage, store and to interact with study participants and pose survey questions, questions, and and she she learned learned how how to to manage, manage, store store and and analyze the data that was collected. Anand also gained questions, and she learned how to manage, store and analyze analyze the the data data that that was was collected. collected.

Anand Anand also also gained gained experience as an editor by working with Dr. Prabhakaran, analyze the data that was collected. Anand also gained experience experience asas anan editor by working working with with Dr.Dr. Prabhakaran, Prabhakaran, who was co-editor ofeditor theby kidney disease volume of Disease experience as an editor by working withvolume Dr. Prabhakaran, who who was was co-editor co-editor of of the the kidney kidney disease disease volume of of Disease Disease Control Priorities, third edition. who wasPriorities, co-editor ofthird theedition. kidney Control Control Priorities, third edition.disease volume of Disease Control Priorities, third edition.

The Fogarty fellowship segued into an NIH career The The Fogarty Fogarty fellowship fellowship segued into into an NIH NIH career career development grant thatsegued allowed her toan expand upon her The Fogarty fellowship segued into anto NIH career development development grant grant that that allowed allowed her her to expand expand upon her her work in India. With support from the National upon Institute development grant that allowed her to expand upon her work work in in India.

India.

With With support support from from the the National National Institute Institute of Diabetes and Digestive and Kidney Diseases, Anand work in India.

With support from theepidemiology National Institute of of Diabetes Diabetes and and Digestive Digestive and and Kidney Diseases, Diseases, Anand Anand conducted mentored research onKidney the and of Diabetes and Digestive and Kidney Diseases, Anand conducted conducted mentored mentored research research on on the the epidemiology epidemiology and and management of CKD in South Asians and found, for conducted mentored research on the epidemiology and management management of of CKD CKD in in South South Asians Asians and and found, found, for for example, that the prevalence of CKD among people in management CKD in and for example, example, that that the the prevalence prevalence of CKD CKD among among people people in into urban India isof similar to South that of ofAsians Indians whofound, emigrated example, that the prevalence of CKD among people in to to urban urban India India is is similar similar to to that that of of Indians Indians who who emigrated emigrated the U.S., but those living in India are more likely to face urban India is similar to that of Indians who emigrated the the U.S., U.S., but but those those living living in in India India are are more more likely likely to to face faceto worse outcomes. the U.S., but those living in India are more likely to face worse worse outcomes. outcomes. worse outcomes.

“My findings are hopefully going to help with health “My “My findings areare hopefully hopefully going going to to help help with health health systemfindings planning and development.

What iswith the true system system planning planning and and development. development.

What What is is the the true true “My findings are hopefully to help with What health burden of kidney disease ingoing their population? are burden burden of of kidney kidney disease disease in in their their population? population?

What What areare system planning and development.

What is the true the types of outcomes their population is experiencing? the the types types of of outcomes outcomes their their population population is is experiencing? experiencing? burden kidney in their population?

What are And howofcan they disease try to prevent most adverse outcomes?”

And And how how can they they try try totheir to prevent prevent most most adverse adverse outcomes?” outcomes?”

Anand said.

“It also has implications for population health the types ofcan outcomes population is experiencing?

Anand Anand said. said.

“It “It also also has has implications implications for for population population health health in the U.S. because weto have a South Asian minority And how can they try prevent most adverse outcomes?” in in the the U.S. U.S. because because we we have have a South a South Asian Asian minority minority population that has facesimplications similar risk for to kidney disease Anand said.here “It also population health population here here that that faces faces similar similar risk risk toare to kidney kidney disease aspopulation people in India and those risks aminority bit disease different in the U.S.living because we have a South Asian as as people people living living in in India India and and those those risks risks are are a bit a bit different different than the Caucasian or African American population.” population here that faces similar risk to kidney disease than than the the Caucasian Caucasian or or African African American American population.” population.” as people living in India and those risks are a bit different

than the Caucasian or African American population.”

RESOURCE RESOURCE RESOURCE http://bit.ly/FellowCKDstudy http://bit.ly/FellowCKDstudy http://bit.ly/FellowCKDstudy RE S OURC E

http://bit.ly/FellowCKDstudy

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QQ&&AA

OMAR SIDDIQI, M.D. M.P.H. OMAR OMARSIDDIQI, SIDDIQI,M.D. M.D.M.P.H. M.P.H.

Dr. Omar Siddiqi first visited Zambia in 2005 when he was a neurology resident at Beth Israel Dr.Dr. Omar Omar Siddiqi Siddiqi firstfirst visited visited Zambia Zambia in in 2005 2005 when when hehe was was a neurology a neurology resident resident at at Beth Beth Israel Israel Deaconess Medical Center, to explore the possibilities of doing global health neurology research Deaconess Deaconess Medical Medical Center, Center, to to explore explore thethe possibilities possibilities of of doing doing global global health health neurology neurology research research there. Named a Fogarty International Clinical Research Fellow in 2010, he moved to the there. there.

Named Named a Fogarty a Fogarty International International Clinical Clinical Research Research Fellow Fellow in in 2010, 2010, hehe moved moved to to thethe southern African country and has been there ever since. In 2018, he helped launch Zambia’s first southern southern African African country country and and hashas been been there there ever ever since. since.

In In 2018, 2018, hehe helped helped launch launch Zambia’s Zambia’s firstfirst neurology research training program. Siddiqi is an assistant professor of neurology at Harvard neurology neurology research research training training program. program.

Siddiqi Siddiqi is an is an assistant assistant professor professor of of neurology neurology at at Harvard Harvard Medical School, the Director of the Global Neurology Program at Beth Israel Deaconess Medical Medical Medical School, School, thethe Director Director of of thethe Global Global Neurology Neurology Program Program at at Beth Beth Israel Israel Deaconess Deaconess Medical Medical Center, and a lecturer at the University of Zambia.

Center, Center, and and a lecturer a lecturer at at thethe University University of of Zambia.

Zambia.

What impact has Fogarty had onon your career?

What What impact impact has has Fogarty Fogarty had had on your your career? career?

Fogarty was the spark that made everything else Fogarty Fogarty was was thethe spark spark that that made made everything everything else else happen.

When I first went to Zambia in 2005, there were happen. happen.

When When I first I first went went to to Zambia Zambia in in 2005, 2005, there there were were few, if any, mechanisms outside of Fogarty that allowed few, few, if any, if any, mechanisms mechanisms outside outside of of Fogarty Fogarty that that allowed allowed me to combine neurology research and global health. meme to to combine combine neurology neurology research research and and global global health. health.

II I was able to return to Zambia in 2010 as a Fogarty fellow was was able able to to return return to to Zambia Zambia in in 2010 2010 asas a Fogarty a Fogarty fellow fellow with an early career scientist’s award, and prove there with with anan early early career career scientist’s scientist’s award, award, and and prove prove there there are important research questions relevant toto lowand areare important important research research questions questions relevant relevant to lowlowand and middle-income countries (LMICs) and the U.S. middle-income middle-income countries countries (LMICs) (LMICs) and and thethe U.S. U.S.

answer important diagnosis and management questions, answer answer important important diagnosis diagnosis and and management management questions, questions, soso the U.S. looks data from countries like Zambia so the the U.S. U.S. looks looks tototo data data from from countries countries like like Zambia Zambia toto to help guide how to treat its TB meningitis patients. help help guide guide how how to to treat treat itsits TBTB meningitis meningitis patients. patients.

How has mentorship influenced your career?

How How has has mentorship mentorship influenced influenced your your career? career?

Mentorship has been critical.

When II started out Mentorship Mentorship has has been been critical. critical.

When When I started started out out onon on this career path, I didn’t know anything about funding this this career career path, path, I didn’t I didn’t know know anything anything about about funding funding opportunities, about how balance the opportunities, opportunities, about about how how toto to balance balance a acareer a career career inin in the the U.S. with something overseas.

But my mentors—Dr. U.S. U.S. with with something something overseas. overseas.

But But mymy mentors—Dr. mentors—Dr. Gretchen Birbeck, who has been doing neurology research Gretchen Gretchen Birbeck, Birbeck, who who has has been been doing doing neurology neurology research research What research question did you investigate? inin Zambia since 2001, and Dr. Igor Koralnik, then What What research research question question did did you you investigate? investigate? in Zambia Zambia since since 2001, 2001, and and Dr. Dr. Igor Igor Koralnik, Koralnik, then then II studied the causes of of infections inin the brain inin the HIV the director the HIV/Neurology Center my home studied I studied thethe causes causes of infections infections in the the brain brain in the the HIV HIV the the director director ofofof the the HIV/Neurology HIV/Neurology Center Center atat at my my home home population, mainly meningitis and encephalitis.

AtAt the institution, Beth Israel Deaconess Medical Center—took population, population, mainly mainly meningitis meningitis and and encephalitis. encephalitis.

At the the institution, institution, Beth Beth Israel Israel Deaconess Deaconess Medical Medical Center—took Center—took time there was just neurologist, from the former me under their wings and gave me sound advice: Start time time there there was just one one neurologist, neurologist, from from the the former former me me under under their their wings wings and and gave gave me me sound sound advice: advice: Start Start Soviet Union, working Zambia, and scant information by finding question you’re interested that’s Soviet Soviet Union, Union, working in in Zambia, Zambia, and and scant scant information information by by finding finding aaresearch aresearch research question question you’re you’re interested interested in,in, in, that’s that’s about my research despite the country’s huge relevant the setting, and that you can carry through about about mymy research topic, topic, despite despite the the country’s country’s huge huge relevant relevant tototo the the setting, setting, and and that that you you can can carry carry through through burden of of tuberculosis meningitis inin the HIV population. toto completion. writing grants with Igor and burden burden tuberculosis meningitis meningitis in the the HIV HIV population. population. to completion. completion.

I Istarted Istarted started writing writing grants grants with with Igor Igor and and We got very good data published paper.

WeWe gotgot very very good data and and published published aa paper. a paper. eventually got support from Fogarty, along with several eventually eventually gotgot support support from from Fogarty, Fogarty, along along with with several several others. others. others.

What are thethe key outcomes ofof your research?

What What are key outcomes outcomes of your your research? research?

We’ve We’ve classified classified full full spectrum spectrum of neurological neurological We’ve classified thethe spectrum of of neurological diseases diseases HIV population population and and found found that that there’s there’s diseases in in thethe HIV population and found that there’s huge a huge neurological disease disease burden burden outside outside of HIV HIV in aa huge neurological disease burden outside ofof HIV inin LMICs. LMICs. This has helped to to spur spur the the neurology neurology training training LMICs. This has helped spur the neurology training program program wewe launched launched in in Zambia Zambia in October October 2018, 2018, which which program Zambia inin October 2018, which will will put put more more boots boots on on the the ground ground and and allow allow us us to to see see will put ground and allow us to see the the disease disease processes processes in in various various parts parts of of the the country. country. the disease various parts of the country.

In In thethe first first year year of of the the program, program, there there were were three three adult adult In the first year of the program, there were three adult and and two two pediatric pediatric neurologists neurologists in training, training, all of them them and two pediatric neurologists inin training, allall ofof them from from Zambia.

Zambia.

This This training training program program will will enrich enrich the the from Zambia.

This training program will enrich the research research environment environment in Zambia Zambia and and allow allow us to look look research environment in in Zambia and allow usus toto look at at neurological neurological diseases diseases in more more detail, detail, build build capacity, capacity, at neurological diseases in in more detail, build capacity, and and answer answer research research questions questions that that help help LMICs LMICs and and and answer research questions that help LMICs and countries countries like like the the U.S. U.S. countries like the U.S.

How How does does research research in Zambia Zambia benefit benefit the the U.S.?

U.S.?

How does research inin Zambia benefit the U.S.?

A lot lot A lot of of thethe diagnostic diagnostic technologies technologies for TB meningitis meningitis A of the diagnostic technologies forfor TBTB meningitis have have been been rolled rolled out out in in LMICs, LMICs, where where the the disease disease have been rolled out in LMICs, where the diseaseisisis highly highly prevalent. prevalent.

TBTB meningitis meningitis occurs occurs in in the U.S., U.S., but but highly prevalent.

TB meningitis occurs in the the U.S., but not not with with thethe critical critical mass mass of of patients patients that that you you need need to to not with the critical mass of patients that you need to 80 Delaware Journal of Public Health – February 2019

What What are are your your goals goals for for neurology neurology inin in Zambia?

Zambia?

What are your goals for neurology Zambia?

In 10-20 10-20 years, years, I’d I’d like like toto to have have a aneuroscience aneuroscience neuroscience institute institute InIn 10-20 years, I’d like have institute with with advanced advanced diagnostics diagnostics and and research research facilities, facilities, where where with advanced diagnostics and research facilities, where Zambians Zambians would would receive receive training training and and local local neuroscientists neuroscientists Zambians would receive training and local neuroscientists would would conduct conduct research. research.

People People from from neighboring neighboring would conduct research.

People from neighboring countries countries that that lack lack neurology neurology training training programs, programs, such such asas as countries that lack neurology training programs, such Botswana, Botswana, Zimbabwe Zimbabwe and and Mozambique, Mozambique, would would come come toto to Botswana, Zimbabwe and Mozambique, would come the the institute institute for for training. training.

South South Africa Africa does does this this quite quite well well the institute for training.

South Africa does this quite well but but Africa’s Africa’s huge, huge, soso so you you need need more more than than one one country country toto to but Africa’s huge, you need more than one country provide provide training training for for others. others. provide training for others.

How How has has neurology neurology advanced advanced inin in LMICs? LMICs? How has neurology advanced LMICs?

When When I Ifirst Ifirst first got got tototo Zambia, Zambia, they they had had nono no neuroimaging, neuroimaging, When got Zambia, they had neuroimaging, they they were were doing doing rudimentary rudimentary testing testing on on spinal spinal fluid, fluid, there there they were doing rudimentary testing on spinal fluid, there were were no no advanced advanced neurological neurological tests, tests, no no training training program. program. were no advanced neurological tests, no training program.

Now, Now, we we have have aatraining atraining training program, program, a aCT aCT CT scanner, scanner, anan an MRI MRI Now, we have program, scanner, MRI scanner, scanner, aafully afully fully functioning functioning neurophysiology neurophysiology lab, lab, and and a aa scanner, functioning neurophysiology lab, and neurology neurology clinic clinic where where we we see see up up to to 60 60 patients patients a day. a day. neurology clinic where we see up to 60 patients a day.

We’ve We’ve moved moved mountains. mountains.

It’sIt’s enormous progress progress and and it’sit’s We’ve moved mountains.

It’senormous enormous progress and it’s been been catalyzed catalyzed byby NIH NIH support. support. been catalyzed by NIH support.

55 5

FOCUS FFOOCCUUSS

Mentorship training in LMICs needs increased support Men Mentorship torshiptraining trainingininLMICs LMICsneeds needsincreased increasedsupport support

By Shana Potash

By By Shana Shana Potash Potash

WW W

Photo by Richard Lord for Fogarty

PhotoPhoto

by Richard LordLord for Fogarty

by Richard for Fogarty

hether helping young scientists shape their careers, conduct ethical research, or define a work-life hether hether helping helping young young scientists scientists shape shape their their careers, careers, balance, mentors are instrumental conduct conduct ethical ethical research, research, or or define define ain work-life a nurturing work-life future balance, generations of global health researchers.

But balance, mentors mentors areare instrumental instrumental in in nurturing nurturing in future low-generations and middle-income countries (LMICs), formal future generations of of global global health health researchers. researchers.

But But mentoring is not often adequately supported by in in lowlowand and middle-income middle-income countries countries (LMICs), (LMICs), formal formal institutions included in formal supported training programs.

To mentoring mentoring is or is not not often often adequately adequately supported byby encourage LMIC organizations to training strengthen mentoring institutions institutions or or included included in in formal formal training programs. programs.

ToTo and institutionalize the practice, Fogarty-funded authors encourage encourage LMIC LMIC organizations organizations to to strengthen strengthen mentoring mentoring produced a new publication to serve as a guide. authors and and institutionalize institutionalize thethe practice, practice, Fogarty-funded Fogarty-funded authors produced produced a new a new publication publication to to serve serve asas a guide. a guide.

The supplement to the American Journal of Tropical The The supplement supplement to to thethe American American Journal Journal of of Tropical Tropical Medicine and Hygiene offers recommendations, case Medicine Medicine and and Hygiene Hygiene offers offers recommendations, recommendations, case case studies and an overview of toolkits to help design studies studies and and an an overview overview of of toolkits toolkits to to help help design design mentorship programs tailored to LMICs. The publication mentorship mentorship programs programs tailored tailored to to LMICs. LMICs. The The publication publication

was inspired by a series of “Mentoring the Mentor” workshops hosted in LMICs by faculty ofMentor” Fogarty’s was was inspired inspired byby a series a series of of “Mentoring “Mentoring thethe Mentor” Global Health Program for Fellows Scholars.

It was Global edited by workshops workshops hosted hosted in in LMICs LMICs byand by faculty faculty of of Fogarty’s Fogarty’s Global Dr. Craig Cohen, Co-director ofScholars. the University of California Health Health Program Program forfor Fellows Fellows and and Scholars.

It was It was edited edited byby Global Health Institute in San Francisco.

More than 40 Dr. Dr. Craig Craig Cohen, Cohen, Co-director Co-director of of the the University University of of California California leaders in global health from around theMore world contributed Global Global Health Health Institute Institute in in San San Francisco.

Francisco.

More than than 4040 to develop and publish the special issue. leaders leaders in in global global health health from from around around thethe world world contributed contributed to to develop develop and and publish publish thethe special special issue. issue.

“Great mentors are not born. Mentoring skills, like any other, must beare developed,” Fogarty Director Dr. Roger “Great “Great mentors mentors are notnot born. born.

Mentoring Mentoring skills, skills, like like any any other, must must beDr. be developed,” developed,” Fogarty Fogarty Director Director Dr. Roger Roger I.other, Glass and Flora Katz, director of theDr. Center’s extraI. mural Glass I. Glass and and Dr.Dr. Flora Flora Katz, Katz, director director of of the Center’s Center’s extraextraprograms, note in the preface to the the supplement. mural mural programs, note note in in thethe preface preface to to thethe supplement. supplement.

“It is programs, our hope this collection of articles will provide a “Itstimulus “It is is our our hope hope this this collection collection of of articles articles will will provide provide a a for increased funding to fill this critical need.” stimulus stimulus forfor increased increased funding funding to to fillfill this this critical critical need.” need.”

Mentorship training must be expanded and given more institutional support in lowand middle-income countries, according to amore new publication bysupport FogartyMentorship Mentorship training training must must be be expanded expanded andand given given more institutional institutional support in in supported authors. lowlowandand middle-income middle-income countries, countries, according according to atonew a new publication publication by by FogartyFogartysupported supported authors. authors.

Formal Formal mentoring mentoring is is notnot yetyet common common practice practice in in many many of of the LMIC institutions that conduct global health research. the the LMIC LMIC institutions institutions that that conduct conduct global global health health research. research.

However, a growing number of their scientists are However, However, a growing aingrowing number number of of their their scientists scientists areare interested mentorship, and there is a strong need for interested interested in in mentorship, mentorship, and and there there is is a strong a strong need need forfor it, according to supplement authors. They emphasize the it,importance it, according according to to supplement supplement authors. authors.

They They emphasize emphasize thethe of creating programs in the context of LMICs, importance importance of the of creating creating programs programs in in thethe context context of of LMICs, LMICs, considering availability of resources and the culture considering considering the the availability availability of of resources resources and and the the culture culture within the institution and the country. “The advancement within thethe institution institution and and the the country. country.

“The “The advancement advancement ofwithin global health research demands sustained career ofdevelopment of global global health health research research demands demands sustained sustained career opportunities for LMIC scientistscareer that can development development opportunities opportunities forfor LMIC LMIC scientists scientists that can can only be attained via the implementation and that dissemination only only be be attained attained via via the the implementation implementation and and dissemination dissemination of culturally compatible mentoring practices.” of of culturally culturally compatible compatible mentoring mentoring practices.” practices.”

Mentoring in the context of LMICs Mentoring Mentoring inin the the context context ofof LMICs LMICs Formal mentoring is not yet common practice in many of

While the existing guidance for successful mentoring While While thethe existing existing guidance guidance forfor successful successful mentoring mentoring is more in line with high-income settings, the authors is is more more in in line line with with high-income high-income settings, settings, thethe authors authors describe how to adapt it, and address the challenges of describe describe how how to to adapt adapt it, it, and and address address thethe challenges challenges of of implementing mentorship programs in LMICs. Institutions, implementing implementing mentorship mentorship programs programs in in LMICs. LMICs. Institutions, Institutions, for example, may not recognize or compensate faculty forfor example, example, may may notnot recognize recognize or or compensate compensate faculty faculty for their mentoring activities, making it financially forfor their their mentoring mentoring activities, activities, making making it financially it financially unrewarding. Education approaches that reflect a unrewarding. unrewarding.

Education Education approaches approaches that that reflect reflect a a country’s history or culture may be more authoritarian, country’s country’s history history or or culture culture may may bebe more more authoritarian, authoritarian, hierarchal or paternalistic and could potentially deter hierarchal hierarchal or or paternalistic paternalistic and and could could potentially potentially deter deter junior scientists from disagreeing or bonding with their junior junior scientists scientists from from disagreeing disagreeing or or bonding bonding with with their their more senior mentor. And the male-dominated academic more more senior senior mentor. mentor.

And And thethe male-dominated male-dominated academic academic culture that is common among LMIC institutions can deter culture culture that that is is common common among among LMIC LMIC institutions institutions can can deter deter women scientists limit their progress. women women scientists scientists oror or limit limit their their progress. progress.

The authors recommend institutions formally acknowledge The The authors authors recommend recommend institutions institutions formally formally acknowledge acknowledge the value of mentoring by giving it a key academic role and thethe value value of of mentoring mentoring byby giving giving it ait key a key academic academic role role and and providing protected time and compensation.

To mediate providing providing protected protected time time and and compensation. compensation.

ToTo mediate mediate

Resources: bit.ly/mentoringsupplement Resources: Resources: bit.ly/mentoringsupplement bit.ly/mentoringsupplement

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FOCUS FOCUS ON ON MENTORING MENTORING SUPPLEMENT SUPPLEMENT FOCUS ON MENTORING SUPPLEMENT FOCUS ON MENTORING SUPPLEMENT thethe effects effects of of a hierarchal a hierarchal culture, culture, rules rules forfor the effects of a hierarchal culture, rules for respectful respectful disagreement disagreement can can bebe established established to to respectful disagreement can be established the effects of a hierarchal culture, rules for to encourage encourage critical critical thinking thinking and and make make mentees mentees encourage critical thinking and make mentees respectful disagreement can be established to comfortable comfortable expressing expressing differences differences of of opinion. opinion. comfortable expressing differences of opinion. encourage critical thinking and make mentees Institutions Institutions should should consider consider thethe age, age, gender, gender, Institutions should consider theofage, gender, comfortable expressing differences of opinion. culture culture and and other other characteristics characteristics of faculty faculty culture and other characteristics of faculty Institutions should consider the age, gender, and and students students to to support support diversity. diversity.

A work-life A work-life and students to characteristics support diversity.

A work-life culture and other of faculty balance balance that that would would allow allow more more opportunities opportunities forfor balance that would allow more opportunities for and students to support diversity.

A work-life women women or or scientists scientists with with family family responsibilities, responsibilities, women or scientists with family responsibilities, balance that would allow more opportunities for forfor example, example, could could increase increase thethe number number and and for example, couldwith increase the and women orofscientists family responsibilities, diversity diversity of mentors. mentors.

Other Other ways ways tonumber to cultivate cultivate diversity of mentors.

Other ways to cultivate for example, could increase the number and quality quality mentors mentors include include joint joint training training with with quality mentors include training diversity of mentors.

Otherjoint ways to cultivate scientists scientists from from high-income high-income countries countries aswith as well well asas scientists from high-income countries as well as quality include joint training with group group ormentors or peer peer mentoring. mentoring. group orfrom peerhigh-income mentoring. countries as well as scientists group or peer mentoring.

AA framework framework forfor mentoring mentoring

A AConceptual ConceptualFramework Frameworkfor forMentoring Mentoring A Conceptual Framework for Mentoring A Conceptual Framework for Mentoring

A framework forexactly? mentoring What What is is mentorship mentorship exactly?

A frequently A frequently cited cited A What framework is mentorship for mentoring exactly?

A frequently cited definition definition describes describes it as it as a process a process in in which which definition describes it as a process in which What is mentorship exactly?

A frequently cited “an “an experienced, experienced, highly highly regarded regarded person person (the (the “an experienced, highly person (the definition describes it asindividual aregarded process (the in which mentor) mentor) guides guides another another individual (the mentee) mentee) mentor) guides another individual (the mentee) “an experienced, highly regarded person (the in in thethe development development and and re-examination re-examination of of development and re-examination of mentor) guides another individual (the mentee) hisin his orthe or her her own own ideas, ideas, learning, learning, personal personal and and his or her own ideas, learning, personal and in the development and re-examination of professional professional development.” development.” hisprofessional or her own development.” ideas, learning, personal and professional development.”

The The relationship relationship between between mentor mentor and and mentee, mentee, The relationship between mentorshould and mentee, according according to to supplement supplement authors, authors, should bebe according to supplement authors, should be The relationship between mentor and mentee, mutually mutually beneficial beneficial with with each each party party learning learning mutually beneficial with each party learning according to supplement authors, should be from from thethe other. other.

This This dynamic dynamic is is central central the other.

This dynamic is central mutually beneficial with each party to from to a conceptual a conceptual framework framework offered offered inlearning in thethe to a conceptual framework offered in the from the other.

This dynamic is central supplement supplement to to help help mentors mentors organize organize their their supplement to help mentors organize their to a conceptual framework offered in the work, work, generate generate new new ideas ideas and and develop develop programs programs work, generate new ideas and develop programs supplement to help mentors organize their within within their their institutions. institutions.

“One “One of of thethe important important within their institutions.

“One of the important work, generate new ideas and develop programs factors factors that that predicts predicts success success in in this this is is thethe factors that predicts between success this is theand within their institutions.

“One ofin the important ‘click’—the ‘click’—the connection connection between the the mentor mentor and mentee,” mentee,” connection between theismentor and mentee,” factors that predicts in this the the‘click’—the the authors authors note. note. success the authors note. ‘click’—the connection between the mentor and mentee,” the authors note.

Visualized Visualized asas concentric concentric circles, circles, thethe framework framework highlights highlights as concentric circles, the framework highlights theVisualized the mentor-mentee mentor-mentee relationship relationship and and interactions interactions that that may may the mentor-mentee relationship and interactions that may Visualized as concentric circles, the framework highlights affect affect it (see it (see graphic). graphic).

Their Their bond, bond, which which may may bebe influenced influenced it gender (see graphic).

Their bond, which may bethat influenced the mentor-mentee relationship interactions may byaffect by age, age, gender and and world world view, view, isand is thethe center center circle. circle.

The The by age, gender and world view, is the center circle.

The affect it (see graphic).

Their bond, which may be influenced model model expands expands next next to to institutional institutional issues issues such such asas model expands toorganizational institutional issues such as by age, gender andnext world view, is the center circle.

Theout available available resources resources and and organizational ethos. ethos.

Farther Farther out available resources and organizational ethos.

Farther out model expands next to institutional issues such as areare cultural cultural and and societal societal aspects aspects including including hierarchy hierarchy and and are cultural and societal aspects including hierarchy and available resources and organizational ethos.

Farther out gender gender roles. roles.

Lastly Lastly areare thethe global global economy economy and and politics, politics, gender roles.

Lastly are the global economy and politics, are cultural and societal aspects including hierarchy and which which may may not not have have much much effect effect on on the the mentor-mentee mentor-mentee which may not have much effect on the mentor-mentee gender roles.

Lastly are the global economy and politics, relationship, relationship, but but may may impact impact their their work. work. relationship, but may impact work. which may not have much effecttheir on the mentor-mentee relationship, but may impact their work.

The The framework framework also also addresses addresses mentee mentee success success and and The framework also addresses mentee success and satisfaction—is satisfaction—is their their work work a job, a job, career, career, mission mission or or satisfaction—is their work a job, career, mission or The framework also addresses mentee success and calling? calling?

Here Here thethe authors authors distinguish distinguish between between coaching, coaching, calling?

Here the authors distinguish between coaching, satisfaction—is their work a job, career, mission or which which is is task-oriented, task-oriented, and and mentoring mentoring which which is is personpersonwhich is and task-oriented, and mentoring which is personcalling?

Here the authors distinguish between oriented oriented and can can nudge nudge the the mentee mentee toward toward a calling acoaching, calling that that oriented and canofnudge mentee toward a calling which is task-oriented, andthe mentoring which is person-that brings brings high high levels levels of satisfaction satisfaction and and success. success. brings and highcan levels of satisfaction success. oriented nudge the menteeand toward a calling that brings high levels of satisfaction and success.

Evaluating Evaluating mentorship mentorship programs programs mentorship programs AsEvaluating As mentorship mentorship is is strengthened strengthened and and more more formal formal programs programs Evaluating As mentorship mentorship is strengthened programs and more formal programs areare developed developed and and implemented, implemented, evaluation evaluation will will bebe needed needed are developed and implemented, evaluation will be needed As mentorship is strengthened and more formal programs to to determine determine best best practices, practices, plan plan mentoring mentoring activities, activities, and and to determine best practices, plan mentoring activities, and are developed and implemented, evaluation will be needed demonstrate demonstrate their their value. value.

ToTo facilitate facilitate that, that, thethe supplement supplement their value. To facilitate that,activities, the supplement to demonstrate determine best practices, plan mentoring and demonstrate their value. To facilitate that, the supplement 82 Delaware Journal of Public Health – February 2019

provides provides a framework a framework identifying identifying sixsix areas areas forfor evaluation evaluation provides a framework identifying sixmeasures areas for evaluation along along with with objective objective and and subjective subjective measures to to assess assess along with objective and subjective measures to assess provides a framework identifying six areas for evaluation them them at at thethe individual individual and and institutional institutional level. level.

The The latter latter them at the individual and institutional level.

The latter along with objective and subjective measures to assess is is particularly particularly important important to to LMIC LMIC institutions institutions seeking seeking is particularly important to LMIC institutions seeking them at the individual and institutional level.

The latter to to grow grow their their mentoring mentoring capacity capacity and and optimize optimize their their to grow their mentoring capacity and optimize their is particularly important tothe LMIC institutions seeking resources, resources, according according to to the authors. authors. the authors. to resources, grow their according mentoringto capacity and optimize their resources, according to relationship the authors.can • •The The mentor-mentee mentor-mentee relationship can bebe assessed assessed at at • The mentor-mentee relationship can be assessed at thethe individual individual level level byby satisfaction satisfaction surveys surveys and and byby • costs The mentor-mentee relationship the individual level by satisfaction surveys and by can be assessed at costs measured measured in in time time or or money, money, forfor example, example, while while costs measured inbytime ordepartments money, fororexample, while the individual level satisfaction surveys and bycan evaluations evaluations byby divisions, divisions, departments or schools schools can evaluations by divisions, departments or schools can costs measured in time or money, for example, while help help identify identify gaps gaps in in institutional institutional support. support. help identify gaps in institutional support. evaluations by divisions, departments or schools can identifycareer gaps in institutional support.

• help •Evaluating Evaluating career guidance guidance at at thethe individual individual level level • Evaluating career guidance at the individual level could could bebe done done byby charting charting thethe progress progress of of mentees mentees could be done by charting the progress of mentees • and Evaluating career guidance at the individual level and appointments appointments or or promotions promotions forfor mentors. mentors.

Their Their and appointments or mentors.

Their could be done by look charting the progress of mentees institutions institutions may may look atpromotions at retention retention offor of prominent prominent institutions may look at retention of prominent and appointments or promotions for mentors.

Their faculty faculty and and staff. staff. faculty and staff. institutions may look at retention of prominent faculty and staff.

• •Academic Academic productivity productivity forfor both both parties parties at at allall levels levels • could Academic productivity for both parties at all levels could bebe viewed viewed through through published published papers, papers, invited invited could be viewed through published papers, invited • talks Academic productivity for both parties at all levels talks or or funded funded grants, grants, but but thethe authors authors suggest suggest they they funded grants, but the authors suggest they could beor viewed through published papers, invited betalks be used used alongside alongside other other categories categories as as they they may may notnot talks or funded grants, but the authors suggest they be used alongside other categories as they may not fully fully reflect reflect a mentor’s a mentor’s contributions. contributions. a mentor’s contributions. befully usedreflect alongside other categories as they may not fully reflect a mentor’s contributions.

• •Networking, Networking, key key to to career career development development and and global global • health Networking, key to career development and global health research, research, can can be be evaluated evaluated at at thethe individual individual health research, can be evaluated at the individual • level Networking, key to career development and global level byby describing describing thethe number number of of collaborators. collaborators. level by describing the number tools of collaborators. health research, can be evaluated attools the individual Institutions Institutions can can use use bibliometric bibliometric to to analyze analyze Institutions can use bibliometric tools to analyze level by describing the number of collaborators.

77 7 Institutions can use bibliometric tools to analyze

7

FOCUS MENTORING SUPPLEMENT FOCUS ON ON MENTORING SUPPLEMENT

securing their own funding is key for mentoring, as is co-authorship, for example, and map the connections securing theirbyown funding is key for m co-authorship, for institutions. example, and map the connections promoting professional development guiding them as between investigators and promoting professional development by between investigators and institutions. they work on a team, manage their time and develop • Wellness, described as an innovation of the framework, communications skills. alsoamust be able to reflects work-lifedescribed balance andas can beinnovation assessed theyMentors work on team, manage their tim • Wellness, an of the framework, promote professional integrity and ethical conduct by being individually with satisfaction surveys, and institucommunications skills. Mentors also m reflects work-life balance and can be assessed a role model for it. tionally using validated tools that measure stress, promote professional integrity and ethi satisfaction lackindividually of self-esteem with and other factors thatsurveys, can lead and instituMentors must haveaproblem solvingfor skills, role model it. patience in to burnout. tionally using validated tools that measure stress, the face of adversity and other knowledge for overcoming lack of self-esteem and other factors that can lead resource limitations, given the LMIC environment. The • Organizational capacity creates the mentoring Mentors must have problem solving sk to burnout. final competency, fostering institutional change, is needed environment and could be measured by looking at the face and to advocate and negotiate for of theadversity development andother knowle the number of mentors and their age, gender and implementation of resource mentoring programs. ethnic diversity, for example.

Evidence of institutionlimitations, given the LMIC en • Organizational capacity creates the mentoring alization, such as established training programs final competency, fostering institutiona environment and could be measured by looking at Case studies for mentorship capacity or promotions for mentors, could be monitored. to advocate and negotiate for the deve the number of mentors and their age, genderdevelopment and Also important is self-perpetuation—to confirm implementation of mentoring program diversity, for mentors. example. Evidence of institutionTo help LMIC institutions develop best practices for thatethnic mentees are becoming mentoring, the supplement contains several case studies. alization, such as established training programs

Competencies for global research Case studies for mentorship or promotions for health mentors, could be monitored.

When instances of plagiarism and cheating were mentoring

cap

development Also that important is self-perpetuation—to discovered at Peru’s Universidad Peruana Cayetano Recognizing high-quality mentorship can transform confirm To help Heredia, LMIC institutions bes that mentees are becoming mentors. the university develop used the trajectory of someone’s a Fogarty grant supplement career and “shape the mentoring, the supplement contains s MENTORING DEFINITION: to develop a free, online identity and success of Competencies for global health research research integrity course. It institutions,” supplement An experienced, highly regarded person (the mentor) When instances of plagiarism and che mentoring includes a mentoring module authors identify nine core Peru’s Universidad Peru Recognizing that high-quality can(the transform withat videos of university competencies for global guidesmentorship another individual mentee) in the discovered investigators discussing Heredia, health research. With the trajectory of northsomeone’s south partnerships being at development and re-examination of his or her own ideas, the role of mentors and a Fogarty career and “shape the their own experiences. The the heart of these initiatives, to develop identity andthe success university and the Peruvian the authors say proposedof learning, personal and professional development. research institutions,” National Science and capabilities will helpsupplement create — STANDING COMMITTEE ON POSTGRADUATE MEDIC AL Technology Council both includes more equitable relationships authors identify nine core require completion of the between investigators from AND DENTAL EDUC ATION, UK with vide competencies for global course for anyone applying high-income countries and health research. With northfor a grant or registering investigat LMICs. as an investigator. Thousands of people have taken thethe role o south partnerships being at online course and the concept of mentoring is now welltheir own Effective communication is paramount.

Not only is the heart of these initiatives, recognized and valued, according to supplement authors. it important to show empathy and compassion and university the authors say the proposed to provide constructive feedback, mentors must be National capabilities help create A scientist aiming to strengthen mentoring at the Kenya comfortable with will cross-cultural and cross-gender — STANDING COMMITTEE ON POSTGRADUATE MEDIC AL Medical Research Institute used a Fogarty grant to assess communication.

Because many LMIC academic Technolo more equitable relationships mentoring at the Institute’s Centre for Microbiology.

The institutions are dominated by men, the authors suggest require co between investigators from AND DENTAL EDUC ATION, UK assessment found universal interest from scientists, but special efforts be made to encourage the growth of female course fo high-income countries and only 40 percent had experience as a mentee and only 20 researchers and support them as role models and mentors percent as a mentor. Barriers to the institutionalizationfor a gran to LMICs. younger women. of mentoring were identified, and a mentorship policy as an investigator.

Thousands of peop manual was drafted. Scientists are now working with Mentors must be able to help mentees align expectations online course and the concept of ment Effective communication is paramount. Not only is U.S. colleagues to develop an institution-wide mentorship with reasonable goals, assess a mentee’s talents, and recognized and valued, according to s it important show and and program. provide knowledgeto and skillsempathy needed to fill thecompassion gaps and to provide constructive feedback, mentors must be achieve success. Addressing diversity is critical—mentors With no formal mentoring program, “supervisor” and should embrace itwith by encouraging collaboration with A scientist aiming to strengthen ment comfortable cross-cultural and cross-gender “guide” are the dedicated roles at India’s Saint John’s all people and by recognizing their own biases, whether Medical Research Institute used a Fog communication. Because many LMIC academic National Academy of Health Sciences and its affiliated conscious or unconscious. the Institute’s institutions are dominated by men, the authors suggest research institute. mentoring Several effortsatare being made to Centre for assessment found universal specialindependence efforts be by made to encourage the female integrate mentorship into the culture.

A new Vice Deaninterest f Fostering demonstrating belief in a growth of position was created to oversee postgraduate training mentee, letting them the lead,them or assisting them in only 40 percent had experience as a m researchers andtake support as role models and mentors

“

“

MENTORING DEFINITION:

”

An experienced, highly regarded person (the mentor) guides another individual (the mentee) in the

development and re-examination of his or her own ideas, learning, personal and professional development.

8 to younger women.

”

percent as a mentor. Barriers to the in 83 of mentoring were identified, and a me

and support improvements, including mentorship. and support improvements, mentorship.

Institution leaders sensitizedincluding staff to the difference and support improvements, including mentorship.

Institution leaders sensitized staff to the difference between mentoring and supervision. In addition, young Institution leaders staff toGlobal the young difference between mentoring andsensitized supervision.

In addition, faculty have been participating in Fogarty’s faculty have been participating in Fogarty’s Global between mentoring andand supervision.

In addition, young Health Program for Fellows Scholars, which gives Health Program for Fellows and Scholars, which givesGlobal them early exposure to mentoring. faculty have been participating in Fogarty’s them early exposure to mentoring.

Health Program for Fellows and Scholars, which gives In Mozambique, a mentorship program was established them early exposure to mentoring.

In Mozambique, a mentorship program was established at the Universidade Eduardo Mondlane.

To maximize

at the Universidade Eduardo Mondlane. maximize a limited pool of mentors, monthly groupTo meetings for a limited pool of mentors, monthly group meetings for interested researchers, ranging from program undergraduate to In Mozambique, a mentorship was established interested researchers, ranging from undergraduate to Ph.D. students, were initiated.

Since these meetings at the Universidade Eduardo Mondlane. To maximize Ph.D. wereand initiated. these meetings began,students, more faculty junior Since researchers have abegan, limited pool of mentors, monthly group more faculty and junior researchers have meetings for become interested in mentorship, mentees have interested researchers, ranging fromhave undergraduate to become in mentorship, mentees found a interested support system in their peer group, and more found a support system in their peer group, and more Ph.D. students, were initiated.

Since these meetings mentees are prepared to mentor the next generation of mentees are prepared to and mentor the next generation of students.more began, faculty junior researchers have students.

Photo Photo

by David

by David Snyder Snyder for Fogarty for Fogarty

become interested in mentorship, mentees have High-quality mentorship can transform an LMIC scientist’s career trajectory There are several key takeaways from the case and shape the identity and of institutions, as notedcareer in thetrajectory supplement, found a support system in their peer group, and more High-quality mentorship cansuccess transform an LMIC scientist’s There are several key takeaways from the case studies, as noted by the authors. Developing a free, published American Medicine and and shapeby thethe identity and Journal success of of Tropical institutions, as noted in Hygiene. the supplement, mentees prepared to conduct mentor next generationpublished of by the American Journal of Tropical Medicine and Hygiene. studies, asare noted by the authors.

Developing a free, online course for responsible ofthe research online course for responsible conduct of research that includes mentoring, and having it endorsed by Mentors need to be well-informed about the latest local students.

that includes mentoring, and sponsor having itin endorsed by Mentors need to be well-informed about biomedical the latest local the most significant research the country, and international regulations governing the most significant research sponsor in the country, and international regulations governing biomedical are best practices that could be replicated. Needs research. Potential violations of IRB and Ethicsan Review High-quality mentorship can transform LMIC scientist’s care There are several key takeaways from the case are best practices that could beand replicated.

Needs research. violations of IRB Ethics Review as noted in assessments can identify gaps help strengthen CommitteePotential approval include changes in an approved and shape the identity andand success of institutions, studies, noted by the Developing assessments can identify gapsauthors. and helpisstrengthen approval include changes in approved published by the American of Tropical Medicine and H mentoring.as While institutional support critical, groupa free,Committee study location, type of sample neededJournal foran research mentoring.

While institutional support is critical, group study location, type of sample needed for research online course for responsible conduct of research or peer mentoring can be effective when resources are procedures, wording used for participant consent or or peer mentoring can be effective when resources are wording used for participant consent or about the l limited.

The authors note that and collaborations amount of participant compensation. that includes mentoring, having itbetween endorsed byprocedures, Mentors need to be well-informed limited.

The authors note that collaborations between amount of participant compensation.

LMIC institutions and those in high-income the most significant research sponsorcountries— in the country, and international regulations governing biom LMIC institutions and in high-income countries— and efforts such as thethose “Mentoring the Mentor” Noting that a researcher’s primary ethical obligation are best that could be Needs Noting Potential violations of IRB and Ethi and effortspractices such as Fogarty the “Mentoring the replicated.

Mentor” that a research. researcher’s primary ethical obligation workshops and the Global Health Fellows and in global health is to “improve the health and wellassessments can identify gaps and help strengthen Committee approval include changes in an a workshops and the Fogarty Global Health Fellows and in global health is to “improve the health and wellScholars program—can serve as catalysts to strengthen being of the individuals and communities they visit,” Scholars program—can serve as catalysts to strengthen being of the individuals and communities they visit,” mentoring. study location, typethe of importance sample needed for res mentoring. While institutional support is critical, group the authors say mentors must teach of mentoring. the authors say mentors must teach the importance of empowering local investigators. or peer mentoring can be effective when resources are procedures, wording used for participant con empowering local investigators.

Addressing ethical issues through mentorship

limited.

Theethical authors note through that collaborations amount of participant compensation.

Addressing mentorship between Mentors play a critical issues role in ensuring scientific Mentoring toolkits LMIC institutions in high-income countries— Mentors play a criticaland role in ensuring scientificof Mentoring toolkits mentorship is through integrity by addressing the those responsible conduct One way to strengthen integrity by addressing the responsible conduct of One way to strengthen mentorship isthat through and efforts such as the “Mentoring the Mentor” Noting that a researcher’s research and serving as a model for it. Through toolkits—written or online resources offerprimary ethical ob research and serving as a model for it.

Through toolkits—written or online resources that offer But literature review, authors identified and guidance to mentors, mentees and workshops andsupplement the Fogarty Global Health Fellows and in global health is institutions. to “improve the health and literature review, supplement authors identified and guidance to mentors, mentees and institutions.

But provided suggestions to avoid misconduct in four areas: material written specifically for LMICs is scarce.

Scholars program—can serve as catalysts to strengthen being of the individuals and communities the provided suggestions avoid misconduct in four areas: material written specifically for LMICs is scarce. preventing plagiarism,todetermining valid authorship, mentoring. the authors say mentors must teach the imp preventing plagiarism, determining valid authorship, the appropriate use of IRBs and considering In the supplement’s final article, researchers reviewed empowering localresearchers investigators. the appropriate use of IRBs and considering In the supplement’s final article, imbalances of power. existing mentoring toolkits—focusing on thosereviewed imbalances of power. existing mentoring toolkits—focusing thosehealth Addressing ethical issues through mentorship developed by organizations involved inon global developed by organizations involved in global To reduce play plagiarism, the authors online in English, and containinghealth any Mentors a critical role insuggest ensuring scientific mentoring, written Mentoring toolkits To reduce plagiarism, the authors suggest online

mentoring, written in English, and containing any

programs that check for it, promoting scientific that could be applied to LMICs. integrity by addressing the responsible conduct of guidelines One way to strengthen mentorship is through programs that check for it,modules promoting guidelines that could be applied to LMICs. writing courses, including on scientific plagiarism in research and serving as a model for it.holding Through toolkits—written or18online resources that offe writing courses, including modules on plagiarism in responsible conduct of research courses, and Authors identified and summarized toolkits— responsible conduct of research courses, and holding Authors identified and summarized 18 toolkits— literature review, supplement authors identified and guidance to mentors, mentees and institution one-on-one discussions about it when editing a providing a brief description, the intended audience, one-on-one discussions about it when editing a providing a brief description, the intended audience, mentee’s work. competenciesmaterial addressed,written tools included and other provided suggestions to avoid misconduct in four areas: specifically for LMICs is scar mentee’s work. competencies addressed, tools included and other the helpful information, along with weblinks to access preventing plagiarism, determining valid authorship, helpful information, along with weblinks to access the Fairness and integrity should be the guiding principles resource. the appropriate useshould of IRBs and considering In the supplement’s final article, researchers Fairness and integrity be the guiding principles resource. in determining authorship of a publication. From the imbalances ofauthorship existing mentoring toolkits—focusing on thos in determining of a publication. initial design of apower. study through the analysisFrom and the With this series of articles, the team of authors aims initial design of a study through the analysis and With this series of articles, the team of authors aims developed byoforganizations involved in global writing phases, mentors can offer guidance on the “to help herald in a new era increased mentoring writing phases, mentorsthe can offer guidance onand the how help herald in a new erawritten of increased mentoring criteria for authorship, appropriate order, in LMICs thatmentoring, leads to advancement of global health To reduce plagiarism, the authors suggest online “to in English, and containin criteria forguest authorship, theauthors. appropriate order, and how in LMICs and thatpractice leads to around.” advancement of global health to handle and ghost research programs that check for it, promoting scientific guidelines that could be applied to LMICs. to handle guest and ghost authors. research and practice around.”

9 writing courses, including modules on plagiarism in 9 responsible conduct of research courses, and holding Authors identified and summarized 18 toolki 84 Delaware Journal of Public Health – February 2019 one-on-one discussions about it when editing a providing a brief description, the intended au

OPINION OPINION ByBy Dr.Dr. Roger Roger I. Glass, I. Glass, Director, Director, Fogarty Fogarty International International Center Center

Failure Failurecan canteach teachvaluable valuablelessons, lessons,lead leadtotoopportunities opportunities Does Does anyone’s anyone’s career career gogo exactly exactly asas planned? planned?

Mine Mine certainly certainly has has not! not!

But But I I wouldn’t wouldn’t change change a thing. a thing.

Every Every experience—whether experience—whether stunning stunning success success or or abject abject failure—has failure—has ledled meme to to where where I am I am today. today.

Photo by David Snyder for Fogarty

It was It was mymy pleasure pleasure to to recount recount some some of of mymy biggest biggest blunders blunders with with a group a group of of mymy peers peers onon a a panel panel at at thethe recent recent American American Society Society of of Tropical Tropical Medicine Medicine and and Hygiene Hygiene annual annual meeting. meeting.

The The goal goal was was to to provide provide unfiltered unfiltered reflection reflection onon thethe importance importance of of learning learning from from failure—how failure—how to to eer trajectory recover, recover, apply apply thethe lessons lessons learned learned and and figure figure out out how how to to the supplement, move onon in in a positive a positive way way from from thethe unexpected unexpected results. results.

Hygiene. move It could It could bebe argued argued that that our our ability ability to to respond respond to to failure failure is is one one of of thethe most most important important skills skills wewe can can develop. develop. latest local

medical For For mymy colleague colleague Dr.Dr. Steve Steve Meshnick, Meshnick, of of thethe University University ics Review of of North North Carolina, Carolina, failure failure came came early early in in hishis research research approved career career in in thethe form form of of two two dead dead cows. cows.

HeHe thought thought hehe had had discovered a cure a cure forfor sleeping sleeping sickness—which sickness—which would would search discovered have been been a significant a significant accomplishment—but accomplishment—but alas, alas, nsent orhave

when when hehe administered administered thethe drug, drug, thethe cows cows immediately immediately went went into into convulsions convulsions and and died. died.

Not Not a promising a promising start… start…

bligationHeHe eventually eventually determined determined that that hishis skills skills were were better better suited suited to to epidemiology epidemiology than than lab lab science, science, and and he’s he’s d wellgone gone onon to to make make impressive impressive discoveries discoveries in in thethe field field of of ey visit,” malaria. malaria. portance of

Failure Failure is is useful, useful, Meshnick Meshnick maintains, maintains, to to achieve achieve personal personal growth growth and and self-awareness. self-awareness.

HeHe says says he’s he’s learned learned that that persistence persistence is is a helpful a helpful trait trait forfor researchers researchers seeking seeking grant grant funding. funding.

Another Another tiptip is is to to h juggle juggle multiple multiple projects, projects, soso if one if one fails, fails, you you have have others others er to to keep keep you you occupied. occupied.

Although Although rejection rejection is is painful, painful, hehe ns. Butsays says it’sit’s helped helped him him gain gain insights insights into into how how to to improve improve hishis research research proposals. proposals.

In In one one case, case, hehe was was forced forced to to rce. collaborate collaborate with with a team a team of of modelers, modelers, which which has has ledled to to a long a long and and fruitful fruitful partnership. partnership.

Finally, Finally, hehe suggests suggests s reviewed scientists scientists trytry not not to to take take failure failure asas a personal a personal affront. affront.

se Figuring how how to to make make lemonade lemonade out out of of lemons lemons saved saved l healthFiguring the the career career of of my my friend, friend, Dr. Dr. Gail Gail Cassell, Cassell, now now a senior a senior ng any 1010

its— udience,

lecturer lecturer at at Harvard Harvard Medical Medical School.

School.

She She leftleft a tenured a tenured position position in in academia academia to to head head EliEli Lilly’s Lilly’s infectious infectious disease disease drug drug discovery discovery and and clinical clinical development development activities. activities.

Shortly Shortly after after she she arrived, arrived, thethe company company made made painful painful cuts, cuts, including including to to her her unit. unit.

A timely A timely phone phone call call out out of of thethe blue blue requesting requesting a supply a supply of of oldold drugs drugs forfor anan ongoing ongoing clinical clinical trial trial of of multi-drug multi-drug resistant resistant TBTB helped helped her her forge forge a new a new path. path.

It was It was thought thought that that MDRTB MDRTB was was tootoo expensive expensive to to treat treat in in lowlowand and middle-income middle-income countries countries but but this this study, study, using using drugs drugs that that were were a halfa halfcentury century old, old, showed showed participants participants could could bebe cured. cured.

That That was was thethe catalyst catalyst that that she she says says began began one one of of thethe largest largest philanthropic philanthropic efforts efforts in in pharma’s pharma’s history. history.

Gail’s Gail’s advice advice to to young young scientists: scientists: bebe open open to to unexpected unexpected opportunities opportunities nono matter matter how how busy busy you you are, are, and and make make it ait priority a priority to to establish establish a network a network of of peers peers and and mentors. mentors.

I was I was amused amused to to hear hear that that Dr.Dr. Peter Peter Agre, Agre, who who won won a a Nobel Nobel Prize Prize in in Chemistry, Chemistry, received received a “D” a “D” in in thethe subject subject in in high high school. school.

AsAs thethe runt runt of of thethe litter litter in in hishis large large family, family, hehe says says hehe learned learned early early onon that that hehe could could benefit benefit from from thethe wisdom wisdom of of others. others.

A conversation A conversation with with another another parent parent at at hishis daughter’s daughter’s school school and and a casual a casual chat chat with with a friend a friend at at a stop a stop onon thethe annual annual family family road road trip trip both both ledled to to valuable valuable collaborations collaborations that that directly directly contributed contributed to to hishis prize-winning prize-winning scientific scientific discoveries. discoveries.

For For mymy part, part, developing developing a potentially a potentially life-saving life-saving rotavirus rotavirus vaccine, vaccine, only only to to have have it crash it crash and and burn burn when when it was it was found found to to cause cause intussusception intussusception in in some some children, children, was was devastating. devastating.

But But failing failing is is anan important important learning learning experience experience and and anan essential essential part part of of growing growing up. up.

MyMy advice advice forfor early early career career scientists scientists is is to to follow follow their their passions passions and and find find knowledgeable knowledgeable mentors mentors to to help help guide guide them them onon their their way. way.

Also Also key, key, is is maintaining maintaining a a sense sense of of humor, humor, especially especially during during thethe tough tough times. times.

One One of of thethe session’s session’s attendees attendees reminded reminded usus of of a lesson a lesson onon thethe importance importance of of optimism optimism in in overcoming overcoming failure, failure, learned learned during during thethe historic historic smallpox smallpox eradication eradication campaign. campaign.

In In thethe words words of of thethe inestimable inestimable Dr.Dr. Bill Bill Foege, Foege, “Recruit “Recruit people people who who areare tootoo young young to to know know it it can’t can’t bebe done.” done.”

RESOURCE RESOURCE Website: Website: http://bit.ly/LearningFailure http://bit.ly/LearningFailure 85

PEOPLE PEOPLE PEOPLE Nobel for Former Fogarty Scholar-in-Residence Nobel Nobel forfor Former Former Fogarty Fogarty Scholar-in-Residence Dr. Tasuku Honjo, who was aScholar-in-Residence Fogarty Scholar-in-Residence in

Dr.Dr. Tasuku Tasuku Honjo, who who was was a Fogarty a Nobel Fogarty Scholar-in-Residence Scholar-in-Residence in in the 1990s,Honjo, has won the 2018 Prize in Physiology or Medicine. thethe 1990s, 1990s, has has won won the the 2018 2018 Nobel Nobel Prize Prize in in Physiology Physiology or or Medicine.

Medicine.

Honjo and NIH grantee Dr. James Allison were recognized “for Honjo Honjo and NIH NIH grantee grantee Dr.Dr. James James Allison Allison were were recognized recognized “for “for theirand discovery of cancer therapy by inhibition of negative their their discovery discovery of of cancer cancer therapy therapy by by inhibition inhibition of of negative negative immune regulation.” immune immune regulation.” regulation.”

Bekker lauded for HIV research and human rights Bekker Bekker lauded lauded forfor HIV HIV research research and and human human rights rights Fogarty collaborator and former trainee Dr. Linda-Gail Bekker has

Fogarty Fogarty collaborator collaborator and and former former trainee trainee Dr.Dr. Linda-Gail Linda-Gail Bekker Bekker has has received the 2018 Desmond Tutu Award for HIV Prevention Research received received thethe 2018 2018 Desmond Desmond Tutu Tutu Award Award forfor HIV Prevention Prevention Research Research and Human Rights.

Bekker, a University ofHIV Cape Town professor, and and Human Human Rights.

Bekker, a University a University of of Cape Cape Town Town professor, professor, was laudedRights. for herBekker, research and her advocacy of personalized was was lauded lauded for her her research research and and her her advocacy advocacy of of personalized personalized models of for care that have “saved lives and helped to break down models models of of care that that have have “saved “saved lives lives and and helped to to break break down down barriers ofcare stigma and discrimination inhelped HIV prevention.” barriers barriers of of stigma stigma and and discrimination discrimination in in HIV HIV prevention.” prevention.”

De Luca recognized for scientific innovation DeDe Luca Luca recognized recognized for scientific scientific innovation Former Fogarty fellow for Dr. Michele Deinnovation Luca was recognized for his

Former Former Fogarty Fogarty fellow fellow Dr.Dr. Michele Michele De Luca Luca was was recognized recognized for hishis research on stem cells and their De therapeutic potential.

A for proresearch research on on stem stem cells cells and and their their therapeutic therapeutic potential. potential.

A proA professor at Italy’s University of Modena and Reggio Emilia, De Luca fessor fessor at at Italy’s University University of of Modena Modena and and Reggio Reggio Emilia, Emilia, DeNew De Luca Luca received aItaly’s 2019 “Innovators in Science Award” from the York received received a 2019 a 2019 “Innovators “Innovators in in Science Science Award” Award” from from the the New New York York Academy of Sciences and the pharmaceutical company Takeda.

Academy Academy of of Sciences Sciences and and thethe pharmaceutical pharmaceutical company company Takeda.

Takeda.

NIH Institute Director Katz mourned NIH NIH Institute Director Director Katz Katz mourned mourned TheInstitute director of NIH’s National Institute of Arthritis and

The The director director of of NIH’s NIH’s National National Institute Institute of of Arthritis Arthritis and Musculoskeletal and Skin Diseases (NIAMS), Dr. and Stephen I. Katz, Musculoskeletal Musculoskeletal and and Skin Skin Diseases Diseases (NIAMS), (NIAMS), Dr. Dr. Stephen Stephen Katz, I. Katz, died suddenly in December 2018. Katz led NIAMS sinceI.1995 died died suddenly suddenly in in December December 2018.

2018.

Katz Katz led led NIAMS NIAMS since since 1995 1995 and was an adjunct investigator in the dermatology branch of the and and was was anan adjunct adjunct investigator investigator in in the dermatology dermatology branch of the the National Cancer Institute, where hethe began his NIHbranch career inof 1974.

National National Cancer Cancer Institute, Institute, where where hehe began began hishis NIH NIH career career in in 1974.

1974.

Former Fogarty advisor, NIH leader Li dies Former Former Fogarty Fogarty advisor, NIH NIH leader Li dies dies Institute on Dr. Ting-Kai Li, aadvisor, former director ofleader NIH’sLi National

Dr.Dr. Ting-Kai Ting-Kai Li,Li, aand former a former director director of of NIH’s NIH’s National National Institute Institute onon Alcohol Abuse Alcoholism and past Fogarty board member, Alcohol Alcohol Abuse Abuse and and Alcoholism Alcoholism and and past past Fogarty Fogarty board board member, member, has died. Known for his research on the metabolism, pharmahas has died. died.

Known Known for hishis research research onon the the metabolism, metabolism, pharmapharmacokinetics and for pharmacogenetics of alcohol, and the neurobiology cokinetics cokinetics and and pharmacogenetics pharmacogenetics of of alcohol, alcohol, and and the the neurobiology neurobiology and genetics of alcohol-related behavior, Li spent most of his and and genetics genetics of of alcohol-related alcohol-related behavior, behavior, Li Li spent spent most most of of hishis career at Indiana University before joining NIH. career career at at Indiana Indiana University University before before joining joining NIH. NIH.

Gramzinski leading U.S. military HIV research effort Gramzinski Gramzinski leading leading U.S. U.S. military military HIV HIV research effort Dr. Robert Gramzinski is the new director of research the U.S. effort Military

Dr.Dr. Robert Robert Gramzinski Gramzinski is is the the new new director director of of thethe U.S. U.S. Military Military HIV Research Program (MHRP), which serves to protect troops HIV HIV Research Research Program Program (MHRP), (MHRP), which which serves serves to to protect protect troops troops from infection and improve global health.

His prior MHRP roles from from infection infection and and improve improve global global health.

His His prior prior MHRP MHRP roles roles included operational oversight ofhealth. activities in several African included included operational operational oversight oversight of of activities activities in in several several African African countries and Thailand.

Previously, he was with NIH’s National countries countries and Thailand.

Thailand.

Previously, he he was was with with NIH’s NIH’s National National Institute ofand Allergy andPreviously, Infectious Diseases.

Institute Institute of of Allergy Allergy and and Infectious Infectious Diseases.

Diseases.

New role for O’Brien with WHO New New role for for O’Brien O’Brien with with WHO WHO The role WHO has appointed Dr. Kate O’Brien as its Director of

The The WHO WHO has has appointed appointed Dr. Dr. Kate Kate O’Brien O’Brien as as itsits Director Director of research of Immunization, Vaccines and Biologicals.

O’Brien, whose Immunization, Immunization, Vaccines Vaccines and and Biologicals.

Biologicals.

O’Brien, O’Brien, whose whose research research includes vaccine clinical trials and disease epidemiology, has includes includes vaccine vaccine clinical clinical trials and disease disease epidemiology, epidemiology, has has been executive director oftrials theand International Vaccine Access been been executive executive director director of of the the International International Vaccine Vaccine Access Access Center at Johns Hopkins Bloomberg School of Public Health.

Center Center at Johns Johns Hopkins Bloomberg Bloomberg School of of Public Public Health.

Health.

She’sat also beenHopkins an advisor to Gavi,School the Vaccine Alliance.

She’s She’s also also been been anan advisor advisor to to Gavi, Gavi, thethe Vaccine Vaccine Alliance.

Alliance.

86 Delaware Journal of Public Health – February 2019

Global Global Global HEALTH Briefs HEALTH HEALTHBriefs Briefs NIH launches free placental atlas tool NIH NIH launches launches free free placental placental atlas atlas tool tool Investigators can now access NIH’s Placental Atlas

Investigators Investigators nownow access access NIH’s NIH’s Placental Placental Atlas Atlas Tool, or PAT,can a can free resource incorporating placental Tool, Tool, or PAT, or PAT, a free a free resource resource incorporating incorporating placental placental data from publications and public databases into a datadata from from publications publications andand public databases databases into a a single website.

Produced bypublic NIH’s Nationalinto Institute single single website. website.

Produced Produced by NIH’s by NIH’s National National Institute Institute of Child Health and Human Development, the tool of Child of Child Health Health andand Human Human Development, Development, thethe tool tool is useful for studying placental development and is useful is useful for for studying studying placental placental development development and and function throughout pregnancy. function function throughout throughout pregnancy. pregnancy.

Website: https://pat.nichd.nih.gov Website: Website: https://pat.nichd.nih.gov https://pat.nichd.nih.gov

African scientists face barriers, report says African African scientists face face barriers, barriers, report report says says A newscientists study of Africa’s young scientists provides

A new Adetails new study study ofchallenges Africa’s young young scientists scientists provides of of theAfrica’s they face inprovides terms of details details of the of the challenges challenges they they face face in terms in terms of of research output, funding, mobility, collaboration research research output, output, funding, funding, mobility, mobility, collaboration collaboration and mentoring.

The book was published by the andand mentoring. mentoring.

The The book book was was published published by the nonprofit organization, African Minds.by the nonprofit nonprofit organization, organization, African African Minds.

Minds.

Full report: http://bit.ly/nextgenAfrica FullFull report: report: http://bit.ly/nextgenAfrica http://bit.ly/nextgenAfrica

WHO says progress on malaria has stalled WHO WHO says says progress on malaria malaria hashas stalled stalled Reductions inprogress malariaon cases have plateaued after

Reductions Reductions in malaria inofmalaria cases cases have have plateaued plateaued after after several years decline, according to the WHO’s several several years years of decline, of decline, according according to the to the WHO’s WHO’s World Malaria Report 2018. A new country-led World World Malaria Malaria Report Report 2018.

2018.

A new Atonew country-led country-led response has been launched scale up prevention response response has has been been launched launched to scale to scale up up prevention prevention and treatment. Ten African countries and India andand treatment. treatment.

Ten Ten African African countries countries and and India account for 70 percent of malaria cases. India account account for 70 70 percent percent of malaria of malaria cases. cases.

Newsfor release: http://bit.ly/Malaria2018 News News release: release: http://bit.ly/Malaria2018 http://bit.ly/Malaria2018

Vax gaps cause measles cases to spike VaxVax gaps gaps cause cause measles measles cases cases to2017, to spike spike Reported measles cases jumped in as

Reported Reported measles measles cases cases jumped jumped in severe 2017, in 2017, as as multiple countries experienced outbreaks, multiple multiple countries countries experienced experienced severe severe outbreaks, outbreaks, according to a report published jointly by the according according atoreport aWHO. report published published jointly by vaccination the by the CDC andtothe Because ofjointly gaps in CDCCDC and and the the WHO. WHO. Because Because of gaps of gaps in vaccination in vaccination coverage, measles outbreaks occurred in all world coverage, coverage, measles outbreaks occurred occurred in all indeaths. world all world regions,measles causing anoutbreaks estimated 110,000 regions, regions, causing causing an an estimated estimated 110,000 110,000 deaths. deaths.

News release: http://bit.ly/MeaslesUp News News release: release: http://bit.ly/MeaslesUp http://bit.ly/MeaslesUp

More research needed to defeat dementia More More research research needed needed to to defeat defeat dementia dementia The World Dementia Council has released a TheThe World World Dementia Dementia hasresearch. has released released a a publication callingCouncil forCouncil more Titled publication publication calling calling for for more more research. research.

Titled Titled Defeating Dementia: the Road to 2025, the report Defeating Defeating Dementia: Dementia: thethe Road Road to 2025, to 2025, thecritical the report report says data sharing and open science are saysto says data data sharing sharing and and open open science science areare critical critical accelerating progress.

While clinical trials on to accelerating to accelerating progress. progress.

While While clinical clinical trials trials on on dementia have more than doubled since 2013, dementia dementia have have more more than than doubled doubled since since 2013, 2013, recruitment shortfalls are causing delays. recruitment recruitment shortfalls shortfalls areare causing causing delays. delays.

Full report: http://bit.ly/DefeatDementia2025 FullFull report: report: http://bit.ly/DefeatDementia2025 http://bit.ly/DefeatDementia2025

WHO: insufficient progress on road safety WHO: WHO: insufficient insufficient progress progress on road road safety safety Traffic deaths continue to rise, on causing 1.35 million

Traffic Traffic deaths deaths continue continue to rise, to rise, causing 1.35 1.35 million fatalities annually, according tocausing the WHO. Itsmillion fatalities fatalities annually, annually, according according the to the WHO. WHO. Its Its are 2018 report on road safetytosays traffic injuries 2018 2018 report report on on road road safety safety says traffic traffic injuries injuries areare now the leading killer ofsays youth aged 5-29 years. nowInterventions now thethe leading leading killer killer of youth of youth aged 5-29 5-29 years. years. have helped inaged wealthier places but Interventions Interventions have have helped helped wealthier in wealthier places places butbut fatalities remain high ininlow-income countries. fatalities fatalities remain remain high high in low-income in low-income countries. countries.

News release: http://bit.ly/WHOtraffic2018 News News release: release: http://bit.ly/WHOtraffic2018 http://bit.ly/WHOtraffic2018 11

1111

JANUARY/FEBRUARY 2019 JANUARY/FEBRUARY JANUARY/FEBRUARY 2019

2019

Funding Opportunity Announcement Funding Opportunity Announcement International Research Scientist Development Award (IRSDA) (K01)

Funding Opportunity Announcement

Details Details

http://bit.ly/IRSDAct International ResearchTrial Scientist Development Award (IRSDA) (K01) Independent Clinical Required http://bit.ly/IRSDAct http://bit.ly/IRSDAn Independent Clinical Trial Not Required Allowed International Research Scientist Development Award (IRSDA) (K01) http://bit.ly/IRSDAnoct Independent Clinical Trial Not Allowed Planning for Noncommunicable and Disorders Research Training Independent ClinicalDiseases Trial Required Planning Noncommunicable Diseases and Disorders Research Training http://bit.ly/NCDlifespan Programsfor in LMICs (D71) Independent Clinical Trial Not Allowed http://bit.ly/NCDlifespan Programs in LMICs (D71) Japan Society for the Promotion of Science U.S. Postdoctoral Planning for Noncommunicable and Disorders Research Training Japan Society the Promotion of Science U.S.Diseases Postdoctoral http://bit.ly/JSPSforUS Fellowships in for Japan Programs in LMICs (D71) http://bit.ly/JSPSforUS Fellowships in Japan Global Infectious Disease (GID) Research Training Program Global http://bit.ly/GIDplan (D71) Infectious Disease (GID) Research Training Program Japan Society for the Promotion of Science U.S. Postdoctoral http://bit.ly/GIDplan (D71) http://bit.ly/GIDtraining (D43) Clinical Trial Optional in Japan http://bit.ly/GIDtraining (D43)Fellowships Clinical Trial Optional For more information, visit www.fic.nih.gov/funding For more information, visitDisease www.fic.nih.gov/funding Global Infectious (GID) Research Training Program

(D71) (D43) Clinical Trial Optional

Global Health Matters For more information, visit Global Health Matters

Deadline Deadline

Details Mar 7, 2019

Mar 7, 2019 Mar 7, 2019

http://bit.ly/IRSDAct Mar 14, 2019 http://bit.ly/IRSDAnoct Mar 14, 2019

Mar 15, 2019

http://bit.ly/NCDlifespan Mar 15, 2019 July 25, 2019 July 25, 2019 http://bit.ly/JSPSforUS July 25, 2019

http://bit.ly/GIDplan http://bit.ly/GIDtraining

Global stroke risk estimates vary by geographic region www.fic.nih.gov/funding Global stroke risk estimates vary by geographic region

One in four people over age 25 is at risk for stroke during their lifetime, One in fourtopeople age 25 is atResearchers risk for stroke during their five-fold lifetime, according a new over scientific study. found a nearly according to a new scientific study.

Researchers found a nearly five-fold Volume 18, No. 1 ISSN: 1938-5935 difference in lifetime stroke risk worldwide—with the highest risk in East Volume 18, No. 1 ISSN: 1938-5935 difference in lifetime riskEurope—and worldwide—with risk in Africa, East Asia and Central andstroke Eastern lowestthe in highest sub-Saharan Asia and Central and Eastern Europe—and lowest in sub-Saharan Africa, where people are at a greater risk of dying earlier from another cause. The Fogarty International Center where greater risk of cause.

Fogarty International Center lifetimepeople stroke are risk at fora25-year-olds in dying 2016 earlier rangedfrom fromanother 8 percent to 39The National Institutes of Health Global stroke risk estimates vary by geo lifetime stroke risk for 25-year-olds in 2016 ranged from 8 percent to 39 National Institutes of Health percent, depending on where they live.

Department of Health and Human Services percent, depending on where they live.

Department of Health and Human Services One in said fourDr.people is atforrisk for stroke duri “Our findings are startling,” Gregoryover Roth age of the25 Institute January/February 2019 Managing editor: Ann Puderbaugh “Our findings are startling,” said Dr. Gregory Roth of the Institute for Health Metrics and Evaluation (IHME) the University Washington, according to aatnew scientificof study.

Researchers found a Managing editor: Ann Puderbaugh Ann.Puderbaugh@nih.gov Health Metrics and Evaluation (IHME) at the University of Washington, and senior author on the study.

“We found extremely high lifetime risk for 18, No. 1 ISSN: 1938-5935 Volume difference in lifetime stroke risk worldwide—with the hig Ann.Puderbaugh@nih.gov and senior study.

“We we found extremely high lifetime risk for stroke, and author based on on the other research evaluated, it is clear that younger Writer/editor: Shana Potash Asia and Central and Eastern Europe—and lowest in su stroke, and based on other research we evaluated, it is clear that younger adults need to think about long-term health risks. They can make a real Writer/editor: Shana Potash Shana.Potash@nih.gov adults needbytoeating think where about long-term health risks.

They can make a real people are at aregularly, greater risk of dying earlier from difference healthier diets, exercising and avoiding Fogarty International Center Shana.Potash@nih.gov Writer/editor: Karin Zeitvogel difference by eating healthier diets, exercising regularly, and avoiding tobacco and alcohol.” lifetime stroke risk for 25-year-olds in 2016 ranged from National Writer/editor: KarinInstitutes Zeitvogel of Health Karin.Zeitvogel@nih.gov tobacco and alcohol.” percent, depending on where they live.

Department of Health and Human Services Karin.Zeitvogel@nih.gov Lifetime risk of stroke occurrence (in %) in both sexes combined, 2016 Web manager: Anna Pruett Ellis Lifetime risk of stroke occurrence (in %) in both sexes combined, 2016 Web manager: Anna Pruett Ellis Anna.Ellis@nih.gov “Our findings are startling,” said Dr. Gregory Roth of th Anna.Ellis@nih.gov Managing editor: Ann Puderbaugh Designer: Carla Conway Health Metrics and Evaluation (IHME) at the University o Designer: Carla Conway Ann.Puderbaugh@nih.gov

January/February 2019 January/February 2019

Global Health Matters

Writer/editor: Shana Potash

All text produced in Global Health Matters is in the Shana.Potash@nih.gov All text domain produced in may Global Matters is credit in the public and be Health reprinted.

Please public domain and may be reprinted.

Please credit Fogarty International Center.

Images must be cleared Writer/editor: Karin Zeitvogel Fogarty International Center.

Images be cleared for use with the individual source, as must indicated. for use with the individual source, as indicated.

Karin.Zeitvogel@nih.gov

SUBSCRIBE: Web manager: Anna Pruett Ellis SUBSCRIBE: www.fic.nih.gov/subscribe Anna.Ellis@nih.gov www.fic.nih.gov/subscribe

and senior author on the study. “We found extremely hig stroke, and based on other research we evaluated, it is c adults need to think about long-term health risks. They c difference by eating healthier diets, exercising regularly tobacco and alcohol.”

Lifetime risk of stroke occurrence (in %) in both sex

Designer: Carla Conway READ READ DOWNLOAD DOWNLOAD RESOURCE SUBSCRIBE All text produced in Global Health Matters is in RESOURCE the Website: http://bit.ly/IHMEstroke SUBSCRIBE Website: http://bit.ly/IHMEstroke public domain and may be reprinted. Please credit Fogarty International Center. Images must be cleared for use with the individual source, as indicated.

87

Chronic Disease is one of the four priority areas in the Delaware SHIP. Health disparities like income level, education, and county of residence can affect an individualâ&#x20AC;&#x2122;s risk of developing a chronic disease.

Helen Arthur, M.H.A., Division of Public Health, Delaware Department of Health and Social Services

Abstract Chronic diseases are the leading causes of morbidity and mortality in Delaware and the U.S. In 2016, 5,888 Delawareans died from chronic diseases; cancer and heart disease accounted for 46% of all deaths statewide. Other commonly diagnosed chronic diseases among Delawareans include heart disease, chronic lower respiratory disease, and diabetes.

Reducing preventable health care costs is critical for Delaware. In 2014, Delaware ranked highest among all U.S. states in per person prescription drug spending. In the same year, Delaware ranked fifth among states for physician and clinical services spending ($2,259 per Delawarean per year) and sixth among states for hospital care spending ($4,078 per Delawarean per year). Chronic disease prevention among Medicaid enrollees, particularly, has the potential to generate substantial costs savings at the state level.

Population aging, advances in medical care, and growing rates of health-damaging behaviors increase the likelihood that the number of Delawareans living with, and dying from, chronic diseases will increase in the future. Continued statewide aggressive public health action is critical for chronic disease prevention as well as efficient management of existing chronic disease cases.

88 Delaware Journal of Public Health â&#x20AC;&#x201C; February 2019

Chronic Disease in Delaware Chronic diseases progress slowly and persist for a long time. Examples include Alzheimer’s disease, cancer, cardiovascular disease (including heart disease, stroke, and other vascular diseases), chronic lower respiratory disease, and diabetes. Vaccines cannot prevent chronic diseases nor can medication completely cure them.

Chronic diseases require ongoing monitoring and treatment; without intervention, they typically worsen over time, often leading to the need for specialized medical care.

Chronic diseases are the leading causes of morbidity and mortality in the United States. Sixty percent of all U.S. adults have at least one chronic disease; nearly one-half (42%) of U.S. adults have more than one chronic condition (Buttorff (Buttorff,, Ruder, & Bauman, 2017). Twelve percent of all U.S. adults have fi five ve or more chronic conditions (Buttorff (Buttorff,, Ruder, & Bauman, 2017). In 2016, 5,888 Delawareans died from chronic disease; combined, cancer and heart disease accounted for 46% of all deaths statewide (Figure 1) (Delaware Health Statistics Center, 2018). Four of the fi five ve leading causes of death among Delawareans are chronic diseases (Delaware Health Statistics Center, 2018).

Figure 1: Age-Adjusted Mortality Rates for the Leading Causes of Death: Delaware vs. U.S., 2016

All rates expressed per 100,000 total population Source: (Centers for Disease Control and Prevention, 2018)

Like other states, Delaware’s chronic disease burden is growing. Population aging, advances in medical care, and growing rates of health-damaging behaviors increase the likelihood that the number of Delawareans living with, and dying from, chronic diseases will increase in the future. Continued statewide aggressive public health action is critical for chronic disease prevention as well as efficient effi cient management of existing chronic disease cases.

To assist in this statewide goal, the Delaware Division of

Public Health (DPH), Health Promotion and Disease Prevention (HPDP) Section will publish an annual brief entitled, Chronic Disease in Delaware: Facts & Figures, 2018. Following the inaugural 2018 edition, the HPDP Section will publish annual updates for the primary goal of summarizing and disseminating chronic disease epidemiological data among partners, consumers, decision-makers, and the public. The Facts & Figures document will also serve as a tool to direct coordinated, statewide public health and policy efforts focused on reducing Delaware’s chronic disease burden. Chronic Disease in Delaware: Facts & Figures, 2018 is aligned with Delaware’s State Health Improvement Plan as well as the Triple Aim of improved patient care experiences, improved population health, and reduced per capita healthcare costs. This article serves as an introduction to Chronic Disease in Delaware: Fact & Figures, 2018, and briefly summarizes the current state of chronic disease in Delaware.

The Cost of Chronic Disease Prevention and management of chronic disease yields tremendous health care cost savings. In 2010, chronic diseases accounted for 86% of all U.S. health care spending; cancer care, alone, accounted for $157 billion in health care costs (Buttorff, Ruder, & Bauman, 2017).

In the same year, the U.S. spent $170 billion treating conditions attributable to cigarette use. Medicare, Medicaid, and other public health care programs paid over 60% of these tobacco-related healthcare costs (Xu, Bishop, Kennedy, Simpson, & Pechacek, 2015). In the U.S., direct medical costs of cardiovascular disease are projected to more than double between 2015 and 2035, sharply increasing from $318 billion to $749 billion (Khavjou, Phelps, & Leib, 2016). Addressing a single chronic condition prior to the development of secondary chronic conditions also yields substantial cost savings. On average, the average annual difference in health care costs between a privately-insured person with one or two chronic conditions ($4,241) versus an individual with five or more chronic conditions ($18,351) exceeds $14,000 (Buttorff, Ruder, & Bauman, 2017).

Reducing preventable health care costs is especially critical for Delaware. In 2014, Delaware ranked highest among all U.S. states in per person prescription drug spending (an average of $1,525 per Delawarean per year) (Kaiser Family Foundation, 2017). In the same year, Delaware ranked fifth among states for physician and clinical services spending ($2,259 per Delawarean 89

per year) and sixth among states for hospital care spending ($4,078 per Delawarean per year) (Kaiser Family Foundation, 2017).

Cancer Cancer is the leading cause of death in Delaware (Centers for Disease Control and Prevention, 2018). From 2010-2014, 27,861 Delawareans were diagnosed with cancer. During the same period, 9,602 Delawareans died from cancer (Division of Public Health, 2018). Delaware’s 2010-2014 cancer incidence rate (a measure of how many people in a population are diagnosed with cancer during a specific period) ranked 2nd highest among U.S. states. For the same period, Delaware’s cancer mortality rate ranked 16th highest among states (Division of Public Health, 2018).

Chronic disease prevention among Medicaid enrollees, particularly, has the potential to generate substantial costs savings at the state level. Medicaid is jointlyfunded by the federal government and the states. At least 50 percent of states’ total Medicaid funds come from the Federal Medical Assistance Percentages (FMAP); states are responsible for generating the remaining portion of Medicaid funds through a combination of general revenues, taxes, local governments, and other sources. In FY2019, Delaware Four cancer types – breast, colorectal, lung, and prostate received 57.55% of its Medicaid funding through (commonly referred to as the “Big 4”) – account for FMAP, leaving the state responsible for generating 49% of all cancer diagnoses and 49% of all cancer the remaining 42.45% of funds (Mitchell, 2018).

Delaware All ratesdeaths expressed perin 100,000 total population(Figure 2) (Division of Public for Disease Control and Prevention, 2018) As Delaware’s total Medicaid spending increases, so, Source: (Centers Health, 2018). too, does the share of funds for which Delaware is Figure 2: “Big 4” Cancers as a Percentage of Total Delaware Cancer responsible.

Diagnoses and Deaths, 2010-2014

Delaware has a comparatively high percentage of residents enrolled in Medicaid. Delaware ranked 5th among states for total percentage increase in Medicaid enrollees from 2000 to 2010 (9.2%) (The Pew Charitable Trusts and the John D. and Catherine T. MacArthur Foundation, 2014). By 2010, Delaware ranked 10th among states in total percentage of residents enrolled in Medicaid (25%). Over the same time period, fewer Delawareans accessed private health insurance through their employers. Notably, Delaware ranked 1st among states for total percentage decrease in employer-sponsored insurance enrollment (-15.3%) from 2000 to 2012 (The Pew Charitable Trusts and the John D. and Catherine T. MacArthur Foundation, 2014).

Source: (Division (Division of of Public Public Health, Health, 2018) 2018) Source:

Although Delaware’s cancer incidence and mortality rates have been historically higher than the comparable From 2000 to 2012, Delaware’s Medicaid spending U.S. rates, the gap has narrowed over the last decade. increased an average of 6.8% annually (The Pew Declining cancer rates are especially noteworthy among Charitable Trusts and the John D. and Catherine T. African Americans in Delaware. Between 2000-2004 MacArthur Foundation, 2014). In 2010, Delaware and 2010-2014, Delaware’s cancer incidence rates for spent $15,840 per elderly and disabled Medicaid African American and Caucasian males declined 15% enrollee and $3,651 per parent and child Medicaid and 4%, respectively. During the same period, the enrollee. Elderly and disabled persons comprise 18% cancer incidence rate for African American females of Delaware Medicaid enrollees while accounting for declined 1% while the comparable rate for Caucasian 49% of all Medicaid payments for services (The Pew females increased 6% (Division of Public Health, Charitable Trusts and the John D. and Catherine T. 2018). From 2000-2004 to 2010-2014, Delaware’s MacArthur Foundation, 2014). Chronic disease and cancer mortality rates for African American and prevention management, including within the growing Caucasian males declined 25% and 17%, respectively.

Medicaid enrollee population, is an essential component Similarly, cancer mortality rates for African American and Caucasian females declined 17% and 12%, to achieving sustainable health care cost savings respectively (Division of Public Health, 2018). within Delaware.

90 Delaware Journal of Public Health – February 2019

Lung cancer continues to account for an overwhelming share of Delaware’s total cancer burden. Of the “Big 4” cancers, lung cancer is the deadliest, accounting for 30% of all cancer deaths and 14% of all newlydiagnosed cancer cases in the state. The lethality of lung cancer stems from stage at diagnosis trends; 53% of all Delaware and U.S. lung cancer cases diagnosed from 2010-2014 were diagnosed in the distant stage after metastasis to distant tissues, organs, or lymph nodes (Division of Public Health, 2018).

Historically, Delaware’s lung cancer incidence and death rates were much higher than those of the U.S. Over time, the gap between U.S. and Delaware lung cancer rates has narrowed. Delaware’s decline in lung cancer burden is due in large part to statewide reductions in tobacco use that began decades ago. Despite quantifiable progress achieved through coordinated public health efforts, Delaware’s lung cancer incidence rate for 20102014 (70.9 per 100,000 population) was statistically significantly higher than the U.S. rate (55.8 per 100,000 population). Similarly, Delaware’s lung cancer mortality rate (52.2 per 100,000 population) was statistically significantly higher than the U.S. rate (44.7 per 100,000 population). For the 2010-2014 time period, Delaware ranked 10th in the U.S. for lung cancer incidence and 13th in the U.S. for lung cancer mortality.

Heart Disease Heart disease (inclusive of coronary heart disease (the most common form of heart disease), heart attack, heart failure, arrhythmia, heart aneurysm, angina (chest pain), rheumatic heart disease, and other heart-related conditions) is the second leading cause of death in Delaware (Centers for Disease Control and Prevention, 2018). In 2016, 1,955 Delawareans died from heart disease, accounting for 22% of all deaths statewide (Delaware Health Statistics Center, 2018). Among Delaware adults, 7% of males and 6% of females report ever having had been diagnosed with coronary heart disease or experiencing a heart attack (Division of Public Health, 2017).

Hypertension and hypercholesterolemia represent two major heart disease risk factors. Hypertension is often

called a “silent killer” because many people do not have recognizable symptoms of the condition. Left untreated, high blood pressure can damage the heart, brain, and kidneys. Regular blood pressure screening is the best way to determine if an individual is hypertensive.

In 2017, prevalence rates for both hypertension and hypercholesterolemia reached 35% among Delaware adults (Division of Public Health, 2018). Hypertension prevalence is correlated with age. In 2017, 15% of Delawareans age 25-34 reported having high blood pressure compared to 61% of Delawareans age 65 or older (Division of Public Health, 2018).

Chronic Lower Respiratory Disease Chronic lower respiratory disease is the third leading cause of death in Delaware (Centers for Disease Control and Prevention, 2018). The most common forms of chronic lower respiratory disease are chronic obstructive pulmonary disease (COPD), emphysema, and chronic bronchitis; these diseases interfere with oxygen flow within the body, resulting in breathing difficulties. In 2016, 540 Delawareans died from chronic lower respiratory disease, representing 6% of all deaths statewide (Delaware Health Statistics Center, 2018).

In 2016, 6% of adult Delaware males and 7% of adult Delaware females reported ever having been diagnosed with chronic lower respiratory disease (COPD, emphysema, or chronic bronchitis) (Division of Public Health, 2017).

Up to 80% of all U.S. COPD deaths are attributable to tobacco use. When smoke from tobacco products is inhaled into the lungs, harmful components within the smoke are deposited into and absorbed by the lungs; over time, this causes many adverse effects within the respiratory system (U.S. Department of Health and Human Services, 2014). The longer an individual smokes, and the more packs of cigarettes smoked, the greater the risk of developing COPD. Pipe smokers and cigar smokers are also at risk for COPD. Other COPD risk factors include exposure to secondhand smoke, indoor and outdoor air pollution, and certain dusts and chemicals that people may contact as part of their job (U.S. Department of Health and Human Services, 2014).

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Diabetes

Chronic Disease Risk Factors

Diabetes is the ninth leading cause of death in Delaware (Centers for Disease Control and Prevention, 2018). In 2016, 203 Delawareans died from diabetes (Delaware Health Statistics Center, 2018). However, the impact of diabetes on the number of deaths statewide is likely underestimated because diabetes is also a contributing risk factor to heart disease, stroke, and other chronic conditions.

A chronic disease risk factor is defined as any factor that makes a person more likely to develop a chronic disease.

Non-modifiable, or unchangeable, risk factors include age, race, and personal health history. Modifiable, or changeable, risk factors are health-damaging behaviors like tobacco use, poor diet, lack of physical activity, and being overweight/obese.

DPH monitors statewide diabetes prevalence via the Delaware Behavioral Risk Factor Surveillance System (BRFSS), an annual statewide random telephone survey designed by the CDC. In 2017, 11.3% of Delawareans age 18 and older (approximately 85,400 adults) reported having been diagnosed with diabetes. This prevalence rate does not include gestational diabetes. Although the BRFSS survey does not distinguish between type 1 and type 2 diabetes, the National Diabetes Information Clearinghouse estimates that between 90-95% of people have type 2 diabetes. An additional 12.5% of Delawarean adults (approximately 78,000 individuals) reported having been diagnosed with prediabetes. People with prediabetes are at elevated risk for developing type 2 diabetes but can significantly reduce their risk through lifestyle modification.

The impact of modifiable risk factors on chronic disease risk cannot be underestimated. Forty-two percent of all cancer diagnoses and 45% of all cancer deaths in the U.S. are attributable to modifiable risk factors (Islami, et al., 2018). Specifically, cigarette smoking accounted for 19% of all cancer cases and 29% of all cancer deaths in 2014. Following tobacco use, excess body weight and alcohol intake have the greatest impact on cancer risk.

Excess body weight accounts for 8% of all cancer cases and 7% of all cancer deaths. Alcohol intake accounts for 6% of all cancer cases and 4% of all cancer deaths (Islami, et al., 2018). As many as 80% of heart disease, stroke, and type 2 diabetes cases are preventable through healthy dietary intake, daily physical activity, and smoking cessation (World Health Organization, 2005).

The risk of developing diabetes is 30-40% greater for active smokers than for non-smokers (U.S. Department of Health and Human Services, 2014).

Modifiable risk factor trends increase Delawareans’ chronic disease risk. In 2017, 31% of Delaware adults reported no physical activity during the previous 30 days other than their regular job. Forty-two percent of Race/ethnicity, sex, education, county of residence, and Delaware adults reported eating fewer than one serving disability status were not significantly associated with of fruits and vegetables per day. In 2016, less than onepre-diabetes or diabetes prevalence among Delawareans in 2017. Conversely, age and weight status remain strong third (32%) of Delaware adults were at a normal weight; 37% of Delaware adults were overweight and another predictors of both 31% were obese. Delawareans age 40-44 have the pre-diabetes and diabetes prevalence highest obesity prevalence rate (39%) followed closely among Delawareans. by Delawareans age 50-54 (38%) (Division of Public In 2017, pre-diabetes Health, 2017). Delaware’s adult obesity rate ranks 23rd prevalence rates were among states (Segal, Rayburn, & Beck, 2017). highest among adults Delaware’s statewide tobacco use prevalence rates have age 55-64 while declined over the past two decades. From 2011 to diabetes prevalence peaked among adults 2017, cigarette smoking prevalence among Delawareans declined from 22% to 17% (Division of Public Health, age 65 and older. Obese Delawareans had the highest 2018). Yet, the need for continued anti-tobacco public pre-diabetes and diabetes prevalence rates (22.4% and health efforts remains. Delaware ranks 27th among 19.6%, respectively). Prevalence rates among obese states in current cigarette use among adults (Centers for adults were approximately twice as high as pre-diabetes Disease Control and Prevention, 2018). In 2017, 22% and diabetes prevalence rates among overweight of Delaware adults – more than one-fifth of the state’s Delawareans (Division of Public Health, 2018).

92 Delaware Journal of Public Health – February 2019

adult population – used at least one type of tobacco (cigarettes, cigars, e-cigarettes, smokeless tobacco, hookahs, and/or other tobacco products) (Division of Public Health, 2018). Cigarette use prevalence is highest among 25-34-year-old Delawareans (26%); 13% of Delawareans age 18-24 and 8% of Delawareans age 65 and older were current smokers in 2017 (Division of Public Health, 2018). In 2016, 57% of Delaware smokers reported having tried to quit smoking within the past year (Division of Public Health, 2017). These data highlight the public health opportunity to interface with large numbers of Delawareans who align with the contemplation, preparation, and action stages of the Transtheoretical Model of intentional behavior change theory (Prochaska, Redding, & Evers, 2002).

Chronic Disease Disparities in Delaware Health disparities occur when socially disadvantaged groups have higher rates of chronic disease and fewer opportunities to achieve optimal health. Health disparities can exist between people of different ages, races, education level, income level, and county of residence; they are often preventable and correctable.

Factors like education, inadequate housing, poor access to healthy foods, lack of health care, and geographic isolation cause health disparities.

Delaware has reduced and/or eliminated several health disparities, most notably closing the gap between African American and Caucasian cancer death rates (Division of Public Health, 2018). However, several important chronic disease health disparities exist among Delawareans. For example, the 2011-2015 age-adjusted heart disease death rate for African American women in Delaware was 29% greater than the rate for Caucasian women (154.4 per 100,000 vs. 119.8 per 100,000, respectively) (Division of Public Health, 2018). Twentyeight percent of Delawareans with less than a high school diploma are current smokers, compared to just 6% of Delawareans who are college graduates (Division of Public Health, 2018).

Forty-four percent of Delawareans with a household income of less than $15,000 have high blood pressure compared to 29% of Delawareans with household income of $50,000 or more (Division of Public Health, 2018). Identifying, reducing, and eliminating preventable health disparities will further reduce Delawareans’ chronic disease burden.

Youth Health Behavior Trends The HPDP Section of DPH monitors youth health trends via the Youth Risk Behavior Surveillance System (YRBSS). YRBSS captures six categories of healthrelated behaviors that contribute to the leading causes of death and disability among youth and young adults.

In 2017, 2,974 middle school students and 2,906 high school students in Delaware completed the YRBSS survey.

Notable health-related trends include declining tobacco and alcohol use rates among Delaware high school students. From 1999 to 2017, the percentage of students who report currently smoking cigarettes fell from 32% to 6%. Conversely, in 2017, 14% of Delaware high school students currently used an electronic vapor product (including e-cigarettes, e-cigars, e-pipes, vape pipes, vaping pens, e-hookahs, and/or hookah pens) (University of Delaware, Center for Drug & Health Studies, 2018).

Over the same time period, the percentage of students who report currently drinking alcohol fell from 47% to 29% (University of Delaware, Center for Drug & Health Studies, 2018). In 2017, fewer than half (44%) of Delaware high school students participated in regular physical activity (defined as 60 minutes of physical activity on at least five of the past seven days); this percentage has remained stable since 2011 when the survey question was added to the YRBSS (University of Delaware, Center for Drug & Health Studies, 2018).

Conclusion Across the state, numerous stakeholders have achieved much success in reducing Delaware’s chronic disease burden. Through DPH’s programming within its HPDP Section, the State remains dedicated to addressing persistent and growing inequities that impact chronic disease development among Delawareans. The annual Chronic Disease in Delaware: Facts & Figures, 2018 issue brief aligns with Delaware’s overall health care reform strategy to achieve improved quality of care, better health outcomes, and reduced health care costs. By monitoring chronic disease trends and identifying Delawareans at elevated risk for chronic disease development, DPH positions itself as a collaborative partner working to achieve cost savings through improved health care resource efficiency.

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References

Author

Buttorff, C., Ruder, T., & Bauman, M. (2017). Multiple Chronic Conditions in the United States. Santa Monica, CA: RAND Corporation.

Helen Arthur, M.H.A., is Section Chief for the Health Promotion and Disease Prevention Section in the Division of Public Health (DPH), where she leads a team of professional and para-professional staff on a mission to improve the quality of life for Delaware’s citizens by promoting health and well-being, fostering self-sufficiency, and protecting vulnerable populations. Mrs. Arthur joined the State of Delaware Department of Health and Social Services (DHSS) in October 2004. She has more than 14 years of experience in public health administration across several areas of DHSS. In DPH, she served as the Oral Health Grant Administrator in the Bureau of Oral Health and Dental Services, the Early Childhood Comprehensive Systems Coordinator in the Maternal and Child Health Bureau, and the Physical Activity, Nutrition and Obesity Prevention Director in the Health Promotion Bureau. Prior to assuming her current position, Mrs. Arthur led in the dual capacity as the Director of Planning and Policy and Deputy Director for the Delaware Health Care Commission (DHCC), which is the primary health policy forum in the State of Delaware. While at the DHCC, Mrs. Arthur provided policy and regulatory support for Governor-appointed Boards legislatively mandated to ensure specific health services for the state and directed the daily program and fiscal operations under the general supervision of a Cabinet-appointed Executive Director.

Centers for Disease Control and Prevention. (2018). Current Cigarette Use Among Adults (Behavior Risk Factor Surveillance System) 2017. Retrieved from https://www.cdc.gov/ statesystem/cigaretteuseadult.html Centers for Disease Control and Prevention. (2018). Stats of the State of Delaware, DE Leading Causes of Death, 2016. Retrieved September 8, 2018, from https://www.cdc.gov/nchs/ pressroom/states/delaware/delaware.htm Delaware Health Statistics Center. (2018). Delaware Vital Statistics Annual Report, 2016.

Delaware Health and Social Services, Division of Public Health. Retrieved from https://www. dhss.delaware.gov/dhss/dph/hp/Files/mort16.pdf Division of Public Health. (2018). Cancer Incidence and Mortality in Delaware, 2010-2014.

Delaware Health and Social Services.

Division of Public Health. (2017). 2016 Core Variables Report, Behavioral Risk Factor Surveillance System. Delaware Health and Social Services . Retrieved from https://dhss.delaware. gov/dph/dpc/Files/de2016corequestions.pdf Division of Public Health. (2018). 2017 Core Variables Report, Behavioral Risk Factor Surveillance System. Delaware Health and Social Services. Retrieved from https://dhss.delaware. gov/dph/dpc/Files/de17core.pdf Division of Public Health. (2018). BRFSS Delaware Calculated Variable Data Report, 2017.

Delaware Health and Social Services. Retrieved September 23, 2018, from https://dhss.delaware. gov/dph/dpc/Files/de17calc.pdf Division of Public Health. (2018). The Burden of Cardiovascular Disease and Transient Ischemic Attack in Delaware, 2011-2015. Delaware Health and Social Services.

Islami, F., Sauer, A., Miller, K., Siegel, R., Fedewa, S., Jacobs, E., . . . Jemal, A. (2018).

Proportion and Number of Cancer Cases and Deaths Attributable to Potentially ModiFiable Risk Factors in the United States. CA: A Cancer Journal for Clinicians, 68(1), 31-54.

Kaiser Family Foundation. (2017). Health Care Expenditures per Capita by Service by State of Residence. Retrieved October 22, 2018, from https://www.kff.org/other/state-indicator/healthspending-per-capita-by-service Khavjou, O., Phelps, D., & Leib, A. (2016). Projections of Cardiovascular Disease Prevalence and Costs: 2015-2035. Research Triangle Park, NC: RTI International.

Mitchell, A. (2018). Medicaid's Federal Medical Assistance Percentage (FMAP). Washington, D.C.: Congressional Research Service.

Prochaska, J., Redding, C., & Evers, K. (2002). The Transtheoretical Model and Stages of Change. In K. Glanz, B. Rimer, & F. Lewis (Eds.), Health Behavior and Health Education: Theory, Research, and Practice (3rd Ed.). San Francisco, CA: Jossey-Bass, Inc. Segal, L., Rayburn, J., & Beck, S. (2017). The State of Obesity: Better Policies for a Healthier America 2017. Robert Wood Johnson Foundation. Retrieved May 20, 2018, from https:// stateofobesity.org/Files/stateofobesity2017.pdf The Pew Charitable Trusts and the John D. and Catherine T. MacArthur Foundation. (2014).

State Health Care Spending on Medicaid: A 50-State Study of Trends and Drivers of Cost.

U.S. Department of Health and Human Services. (2014). The Health Consequences of Smoking -- 50 Years of Progress: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, OfFice on Smoking and Health.

University of Delaware, Center for Drug & Health Studies. (2018). 2017 Youth Risk Behavior Survey Results, Delaware High School Survey, Trend Analysis Report. Retrieved from https:// www.cdhs.udel.edu/content-sub-site/Documents/2017%20Epi%20Report/2017%20DE%20 HS%20Trend%20Report.pdf World Health Organization. (2005). Preventing chronic diseases: A vital investment. Geneva: World Health Organization. Retrieved May 19, 2018, from http://www.who.int/chp/chronic_ disease_report/contents/part1.pdf?ua=1 Xu, X., Bishop, E., Kennedy, S., Simpson, S., & Pechacek, T. (2015). Annual healthcare spending attributable to cigarette use: An update. American Journal of Preventive Medicine, 48(3), 326-33.

94 Delaware Journal of Public Health – February 2019

Mrs. Arthur’s experiences cover a broad-spectrum of administrative services to include: management of statewide population health programming aimed at addressing behavioral, social and health intervention strategies across the life span, management of theory and practice and development of innovative programs and services.

Her education, dedication and professional experiences bolster her sincere commitment to addressing social determinants of health among Delaware’s diverse populations. Mrs. Arthur received a Master of Science in Management degree with a focus in Health Care Administration from Wilmington University in December 2011 and her undergraduate degree from Old Dominion University’s School of Health Sciences.

SAVE THE DATE FOR OUR POLICY ACADEMY

April 17, 2019 “Reducing Health Inequities

by Addressing Structural Racism” Inviting Delaware residents, policymakers; advocates; media, academics; students; and practitioners across a range of sectors, including but not limited to health and social services.

The Tower at STAR Audion 100 Discovery Blvd., Newark, DE 19713

S AV E T H E D AT E 4.17.19 chs.udel.edu

HEALTH CARE PROVIDERS

Research has shown that a lung cancer screening can save lives.

A low-dose CT scan has been proven to reduce mortality risk in smokers and former smokers by 20 percent. The screening: • Is the result of findings of the National Lung Screening Trial • Has been endorsed by the American Cancer Society, American Lung Association, and U.S. Preventive Services Task Force Your patients should be screened if they: • Are 55 to 80 years of age.

• Have smoked the equivalent of a pack a day for 30 or more years, or two packs a day for 15 or more years.

• Currently smoke or quit smoking within the last 15 years.

Talk to your patients who smoke or have smoked about the lung cancer screening.

Or they can call (302) 754-5574 to have a screening nurse navigator schedule a screening for them.

302-754-5574 | HealthyDelaware.org/LungScreenings

DELAWARE HEALTH AND SOCIAL SERVICES Division of Public Health Bureau of Chronic Diseases

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The DPH uses Policy, Systems, and Environmental (PSE) level strategies in their programs and plans, and aligns them with the recommendations of the Delaware SHIP report. This alignment will allow the DPH to evaluate current programs, and determine if changes need to be made to improve the health of Delawareans.

Population Health

Health

Health Equity

Social Determination of Health

Lisa M.G. Henry, M.S. Division of Public Health Delaware Department of Health and Social Services

The Delaware Division of Public Health (DPH) has worked to improve the health of the state’s residents both on an individual level, and as a whole at the population level, for many years. Most recently, DPH adopted a new strategic approach to how it addresses population health specifically. Over the last two to three years, DPH began to foundationally reorganize and intentionally connect staff with organizations and communities that are also working toward addressing population health issues. To further the Division’s efforts and lay additional groundwork, DPH formed a small working group in 2018 to discuss and solidify a population health plan.

The working group agreed that DPH staff needed to adopt common language. The group researched and reviewed various definitions for common terms such as health, population health, health equity, and social determinants of health and ultimately agreed on the following definitions: 96 Delaware Journal of Public Health – February 2019

The Division of Public Health Adopts New Population Health Approach

Cassandra Codes-Johnson, M.P.A. Division of Public Health Delaware Department of Health and Social Services

• Health – The state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity (World Health Organization, 2018).

• Population Health – The health outcomes of a group of individuals, including the distribution of such outcomes within the group. Population health includes the interrelated conditions and factors that influence the health of populations over the life course, identifies systematic variations in their patterns of occurrence, and applies the resulting knowledge to develop and implement policies and actions to improve the health and well-being of those populations (Kindig & Stoddart, 2003).

• Health Equity – Achieving the conditions in which all people have the opportunity to reach their health potential; the highest level of health for all people (Knight, Ransford, Gugerty, Dugan, & CodesJohnson, 2015).

• Social Determinants of Health – The circumstances in which people are born, grow, live, work, and age, as well as the systems put in place that influence health.

The underlying environmental, economic, social, and political structures that determine the quality and distribution of resources needed for health (Knight, Ransford, Gugerty, Dugan, & Codes-Johnson, 2015).

Next, the working group determined an action framework that DPH staff could embrace at all levels and could use to guide the development of strategic intentional goals focusing on addressing specific population health issues. The group reviewed various concepts and settled on the Robert Woods Johnson Foundation (RWJF) Culture of Health Framework, which is a collaboration between the RWJF and RAND Corporation (Robert Wood Johnson Foundation, 2019).

The Robert Wood Johnson Foundation has committed itself to a vision of working alongside others to build a national Culture of Health (Figure 1). The Culture of Health Action Framework sets a national agenda to improve population health, equity, and well-being.

Informed by rigorous research on the multiple factors that affect health, it recognizes that there are many ways to build a Culture of Health, and provides numerous entry points for all types of organizations to get involved.

The DPH team determined that the framework was an appropriate model to track progress in Delaware, in part because it encourages work across all sectors.

The RWJF Culture of Health Framework contains four action areas (Figure 2). These action areas represent significant strategic opportunities to realize the culture of health at the community level. Each action area has drivers. The drivers are priority areas where attention and innovation are needed to make ongoing systemic, cultural, and social change that can impact health.

Lastly, the framework provides measures (Figure 3).

DPH developed unique measures to track positive and negative changes in each action area over time.

In addition to adopting the Culture of Health Framework, the DPH team developed an internal strategy map (Figure 4). This strategy map will guide day-to-day efforts towards improving specific population health issues. The DPH team incorporated the Culture of Health action areas into the strategy map. The strategy map will be used as a tool to guide the implementation of strategic initiatives, as well as to track internal efforts toward achieving identified population health goals.

The DPH Population Health Plan and Strategy Map was shared with the DPH Leadership Team to obtain feedback and gain approval for implementation. Using the Map as a guide, Leadership team members were asked to document Policy, Systems and Environmental (PSE) level strategies that their programs are either currently engaged in, or could potentially implement in the near future, that are believed to have a positive impact on specific population health indicators. PSE change approaches seek to go beyond programming and into the systems that create the structures in which we work, live, and play. An effective PSE approach should seek to reach populations and uncover strategies for impact that are sustainable. Efforts may accelerate the adoption or implementation of effective interventions by effectively integrating approaches into existing infrastructures. Such approaches often involve the input of advocates, decision makers, and policy makers (The Food Trust, 2013).

As DPH works internally, using the strategy map to track its efforts, it is also employing continuous quality improvement review to help determine if its efforts have positive impacts. The Division has also embarked on a path to provide more information to the public regarding population health and the factors that impact health outcomes. To that end, DPH is developing a State of Delaware Population Health Indicators Scorecard (Figure 5). The scorecard will provide more timely trend data for various clinical, social, and environmental data points. This scorecard contains measures across nine areas: community safety, healthy lifestyles, infectious diseases, maternal and child health, health services utilization, chronic disease, mental health and substance use disorder, economy, and education.

The DPH population health strategy also supports, and aligns with, State Health Improvement Plan (SHIP) goals. The population health scorecard will highlight and inform the public regarding how Delaware is trending on important indicators that impact SHIP goals. The division’s internal population health strategy work is designed to create alignment throughout programs that will allow DPH to evaluate current investments being made and make determinations as to whether current strategies are working or if a shift in investments would better support SHIP goals.

By following these data points and intentionally working to improve the clinical, social, and environmental health determinants, DPH and others can work collectively toward improving the state’s population health.

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References Kindig, D., & Stoddart, G. (2003). What is population health? American Journal of Public Health, 93(3), 380-383. Retrieved from https://ajph.aphapublications.org/doi/abs/10.2105/ AJPH.93.3.380 Knight, E. K., Ransford, G., Gugerty, P., Dugan, E., & Codes-Johnson, C. (2015).

Health Equity Guide for Public Health Practitioners and Partners. Delaware Health and Social Services. Retrieved from https://www.dhss.delaware.gov/dph/mh/files/ ealthequityguideforpublichealthpractitionersandpartners.pdf

Robert Wood Johnson Foundation. (2019). Building a Culture of Health. Retrieved from rwjf. org: https://www.rwjf.org/en/cultureofhealth/taking-action.html The Food Trust. (2013, 11). Policy, Systems and Environmental (PSE) Change. Retrieved from healthtrust.org: http://healthtrust.org/wp-content/uploads/2013/11/2012-12-28-Policy_ Systems_and_Environmental_Change.pdf World Health Organization. (2018). Frequently Asked Questions. Retrieved from who.int: https://www.who.int/suggestions/faq/en/

Figure 1: 10 Principles for a Culture of Health.

Source: https://www.rwjf.org/en/cultureofhealth/about/how-we-got-here.html#ten-underlying-principles

Figure 2: Culture of Health Taking Action.

Source: https://www.rwjf.org/content/dam/COH/PDFs/MovingForwardTogetherFullReportFinal.pdf

98 Delaware Journal of Public Health â&#x20AC;&#x201C; February 2019

INTRODUCING THE UPDATED CULTURE OF HEALTH MEASURES

Figure 3: Culture of Health Framework.

CULTURE OF HEALTH NATIONAL MEASURES ACTION AREAS

1 MAKING HEALTH A SHARED VALUE

DRIVERS

MEASURES Recognized influence of physical and social factors on health

MINDSET AND EXPECTATIONS

Internet searches for health-promoting information Community connection

SENSE OF COMMUNIT Y

Valued investment in community health Voter participation

CIVIC ENGAGEMENT

2 FOSTERING CROSS-SECTOR COLLABORATION TO IMPROVE WELL-BEING

NUMBER AND QUALIT Y OF PARTNERSHIPS INVESTMENT IN CROSS-SECTOR COLL ABORATION

Volunteer participation Hospital partnerships Youth exposure to advertising for unhealthy foods Business leadership in health Federal investment in Health in All Policies Support for working families (FML A)

POLICIES THAT SUPPORT COLL ABORATION

Collaboration among communities and law enforcement New Measure: Walkability

3 CREATING HEALTHIER, MORE EQUITABLE COMMUNITIES

BUILT ENVIRONMENT AND PHYSICAL CONDITIONS

Public libraries Youth safety Housing affordability

SOCIAL AND ECONOMIC ENVIRONMENT

Residential segregation Enrollment in early childhood education Climate adaptation and mitigation

POLICY AND GOVERNANCE

Air quality Access to comprehensive public health services

4 STRENGTHENING INTEGRATION OF HEALTH SERVICES AND SYSTEMS

Health insurance coverage

ACCESS TO CARE

Routine dental care

CONSUMER EXPERIENCE

BAL ANCE AND INTEGRATION

OUTCOME

IMPROVED POPULATION HEALTH, WELL-BEING, AND EQUITY

Access to alcohol, substance use, or mental health treatment

Consumer experience with care Population-based alternative payment models Electronic medical record linkages Full scope of practice for nurse practitioners

OUTCOME AREAS

MEASURES

ENHANCED INDIVIDUAL AND COMMUNIT Y WELL-BEING

New Measure: Incarceration

MANAGED CHRONIC DISEASE AND REDUCED TOXIC STRESS

Individual well-being

Adverse childhood experiences Disability-adjusted life years related to chronic disease End-of-life care expenditures

REDUCED HEALTH CARE COSTS

Preventable hospitalizations Family health care costs

Source: https://www.rwjf.org/content/dam/COH/PDFs/MovingForwardTogetherFullReportFinal.pdf.

10 ROBERT WOOD JOHNSON FOUNDATION 99

Figure 4: Division of Public Health Population Health Strategy Map. DHSS Strategy Map

Vision: Improved Population Health, Well-Being and Equity

Perspective

STRATEGIC OBJECTIVES

Strategic Focus: Health Status

Revised 10-4-18

Improved Health Status of All Delawareans 2. Minimize Health

Executive Sponsor: Cassandra Codes-Johnson

1. Improve Health Outcomes

3. Reduce Healthcare Costs

Risks

Assets

Process & Learning

Implementation

Fostering Cross-Sector Collaboration Making Health a Shared Vision

5. Mobilize Communities and Health systems

4. Promote Healthy Communities

Strengthening Integration of Health Service

Creating Healthier, More Equitable Communities

6. Address the Social Determinants of Health

8. Provide Technical Assistance to Community and Strategic Partners

10. Obtain and Sustain Funding

11. Build and Nurture Partnerships

7. Integrate Public Health, Communities, and Healthcare

9. Disseminate Data

12. Assure and Retain a Competent Workforce

13. Track Data

Source: Delaware Department of Health and Social Services, Division of Public Health, 2018

Figure 5: Population Health Scorecard Measures, Division Of Public Health, 2018

Source: Delaware Department of Health and Social Services, Division of Public Health, 2018

Authors Cassandra Codes-Johnson, M.P.A., is currently the Associate Deputy Director for the Delaware Division of Public Health (DPH) and provides oversight for over 300 dedicated public health staff that provide a variety of services to protect and promote the health of Delawareans. A Lean Six Sigma Greenbelt, she is an organizational management and Public Health professional with over twenty years of experience in health care. Over the years, Cassandra has worked in the private, nonprofit and government sectors with one clear goal in mind: identify opportunities to improve the lives of people through the improvement of systems and processes.

100 Delaware Journal of Public Health â&#x20AC;&#x201C; February 2019

Lisa M.G. Henry, M.S., is the Director of Community Health Services for the Division of Public Health within the Delaware Department of Health and Social Services. Ms. Henry previously served as the Chronic Disease Bureau Chief within the Delaware Division of Public Health and has been with the Division for nearly 14 years. She is a graduate of the University of Delaware, where she received a Master of Science in Health Services Administration; and a graduate of Eckerd College where she received a Bachelor of Arts degree in Management.

Save The Date: May 7, 2019 On behalf of the Board of Directors, the President and Executive Director invite you to join us for our

89th Annual Meeting, Keynote Address & Awards Ceremony The Keynote Address will be delivered by David L. Heymann, M.D., D.T.M.&H., C.B.E. Dr. Heymann will discuss his career in global health and combating infectious disease. He will focus on the last remaining outposts of polio, and the importance of global polio eradication.

Dr. Heymann is Head of the Centre on Global Health Security at the UK’s Royal Institute for International Affairs (Chatham House), and Professor of Infectious Disease Epidemiology at the London School of Hygiene and Tropical Medicine.

He has served in senior positions in the US CDC and the World Health David L. Heymann, M.D., D.T.M.&H., C.B.E. Organization, including as WHO Assistant Director-General, and as Representative of the Director-General for polio eradication. Dr. Heymann has worked on infectious diseases worldwide, including in the smallpox eradication campaign (India); the Ebola outbreak in then-Zaire in 1978; Legionnaire’s disease (Philadelphia); and leading the global response to SARS. He received the Commander of the Order of the British Empire (CBE) in 2009; is a member of the US National Academy of Medicine and the UK Academy of Medical Sciences; holds three honorary doctorates; and has received the highest awards from the American Public Health Association and the American Society of Tropical Medicine & Hygiene. He is Editor in Chief of the APHA’s Control of Communicable Disease Manual, the most widely used infectious disease text in the world.

This year’s Lewis B. Flinn’s President’s Award is being presented to Sherman L. Townsend for his 30 year Chairmanship of the Delaware Institute of Medicine Education and Research. DIMER has been Delaware’s medical school alternative since 1969 with agreements with Sidney Kimmel Medical College of Thomas Jefferson University and the Philadelphia College of Osteopathic Medicine - both in Philadelphia, PA. The Executive Director’s Public Health Recognition will be presented to the William J Holloway Community Program (formerly the HIV Program at Christiana Care Health System) which was started in 1989. This award will be accepted by Susan Szabo, M.D. and Arlene Bincsik, R.N. Event: Annual Meeting of the Delaware Academy of Medicine/Delaware Public Health Association Date: Tuesday, May 7, 2019 Time: 6:00 PM to 8:30 PM Location: Deerfield Country Club Address: 507 Thompson Station Rd, Newark, DE 19711

Register online today!

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Studying how chronic disease (a SHIP priority area) affects a population requires data, epidemiology, and biostatistics. By working together, programs throughout Delaware can develop programs and direct funding to areas and populations that need them the most.

The Data of Disease: How Data Collection Leads to Healthy Populations

Katherine Smith, M.D., M.P.H.

Families in the 18th and 19th centuries commonly had many children, simply because children in these time periods had a much greater risk of dying due to infectious disease, poor sanitation, and poor nutrition than many children alive today. Vaccines, good sanitation practices, better food availability, and access to healthcare have reduced childhood mortality, and led to what scientists call an “epidemiological transition:” fewer children dying leads to smaller families, which in turn create larger, older populations in which the main causes of death are no longer infections, but instead chronic diseases (Dye, 2013).

In this century, chronic diseases are the major cause of death and disability worldwide (WHO, 2005).

By definition, a chronic disease is one lasting three or more months (National Health Council, 2019).

These conditions are persistent: they generally cannot be prevented by vaccines or “cured” by medication, rarely “just go away,” and are the leading causes of death and disability in the United States (Centers for Disease Control and Prevention [CDC], 2009). In 2005, almost half of all American adults had at least one chronic illness, and by 2009 the U.S. was spending more than 75% of our healthcare budget on chronic conditions (CDC, 2009). In 2015, 67.7% of Medicareenrolled persons over the age of 65 years had two or more chronic conditions, and those numbers are still rising (CDC, 2019a).

102 Delaware Journal of Public Health – February 2019

Now the question researchers are asking is, “what can we do about it?”

Epidemiology and Biostatistics: Why Math is Important When studying a disease, one of the first things scientists look at is the incidence – what is the rate of new or newly diagnosed cases of a disease? Incidence rate is a very good indicator for infectious disease, because it shows scientists the “first” time someone has the disease. Incidence can be further categorized into different subsets – we can look at the incidence rate based on gender, or racial origin, by age group, or by diagnosis.

When studying chronic disease, however, we need to look a little deeper. Researchers look at the prevalence – the actual number of cases, either at one specific point in time (point prevalence) or over a period of time (period prevalence) that exist in a community.

Incidence and prevalence work together, but which is more important depends on the disease. In the case of a flu epidemic, the incidence rate (the number of people catching the flu) may be very high. But because many people recover after a few weeks, the prevalence of the flu may be very low. In the case of a chronic disease, like cancer, the number of new cases in a given time period may be very low, but the total number of cases may increase, because people are living with the disease.

As we transitioned into a society in which more people died of chronic disease than they did of infectious disease, scientists had to re-think the disease process.

They wanted to know what the underlying causes of chronic disease were, if they could be prevented or controlled, and what impact these diseases have on the health of individuals and communities. To answer all these questions, they needed data (Remington & Brownson, 2011).

Risk vs. Protection There are several diseases that meet the definition of chronic: cardiovascular disease (heart disease and stroke), cancer, chronic respiratory diseases (chronic obstructive pulmonary disease (COPD) and asthma), diabetes, and a slew of other conditions (mental disorders, vision and hearing impairments, oral diseases, bone and joint disorders, genetic disorders, etc.) (World Health Organization [WHO], 2005).

In the 1960s, researchers began to use large-scale studies like the Framingham Heart Study, the Seven Countries Study, and the British Doctors Study to determine why people were getting sick. By looking at such large groups of people, researchers could see trends in the data: they discovered that the presence of certain things – “risk factors” – put people at a greater risk of contracting a disease, and other things – “protective factors” – tended to keep diseases from happening (Remington & Brownson, 2011). They also found that some risk factors (primarily cigarette smoking, poor diet, physical inactivity, and high blood pressure) could contribute to multiple chronic diseases (Remington & Brownson, 2011). No study has found the “cause” of chronic diseases, but using different studies, different study designs, and different populations of people, scientists now know that there are many factors that can increase (or decrease) an individual’s risk of disease.

The WHO lists several risk factors of chronic disease, some modifiable and some not. Modifiable risk factors include an unhealthy diet, physical inactivity, consumption of alcohol, and tobacco use. Nonmodifiable risk factors are things like age and genetics.

As research has continued, so-called “intermediate risk factors” like high blood pressure, high blood glucose, and/or being overweight or obese have been found to contribute to the development of chronic disease (WHO, 2005). Researchers also believe that the Social Determinants of Health are fundamental causes of chronic disease. The conditions in which people grow,

live, work, and play; the factors affecting their daily lives; their ability to access fresh food, health care, and exercise; their mental health and ability to handle stress – all of these things have been found to contribute to chronic disease (WHO, 2011). By gathering data, researchers can focus prevention efforts to target risk factors specific to communities (Remington & Brownson, 2011).

Personalized Medicine Doctors create an individual, customized treatment plan, based on each person’s disease susceptibility. This plan uses a person’s genome to pinpoint therapies and treatments that will work with a patient’s immune system to tailor health care to that patient.

By contrast, certain factors can prevent or protect against the development of chronic disease. Regular consumption of fruit and vegetables, access to healthcare services, and the ability to maintain an exercise regimen have all been shown to decrease the risk of chronic disease within a community (Malta & Bernal, 2014). Preventive screening for different types of cancer, heart disease, and other chronic diseases have been shown to avoid or delay the onset of disease, keep diseases from getting worse, reduce healthcare costs, and allow people to lead productive lives (CDC, 2019b). Making lifestyles healthier by providing access to basic utilities, making streets and neighborhoods safer, decreasing socioeconomic class differences, and providing social support can lead to healthier diet choices, tobacco and alcohol cessation, and healthier habits (WHO, 2011).

All of this data – incidence rate, prevalence rate, risk factors and protective factors – are based on populations, not a single individual. While individuals living in the same community may have some of the same risk factors (clean air, abundant outdoor spaces, access to fresh food), other factors are likely different (smoking tobacco, genetic factors, ability to access healthcare). It is the interaction of these risk and protective factors that may lead an individual to be diagnosed with a chronic disease. Unfortunately, there are no absolutes: just because an individual has all of the known risk factors for asthma, does not mean that she will suffer from it.

Where do we go from here?

Thirty percent of adults living in Kent County reported that they have no leisure-time physical activity. In 103

Sussex and New Castle Counties, that number is 27% and 25%, respectively (County Health Rankings and Roadmaps, 2018). In Kent County, there is one primary care physician for 2,200 people; in Sussex (1 to 1,530) and New Castle (1 to 1,230) those numbers are better (County Health Rankings and Roadmaps, 2018). In 2015, non-Hispanic white adults were more likely than non-Hispanic black adults to die of coronary heart disease in Delaware (CDC, 2019a).

Non-Hispanic black Delawareans are almost twice as likely to have diabetes than non-Hispanic whites, and are more likely to be obese or overweight (CDC, 2019a). Using data like this, programs and institutions can direct their resources to people in high-priority areas like the City of Wilmington or Sussex County, update their disease screening protocols, or add prevention programs in high-risk communities.

At this point in time, researchers cannot pinpoint one or multiple factors that will accurately predict if a person will or will not be diagnosed with a chronic disease, although there are many interesting opportunities for personalized Metabolic Syndrome medicine in the Metabolic Syndrome is a group very near future. of risk factors (high blood Researchers are pressure, high blood sugar, learning how to excess body fat around the tailor interventions waist, and abnormal cholesterol to people based and/or triglycerides) that, when on their personal occurring together, can increase risk of disease or an individual’s risk of heart expected response disease, stroke, and diabetes. to treatments. More If one or more or these risk and more, scientists factors is decreased, an are noticing that some risk factors individual’s risk of being occurring together diagnosed with multiple increase a person’s chronic diseases may be risk of many reduced dramatically. chronic diseases (see side bar). It is only by continuously gathering data, and looking at that information on a population scale, that we will continue to fight the chronic diseases that are present in our communities.

There are many institutions, non-profits, volunteer organizations, and individuals in Delaware committed to reducing the burden of chronic disease in the First State. Indeed, this is the basis for the newly formed Delaware Chronic Disease Collaborative 104 Delaware Journal of Public Health – February 2019

(www.dechronicdiseasecolaborative.org). Over 74% of Medicare-enrolled Delawareans over the age of 65 years have two or more chronic conditions, and 10% of all Delawareans over the age of 18 have diabetes. Over 30% of adults are considered obese, and almost 50% of persons in Delaware have had a stroke (CDC, 2019a).

By working together, organizations throughout the state can decrease the burden chronic disease places on our communities, families, and individuals.

Data are used in institutional decision-making every day, and the healthcare industry is no different.

Planners all over the state use the data gathered by state, federal, and local institutions to direct their funding, plan their projects, and evaluate the effectiveness of those programs on an ongoing basis. In this way, individuals - in Delaware and across the nation – can get the most up-to-date health information as soon as possible, and live their healthiest lives.

References Centers for Disease Control and Prevention [CDC]. (2009). The Power of Prevention: Chronic disease --- the public health challenge of the 21st century. Centers for Disease Control and Prevention.

CDC. (2019a). Leading Indicators for Chronic Diseases and Risk Factors. Retrieved from cdc. gov: https://chronicdata.cdc.gov/ CDC. (2019b). Preventive Health Care. Retrieved from cdc.gov: https://www.cdc.gov/ healthcommunication/toolstemplates/entertainmented/tips/PreventiveHealth.html County Health Rankings and Roadmaps. (2018). Explore Health Rankings: Delaware. Retrieved from County Health Rankings: http://www.countyhealthrankings.org/app/delaware/2018/ compare/snapshot Delaware Health and Social Services. (2018). Prevlaence of Selected Chronic Diseases Among Delaware Adults, 2017. Retrieved from delaware.gov: https://www.dhss.delaware.gov/dhss/dph/ dpc/2017chronicdiseases.html Dye, C. (2013). After 2015: infectious diseases in a new era of health and development.

Philosophical Transactions of the Royal Society of London. Series B, Biological Sciences, 369(1645). doi:10.1098/rstb.2013.0426 Malta, D. C., & Bernal, R. T. (2014). Comparison of risk and protective factors for chronic diseases in the population with and without health insurance in the Brazilian capitals, 2011. Rev Bras Epidemiol Suppl PeNSE, 241-255. doi:10.1590/1809-4503201400050019 McKenna, M., & Collins, J. (2010). Current issues and challenges in chronic disease control. In P. Remington, R. Brownson, & M. Wegner (Eds.), Chronic Disease Epidemiology and Control (pp. 1 - 16). Washington, DC: American Public Health Association.

National Health Council. (2019). About Chronic Conditions. Retrieved from NationalHealthCouncil.org: http://www.nationalhealthcouncil.org/newsroom/about-chronicconditions Remington, P. L., & Brownson, R. C. (2011). Fifty Years of Progress in Chronic Disease Epidemiology and Control. Centers for Disease Control and Prevention. Retrieved from https:// www.cdc.gov/mmwr/preview/mmwrhtml/su6004a12.htm World Health Organization [WHO]. (2005). Chronic Diseases and Their Common Risk Factors.

World Health Organization. Retrieved from https://www.who.int/chp/chronic_disease_report/ media/Factsheet1.pdf WHO. (2011). Political Declaration at the World Conference on Social Determinants of Health. (pp. 19-21). Rio de Janeiro, Brazil: WHO.

Author Katherine Smith, M.D., M.P.H., has led research projects on foreign and domestic immunization practices, the role of women and sexism in American society, and the use of advance directives in Delaware.

Her dual degrees allow her a unique take on medical and public health issues, and her dual citizenship adds an international perspective, allowing her to act in ways that truly benefit citizens and society.

Social Determinants of Health: Life Expectancy and the Relationship with Race, Education and Poverty in Delaware Kalyn McDonough, Ph.D.

The social determinants of health (SDH) are widely understood as the conditions in which people are born, grow, work, live, and age, and they are influenced by larger structural forces, such as economic, education, and political systems (WHO, 2018). These conditions are often overlapping and cumulative. For example, in areas of low economic opportunity, there may also be challenged education systems, food insecurity, unstable housing, and a lack of safe recreational spaces. These social determinants work in conjunction to contribute to poor population health and health inequities. With this understanding, geographic information system (GIS) was used to explore the relationship of social determinants of health within two cities in Delaware.

The visual analysis revealed that in communities with higher poverty rates and lower educational attainment there was also lower life expectancy when compared with communities with lower poverty rates and higher educational attainment. In the city of Wilmington, there was as much as a 12.9 year life expectancy difference between communities, and in Dover as much as a 8.7 year life expectancy difference. Disparities were also seen between racial groups. As these conditions are not naturally occurring, but rather the result of socially constructed institutions and public policy, measures can and should be taken to address SDH and support optimal health for all Delawareans.

Author Kalyn McDonough, Ph.D., is a second year doctoral student at the Joseph R. Biden, Jr. School of Public Policy and Administration at the University of Delaware. She is a graduate research assistant for the Partnership for Healthy Communities- a Community Engagement Initiative and for the Center for Community Research and Service. Her research focus is in sport for development, sport with justice-affiliated youth, and sport policy.

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Social Determinants of Health: Life Expectancy and the Relationship with Race, Education and Poverty in Delaware Kalyn McDonough Ph.D. Candidate, School of Public Policy and Administration

Description • The social determinants of health (SDH) are widely understood as the conditions in which people are born, grow, work, live, and age, and they are influenced by larger structural forces, such as economic, education, and political systems, which impact the conditions of daily life (WHO, 2018).

• The conditions in which people live are not naturally occurring, but are a result of socially constructed institutions and public policy. These conditions impact the long-term health of individuals, and have contributed to persistent health inequities (USDHHS, 2015; Bailey et al., 2017).

• The conditions which negatively impact peoples’ health are often overlapping and can be cumulative. For instance, in areas of low economic opportunity, there may also be challenging education systems, food insecurity, unstable housing, and a lack of safe recreational spaces. These social determinants work in conjunction to contribute to poor population health.

• As a result of structural racism, and other discriminatory practices, certain groups (based on race, gender, socioeconomic status, sexual orientation, and disability status) are more likely to be negatively affected by the social determinants of health, resulting in health inequities (Bailey et al., 2017; USDHSS, 2015; Knight, Ransford, Gugerty, Dugan, & CodesJohnson, 2015).

Life Expectancy in Wilmington

84.1 73.6

Wilmington 70.9

71.2

Demographics Predominant racial or ethnic group between 2012-2016.

Predominant Racial or Ethnic Group Year: 2012-2016 Shaded by: Block Group, 2010 Insufficient Data White >90% White 70-90% White 50-70% White <50% Black >90% Black 70-90% Black 50-70% Black <50% Hispanic >90% Hispanic 70-90% Hispanic 50-70% Hispanic <50% Asian >90% Asian 70-90% Asian 50-70% Asian <50% Native American/ Alaska Native >90% Native American/ Alaska Native 70-90% Native American/ Alaska Native 50-70% Native American/ Alaska Native <50% Native Hawaiian/ Pacific Islander 50-70% Native Hawaiian/ Pacific Islander <50% Other >90% Other 70-90% Other 50-70% Other <50% Two Or More >90% Two Or More 70-90% Two Or More 50-70% Two Or More <50% Tie Between Categories Source: Census

Life Expectancy in Dover

81.2

78 77

72.5

Dover

Demographics Predominant racial or ethnic group between 2012-2016.

Predominant Racial or Ethnic Group Year: 2012-2016 Shaded by: Block Group, 2010 Insufficient Data White >90% White 70-90% White 50-70% White <50% Black >90% Black 70-90% Black 50-70% Black <50% Hispanic >90% Hispanic 70-90% Hispanic 50-70% Hispanic <50% Asian >90% Asian 70-90% Asian 50-70% Asian <50% Native American/ Alaska Native >90% Native American/ Alaska Native 70-90% Native American/ Alaska Native 50-70%

:Source: Dahlgren & Whitehead, 1991.

Data Sources: Demographics, Education, & Poverty- U.S. Census American Community Survey, Policy Map, 2012-2016; Life Expectancy – National Center for Health Statistics. U.S. Small-Area Life Expectancy Estimates Project (USALEEP): Life Expectancy Estimates File for {Jurisdiction}, 2010-2015. National Center for Health Statistics. 2018.

106 Delaware Journal of Public Health – February 2019

Native American/ Alaska Native <50% Native Hawaiian/ Pacific Islander 50-70% Native Hawaiian/ Pacific Islander <50% Other >90% Other 70-90% Other 50-70% Other <50% Two Or More >90% Two Or More 70-90% Two Or More 50-70% Two Or More <50% Tie Between Categories Source: Census

Center for Community Research & Service https://www.sppa.udel.edu/ccrs Partnership for Healthy Communities https://sites.udel.edu/healthycommunities/

Education, Poverty in Wilmington Estimated percent of people with a Bachelor's degree between 2012-2016.

Percent Population with Bachelor's Degree Year: 2012-2016 Shaded by: Block Group, 2010 Insufficient Data 7.34% or less

31%

7.35% - 12.59% 12.60% - 18.82% 18.83% - 27.64%

4%

27.65% or more Source: Census

25%

20%

5%

37%

2%

58%

In Delaware, the effects of the social determinants of health are evident.

• Displayed on the maps, communities in Wilmington where residents have less education and a higher poverty rate, have a life expectancy that is 12.9 years less than those with more education and a lower poverty rate.

• In Dover, communities with lower levels of education and a higher poverty rate, have a life expectancy that is 8.7 years less than those with more education and a lower poverty rate.

• These disparities are also seen between racial groups.

Education, Poverty in Dover Estimated percent of people with a Bachelor‘s degree between 2012-2016.

Percent Population with Bachelor's Degree

Estimated percent of all people that are living in poverty as of 2012-2016.

Year: 2012-2016 Shaded by: Block Group, 2010

Insufficient Data

Insufficient Data

6.03% or less

7.34% or less

6.04% - 10.48%

7.35% - 12.59%

10.49% - 16.14%

12.60% - 18.82% 18.83% - 27.64%

22%

27.65% or more Source: Census

16.15% - 25.57% 25.58% or more

'#

Source: Census

18%

$&#

7% 17%

Percent of People in Poverty Year: 2012-2016 Shaded by: Census Tract, 2010

!"# $%#

Poster prepared for GIS Day 2018, University of Delaware, November 14, 2018

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STATE SEAL HERE Delaware Governor John Carney Governor Carney Announces Trauma-Informed Initiatives Family Services Cabinet Council launches Compassionate Champion Award, Trauma Awareness Month Planning WILMINGTON, Del. – Governor John Carney on Tuesday announced two new initiatives from the Family Services Cabinet Council to implement Executive Order 24, which launched efforts to make Delaware a trauma-informed state. The Family Services Cabinet Council – a cabinetlevel group reestablished by Governor Carney in February 2017 to coordinate public and private services for Delaware families – will promote Trauma Awareness Month throughout Delaware during May 2019 and launch the Compassionate Champion Award, a recognition program for champions of this work.

“We need to do everything we can to support children and families in Delaware who are affected by trauma in their lives,” said Governor Carney. “Delaware has many dedicated, boots-on-theground workers and organizations that are practicing trauma-informed care and helping Delawareans get the services they need. We are committed to working together to support, promote, and recognize more of these efforts to help build stronger, healthier and more traumainformed communities across our state.”

Learn more about the Family Services Cabinet Council: de.gov/fscc The Compassionate Champion Award is a new trauma-informed care recognition program to highlight outstanding achievement by individuals and organizations that provide traumainformed services.

This award will recognize individuals or teams in government, non-profit and private organizations, first responder professions, education, and other agencies that have taken steps toward providing services in a manner consistent with trauma-informed care criteria in the Delaware Developmental Framework for Trauma Informed Care, a document that outlines best practices for trauma-informed care. The Framework was adapted from the Missouri Model of trauma-informed care, and was produced in collaboration by the Family Services Cabinet Council ACEs Subcommittee and the Compassionate Connections Partnership.

The Compassionate Champion Award nomination form is now available, and the deadline to apply is April 1, 2019. Nominations may also be submitted by downloading the application found on the Compassionate Champion Award webpage and emailing the form to fscc@delaware.gov, or mailing it to Compassionate Champion Award, Office of the Governor – Carvel State Office Building, 820 N. French Street, 12th Floor, Wilmington, DE 19801.

108 Delaware Journal of Public Health – February 2019

“The Children’s Department is pleased to be on the frontline of Delaware’s efforts to become a trauma-informed state,” said Josette Manning, Secretary of the Delaware Department of Services for Children, Youth, and Their Families. “Adverse childhood experiences can have life altering impacts if they are not recognized and addressed properly. The Compassionate Champion Award will help recognize the important work that is being done every day in Delaware to help increase awareness and mitigate the impact of trauma on our children, families and communities.”

“We must support our educators by providing the training and resources they need to be better informed about of the effects of trauma on students,” said Dr. Susan Bunting, Secretary of the Delaware Department of Education. “Recent state-sponsored professional development has offered educators the chance to learn more about the research around childhood trauma and the effect of toxic stress on brain development. Our hope is that such training will translate into their more effectively supporting those who have been impacted by trauma.”

“Awareness of trauma is a critical step in supporting and promoting recovery for Delawareans, young people and adults, who have experienced trauma in their lives,” said Dr. Kara Odom Walker, a board-certified family physician and Secretary of the Delaware Department of Health and Social Services. “At the Department of Health and Social Services, we have trained 1,000 employees who have the greatest level of direct client contact in the trauma-informed approach. A workforce that understands what trauma is, how it affects people across their lifespans, and the most effective ways to assess and meet our clients’ needs will help us build resilience among the people we serve so they learn to thrive in their communities.”

The Family Services Cabinet Council also invites members of the public to participate in planning for Trauma Awareness Month happening this May. Organizations and individuals involved with trauma-informed care are encouraged to submit event ideas for Trauma Awareness Month, and information for trauma-related events already scheduled in May, using an online form.

Events submitted before March 15, 2019 will be reviewed and added to a digital calendar that is shared with the public prior to Trauma Awareness Month to promote trainings, workshops and other events.

Members of the public who would like to be involved with Trauma Awareness Month planning are invited to attend the Trauma Awareness Month Steering Group’s public meetings on February 20, and March 20, 2019. The meeting details will be listed on Delaware’s public meeting calendar.

In October 2018, Governor Carney signed Executive Order 24, making Delaware a traumainformed state and providing direction for the Family Services Cabinet Council to help mitigate the impact of adverse childhood experiences (ACEs) and build resilience in children, adults and communities.

Find more information about the Family Services Cabinet Council, the Compassionate Champion Award, and Trauma Awareness Month here: de.gov/fscc 109

The Delaware Journal of Public Health is delighted to welcome content from the Trust for America’s Health in this issue.

Wellness and Prevention Digest Reports and Announcements Trust for America’s Health (TFAH) is pleased to announce the release of Ready or Not: Protecting the Public’s Health from Diseases, Disasters and Bioterrorism. The report examines the nation’s ability to prepare for and respond to public health emergencies, tracks progress and areas in need of improvement, and suggests actionable steps stakeholders and policymakers can take to strengthen emergency readiness.

This year’s report provides a series of recommendations across 11 high priority areas to address emergency response readiness concerns. Among the top priorities: • • • •

Congress should restore funding for public health and health system preparedness and response as well as global health security, and support a complementary emergency response fund.

Congress should pass the Pandemic and All-Hazards Preparedness and Advancing Innovation Act. Investment in disease surveillance and data infrastructure needs to be significantly increased.

The “last mile” of medical countermeasure distribution, meaning ensuring that important medications or other needed supplies get to the right person at the right time, needs to be strengthened.

On Monday, Senate Appropriations Committee Chairman Richard Shelby and House Appropriations Committee Chairman Nita Lowey announced they had reached a deal “in principle” to avert another partial shutdown. However, Politico is reporting there are still details being worked out, and it is unclear if the President will sign it. The current continuing resolution expires on Friday.

The National Institute on Minority Health and Health Disparities at NIH recently published the American Journal of Public Health special issue New Perspectives to Advance Minority Health and Health Disparities Research.

CDC recently published an article in the journal Clinical Infectious Diseases describing the effectiveness of the influenza vaccine and the number of illnesses, hospitalizations, and deaths prevented by flu vaccine during the 2017-18 flu season. The study shows last season’s flu vaccine prevented more than 7 million illnesses, 109,000 hospitalizations and 8,000 deaths associated with flu.

110 Delaware Journal of Public Health – February 2019

Last week, the nation lost a great fighter for health with the passing of Rep. John Dingell. Serving in the House for nearly 60 years, Dingell presided over the vote to pass the original Medicare legislation and introduced his own national health coverage bill at the start of every Congress. As Chairman of the Energy & Commerce Committee, he was perhaps best known for his lifelong fight to expand access to healthcare, as well as working with his colleagues on modernizing FDA, NIH, and CDC.

Take Action TFAH and the American Public Health Association are circulating this organizational sign-on letter to House and Senate Labor-HHS-Education appropriations subcommittee leaders in support of $230 million for CDC’s National Center for Environmental Health, which would represent an approximate 10 percent increase for the center. Please fill out this form by COB on February 22nd to join the letter.

Several organizations, including SOPHE, APIAHF, National Association of Community Health Centers, Prevention Institute, Public Health Institute, and TFAH are circulating an organizational sign-on letter supporting increased funding for CDC’s REACH program. Please fill out the form here to join the letter by COB Thursday, February 28th.

The CDC Coalition is circulating an organizational sign-on letter supporting $7.8 billion in funding for CDC's program level. Please fill out the form here to join the letter by COB Thursday, February 28th.

HHS has put out a Request for Information: Improving Efficiency, Effectiveness, Coordination and Accountability of HIV and Viral Hepatitis Prevention, Care and Treatment Programs. This is an opportunity to weigh in on two separate national strategies on HIV and Hepatitis. Comments are due March 11, 2019 to HepHIVStrategies@hhs.gov.

As you may have seen, the USDA announced a proposed rule that would enforce time limits on SNAP benefits for unemployed and underemployed people who can’t document sufficient weekly work hours. This proposed rule is a version of provisions that were rejected in the 2018 Farm Bill, and could result in an estimated 775,000 people losing benefits. FRAC has launched a platform for comments to the USDA in opposition to the proposed rule. Comments are due April 2, 2019.

Funding Opportunities The de Beaumont Foundation and Aspen Institute have launched the PHRASES: Public Health Reach Across Sectors Fellows program to help public health professionals hone their communication skills to improve cross-sector collaboration. Please see here for more information and to apply. Deadline, February 28th.

The American College of Preventive Medicine is collaborating with the American Medical Association and Black Women’s Health Imperative to offer three grants to healthcare organizations to develop innovative strategies to identify prediabetes and refer high-risk African American and Hispanic women to a CDC-recognized diabetes prevention program. Proposal submissions for this funding opportunity will be accepted through March 19th at 5:00 p.m. (ET).

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Events The Milken Institute School of Public Health at the George Washington University is hosting a seminar on March 21st from 9:00 – 11:00 a.m. on 3 WINS Fitness: The Largest Free Exercise and Diabetes Prevention Program in Los Angeles. This nationally recognized program is led by California State University, Northridge Kinesiology faculty and students who deliver exercise for all fitness levels and include both falls and diabetes prevention at six sites (parks, churches, schools) for over 400 participants. During this event, you’ll learn about the 3 WINS Fitness model and how it fits into national frameworks such as the Centers for Disease Control and Prevention's Active People, Healthy Nation framework, the National Physical Activity Plan, and the American Council on Exercise's Prescription for Activity. Afterward, a discussion with stakeholders around opportunities to scale the program across the nation will take place. RSVP here.

The 2019 HIV Diagnostics Conference will take place from March 25th-28th in Atlanta, GA which will focus on HIV diagnostic testing in laboratories, public health programs and clinical practice, as well as STI and HCV testing. On March 28th, CDC and FDA will hold a session seeking audience feedback on the proposed reclassification of HIV and HCD tests. Registration deadline, March 15th.

Reminder - Join Trust for America's Health on Wednesday, February 27th from 12:00 - 1:30 p.m. for a Congressional Briefing that will explore the findings of the report on the Report The State of Obesity 2018: Better Policies for a Healthier America. Speakers will cover the latest national obesity rates and trends, highlight promising approaches states and localities have undertaken to ensure healthy communities, and offer recommendations for leaders and policymakers to prioritize efforts that help all Americans lead healthier lives.

Speakers include experts from TFAH, Robert Wood Johnson Foundation, CDC and Boston University School of Medicine. For more information and to RSVP, click here.

Opportunities to Join the TFAH Team TFAH has an opening for a Government Relations Manager with a focus on infectious disease prevention and other public health issues. The Government Relations Manager will be responsible for developing and managing the legislative, federal oversight and regulatory strategy on a range of priority issues related to infectious disease as well as federal appropriations that impact public health and prevention. Full Description.

TFAH is hiring for a Social Strategy and Web Publishing Manager to work with the Director of Strategic Communications and Policy Research to plan, execute, monitor, measure and continually improve TFAH's use of social media and its website to advance the organization's mission. Responsibilities include creating and executing weekly and special event social content calendars and marketing plans via both organic and paid media reach. This position will monitor TFAH's social media feeds (primarily Twitter) and collect site analytics to measure campaign impact and create reports. In addition, the incumbent will be the content manager for TFAH's website. Full description.

Opportunities and Deadlines The Association of State and Territorial Health Officials is looking for organizations to join the 22 by 22 campaign, an initiative urging Congress to increase funding for the Centers for Disease Control and Prevention (CDC) 22 percent by fiscal year 2022 (FY22). For more information or to sign onto the campaign, contact Carolyn Mullen at cmullen@astho.org.

112 Delaware Journal of Public Health – February 2019

The American Lung Association is launching the "Year of Air Pollution & Health" (YAPH) in 2019 to increase public education and engagement around air pollution, climate change and health. Each month of the year will focus on a different aspect of air pollution and climate change â&#x20AC;&#x201C; from major pollution sources, to vulnerable populations, to steps everyone can take to protect the air we all breathe. Januaryâ&#x20AC;&#x2122;s focus is all about the impact of air pollution on real people like you. We would love to hear why healthy air matters to you! Please take a minute to fill out this short survey to let us know why you fight for healthy air.

The National Alliance for Nutrition and Activity (NANA) is asking organizations to sign a pledge to have healthy meetings, conferences, and events. To assist organizations, NANA has developed a Healthy Meeting Toolkit. (no deadline)

Regulatory Comments The Pain Management Best Practices Inter-Agency Task Force released their draft report entitled Pain Management Best Practices: Updates, Gaps, Inconsistencies, and Recommendations. The Task Force was created by the Comprehensive Addiction and Recovery Act (CARA) of 2016 with the goal of identifying, revising, and developing a strategy for disseminating information about best practices for pain management (including chronic and acute pain) and includes representatives from federal agencies and non-federal stakeholders. The draft report is open for a 90-day public comment period. More information on submitting comments can be found here. Deadline, April 1st.

Funding Opportunities and Awards The National Adult and Influenza Immunization Summit (NAIIS) is soliciting candidates for the 2019 NAIIS Immunization Excellence Awards. The 2019 awards recognize individuals and organizations that have made extraordinary contributions towards improving vaccination rates within their communities during 2018. The winners will be presented with their awards at the National Adult and Influenza Immunization Summit meeting (to be held in May 14-16, 2019, location Atlanta, GA; awards ceremony will be May 15). The national winner in each category will be invited to present their programs at the National Adult and Influenza Immunization Summit meeting. To submit a nomination, please click here. The deadline to submit is February 15, 2019.

America Walks is excited to announce the opening of applications for the 2019 class of The Walking College.

The Walking College is an interactive, online educational program for walkable community advocates. America Walks is an inclusive organization and we seek applications from diverse individuals who are interested in getting more involved in the walking movement. Learn more and ask questions at our Twitter Chat on February 11th at 1:00 p.m. (ET) using #WalkingCollege. Deadline, February 28th.

TRUST FOR AMERICA'S HEALTH 1730 M ST NW SUITE 900 WASHINGTON, DC 20036 P (202) 223-9870 F (202) 223-9871 E INFO@TFAH.ORG

FACEBOOK TWITTER SUBSCRIBE to this e-newsletter directly

113

Delaware Journal of

Public Health

Submission Guidelines

updated October 16, 2018

About the Journal Established in 2015, The Delaware Journal of Public Health is a bi-monthly, peer-reviewed electronic publication, created by the Delaware Academy of Medicine/Delaware Public Health Association. The publication acts as a repository of news for the medical, dental, and public health communities, and is comprised of upcoming event announcements, past conference synopses, local resources, peer-reviewed content ranging from manuscripts and research papers to opinion editorials and personal interest pieces, relating to the public health sector. Each issue is largely devoted to an overarching theme or current issue in public health.

The content in the Journal is informed by the interest of our readers and contributors. If you have an event coming up, would like to contribute an Op-Ed, would like to share a job posting, or have a topic in public health you would like to see covered in an upcoming issue, please let us know.

If you are interested in submitting an article to the Delaware Journal of Public Health, or have any additional inquiries regarding the publication, please contact DJPH Deputy Editor Elizabeth Healy at ehealy@delamed.org, or the Executive Director of The Delaware Academy of Medicine and Delaware Public Health Association, Timothy Gibbs, at tgibbs@delamed.org

Information for Authors Submission Requirements The DJPH accepts a wide variety of submission formats including brief essays, opinion editorials pieces, research articles and findings, analytic essays, news pieces, historical pieces, images, advertisements pertaining to relevant, upcoming public health events, and presentation reviews. If there is an additional type of submission not previously mentioned that you would like to submit, please contact a staff member.

Submissions should be completed under general APA guidelines for formatting and citations. Articles should be written in Microsoft Word format, in a clear, easily readable font with 1.5-inch to 2-inch spacing, and 1-inch margins. The suggested font is 12 point Times New Roman. Once completed, articles should be submitted via email to ehealy@delamed.org as an attachment. Graphics, images, info-graphics, tables, and charts, are welcome and encouraged to be included in articles. Please ensure that all pieces are in their final format, and all edits and track changes have been implemented prior to submission.

114 Delaware Journal of Public Health â&#x20AC;&#x201C; February 2019

Submission Length While there is no prescribed word length, full articles will generally be in the 2500-4000-word range, and editorials or brief reports will be in the 1500-2500-word range. If you have any questions regarding the length of a submission, or APA guidelines, please contact a staff member.

Copyright Opinions expressed by contributors and authors do not necessarily reflect the opinions of the DJPH or affiliated institutions of authors. Copying for uses other than personal reference or interest without the consent of the DJPH is prohibited. All material submitted alongside written work, including graphics, charts, tables, diagrams, etc., must be referenced properly in accordance with APA formatting.

Conflicts of Interest Any conflicts of interest, including political, financial, personal, or academic conflicts, must be declared prior to the submission of the article, or in conjunction with a submission. Conflicts of interest are any competing interests that may leave readers feeling misled or

deceived, and/or alter their perception of subject matter. Declared conflicts of interest may be published alongside articles in the final electronic publication.

Abstracts

Nondiscriminatory Language

The word limit is 200 words, including headings. A title page should be submitted with this abstract as well.

Use of nondiscriminatory language is required in all DJPH submissions. The DJPH reserves the right to reject any submission found to be using sexist, racist, or heterosexist language, as well as unethical or defamatory statements.

Additional Documents and Information for Authors Please Note: All authors and contributors are asked to submit a brief personal biography (3 sentences maximum) and a headshot along submissions. These will be published alongside final submissions in the final electronic publication. For pieces with multiple authors, these additional documents are requested for all contributors.

Authors must submit a structured or unstructured abstract along with their article.

Structured abstracts should employ 4-5 headings: Objectives (begins with “To…”) Methods Results Conclusions A fifth heading, Policy Implications, may be used if relevant to the article.

Trial Registration information is required for clinical trials and must be included in the final version abstract All abstracts should provide the dates(s) and location(s) of the study is applicable.

Note: There is no Background heading.

Example of Information in Abstract Objective: State the objective or study question starting with “To …” (e.g., “To determine whether…”).

Methods: Provide the basic design, place, year(s), setting, and number of participants of the study. If applicable, include the name of the study, the duration of follow-up. Indicate exposure and outcomes.

Results: Include quantitative results.

Conclusions: Provide only conclusions of the study that are directly supported by the results, whether positive or negative.

Policy implications: Provide a statement of relevance indicating implications for health policy, avoiding speculation and overgeneralization.

Trial Registration: For clinical trials, the name of the trial registry, registration number, and URL of the registry must be included in the cover letter ONLY and in the manuscript only after it is officially accepted.

Relevant Abbreviations should be mentioned here and will not be counted in the word limit.

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DATA TO DECISION MAKING LEXICON OF TERMS

Age Adjusting

A common method among descriptive epidemiological studies to remove the effect of age on determination of rates that describe groups.

Choropleth (map)

A thematic map in which areas are shaded or patterned in proportion to the measurement of the variable being displayed (i.e. population density, per-capita income).

Chronic Disease

Health Disparity

Differences in the health status of different groups of people.

Health in All Policies (HiAP)

This term was first used in Europe in 2006, with the aim of collaborating across sectors to achieve common health goals.

Hypertension

High blood pressure

A condition or disease that is persistent, or otherwise long-lasting in its effects.

Incidence

Ciliary Beat Frequency

Mortality

The number of times cilia (short, hair-like structure found in large numbers on the surface of some cells) beat per minute. Normal frequency is 11-16 per second.

Dataset

A collection of related features that share a common coordinate system.

Downstream Determinant of Health

Outcomes of factors that can be more easily mitigated or prevented by an individual, like changing eating habits or immunization (e.g. injuries, infectious disease, infant mortality, etc.).

Epidemiology

The branch of medicine that deals with the incidence, distribution, and possible control of diseases and other factors relating to heatlth.

Geocoding

Provide geographical coordinates corresponding to a location

Geospatial

Relating to or denoting data associated with a particular location.

Geographic Information System (GIS)

A system designed to capture, store, manipulate, analyze, manage, and present all types of geographical data.

Gestational Diabetes

A condition characterized by an elevated level of glucose in the blood during pregnancy, typically resolving after the birth.

116 Delaware Journal of Public Health â&#x20AC;&#x201C; February 2019

The occurrence, rate, or frequency of a disease.

Death, especially on a large scale

Personalized Medicine

A model of medicine that tailors medical decisions, practices, interventions, and/or therapies to an individual patient, based on their genetics.

Prevalence

The proportion of a particular population found to be affected by a medical condition. This can be at a certain period of time (point prevalence) or over a given period (period prevalence).

Pre-diabetes

A condition characterized by slightly elevated blood glucose levels, regarded as indicative that a person is at risk of progressing to type 2 diabetes.

Shapefile

A simple data format for storing the geometric location, shape, and attribute information of geographic features used in GIS software.

Social Determinants of Health

The circumstances in which people are born, grow, live, work, and play; as well as the underlying environmental, economic, social, and political structures that determine the quality and distribution of resources needed for health.

Upstream Determinant of Health

Factors that are outside of the control of the individual, usually have â&#x20AC;&#x153;trickle-downâ&#x20AC;? effects on other determinants. Generally policy and programs (pollution, education) and social inequities (class, race/gender, sexual orientation).

DATA TO DECISION MAKING RESOURCES ArcGIS Using interactive maps to connect people, locations, and data. https://www.arcgis.com/index.html

Delaware Behavioral Health Consortium The Behavioral Health Consortium is an advisory body comprised of community advocates, law enforcement, healthcare professionals, and state leaders that will assess and outline an integrated plan for action to address prevention, treatment, and recovery for mental health, substance use, and co-occurring disorders. https://ltgov.delaware.gov/behavioral-health-consortium/

Delaware Cancer Consortium The Delaware Cancer Consortium was originally formed as the Delaware Advisory Council on Cancer Incidence and Mortality in March 2001 to advise the governor and legislature on the causes of cancer incidence and mortality and potential methods for reducing both. https://www.healthydelaware.org/consortium

Delaware Chronic Disease Coalition The Delaware Chronic Disease Collaborative (DCDC) is a website for people with chronic diseases to provide them with information about chronic diseases in the United States and Delaware. http://dechronicdiseasecoalition.org/

Delaware Health Statistics Center The Delaware Health Statistics Center (DHSC) is responsible for the data collection, validation, statistical analysis and maintenance of a comprehensive collection of health statistics. We provide information essential for identifying local and statewide problems, while supporting public health programs and research. Information is made available through the production of reports, data summaries and analysis, map generation and provision of public use files. https://www.dhss.delaware.gov/dhss/dph/hp/healthstats.html

Delaware Healthy Mother and Infant Consortium The mission of the Delaware Healthy Mother & Infant Consortium (DHMIC) is to provide statewide leadership and coordination of efforts to prevent infant mortality and to improve the health of women of childbearing age and infants throughout Delaware. http://dethrives.com

Delaware State Health Improvement Plan The State Health Departmentâ&#x20AC;&#x2122;s SHIP addresses the needs of all citizens in the state. The SHIP is a long-term, systematic plan to address issues identified in the SHA. The purpose of the SHIP is to describe how the health department and

the community it serves will work together to improve the health of the population in their jurisdiction. The community, stakeholders, and partners can use a solid SHIP to set priorities, direct the use of resources, and develop and implement projects, programs, and policies. http://delawareship.org/

Division of Public Health Promotion and Disease Prevention The Health Promotion and Disease Prevention Section of the Division of Public Health has the responsibility for prevention and control of chronic diseases and their risk factors. Section programs address cancer, diabetes, cardiovascular disease, tobacco use, physical activity, nutrition, health education, chronic disease epidemiology, and collection of behavioral risk factor data. https://dhss.delaware.gov/dph/dpc/dpcsection.html

Healthcare Spending Benchmark In May, 2017, Secretary Kara Odom-Walker announced her proposal for the adoption of benchmark expenditure cost reductions to improve healthcare costs across the state.

Benchmark Links: http://dechronicdiseasecoalition.org/?page_id=475

Healthy Communities Delaware Healthy Communities Delaware is a consortium of public, nonprofit and private organizations committed to taking a collective approach to align efforts and invest in projects, programs and policies aimed at improving the health of people in low-wealth communities in the state. https://sites.udel.edu/cas-hcd/about/

Help Is Here Delaware Information on prevention, addiction, treatment, and recovery. http://www.helpisherede.org

University of Delaware: Partnership for Healthy Communities As part of the Community Engagement Initiative at the University of Delaware, the Partnership for Healthy Communities (PHC) seeks to improve the health and well-being of Delaware residents, especially those living in communities that experience social and economic disadvantages. We do this in partnership with communitybased organizations, state and local agencies, students, and colleagues across the University, and communities themselves. https://sites.udel.edu/healthycommunities/

The Value Institute at Christiana Care A diverse team of experts collaborating in the discovery and delivery of value-centered knowledge to improve health. https://research.christianacare.org/valueinstitute/ 117

In Memoriam

LTG WILLIAM H. DUNCAN. M.D. 18 February 1930 - 19 December 2018

Authored by Joseph Kestner M.D.; Past-President (20062008) and current Board member, Delaware Academy of Medicine/Delaware Public Health Association Bill was a native Delawarean hailing from New Castle. He attended the William Penn High School and graduated from the PS DuPont High School in Wilmington.

After a year at the University of Delaware he entered the U.S. Military Academy by means of a competitive appointment as the son of a deceased veteran of WW II. Following graduation from West Point in 1952 and some training which included jump school he was sent to Korea as an infantry lieutenant. At the completion of his military obligation he entered Temple University Medical School graduating in 1959. An internship at the Delaware Hospital followed. Bill then opened a family medicine practice at Foulk and Silverside Roads in North Wilmington. Shortly thereafter Bill was appointed the part time supervisor of the Delaware Hospital ER. Following the merger of the Delaware, Memorial and Wilmington General Hospitals, Bill became the director of ambulatory and emergency services of the Wilmington Medical Center, a full time position. In 1975 Bill was appointed vice president for medical affairs at St. Francis Hospital.

This is when I first met Bill. He and I interacted on the credentials committee where applications to join the medical staff were reviewed and evaluated. On occasion there was controversy. Bill always valued the perspective of the committee members. Bill was also a source of advice on dealing with hospital administrators. If there was an adverse event or unexpected death (prior to review committees) Bill would be on the phone wanting to know the details. As an examiner for the FAA and air traffic controllers he would follow up on patients he referred.

We worked together on nominating committees where he was transparent and open to advice and suggestions. Bill retired from St. Francis in 1993.

All during this time Bill was active in the PA and later the DE National Guard eventually as commanding officer of the 116th Surgical Hospital (Mobile Army) and later as commander of the 261st Signal Command. During his military career Bill served in three branches of the army: Infantry, Medical Corps and Signal Corps. He retired from the National Guard in 1987 receiving many recognitions and awards. Bill was appointed a charter member of the

Army Historical Foundation. His lifelong interest in the military also continued with the Delaware National Guard Heritage Committee and the Delaware Military Museum.

Bill was the 19th president of the Delaware Academy of Medicine in 1976 and 77. He was chairman of the planning committee for the Academy’s 50th anniversary celebration in 1980. This three day event included cultural, educational and social activities. Some notable speakers included Isaac Asimov, Ph.D., Eli Ginsberg, Ph.D., and Edmond Pelligrino, M.D. Bill believed his most significant accomplishment while president of the Academy was to stabilize a precarious financial situation.

Bill was an author. His Founders of the Medical Society of Delaware, was published in 2017. He was working on a biography of James Tilton, M.D., a founder of the Medical Society of Delaware and its 1st president at the time of his death. He documented the service of Delaware Physician Veterans of WW II (1994) and the Korean War (2000) in the Delaware Medical Journal.

His most recent effort, the Contemporary Veterans Project published in the Delaware Medical Journal in Nov-Dec 2018 was to recognize the service of those Delaware Physician Veterans post Korean War. This is where Bill and I reconnected. It was my honor to assist Bill in completing this project and identifying every possible Delaware physician veteran post Korean War. This collaboration was interesting, rewarding and fun – all because of Bill Duncan.

Bill was a leader. He was open, transparent, articulate and he listened. He had a vision of what was to be accomplished. He led infantry units, medical services, the St. Francis Hospital Medical Staff, Temple University Alumni, a U.S. Army Mobile Surgical Hospital and Signal Battalion, the Medical Society of Delaware and the Delaware Academy of Medicine. One thing to recognize is whatever Bill did – he did well.

He would on occasion speak of his Dad, a soldier and veteran of WW I and WW II who died when Bill was quite young. I can just imagine what Bill’s Dad might say if he was here today, “Well done, son. Mission accomplished.”

-Ted Kestner, M.D.

Index of Advertisers Save The Date Focus on Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 John H. Ammon Medical Education Center The DPH Bulletin February 2019 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Division of Public Health, Department of Health and Social Services DHSS Press Release . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Delaware Division of Public Health Mini-Medical School . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 John H. Ammon Medical Education Center Raising Our Voices, Strengthening Our Communities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Delaware Healthy Mother and Infant's Consortium's Summit The Nation's Health - February/March 2019 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 American Public Health Association Save The Date For Our Policy Academy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 University of Delaware Lung Cancer Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 Division of Public Health Save The Date 89th Annual Meeting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 Delaware Journal of Pubic Health Governor Carney Announces Trauma-Informed Initiatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108 Delaware Governor John Carney DJPH Submission Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 Delaware Journal of Public Health The DPH Bulletin January 2019 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 Division of Public Health, Department of Health and Social Services

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From the history and archives collection

Major Walter Reed, M.D.

(September 13, 1851 â&#x20AC;&#x201C; November 22, 1902) Walter Reed was a U.S. Army physician who, in 1901, led the team that postulated and confirmed the theory that yellow fever is transmitted by a particular mosquito species, not by direct contact. The team collected data about mosquitoes, and observed transition patterns. They built on the work of others, and disproved other theories through rigorous science. Their insights gave impetus to the new fields of epidemiology and biomedicine, and led to public health decision making that saw houses fumigated and wet areas drained. Patients sick with yellow fever were quarantined in screened areas so mosquitoes could not pick up and transfer more virus-infected blood, and countless lives were saved. Their work led to public health practices that are still in practice today.

120 Delaware Journal of Public Health â&#x20AC;&#x201C; February 2019

The DPH Bulletin

From the Delaware Division of Public Health Federal opioid resources help build resilient communities

Two federal resources can help communities impacted by the opioid epidemic.

The Office of National Drug Control Policy and the U.S. Department of Agriculture (USDA) published a list of links to federal resources such as grants, trainings, and programs. The document represents the work of agencies on the Federal Rural Opioids Interagency Working Group. Read Federal Resources for Rural Communities to Help Address Substance Use Disorder and Opioid Misuse at https://www.rd.usda.gov/files/RuralResourceGuide.pdf.

Community leaders, researchers, and policymakers can determine their most effective actions by first using the Opioid Misuse Community Assessment Tool (https://www.usda.gov/topics/opioids) and at https://opioidmisusetool.norc.org. Users can overlay opioid misuse data with socioeconomic, census, and other information. For local resources to combat the opioid epidemic, visit HelpIsHereDE.com.

What to do if the power goes out

Winter electrical outages can become dangerous.

Follow these tips to stay safe if the power goes out:  Add your electric company as a contact on your cell phone and post the number at home. Check the circuit breaker before reporting a power loss.  Listen to the news on a battery-powered or hand-cranked radio. Buy batteries now; prepareDE.org has a supply list.  To prevent fire, use flashlights, not candles.  Dress warm with a knit hat, gloves, sweaters, sweatshirts, and jackets.  Never use kerosene heaters, grills, outdoor heaters, or generators inside the home or garage. Carbon monoxide poisoning causes serious illness and can be fatal.  Avoid opening the refrigerator and freezer.

If a power outage continues during extreme cold events, it may be necessary to seek shelter at nearby public places or shelters, if travel is safe.

Before setting out, check availability by contacting Delaware 211 by phone, its mobile app, or by visiting www.delaware211.org.

January 2019 Cervical cancer screenings detect abnormal cells early

January is Cervical Health Awareness Month. As part of that observance, the Division of Public Health (DPH) reminds women that it is important to get regular cervical cancer screenings. Cancer can develop in the tissues of the cervix, which is located in the lower part of the uterus connected to the birth canal. Cervical cancer occurs most often in women over the age of 30.

Cervical cancer can be prevented by getting regular screenings. During a pelvic exam, a health care provider will perform a Papaniculaou (Pap) test.

During the test, cells are brushed from the cervix onto a slide so they can be examined under a microscope.

Women ages 21 to 29 should have a pap test every three years. Women ages 30 to 65 should have a pap test every three years or a pap and human papillomavirus (HPV) test (co-test) every five years. When women reach age 65, their health care providers will advise them if they should continue their Pap tests. Certain women are at higher risk and may require more frequent screening. Women should talk to their health care providers about how frequently they should be screened if they:   

Have an HIV infection Have had an organ transplant Have been exposed to the drug known as DES, a synthetic form of estrogen.

An infection called HPV is the main cause of cervical cancer. There is no cure for HPV infections, but a vaccine is available that has been proven effective in protecting against cancers caused by HPV. The HPV vaccine offers the best protection to children and teens if they receive the recommended dosage needed to develop an immune reaction.

Delawareans should talk to their health care providers about the HPV vaccine to protect themselves and their children against the threat of HPV-related cancers.

For more information on cervical cancer screening, visit DPH’s website at this link: https://www.dhss.delaware.gov/dhss/dph/dpc/sfl.html.

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Delaware Academy of Medicine / DPHA 4765 Ogletown-Stanton Road Suite L10 Newark, DE 19713

www.delamed.org | www.delawarepha.org Follow Us:

The Delaware Academy of Medicine is a private, nonprofit organization founded in 1930. Our mission is to enhance the well being of our community through medical education and the promotion ofpublic health. Our educational initiatives span the spectrum from consumer health education tocontinuing medical education conferences and symposia.

The Delaware Public Health Association was officially reborn at the 141st Annual Meeting of the American Public Health Association (AHPA) held in Boston, MA in November, 2013. At this meeting, affiliation of the DPHA was transferred to the Delaware Academy of Medicine officially on November 5, 2013 by action of the APHA Governing Council. The Delaware Academy of Medi-cine, who’s mission statement is “to promote the well-being of our community through education and the promotion of public health,” is honored to take on this responsibility in the First State.

ISSN 2639-6378