Harriet Tubman, whose stamp is used on this postcard, was an American abolitionist and social activist who was all about rescuing and moving enslaved people- many of them came right through Delaware.
Public Health
making great strides toward addressing place-based disparities, and encouraging community empowerment from the Wilmington Riverfront in New Castle County to Sussex and Kent Counties.
DearDelawareFriend,is
Volume 8 | Issue 3 August 2022 A publication of the Delaware Academy of Medicine / Delaware Public Health Association
Delaware Journal of
www.delamed.org | www.djph.org
Place Matters
From all of us.
August 2022 Volume 8 | Issue 3
Liz Healy, M.P.H. Managing Editor
Kate Smith, M.D., M.P.H. Copy Editor
20 | Policy Recommendations for Reducing Tobacco Exposure for Youth and Adults in Wilmington, Delaware
Benjamin L. Golden, M.D.
Prabhdeep Uppal, D.O.
94 | Impact of USUnitedonSociodemographicNeighborhoodCharacteristicsFoodStoreAccessibilityintheStatesBasedonthe2020CensusData
Omar A. Khan, M.D., M.H.S.
Scott D. Siegel, Ph.D., M.H.C.D.S.
48 | Global Health Matters July/August 2022
Delaware Journal of
Erin K. Knight, Ph.D., M.P.H.
Kalyn McDonough, Ph.D., M.S.W.
14 | What Shapes People Living with HIV’s Experiences of HIV Stigma in Delaware? A Qualitative Exploration of Place and Social Position
Stephen C. Eppes, M.D. Secretary
Eric Plautz, M.S.
Jeffrey M. Cole, D.D.S., M.B.A. Treasurer
Kyma Fulgence-Belardo, B.A.
Valerie A. Earnshaw, Ph.D.
90 | The Where and the How: Ensuring those with Disabilities have the People Power for Healthy Living
Timothy E. Gibbs, M.P.H. Executive Director, Ex-officio CharmaineDanielBrianJosephErinDavidDIRECTORSM.Bercaw,M.D.LeeP.Dresser,M.D.EricT.Johnson,M.D.M.Kavanaugh,M.D.JosephKelly,D.D.S.F.Kestner,Jr.,M.D.W.Little,M.D.,Ph.D.ArunV.Malhotra,M.D.J.Meara,M.D.,D.M.D.AnnPainter,M.S.N.,R.N.JohnP.Piper,M.D.Wright,M.D.,M.S.H.P.EMERITUSRobertB.Flinn,M.D.BarryS.Kayne,D.D.S.
Fogarty International Center
Mathew K. Hoffman, M.D., M.P.H., F.A.C.O.G.
Lindsay Hoffman, Ph.D.
Shay Lukas, P.A./M.P.H. Candidate Sachi Brathwaite, M.S.
COVER
William Swiatek, M.A., A.I.C.P.
Xueli Qiu, M.S.
Delaware Academy of Medicine
Timothy E. Gibbs, M.P.H. Executive Director
Karyl T. Rattay, M.D., M.S. William J. Swiatek, M.A., A.I.C.P.
10 | Healthy Communities Delaware: Accelerating Place-Based Efforts to Improve the Vital Conditions for Health, Well- Being and Equity
Maggie Ratnayake, L.P.C.M.H., A.T.R., N.C.C.
Board of Directors:
Sarah Albrecht, M.S.
Jessica Neave, M.S.
Victor W. Perez, Ph.D.
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.
Dear DelawareFriend,is making great strides toward addressing place-based disparities, and encouraging isHarrietKentCastleWilmingtonempowermentcommunityfromtheRiverfrontinNewCountytoSussexandCounties.Tubman,whosestampusedonthispostcard,was
Allison Y. Zhu
28 | Aging in Place: Are We Prepared?
A publication of the Delaware Academy of Medicine / Delaware Public Health Association
Melissa A. Harrington, Ph.D.
Timothy E. Gibbs, M.P.H. Publisher
3 | In This Issue
Madeline M. Brooks, M.P.H.
Scott D. Siegel, Ph.D., M.H.C.D.S. Guest Editor
Laura Lessard, Ph.D., M.P.H.
S. John Swanson, M.D. President Killingsworth
Timothy E. Gibbs, M.P.H.
Omar A. Khan, M.D., M.H.S. M. Burday, M.D.
Harshitha Henry, B.S.-c
Abhigna Rao, B.A.
78 | Greening, Revitalization, and Health in South Wilmington, Delaware
Delaware Public Health Association
42 | Shining the Light on You: An Evidence-Based Program Designed to Improve the Health and Wellbeing of Family Child Care Professionals
A. Panicker, M.D.
114 | Lexicon & Statistics Definitions
Melissa K. Melby, Ph.D. Mia A. Papas, Ph.D.
Kate Dupont Phillips, M.P.H.
4 | Guest Editor
119 | Index of Advertisers
Omar A. Khan, M.D., M.H.S. (Co-Chair) Immediate Past President
Olivia Mwangi, M.S.
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an American abolitionist and social activist who was all about rescuing and moving enslaved people- many of them came right through Delaware. From all of us.
60 | The Benefits of Community Engaged Research in Creating Place-based Responses to COVID-19
Ismael Medina, M.S.W.
Suzanne Fields Image Director
Neal Emery, M.D.
Omar Khan, M.D., M.H.S. Editor-in-Chief
102 | Let It End With Us Kelly Shannon
Khaleel S. Hussaini, Ph.D.
Jason Bourke, Ph.D.
Copyright © 2022 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
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Scott D. Siegel, Ph.D., M.H.C.D.
Lynn Jones, FACHE President-Elect Professor Rita Landgraf (Co-Chair) Vice President
Omar Khan, M.D., M.H.S. Chair
Dorothy Dillard, Ph.D. Matthew Billie
Amy Bleakley, Ph.D., M.P.H. Allison Karpyn, Ph.D.
ISSN 2639-6378
Charmaine Wright, M.D., M.S.H.P.
Rui Li, JenniferPh.D.Miles, B.S. Maridelle Dizon, B.S.
Nicole Bell-Rogers, Ed.D., F.N.P.-C., R.N. Sharron Xuanren Wang, Ph.D.
Louis E. Bartoshesky, M.D., M.P.H. Gerard Gallucci, M.D., M.H.S.
32 | The Changing Landscape of Healthcare and the Need to Focus on Local Geography
86 | The Case Race-BasedAgainstGFR
116 | The Healing Arts in History: Location, location, location! Sharon Folkenroth Hess, M.A.
Natalie M. Brousseau, Ph.D. E. Carly Hill, B.S.
James McGuire
Rena Hallam, Ph.D.
Karen R. Swanson, R.N., B.S.N., A.C.R.N., C.C.R.C. Arlene K. Bincsik, R.N., M.S., C.C.R.C., A.C.R.N.
68 | A Reflection on the Relationship Between Place and Health: Understanding Undergraduate Student Experiences and Priorities During COVID-19the Pandemic
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 Advertising:302-733-3989Please 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.
Stephen Metraux, Ph.D.
David Tam, M.D., M.B.A., C.P.H.E., F.A.C.H.E.
34 | Prior Evictions Among People Experiencing Homelessness in Delaware
Verna Hensley
108 | Pre and CesareanPost-LockdownDeliveriesand Perinatal Quality Indicators During the COVID-19 Pandemic
Delaware Journal of Public Health
OFFICERS
Pat Swanson, B.S.N., R.N.
6 | Partnership for Healthy UtilizingCommunities:anEquity, PlaceBased Approach to Guide Our Collaborative Work on Health Equity in Delaware
3
Omar A. Khan, M.D., M.H.S. DelawareEditor-in-Chief,Journal of Public Health
Place Matters
DOI: 10.32481/djph.2022.08.001
The City of Wilmington Riverfront is an outstanding example of a formerly depressed area which, through massive investment and infrastructure improvement initiatives, has been reborn to the destination it is today. However, there is always a matter of displacement of communities when initiatives such as these take place, along with the lingering question of “why didn’t you go a bit further up or downstream?” to improve other areas.
“Place Matters” aligns planning and public health as partners along with institutions like higher education and our State’s healthcare institutions. It also aims to engage every community member in a conversation which prompts us to think about the deep implications of where something is, and how it can lead to healthy lifestyles, safe neighborhoods, navigable environments, high quality education and gainful employment. Place is thus a proxy for everything else, and as always, it all matters to health.
Timothy E. Gibbs, M.P.H DelawarePublisher, Journal of Public Health
IN THIS ISSUE
Health matters and, as always, intersects with every other aspect of society. One of the most important aspects is place and thus, “Place Matters.” In public health we know this to be a truth, yet the concept of “place” can be difficult to understand and even more difficult to manage. So what is “place?”
Place happens at the intersection of the natural and built environment, as they intersect with social, economic, and political factors. This is to say, it is difficult to look at one aspect of place without observing and assessing the influence of the other factors. Case in point: any place along a body of water or a river – an attribute shared by much of Delaware.
Timothy E. Gibbs, M.P.H. Publisher, Delaware Journal of Public Health
Omar Khan, M.D., M.H.S. Editor-in-Chief, Delaware Journal of Public Health
In Claymont and certain parts of Wilmington, being located along the Delaware and Christina Rivers places communities in jeopardy of flooding, and can add to long-standing neglect. Much of the Delaware River waterfront was taken over by rail, industrial, and highway systems, cleaving communities from waterfront recreational areas. Traveling further down the Delaware River brings you to Historic New Castle, and below it, Delaware City. While these areas are still on the flood plain, the social, political, and economic factors have combined in such a way as to create more desirable communities. As one travels further down the Delaware Bay to the beaches, we see the value of property skyrocket as these areas have long been coveted resort areas and are now becoming year-round residential areas.
We look forward to your thoughts and as always look forward to your feedback.
2. Rothstein, R. (2018). The Color of Law. Liverright Publishing Corp.
8 Morgan, H. (2022). Resisting the movement to ban Critical Race Theory from schools. Clear House The Clearing House: A Journal of Educational Strategies, Issues and Ideas, 95(1), 35 41 https://doi.org/10.1080/00098655.2021.2025023
5. Hartt, M. D. (2017). Matthew Desmond, Evicted: Poverty and Profit in the American City. Penguin Books. doi: https://doi.org/10.1080/02723638.2017.1300755
4 Hahn, R. A. (2022, March 24). School segregation reduces life expectancy in the US black population by 9 years. Health Equity, 6(1), 270 277 https://doi.org/10.1089/heq.2021.0121
While likening ZNA to DNA provides a useful analogy, there are important distinctions to be made. Our DNA is a unique recombination of genetic information passed down from our parents—and ultimately the full human genetic pool. In other words, we inherit our genetic code through an “equal opportunity” process. One’s zip code at birth, by contrast, is largely predetermined by historical laws that have mandated the segregation of people by race and ethnicity over many generations – the de facto effects of which persist today.2 Attempts to remedy these injustices, whether through the passage of the Fair Housing Act of 1968 or Supreme Court rulings such as Brown v. Board of Education, represented important strides in the cause to advance civil rights and, by extension, health equity. However, the promise of these legislative and judicial milestones was never fully realized. Our neighborhoods and schools remain segregated, with life and death consequences.3,4 To paraphrase the words of Chief Justice Warren, separate is still not equal.
Where does that leave us? If we cannot count on Congress or the Supreme Court, then we must act locally. Scholars and academic institutions, health care organizations, public health officials, and not-for-profit organizations can join with marginalized communities to advance a bold, reinvigorated approach to advancing health equity across all of Delaware’s neighborhoods. To quote David Imbroscio, “…mobilized and democratically empowered local communities should employ a full range of public/community-controlled regulatory powers toward the construction of a robust affordable housing and anti-poverty/ anti-inequality urban policy agenda (p.238).”9 May the examples of this approach described in this special issue be a springboard for empowered, place-based action to advance health equity in the First State.
3. Williams, D. R., & Collins, C. (2001, September-October). Racial residential segregation: A fundamental cause of racial disparities in health. Public Health Rep, 116(5), 404–416. https://doi.org/10.1016/S0033-3549(04)50068-7
6 Metcalf, G. (2018). Sand castles before the tide? Affordable housing in expensive cities. The Journal of Economic Perspectives, 32(1), 59 80 https://doi.org/10.1257/jep.32.1.59
4 Delaware Journal of Public Health - August 2022
9. Imbroscio, D. (2021). Rethinking exclusionary zoning or: How I stopped worrying and learned to love it. Urban Affairs Review, 57(1), 214 251. https://doi.org/10.1177/1078087419879762
1. Collins, F. [@NIHDirector]. (2015, May 29). If DNA is our biological blueprint, ZNA (zipcode at birth) is the blueprint for behavioral & psycho-social makeup [Tweet]. Twitter. https://twitter.com/nihdirector/ status/604303767408889856?s=21&t=ufijcj5bV72K8up2mTmHQA
The Supreme Court, once a bulwark against the discriminatory laws and markets, now appears poised to take us back to an era that predated the civil rights movement. Case in point, quite literally, Justice Alito recently wrote for the majority in Dobbs v. Jackson Women’s Health Organization that the only unenumerated rights that should be protected by the Constitution are those “deeply rooted in this Nation’s history and tradition” (p. 2).7 Any honest reading of US history will find an unmistakable tradition of forcible segregation, even if certain states are now outlawing the teaching of that history to future generations.8 While we can only speculate about what opinions the Supreme Court will render next, it is probably safe to assume that the judiciary will not help to remedy place-based health inequities.
REFERENCES
DOI: 10.32481/djph.2022.08.002
The cause to advance civil liberties is not merely unfulfilled; it is now in retreat. For one, dwindling supplies of affordable housing and concentrated poverty limit who gets to live in communities conducive to health. The impact falls disproportionately on racial/ ethnic minorities and other marginalized groups, which stands to exacerbate preexisting place-based inequities.5 Given the way the housing market is currently structured, these trends are unlikely to improve absent government intervention.6
Scott D. Siegel, Ph.D., M.H.C.D.S. Director, Population Health Research, ChristianaCare; Licensed Psychologist
7. Dobbs v. Jackson Women’s Health Organization, 597, U.S. p. 2 (2022).
Advancing Health Equity through Empowered Place-Based Community Action
This special issue features the inexorable link between health and place. As Dr. Francis Collins, the former Director of the National Institutes of Health, once remarked, “If DNA is our biological blueprint, ZNA (zip code at birth) is the blueprint for behavioral and psychosocial makeup.”1 While Dr. Collins was defining ZNA in terms of residential address at birth, place more broadly defined can refer to the settings where we attend school, work, purchase food, recreate, seek care, and live out our years. As the articles in this issue clearly illustrate, this broader concept of place is critical to the health of Delaware’s residents.
apha.org/annual-meeting
Make plans to gather with friends and colleagues from around the nation, and world, for four days of insightful presentations, engaging activities and face-toface networking. With more than 1,000 presentations, we’re covering nearly every public health topic. Plus, the 2022 Annual Meeting and Expo is the culmination of APHA’s 150th anniversary celebration, so we’ve got even more planned than normal for this exciting educational event.
Important reminder: The 2022 mid-term elections will be Tuesday, Nov. 8, so be sure to vote early.
150 Years of Creating the Healthiest Nation: Leading the Path Toward Equity
The American Public Health Association’s 2022 Annual Meeting 7 Expo
Boston | November 6-9, 2022
Can’t travel? We’re hosting a digital version of APHA 2022 on Nov. 14-16. This will in clude access to recordings of more than 120 sessions from the Annual Meeting. Of course, the Featured and General Sessions are included, along with up to two ses sions selected by each APHA Section. You’ll even be able to participate live in the
5
When it comes to a healthy community, the University of Delaware’s Partnership for Healthy Communities (PHC) understands that place matters. Through the culmination of lived experiences and empirical research, there is a well-established understanding that there are healthy communities and less healthy communities and that this is a result of varying conditions in these communities, conditions referred to as the social determinants of health (SDoH). These varying conditions have been produced and reproduced through political systems, economic and social policies, and social norms, and resulted in persistent health inequities. PHC utilizes this knowledge and evidence to inform the collaborations and investments with communities that have the most to gain in the state of Delaware. Through a description of its four strategic partnerships, we outline how an equity, place-based approach guides our collaborative work to achieve health equity in our state.
What is critical to note is that the variance in these conditions in communities is not by chance, but rather, is the result of political systems, economic and social policies, and social norms.1 Due to the established relationship between SDoH and health equity, and the intentional nature of varying
PARTNERSHIP FOR HEALTHY COMMUNITIES
Kalyn McDonough, Ph.D., M.S.W Postdoctoral Fellow, Partnership for Health Communities, University of Delaware
ABSTRACT
6 Delaware Journal of Public Health - August 2022
When it comes to a healthy community, place matters. There are varying ways in which the term “community” can be defined; it can refer to populations that identify through shared values, characteristics, and/or cultural backgrounds. It can also be used to represent a geographic location or physical place. A growing body of evidence now highlights what many public health practitioners and community members long recognized, which is that place matters when it comes to health and health equity. This empirical and practical understanding not only outlines that there are healthy communities and less healthy communities, but also helps us to understand that this difference is the result of varying conditions in these communities.
HEALTHY COMMUNITIES
THE (IN)EQUITY OF PLACE
These conditions are often referred to as the social determinants of health (SDoH) or the non-medical factors that influence health. WHO defines SDoH as “... the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life.”1 These conditions include access to quality education, opportunities for a liveable income, stable housing, non-discrimination as well as social inclusion, among others. In 2008, the WHO Commission on SDoH summarized decades of research and concluded that health inequities were largely the result of differences in SDoH.2
PHC utilizes this knowledge and evidence to inform the collaborations with and investments in communities that have the most to gain. PHC is a university-wide community engagement initiative at the University of Delaware which works to align, strengthen, and partner the University’s research, educational and service capabilities with the expertise of community members and organizations on issues of health equity. Recognizing the impact of place on
DOI: 10.32481/djph.2022.08.003
Recognizing the persistent health inequities specifically among Black communities, structural racism is increasingly being identified as the root cause.4 Structural racism has been defined as the “...totality of ways in which societies foster racial discrimination through mutually reinforcing systems of housing, education, employment, earnings, benefits, credit, media, healthcare and criminal justice.”4 These ‘reinforcing systems’ in turn deprived many communities of color from the vital conditions necessary to achieve one’s full health potential. A map of Wilmington outlined in Figure 1 shows that communities with a higher percentage Black population generally experienced the lowest life expectancy, with as much as a 16 year life expectancy difference across neighborhoods. This historical and present- day understanding is what informs and guides the work of the University of Delaware’s Partnership for Healthy Communities (PHC), specifically as it pertains to adopting an equity and place-based approach in our work.
community conditions through existing policies and systems, this has led to an understanding of health inequities as “differences in health which are not only unnecessary and avoidable, but, in addition, are considered unfair and unjust.”3
Partnership for Healthy Communities: Utilizing an Equity, Place-Based Approach to Guide Our Collaborative Work on Health Equity in Delaware
health, PHC operates as a backbone to support four strategic partnerships in implementing place-based initiatives with communities.
residents felt were facilitators and barriers to health and well-being in their communities, identify community-based organizations key to resilience efforts, and co-create priorities and solutions to promote health equity in the state.6 When we understand that place matters, we recognize the unique aspects of varying communities and the essential nature of listening to the expertise of community members to guide the work of health equity.
Community Well-Being Initiative (CWBI)
H.E.A.L.T.H. for All (Health, Engagement, Access, Learning, Teaching, Humanity)
in Wilmington, Delaware neighborhoods, 2018.5 7
by percentage
may be contacted at kaymcd@udel.edu
State Health Improvement Plan (SHIP)
For the last four years, PHC has helped manage Delaware’s State Health Improvement Plan (SHIP) process with the State of Delaware’s Department of Health and Social Services, Division of Public Health. This process involves assessing progress and ensuring synergy among stakeholders in regards to recommendations from the 2018-2023 SHIP plan. A SHIP is considered best practice among state health departments and required for accreditation by the Public Health Accreditation Board (PHAB). Along with a focus on addressing prior recommendations, there is an opportunity to identify existing gaps and promising practices to support improvements in population health.
Finally, our fourth strategic partnership, the Community Well-Being Initiative (CWBI), utilizes a collective impact framework to promote well-being among communities made vulnerable through high levels of inequities and trauma. Funded by the State of Delaware’s Department of Health and Social Services, Division of Substance Abuse and Mental Health, the initiative partners a diverse group of stakeholders including grassroots coalitions, educational institutions, healthcare sectors, and community-based organizations who support the implementation and evaluation of engagement strategies. Adopting a community-driven, place-based prevention approach, a group of community members from targeted neighborhoods in Wilmington have been trained by Network Connect as community well-being “ambassadors.” The ambassadors promote resiliency and well-being across the Thelifespan.evidence
At the core of the SHIP work are the principles of community engagement and ensuring that community voices are not only heard, but inform the ways in which resources and investments in health will be allocated in the future. In May 2022, community conversations were conducted in all three Delaware counties to understand the broader needs and resources as it relates to community health and well-being. Specifically, the conversations sought to understand what
In 2021, the H.E.A.L.T.H. for All Program evolved from an existing Mobile Healthcare and Wellness program, designed to address SDoH through a collaborative, communitybased approach while also training UD students as the next generation of the public health workforce. A partnership between PHC, Highmark Blue Cross Blue Shield Delaware, and the Lt. Governor’s Challenge, the program works with community-based organizations to understand their needs and then embed and align health and wellness care initiatives with existing efforts at community sites in Delaware neighborhoods made most vulnerable through inequity. For example, in terms of health care access as a SDoH, H.E.A.L.T.H. for All works to alleviate gaps in care, so that as residents’ needs and access to health services change in the community, the program can pivot accordingly. Another strength of H.E.A.L.T.H. for All is that it trains UD students in the practice of community engagement and the value of place-based approaches, conveying this principle, knowledge and experience to future public health professionals.
Healthy Communities Delaware (HCD) is managed as a collaboration among PHC, Delaware Division of Public Health, and the Delaware Community Foundation. This place-based initiative focuses on partnering with communities through sustainable financial investment to transform and improve the SDoH, or what HCD refers to as vital conditions, to create communities of opportunity. An in-depth description of HCD, including its core tenants of community engagement and place-based approach, is presented in another article in this journal issue.
behind the relationship between place and health guides where our work at PHC is focused in order to address health inequities in communities that have the most to gain in our state of Delaware. Our strategic partnerships continue to help us learn and reinforce to us the value of local knowledge and expertise as critical contributors to place-based work in advancing health equity, as well as ensuring that a focus on healthy communities includes being data-informed and requires staying intentionally focused on Dr.SDoH.McDonough
Healthy Communities Delaware (HCD)
life
Figure 1. Estimated expectancy of black residents
1. Health Organization. Social determinants of health. Retrieved July 17, 2022, from: https://www.who.int/health-topics/social-determinants-of-health
8 Delaware Journal of Public Health - August 2022
REFERENCES
5 Center for Community Research and Service. (2018). Estimated life expectancy by percentage of black residents in Wilmington, Delaware neighborhoods, 2018. Health Equity Guide for Public Health Practitioners and Partners, 2, 86.
6 Delaware Health and Social Services, Division of Public Health. (2022). DPH community assessments underway to inform future COVID-19 response efforts and improve health. https://news.delaware.gov/2022/01/25/dph-communityassessments-underway-to-evaluate-covid-19-response-andimprove-health/
4. Bailey, Z. D., Krieger, N., Agénor, M., Graves, J., Linos, N., & Bassett, M. T. (2017, April 8). Structural racism and health inequities in the USA: Evidence and interventions. Lancet, 389(10077), 1453 1463. https://doi.org/10.1016/S0140-6736(17)30569-X
2. World Health Organization Commission on Social Determinants of Health. (2008). Closing the gap in a generation: Health equity through action on the social determinants of health. https://www.who.int/publications/i/item/WHO-IER-CSDH-08.1
3 Whitehead, M. (1992). The concepts and principles of equity and health. International journal of health services: Planning, administration, evaluation, 22(3), 429–445. https://doi.org/10.2190/986L-LHQ6-2VTE-YRRN
Stories of note include:
Kim Q&AKrisbergwithMargaret
The Nation’s Health headlines
UN report: Global hunger rises during COVID-19 pandemic Eeshika PreparingDadheechforextreme
What will it mean if COVID-19 becomes endemic?
Hamburg: Why the US needs a national public health systemEeshika Dadheech
Editorial:NicolausClimate change affects us all, but it doesn’t impact us equally Katherine Catalano
Vote for climate justice: Questions to ask candidates for office this election season
HIGHLIGHTS FROM The NATION’S
September 2022
HEALTH A PUBLICATION OF THE AMERICAN PUBLIC HEALTH ASSOCIATION 9
Americans face high risks from natural disasters: 2022 Healthiest Communities findings Kim Krisberg
weather: Don’t wait until it’s too late Teddi Nicolaus
As public health does double duty, everyday work falls behind Teddi
Online-only news from The Nation’s Health newspaper
States not waiting on Congress to take action on climate change Mark IndigenousBarna
Figure 1. The Vital Conditions for Health and Well-Being
Place matters when it comes to health and well-being. Communities across Delaware look starkly different when it comes to life expectancy and quality of life outcomes. In a few census tracts in Delaware, residents live an average of 86 years.1 In other census tracts, residents can expect to live for only 68 years -- an 18-year difference, based on “place.” This is in large part due to the difference in community conditions that either support or hinder well-being and opportunity. These community conditions do not occur by chance; they are the result of policies, systems, and inequitable distribution of power.
Kate Dupont Phillips, M.P.H. Executive Director, Healthy Communities Delaware
ABSTRACT
Healthy Communities Delaware: Accelerating Place-Based Efforts to Improve the Vital Conditions for Health, Well-Being and Equity
DOI: 10.32481/djph.2022.08.004
The presence or absence of the vital conditions in our communities shapes our opportunity to thrive. There are significant inequities in communities across Delaware when it comes to the vital conditions. In some neighborhoods it’s easy to walk or bike to a local park or playground; homes are warm, dry and safe; we can easily drive or take a short bus ride to the grocery store; and there are quality learning opportunities for children, youth and adults. In other neighborhoods, there are
no parks within walking distance; there is frequent gun violence which both injures children and keeps them indoors; public transportation to work and the grocery store is unavailable or inefficient; homes are deteriorating, unsafe and unhealthy. Many of these differences are due to legacies of harm and exclusion, most notably structural racism against Black, Brown and Indigenous communities.4
Healthy Communities Delaware (HCD) is a place-based initiative to improve health, well-being and equity across Delaware. HCD is a network of community-based and investment partners working to create thriving communities through improvement in the vital conditions. Vital conditions are the components of communities that we all need, all the time, to thrive and reach our full potential-- humane housing, a thriving natural world, lifelong learning, meaningful work and wealth, reliable transportation, basic needs for health and safety, and a sense of belonging and civic muscle. HCD invests in communities through community-based organization partners, who work to improve the vital conditions in their communities, informed by data and resident priorities. The key tenets of the Healthy Communities Delaware approach--place-based, community-driven, equity-focused and improving the vital conditions—work together to create more communities of opportunity across Delaware.
HEALTHY COMMUNITIES DELAWARE
The Healthy Communities Delaware (HCD) initiative was created to support communities in improving the vital conditions in order to improve health, well-being and equity. Healthy Communities Delaware is a network of investment and community-based partners working to create healthy, safe and vibrant communities across Delaware. It is managed as a collaboration among the
10 Delaware Journal of Public Health - August 2022
Up to 80% of our health is influenced by what many call the social determinants of health--the conditions in the places where people live, learn, work and play that influence our health.2 Over the past few years, the field has adopted a more holistic way of thinking about these community conditions, using the Vital Conditions for Health and Well-Being Framework (Figure 1).3 Simply put, the Vital Conditions are the things that all people need all the time to be healthy and well, and to reach their full potential. These include reliable transportation, meaningful work and wealth, lifelong learning, basic needs for health and safety, humane housing, a thriving natural world and belonging and civic muscle. Each vital condition is distinct and necessary, and together they form an interdependent system that impacts community and individual health and well-being.
Over the last two years of HCD investment (July 2020 – June 2022) the original eleven community-based partners have made significant progress in improving the vital conditions in neighborhoods across Delaware. Some of these achievements
With the goal of becoming HCD partners and receiving investment and support, an initial group of communitybased organizations or coalitions responded to a request for proposals (RFP) in April 2020. Eleven were selected for long-term collaboration and investment. An additional seven communities were added to the network in July 2022 through a similar RFP process. Healthy Communities Delaware community-based partners are working to improve the vital conditions in the communities mapped in Figure 2. Many communities approach community development and improvement of the vital conditions as a process of forming partnerships, assessing needs and strengths, prioritizing and planning, implementation and evaluation. Healthy Communities Delaware engages community partners at whatever stage they may be in this process. HCD investment can support any stage of the work as well as capital, staff and capacity building costs. In many cases the stabilizing investment from HCD supports community-based partners to leverage significant additional funding to advance their work.
Work to improve the vital conditions is a long game--we must be committed for decades to come. Inequities have been created by policies and systems that were never built for all people to thrive. These inequities have been created over generations, and will take generations to change. Repair of Healthy Communities Delaware Partner Communities
Figure 2.
One of the core tenets of Healthy Communities Delaware’s approach is that residents of the communities themselves have prioritized the work proposed for investment. Lived experience in a place gives one an intimate knowledge of context. The people who live in a community are best positioned to understand challenges and assets, and therefore to inform and be engaged in implementing solutions. Because of this approach, HCD community partners are addressing a variety of the vital conditions within and across communities. Some are building affordable housing, repairing homes, and revitalizing parks and playgrounds. Others are increasing early learning opportunities, creating community gardens, or conducting workforce development activities. Others are at the beginning of their journey, and are developing community assessments to understand assets and challenges. Most communities are working on advancing several of the vital conditions at the same time, in the spirit of comprehensive community development.
include: six community action plans and needs assessments created; three community gardens created/maintained; over 450 neighborhood revitalization services completed (homes, community, business); 28 affordable housing units in progress; two park/playground designs created; seven residents received leadership training; and more.
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Delaware Division of Public Health, the University of Delaware Partnership for Healthy Communities and the Delaware Community Foundation.
The Healthy Communities Delaware network is made up of 18 community-based organizations and five investment partners working to advance the vital conditions in local neighborhoods. HCD focuses on communities that have suffered decades of disinvestment and the resulting health and social inequities--those communities that have the most to gain. Communities of interest are identified by having a highrisk score on the Social Vulnerability Index2 and/or the Area Deprivation Index.5,6 The Social Vulnerability Index combines 15 census variables to identify communities that may need support before, during or after disasters. The Area Deprivation Index measures neighborhood disadvantage through a 17-indicator index across the domains of income, education, employment and housing quality.
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these conditions is not sufficient; renewal both in terms of process and outcome is necessary.
1. Tejada-Vera, B., Bastian, B., Arias, E., Escobedo, L. A., & Salant, B. (2020). Life expectancy estimates by U.S. census tract, 2010-2015. National Center for Health Statistics. Retrieved from: https://www.cdc.gov/nchs/data-visualization/life-expectancy/index.html
People who are experiencing the effects of structural inequities often have the least power to change the systems that are perpetuating them. Power is derived from relationships, access to resources, opportunity to participate in decisionmaking, and the dominant narratives of American society. Community power-building is recently being recognized as a strategy to improve health equity.7 Healthy Communities Delaware works to acknowledge and advance community power-building through our processes and in the near future, will do so through explicit power-building strategies. Each step a community takes to make improvements can bring both physical changes in a community that we can see--a new affordable housing complex--as well as intangible assets like increasing a sense of belonging and connection among people and place. But to have both, intentionality to the process and goal of building community power is necessary.
Ms. Dupont Phillips may be contacted at: kate@healthycommunitiesde.org
4. Centers for Disease Control and Prevention. (2021). Racism and Health. Retrieved from: https://www.cdc.gov/healthequity/racism-disparities/index.html
7. Farhang, L., & Morales, X. (2022). Building community power to achieve health and racial equity: principles to guide transformative partnerships with local communities. NAM Perspectives. Commentary, National Academy of Medicine, Washington, DC. https://doi.org/10.31478/202206d. Retrieved from https://nam.edu/building-community-power-to-achieve-healthand-racial-equity-principles-to-guide-transformative-partnerships-withlocal-communities/
REFERENCES
Given the influence of place on well-being and quality of life, we must think and work holistically, across sectors, to improve the vital conditions for health and well-being. We must strategically increase and align investment in the communities that have the most to gain, shifting power to communities, and working together to create places where all people have the opportunity to thrive. The key tenets of the Healthy Communities Delaware approach--place-based, communitydriven, equity-focused and improving the vital conditions— work together to create more communities of opportunity across Delaware.
3. Community Commons. (n.d.) The seven conditions for health and well-being. Retrieved from: https://www.communitycommons.org/collections/Seven-VitalConditions-for-Health-and-Well-Being
2. Centers for Disease Control and Prevention. (2022). Social vulnerability index. Retrieved from: https://www.atsdr.cdc.gov/placeandhealth/svi/index.html
5 Kind, A. J. H., & Buckingham, W. R. (2018, June 28). Making neighborhood disadvantage metrics accessible: The neighborhood atlas. The New England Journal of Medicine, 378(26), 2456 2458 https://doi.org/10.1056/NEJMp1802313
6 University of Wisconsin School of Medicine Public Health (n.d.). 2018 area deprivation index v2.0. Retrieved from https://www.neighborhoodatlas.medicine.wisc.edu/
ATOPOWERTHESAVELIFE
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Download the OpiRescue Delaware app to learn how to respond to an overdose and administer HelpIsHereDE.com/appNarcan.
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experiences of stigma among PLWH throughout Delaware: place and social position.
Department of Human Development and Family Sciences, University of Delaware
Department of Human Development and Family Sciences, University of Delaware
Valerie A. Earnshaw, Ph.D.
Natalie M. Brousseau, Ph.D.
What Shapes People Living with HIV’s Experiences of HIV Stigma in Delaware? A Qualitative Exploration of Place and Social Position
Objectives: To understand how place and social position shape experiences of HIV stigma among people living with HIV (PLWH) in Delaware. HIV stigma impedes the health and wellbeing of PLWH. Yet, HIV stigma is often studied through psychosocial perspectives without considering social-structural conditions. Recent theorists have hypothesized that place and social position, two key social-structural conditions, fundamentally shape PLWH’s experiences of stigma. Due to residential segregation of racial/ethnic and lesbian, gay, bisexual, transgender, and queer (LGBTQ) populations, place and social position are often inextricably intertwined within the U.S. Methods: Qualitative interviews were conducted with 42 PLWH and 14 care providers in 2017. Interviews were conducted with English- and Spanish-speaking PLWH in all three counties in Delaware, including: Wilmington in New Castle County, Smyrna in Kent County, and Georgetown in Sussex County. Results: Results suggest that PLWH’s experiences of HIV stigma are shaped by place and social position. Although HIV stigma is still prevalent across Delaware, participants reported that HIV stigma is more pronounced in Kent and Sussex counties and in rural areas. Latinx and Haitian PLWH are at greater risk of experiencing HIV stigma than other racial/ethnic groups, with participants identifying misinformation within Latinx and Haitian communities as a key driver of HIV stigma. HIV stigma is further compounded by medical mistrust in the Haitian community. In contrast, participants noted that LGBTQ PLWH in Sussex County are somewhat buffered from HIV stigma by the LGBTQ community, which is reported to be more knowledgeable about HIV and accepting of PLWH. Conclusions: Multi-level interventions that address social-structural conditions in addition to individual-level factors are recommended to best address HIV stigma in Delaware. Interventions should target drivers of stigma, such as lack of knowledge, and consider how place and social position uniquely shape PLWH’s experiences of stigma.
Institute for Collaboration on Health, Intervention, and Policy; University of Connecticut
DOI: 10.32481/djph.2022.08.005
Delaware is located in the South, the region with the highest rates of new HIV diagnoses in the U.S.8,9 Although Delaware is the second-smallest state in the U.S., its HIV incidence rate is ranked as the 16th highest in the nation (11.2 per 100,000 persons10). Delaware is comprised of three counties. New Castle is the northernmost and most populous county and is home to 73% of Delawareans living with HIV. Located in New Castle County, Wilmington is the largest city in Delaware and is home to over half (56%) of PLWH in New Castle and onethird (36%) of PLWH in Delaware. Kent and Sussex counties are south of New Castle, more rural, and are home to 12% and 15% of Delawareans living with HIV respectively. Routes of HIV transmission in New Castle and Kent counties are similar, with sexual contact among heterosexual individuals and men who have sex with men accounting for comparable HIV cases (i.e., 37% and 35% respectively in both counties). In Sussex County, rates of transmission are highest among men who have sex with men
Ismael Medina, M.S.W.
William J. Holloway Community Program, ChristianaCare Arlene K. Bincsik, R.N., M.S., C.C.R.C., A.C.R.N.
William J. Holloway Community Program, ChristianaCare
Karen R. Swanson, R.N., B.S.N., A.C.R.N., C.C.R.C.
Decades of research suggests that stigma, or social devaluation and discrediting, undermines outcomes and exacerbates inequities along the full HIV care continuum.1,2 The majority of HIV stigma research to date has focused on the individual level, and has demonstrated that individual people living with HIV (PLWH) who experience greater stigma have worse mental health, are less likely to be linked to care, are less adherent to antiretroviral therapy, and are less likely to achieve viral suppression.3,4 Yet, theorists working in structural stigma5 and intersectionality6,7 have called on HIV researchers to shift their focus beyond the individual level and attend to social and structural conditions to better understand experiences and outcomes of HIV stigma. Greater understanding of the social-structural conditions that shape HIV stigma is critical for tailoring intervention strategies to reduce and promote resilience to HIV stigma. The current study therefore explores two key interrelated social-structural conditions that shape
INTRODUCTION
ABSTRACT
Xueli Qiu, M.S.
E. Carly Hill, B.S.
Latin American Community Center
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Department of Human Development and Family Sciences, University of Delaware
Although recent work on structural stigma and intersectionality underscores the importance of considering social-structural conditions when studying stigma, researchers to date have arguably understudied these conditions. Better understanding of the role of social-structural conditions in shaping the experiences of HIV stigma can inform tailored intervention strategies to address HIV stigma. The current study uses qualitative methods to explore how two interrelated social-structural conditions, including place and social position, shape the experiences of stigma among PLWH throughout the state of Delaware.
Social-structural conditions may play key roles in shaping experiences of HIV stigma among PLWH. Hatzenbuehler’s definition of structural stigma spans societal-level conditions, cultural norms, and policies that constrain the opportunities, resources, and wellbeing of stigmatized people.5 Structural stigma research has drawn attention to place-based variability in experiences and outcomes of stigma. Evidence generally suggests that stigmatized people living in places with greater structural stigma, indicated by aggregated attitudinal data and/or policy analysis, report greater individual-level experiences of stigma and have worse health outcomes than stigmatized people living in places with less structural stigma.5 Quantitative research on structural stigma often incorporates countries and states as the unit of analysis, and therefore much work on structural stigma to date has been conducted at macro levels (e.g., national, international). Yet there may be important variations in structural stigma at more local geographic levels, including within states. Evidence suggests that community members living in rural areas have less knowledge of HIV and contact with PLWH than community members in urban areas, in part due to differences in their social network structures.11 Given that knowledge and contact are drivers of HIV stigma,1 HIV stigma in rural areas may be greater than in urban areas. For example, a study conducted in Georgia suggests that PLWH in rural areas experience greater enacted stigma and internalized stigma than their counterparts who live in urban areas.12 In Delaware, Kent and Sussex counties are more rural than New Castle County, with populations per square mile one-quarter to one-fifth the size of New Castle.9
Qualitative Protocol
Social positions may play an additional role in shaping experiences of HIV stigma. Intersectionality theory draws attention to the multiple, interlocking systems of oppression and privilege that give rise to inequities in HIV and other health outcomes.6,7 These interlocking systems shape the ways in which individuals living at the intersections of multiple social positions experience HIV stigma. The concept of intersectional stigma was introduced by Berger to describe stigma experienced by Black women living with HIV at the intersections of sexism, racism, and HIV stigma.6 Since then, much research on intersectional stigma in the U.S. has focused on intersections of racism, homophobia, and HIV stigma given that Black gay and bisexual men are disproportionately affected by the HIV epidemic. Some of this work suggests Black gay men are “triply cursed”13 and that the stigmatization of homosexuality and HIV, along with racism, make it difficult for Black gay men living with HIV to seek support and HIV care.13,14 Although arguably less research to date has focused on the intersections of other social positions, some work suggests that features of Latinx culture shape experiences of stigma.15 Moreover, Haitian PLWH have historically faced pronounced stigma in the U.S.,5,6 the legacy of which may continue to shape their experiences today.
To develop a comprehensive understanding of HIV stigma, we interviewed both PLWH and providers, achieving data source triangulation.20 Participants included 42 PLWH and 14 providers, with 24 participants from Wilmington, 13 from Smyrna and 19 from Georgetown. More interviews were conducted in Wilmington because there were more Spanish-speaking PLWH in Wilmington than at the other sites. Among PLWH, 30 participants spoke English and 12 spoke Spanish; 28 identified as men and 14 as women; 16 identified as Black, 13 as Latinx, 7 as White, and 5 as another race/ethnicity; and 20 identified as LGBTQ, 18 as heterosexual, and 4 as another sexual orientation. PLWH had been living with HIV for an average of 10.7 years.
Social-Structural Conditions Shaping Experiences of HIV Stigma
ProceduresMETHOD and Participants
(59%). Health inequities persist in Delaware: 58% of Delawareans living with HIV are African American and 8% are Latinx.10
PLWH and providers were recruited in 2017 from an HIV care program within several locations in Delaware. Individuals were eligible to participate if they were age 18 or older, spoke English or Spanish, and received or provided care at one of three locations, including Wilmington in New Castle County, Smyrna in Kent County, and Georgetown in Sussex County. Participants were recruited via flyers and word of mouth. Informed consent was obtained from interested individuals, and then interviews lasting up to an hour were conducted in private rooms. Interviews with Spanish-speaking participants were conducted with an interpreter. All interviews were conducted in person, digitally recorded, and later transcribed. Study procedures received institutional review board approval by the University of Delaware.
Importantly, place and social positions are intertwined due to residential segregation. Racial and ethnic residential segregation persists in Delaware. For example, although the Latinx population is generally equally distributed at the county-level (11.0% New Castle, 7.8% Kent, 9.8% Sussex),16 pockets of segregated
Current Study
The parent study was designed to compare barriers to HIV care throughout Delaware; therefore, a semi-structured qualitative protocol was developed to broadly explore barriers to HIV care. PLWH were asked questions about their experiences with HIV care (e.g., “Please tell me about your experiences with HIV care,
15
communities persist at local levels. Similar to the rest of the U.S.,17 Latinx residential segregation in Delaware reflects economic inequality, employment segregation, and local population dynamics. Delaware is additionally home to a sizeable Haitian community in Kent and Sussex counties, where they constitute the majority of the workforce for the state’s poultry industry.18 Residential segregation of lesbian, gay, bisexual, transgender, and queer (LGBTQ) households also exists throughout the U.S. and in Delaware. Residential segregation of LGBTQ households may be driven, in part, by LGBTQ individuals leaving communities with greater LGBTQ stigma in favor of more LGBTQ-friendly communities.19 Rehoboth is a LGBTQ-friendly community in Sussex County.
Participants also reported that community members continued to believe that HIV is a death sentence. Another PLWH in Smyrna reported that they had been called the “grim reaper.”
Analysis
Lack of knowledge was identified as the primary driver of HIV stigma throughout the state. Participants perceived that
“(My primary care physician) didn’t even know about PrEP. And I had asked them about PrEP before. And he didn’t know. Like this was before I was diagnosed as HIV positive. I asked about it in 2013 when I found out about it and he was like “What is that?” And like this is my doctor.”
Providers in Georgetown additionally noted that that primary care physicians continue to stigmatize PLWH, despite advances in HIV knowledge within the medical field. One noted: “I mean there’s certainly doctors that still get a patient with HIV and even though they know it’s a treatable disease they sort of shun away from it or have their own reservations about… how this patient got this disease and all that. And people come in here like “Well you sent me to this doctor for primary care but as soon as he saw me he put gloves on” this and that.”
All interviews were transcribed in English, and then analyzed using a grounded theory approach. Following standard qualitative data analysis methods,21 three members of the study team read the transcripts and identified recurring themes. They then created a codebook listing themes, detailed definitions of themes, inclusion/exclusion criteria, and example quotes. Themes included individual-, interpersonal-, and structural-level barriers as well as recommendations to address barriers. Using Dedoose, a qualitative data management program, two members of the team independently coded approximately 20% of transcribed text. An interrater reliability of Kappa=0.90 was achieved, and then team members coded the rest of the transcripts. Disagreements were resolved through discussion. The current paper focuses on a subset of themes related to stigma, including enacted and anticipated stigma at the interpersonal level, and community stigma and knowledge at the structural level. These themes overlapped with several others, such as disclosure and concealment at the interpersonal level and experiences with care outside of the HIV program at the structural level.
PlaceRESULTS
community members continue to have misperceptions of HIV. For example, many PLWH and providers encountered community members who still thought HIV could be spread through hugging, touching, shaking hands and eating together. One PLWH in Smyrna commented: “those people are very ignorant, and rude, and just, just, illiterate to what’s really going on.”
Participants reported that HIV stigma is still prevalent in all three counties within Delaware. PLWH at every site reported that they had experienced enacted stigma from members of their community. As examples, a PLWH from Wilmington described social rejection and distancing: “They don’t wanna talk to you, get close to you... on the street where you live, everybody know. So everybody just go back inside like just breathing the same air is gonna get you sick.” A PLWH from Smyrna described judgment and gossip from others: “Once the wrong people know, then that’s when it turns into a disaster. Then everybody knows and then once everybody knows, everybody’s judging you.”
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“Providers not feeling comfortable treating them in terms of primary care even if their HIV is under control… We have great things for HIV care, but patients nowadays are not dying from HIV. They’re dying of heart failure, of diabetes, of depression, of MIs, cancer… I think stigma is playing a role.”
Although participants reported stigma throughout the state, PLWH and providers in Georgetown noted that stigma was more pronounced “down here” (i.e., in the Southern part of the state) than in the Northern part of the state. For example, a PLWH in Georgetown noted that “it’s just a very closed channel down here.” Participants in Georgetown described macroaggressions, or particularly harmful forms of stigma. For example, a PLWH in Georgetown described being fired from their job at a landscaping company after their HIV-status was revealed to their coworkers: “I don’t know how they found out but they did. So they were cracking fag jokes and stuff about HIV... It got to the point where (my boss) found out that I was having a lot of issues with the guys and he said “I’m going to have to let you go because for your sake and for the morale of my people” and so I took him to court and you know, I got a small settlement but at least I hope it taught him that discrimination has no place.”
Similarly, a provider in Smyrna highlighted that stigma from primary care providers undermined PLWH’s ability to access quality care for other chronic health conditions and comorbidities:
Participants noted that the lack of knowledge about HIV was particularly problematic in Georgetown, extending into healthcare settings outside of the HIV program. One PLWH observed that their primary care physician lacked essential knowledge about PrEP (i.e., an HIV prevention medication). They reported:
A PLWH in Georgetown added that people “looked at people with HIV or AIDS as degenerates, whores, even pedophiles” in their community. A provider from Wilmington shared similar perspective, saying that “I’m seeing it (stigma) no different in 2017 than what I saw in the 80s. It’s just as prevalent.”
including when you first started and how it’s gone so far.”) as well as barriers to and facilitators of HIV medical appointments (e.g., “What kinds of things make it challenging or difficult for you to come in for your appointments?”), HIV medication adherence (e.g., “What kinds of things make it easier for you to take your medication?”), and other healthcare (e.g., “Have you tried to see doctors or psychologists outside of the HIV program? If so, how has that gone?”). Because local stakeholders suggested that stigma was a barrier to HIV care, several interview questions focused on individuals’ experiences of stigma (e.g., “How much has the stigma of HIV been a problem for you? In other words, do you feel that people treat you differently or mistreat you because they know that you have HIV?”). Providers were asked questions about the same broad themes, with questions tailored to query about their perceptions of PLWH’s experiences (e.g., “Is stigma or discrimination a problem for your patients? In other words, do people treat your patients differently or mistreat them because they know that they’re living with HIV?”).
In contrast to the experiences of Latinx and Haitian PLWH, PLWH and providers noted that gay men experienced less HIV stigma in the state. This was especially case in Georgetown, which is close to Rehoboth. One provider in Georgetown reported that “I think in today’s world (HIV is) still very taboo, still very stigmatized. But I think now certain populations, or especially our gay men, are way more open about it.” A PLWH in Georgetown noted that they experience more stigma from heterosexuals, whom they viewed as less knowledgeable about HIV:
Several social positions emerged as particularly important in shaping individuals’ experiences of HIV stigma. Latinx PLWH described substantial HIV stigma within the Latinx community, which led many to anticipate stigma and conceal their HIV status. A Latinx PLWH in Georgetown reported that “the Hispanic culture is sometimes very judgmental and can discriminate for PLWH.” Another Latinx PLWH in Wilmington stated that “Hispanic culture is very tough when it comes to HIV and they might think bad about the disease and have negative perceptions about HIV.” Several participants identified lack of knowledge as a key driver of HIV stigma in the Latinx community. One Latinx PLWH in Wilmington noted:
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The current study explores how social-structural conditions shape experiences of stigma among PLWH within Delaware. Results suggest that experiences of stigma among PLWH are shaped by their place and social position. Replicating previous findings identifying place-based differences in experiences of HIV stigma,12 PLWH living in the Southern part of the state and in more rural areas described more pronounced HIV stigma than PLWH living in the Northern part of the state and in more urban areas. Concerning social positions, Latinx PLWH expressed significant concerns surrounding anticipated stigma and more Latinx PLWH concealed their HIV-status than PLWH in other social positions. Healthcare providers perceived that Haitian PLWH are at elevated risk of HIV stigma, and stigma within the Haitian community was attributed to perceived low levels of knowledge about HIV and compounded by medical mistrust. In contrast to the experiences of Latinx and Haitian PLWH, participants reported that PLWH generally experienced less stigma within the LGBTQ community. Although there have been recent upticks in LGBTQ stigma in the U.S., evidence suggests that LGBTQ stigma has generally decreased over the past two decades.22 LGBTQ individuals experiencing greater resilience and empowerment associated with their LGBTQ identities may also experience greater resilience and empowerment associated with other aspects of the self, including their HIV status.
A provider from Smyrna identified stigma as a barrier to patientprovider communication, stating that “in Haitian cultures, if you have HIV, you are not a part of the community anymore and so we have patients that don’t want their names used with the translator service.” Another provider from Georgetown shared a story of a Haitian PLWH who concealed her HIV status due to pronounced anticipated stigma. She stopped taking her HIV
medication because she was unable to hide the medication, which led to a severe infection and death.
Latinx participants expressed worrying about others learning about their HIV status and concealed their HIV. Whereas most White and Black PLWH described disclosing their HIV status to several other people, approximately half of Latinx PLWH noted that they had disclosed to one or no other people outside of their healthcare team.
Social Positions
“It’s more of a stigma when I deal with straight America. Like it’s wreaked havoc on the gay population so like a lot of … you know when I talk to the gay population they’re a little more understanding and they get that it doesn’t define you and that it’s not a death sentence. …. when I deal with the straight population it’s just like they’re a little bit more uninformed. And it’s crazy because it’s like its being brought to their doorstep now because of IV drug use.”
DISCUSSION
Results additionally suggest that place and social positions
“A lot of Hispanics think that you’re living with HIV and you come into my house and just because you give me a handshake or a hug that you’re going to transmit HIV, or that just because you’re eating with them or that you’re sharing utensils that somebody’s going to get infected but that’s not the case.”
“We have also a large population of patients from Haiti… the main thing in access to care is trust. You know, these patients have to be seen again and again for complications before they actually buy into (medical care). But we still have patients that will travel back to their country to see a spiritual leader to, you know, offer them a potion so they can get rid of the disease, and I’ve had plenty of those patients that will be here for a while and then disappear and come in a hospital and we’ll have to deal with, you know, things all over again. So, there is a trust issue in that specific group and also a stigma within their own community.”
Providers reported that Haitian PLWH also experienced substantial HIV stigma within the Haitian community. One provider in Smyrna noted that their Haitian patients “said they didn’t want to state what their diagnosis was because it was not something that their culture accepts readily, and that there would be further… problems for them if it were known.” Similar to HIV stigma in the Latinx community, providers perceived that HIV stigma in the Haitian community was rooted in misinformation. A provider in Georgetown reported that “the Haitian population… believes that there is no HIV. HIV doesn’t really exist.” Different than the Latinx community, providers perceived that HIV stigma was compounded by pronounced medical mistrust, ultimately undermining healthcare engagement. A provider in Georgetown noted:
Both PLWH and providers noted that many LGBTQ PLWH in Georgetown and Rehoboth experience positive health outcomes. One provider in Smyrna noted that LGBTQ PLWH tend to be more adherent to their medication because “all the gay men from the beach that are highly educated, smart, intelligent. They understand the regimen, they understand the vernacular and they come to their appointments.” However, not all LGBTQ PLWH have positive outcomes and experiences. Another provider described a PLWH patient who anticipated significant HIV and LGBTQ stigma from their family, and therefore concealed both their HIV-status and sexual orientation from them.
Ms. Qiu may be contacted at sherryq@udel.edu.
18 Delaware Journal of Public Health - August 2022
Strengths and Limitations
The current study suggests that social-structural conditions, including place and social positions, may fundamentally shape experiences of stigma among PLWH in Delaware. Theorists have argued for the importance of multi-level stigma interventions that include stigma reduction components at the structural, community, interpersonal, and individual levels.25 Evidence suggests that there has been some progress: A recent review identified several stigma interventions that operated at more than one social-ecological level.25 Interventionists should continue to develop and evaluate interventions that address stigma at multiple social-ecological levels. It may be particularly important to integrate empowerment-based components to combat intersectional stigma.26 Moreover, results suggest that HIV stigma interventions may not be able to take a “one size fits all” approach, but instead may need to be tailored to specific places and social positions in Delaware.
3 Rueda, S., Mitra, S., Chen, S., Gogolishvili, D., Globerman, J., Chambers, L., Rourke, S. B. (2016, July 13). Examining the associations between HIV-related stigma and health outcomes in people living with HIV/AIDS: A series of meta-analyses. BMJ Open, 6(7), e011453. https://doi.org/10.1136/bmjopen-2016-011453
1. Stangl, A. L., Earnshaw, V. A., Logie, C. H., van Brakel, W., C Simbayi, L., Barré, I., & Dovidio, J. F. (2019, February 15). The Health Stigma and Discrimination Framework: A global, crosscutting framework to inform research, intervention development, and policy on health-related stigmas. BMC Medicine, 17(1), 31. https://doi.org/10.1186/s12916-019-1271-3
The authors thank the participants, as well as the care providers and program staff, for their support of and contributions toward this work. This work was supported by the National Institutes of Health (T32MH074387, NMB). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Mental Health.
Much previous work on HIV stigma focuses on the micro level by studying individuals living with HIV, resulting in a desocialized and decontextualized understanding of experiences of HIV stigma.23 Researchers are beginning to focus on the macro level by studying structures, including how variation in structural stigma between states impacts experiences and outcomes of stigma.24 The current study focuses on the mezzo level, exploring how socialstructural conditions spanning one U.S. state shape PLWH’s experiences of stigma. The study draws on a diverse sample in terms of race, ethnicity, and sexual orientation and incorporates perspectives of both PLWH and providers.
Justification of use of data from more than three years ago: Data for this project were collected in 2017, five years ago. Although we understand that DJPH typically prioritizes manuscripts with data collected within the past three years, we have no reason to believe that the results reported have changed since the data were collected. Stigma processes are very slow to change. As described in this paper, some participants noted that HIV stigma in Delaware was just as strong in 2017 as it was in the 1980s. We have no reason to believe that substantial changes in HIV stigma occurred between 2017 and 2022. Moreover, the epidemiologic profile of HIV has remained stable in Delaware. We therefore believe that our discussion of the roles of place and social position in shaping HIV stigma throughout Delaware remain relevant.
Public Health Implications
intersect to shape experiences of stigma in Delaware, likely due to residential segregation of racial/ethnic minority and LGBTQ populations within the state. For example, experiences of stigma among Haitian PLWH were described by providers in Smyrna and Georgetown, but not Wilmington. In contrast, participants in Georgetown remarked that gay men experience less stigma in Georgetown and Rehoboth, perhaps because Rehoboth is a LGBTQ-friendly town.
Several limitations of the study should be acknowledged. Findings surrounding HIV stigma experienced by Haitian PLWH are based on providers’ perspectives. We were unable to recruit Haitian participants for a variety of reasons (e.g., mistrust of the medical and research community among patients). These results are reported given that the experiences of Haitians living with HIV in the U.S. have arguably been underreported in recent years, and are critical to understanding the landscape of HIV stigma in Delaware. Future studies should seek to explore experiences of stigma from the perspectives of Haitian PLWH. Additionally, comparisons of experiences of stigma were made with qualitative methods. Future quantitative studies can measure and compare levels of stigma between groups to identify statistically significant differences. Finally, this study was conducted in partnership with one HIV care program in Delaware. Although this program serves the largest number of PLWH in the state, results may not be generalizable to PLWH receiving care from other programs. Future work should be conducted in partnership with more HIV care programs and in more locations to develop more generalizable and nuanced understanding of variations of experiences of HIV stigma within Delaware and elsewhere.
4. Earnshaw, V. A., Bogart, L. M., Laurenceau, J. P., Chan, B. T., Maughan-Brown, B. G., Dietrich, J. J., . . . Katz, I. T. (2018, October). Internalized HIV stigma, ART initiation and HIV-1 RNA suppression in South Africa: Exploring avoidant coping as a longitudinal mediator. Journal of the International AIDS Society, 21(10), e25198. https://doi.org/10.1002/jia2.25198
AUTHOR NOTES
6. Berger, M. T. (2004). Workable sisterhood: The political journey of stigmatized women with HIV/AIDS. Princeton, NJ: Princeton University Press. https://doi.org/10.1515/9781400826384
2 Link, B. G., & Phelan, J. C. (2001). Conceptualizing stigma. Annual Review of Sociology, 27(1), 363 385 https://doi.org/10.1146/annurev.soc.27.1.363
ACKNOWLEDGEMENTS
REFERENCES
5 Hatzenbuehler, M. L. (2016, November). Structural stigma: Research evidence and implications for psychological science. The American Psychologist, 71(8), 742 751. https://doi.org/10.1037/amp0000068
23. Castro, A., & Farmer, P. (2005, January). Understanding and addressing AIDS-related stigma: From anthropological theory to clinical practice in Haiti. American Journal of Public Health, 95(1), 53 59. https://doi.org/10.2105/AJPH.2003.028563
15. Nunez, I. (2020). The intersection of race and sexuality amongst Hispanic/Latino men who have sex with men (MSM) in central California: HIV disparities (Unpublished master’s thesis). California State University, Stanislaus, California, CA.
18. The Haitian Times. (2020, May 12). Haitian immigrants at risk in Delaware poultry industry. https://haitiantimes.com/2020/05/12/haitian-immigrants-at-risk-indelaware-poultry-industry/
20 Patton, M. Q. (1999, December). Enhancing the quality and credibility of qualitative analysis. Health Services Research, 34(5 Pt 2), 1189 1208. https://pubmed.ncbi.nlm.nih.gov/10591279
19
10 Delaware Department of Health and Social Services, Division of Public Health. (2020). Delaware HIV Surveillance report [PDF file]. Retrieved from https://www.dhss.delaware.gov/dhss/dph/epi/files/2020hivepiprofile.pdf
21 Miles, M. B., Huberman, M. A., & Saldaña, J. (2019). Qualitative data analysis: A methods sourcebook (4th edition). SAGE.
25 Rao, D., Elshafei, A., Nguyen, M., Hatzenbuehler, M. L., Frey, S., & Go, V. F. (2019, February 15). A systematic review of multi-level stigma interventions: State of the science and future directions. BMC Medicine, 17(1), 41 https://doi.org/10.1186/s12916-018-1244-y
13 Arnold, E. A., Rebchook, G. M., & Kegeles, S. M. (2014, June). ‘Triply cursed’: Racism, homophobia and HIVrelated stigma are barriers to regular HIV testing, treatment adherence and disclosure among young Black gay men. Culture, Health & Sexuality, 16(6), 710 722 https://doi.org/10.1080/13691058.2014.905706
22 Pew Research Center. (2019, May 14). Attitudes on same-sex marriage. Retrieved from https://www.pewresearch.org/religion/fact-sheet/changing-attitudes-ongay-marriage/
7 Bowleg, L. (2021, January). Evolving intersectionality within public health: From analysis to action. American Journal of Public Health, 111(1), 88 90 https://doi.org/10.2105/AJPH.2020.306031
11. Veinot, T. C., & Harris, R. (2011, Summer). Talking about, knowing about HIV/AIDS in Canada: A rural-urban comparison. J Rural Health, 27(3), 310 318. https://doi.org/10.1111/j.1748-0361.2010.00353.x
14 Quinn, K., Bowleg, L., & Dickson-Gomez, J. (2019, July). “The fear of being Black plus the fear of being gay”: The effects of intersectional stigma on PrEP use among young Black gay, bisexual, and other men who have sex with men. Soc Sci Med, 232, 86 93 https://doi.org/10.1016/j.socscimed.2019.04.042
9. United States Census Bureau. (n.d.). QuickFacts United States. Retrieved from https://www.census.gov/quickfacts/fact/table/US/RHI125221
24 Baugher, A. R., Whiteman, A., Jeffries, W. L. I., IV, Finlayson, T., Lewis, R., & Wejnert, C., & the NHBS Study Group. (2021, August 1). Black men who have sex with men living in states with HIV criminalization laws report high stigma, 23 U.S. cities, 2017. AIDS (London, England), 35(10), 1637 1645 https://doi.org/10.1097/QAD.0000000000002917
26. Logie, C. H., Earnshaw, V., Nyblade, L., Turan, J., Stangl, A., Poteat, T., Baral, S. (2022, Aug). A scoping review of the integration of empowermentbased perspectives in quantitative intersectional stigma research. Global Public Health: An International Journal for Research, Policy and Practice, 1451 1466. https://doi.org/10.1080/17441692.2021.1934061
8. Center for Disease Control and Prevention. (2020, June). HIV in the United States by region. Retrieved from https://www.cdc.gov/hiv/statistics/overview/geographicdistribution.html
16 United States Census Bureau. (n.d.). QuickFacts Delaware. Retrieved from https://www.census.gov/quickfacts/fact/map/DE/POP060220
12 Kalichman, S. C., Katner, H., Banas, E., Hill, M., & Kalichman, M. O. (2020, November). Cumulative effects of stigma experiences on retention in HIV care among men and women in the rural southeastern United States. AIDS Patient Care and STDs, 34(11), 484 490. https://doi.org/10.1089/apc.2020.0144
19 Poston, D. L., Compton, D. R., Xiong, Q., & Knox, E. A. (2017). The residential segregation of same-sex households from different-sex households in metropolitan USA, circa-2010. Population Review, 56(2). https://doi.org/10.1353/prv.2017.0005
17 Lichter, D. T., Parisi, D., & Taquino, M. C. (2016). Emerging patterns of Hispanic residential segregation: Lessons from rural and small-town America. Rural Sociology, 81(4), 483 518. https://doi.org/10.1111/ruso.12108
Policy Recommendations for Reducing Tobacco Exposure for Youth and Adults in Wilmington, Delaware
Living in close proximity to tobacco retailers—stores that are licensed to sell tobacco products (e.g., “corner stores”)—
Living in a neighborhood with a high density of retailers can make exposure to tobacco products difficult to avoid. Adolescents with frequent exposure to tobacco retailers can develop prosmoking attitudes and are more likely to initiate smoking.9,10 Adults who want to quit smoking report frequent and easy access to tobacco products as a significant barrier.7 Low-SES, urban communities with higher concentrations of people of color tend to have the greatest concentration of tobacco retailers.11 Many urban neighborhoods experience both proximity and density effects, and reducing tobacco retailer density by 50% has been shown to reduce the proportion of residents living within 500 meters of a tobacco retailer.6
20 Delaware Journal of Public Health - August 2022
DELAWARE CONTEXT
Despite national progress in reducing smoking rates over the last fifty years, racial and socioeconomic disparities in smoking behavior remain.1 Seventy percent of the current adult smoking population has a low socioeconomic status (SES).2 While the rate of smoking is roughly similar between racial groups, African Americans have lower quit rates than their white counterparts, increasing their risk of lung cancer and other tobacco-attributable illnesses.3 Reductions in smoking behavior that have been achieved in the last fifty years have come largely from the introduction of excise taxes, mass media marketing bans, public messaging campaigns, and smoking cessation treatment. The tobacco industry has sidestepped many marketing regulations of the last half century by investing in point-of-sale marketing campaigns within communities of color to “…establish and maintain demand for tobacco products in low SES and segregated communities” (p. 2).4 For example, two thirds of the tobacco industry’s marketing budget is spent on retailer discounts in order to nullify excise taxes on tobacco.5 In response, local governments have made efforts in recent years to reduce exposure to pointof-sale marketing by reducing the geographic concentration of tobacco retailers, with mixed result. We join these efforts by examining the projected impacts of policy solutions that have demonstrated success elsewhere, including nearby Philadelphia. Combs et al. refer to areas with high concentrations of tobacco retailers as tobacco swamps 6 In these areas, residents can be impacted by tobacco retailer proximity (as in the distance between residents and retailers), density (as in the number of retailers per geographic unit, or per capita), or both.6
ABSTRACT
INTRODUCTION
DOI: 10.32481/djph.2022.08.006
contributes to a higher risk of cigarette smoking and a greater difficulty in quitting.7 Individuals who currently smoke and live within 500 meters of a tobacco retailer are about half as likely to quit smoking as those outside of that radius. A 500-meter buffer between a person’s place of residence and the nearest retailer disincentivizes smoking and correlates with a 20 to 60% increase in their chances of successfully quitting.8
Jason Bourke, Ph.D. Director, Master of Public Administration Program, Delaware State University Madeline M. Brooks, M.P.H. Research Investigator, Institute for Research on Equity & Community Health (iREACH), ChristianaCare Scott D. Siegel, Ph.D., M.H.C.D.S. Director, Population Health; Institute for Research on Equity & Community Health (iREACH), ChristianaCare
Similar to the disparities observed nationally, recent research has shown that the density of tobacco retailers is considerably higher in lower-SES, highly segregated communities in Delaware.4,5 For example, an analysis of New Castle County found that Wilmington accounts for 15% of the county’s population but more than 27% of the county’s tobacco retailers. Among Wilmington residents who smoke, in a deidentified ChristianaCare sample, more than 80% lived in medium- and high-density residential zones, zones which house 54% of the city’s population. It might be expected that a city with a commercial district would have more businesses of any type relative to the surrounding communities.
Objective: To highlight and recommend policies that can be projected to reduce disproportionate tobacco exposure for youth and adults in Wilmington, Delaware’s densest and most disadvantaged neighborhoods. Four policy options were drawn from the literature: pharmacy tobacco bans, zoning-based tobacco retailer reductions, residential density caps, and buffers around K-12 schools. Method: Changes in tobacco retailer density and resident-to-retailer distance in Wilmington’s medium- and high- density residentially zoned neighborhoods were projected using GIS analysis of current conditions and projections for each of the four policies. Results: Banning tobacco sales in pharmacies was found to be least effective, while 500-meter buffers around K-12 schools was projected to have the greatest impact on both retailer density and resident-to-retailer distance. Policy Implications: As a result of these findings, the authors recommend a ban of tobacco sales with a 500-meter radius of all K-12 schools in the City of Wilmington.
PROPOSED SOLUTIONS FOR WILMINGTON
SOLUTIONS
We projected the impacts of four policies on tobacco retailer density and resident-to-retailer distance in Wilmington by building on previous spatial analyses conducted by Brooks et al.5 Tobacco retailers were identified using Delaware Division of Revenue data for businesses with a tobacco retail license as of April 17, 2019. Geographic information systems were used to map these retailers and estimate their density citywide and within medium- and high-density residential zones (Table 1), as well as retailers’ proximity to K-12 schools. Average resident-to-retailer distance was estimated by simulating point locations for city residents, proportional to population counts within block groups, and measuring their average straight-line distance from the nearest tobacco retailer (Table 2).
Relatively recently, efforts to limit the number and density of tobacco retailers have been implemented in New York, San Francisco and Philadelphia with mixed but promising results.12 Many of these approaches reduce density by curtailing tobacco retail licenses by store type, location, or proximity to certain other features. “The primary policy approaches to reducing tobacco retailer density include prohibiting sales in specific retailer types and near youth-populated areas, targeting clusters of retailers, and capping the number of retailers to a certain amount within a community” (p. 2).12
study of these efforts demonstrated an overall 20% reduction in tobacco retail locations three years after the policies were implemented.13 Relative reductions were greatest in low-income districts, but tobacco retailer density still remained higher in less affluent areas.13 Other studies have also found that denying licenses within varying radii of K-12 schools has shown promise in reducing tobacco retailer density in low-SES communities of color.13
Our policy goal is to reduce the number and density of tobacco retailers and increase the resident-to-retailer distance in Wilmington’s low-SES, medium- and high-density, residentially zoned neighborhoods. Philadelphia’s success at reducing tobacco retailer density is promising and offers a few policy suggestions worth examining in Wilmington. Some of these solutions are out of reach of Wilmington city government alone but could be bolstered with support from the State of Delaware. For example, the city of Philadelphia controls tobacco licenses,13 whereas in Delaware tobacco licensing is handled by the state.
Limiting tobacco retail in pharmacies shows promise in affluent, suburban areas, but in low-SES, urban communities, pharmacies don’t account for enough of the tobacco retailer density to make a difference.12 This strategy has indeed resulted in reductions in tobacco retailer numbers, but most of the reductions have taken place in more affluent, predominantly White, and less dense communities.12Philadelphiatook a much more comprehensive approach to reducing tobacco retailer density in 2017. Philadelphia’s policies included capping retailer density to one retailer per 1,000 daytime population in each district, 500-foot buffers around schools, increasing the licensing fee from $50 to $300, and toughening penalties for youth sales violations. Lawman et al.’s longitudinal
However, more than 40% of Wilmington’s tobacco retailers were located in residential zones, more than ten times the rate observed for more affluent and predominantly White parts of the county. At least 60% of Wilmington youth reside in the same residential zones that contain a high density of tobacco retailers. Outside of Wilmington, tobacco retailers were much more likely to be situated in commercially zoned areas.4,5
Table 1. Comparison of Policies by Changes in Tobacco Retailer Density Policy Option City of (RetailersTobaccoWilmingtonRetailerDensityper1,000Residents) Medium-/High-Density Residential Zone Tobacco Retailer Density (Retailers per 1,000 Residents) Pre-policy Post-policy % change Pre-policy Post-policy % change Ban within pharmacies 2.38 2.30 -3.4% 1.76 1.76 0.0% 50% reduction in retailers within medium-/high-density residential zones 2.38 1.90 -20.2% 1.76 0.88 -50.0% Citywide density cap of 1 retailer/1000 people 2.38 1.00 -58.0% 1.76 0.78 -55.7% Ban within 500 m of K-12 schools 2.38 0.52 -78.2% 1.76 0.47 -73.3% Table 2. Comparison of Policies by Changes in Tobacco Retailer Proximity Policy Option City of AverageWilmingtonResident-to-Retailer Distance (Meters) Medium-/High-Density Residential Zone Average Resident-to-Retailer Distance (Meters) Pre-policy Post-policy % change Pre-policy Post-policy % change Ban within pharmacies 277.94 279.63 +0.6% 220.61 221.32 +0.3% 50% reduction in retailers within medium-/high-density residential zones 277.94 295.65 +6.4% 220.61 247.21 +12.1% Citywide density cap of 1 retailer/1000 people 277.94 392.37 +41.2% 220.61 357.37 +62.0% Ban within 500 m of K-12 schools 277.94 597.46 +115.0% 220.61 532.84 +141.5% 21
CHALLENGES AND DRAWBACKS
Any policy limiting or prohibiting tobacco sales will necessarily impact the businesses that sell tobacco. Retailers that make significant portions of their income from tobacco sales can be expected to oppose these regulations. Retailers would not be alone in their opposition to such an approach, as we have seen tobacco companies go to great lengths to skirt regulations. Whether their methods include sowing community discord, or direct legal challenges, officials should be prepared for conflict. Tobacco companies may also try to appeal to state lawmakers to preempt city regulations. While this strategy may have worked in other states, Delaware lawmakers recently increased the age of tobacco sales from 18 to 21,14 signaling a statewide interest in reducing smoking behavior and protecting youth.
To make zoning-based restrictions more palatable to store owners, policymakers may also choose to include incentives for ceasing tobacco sales. As part of Philadelphia’s Food Trust Initiative, participating corner stores were incentivized to offer healthier food products and were provided storage and refrigeration equipment to maintain their stock. To become certified as a Healthy Corner Store, they had to agree to decrease the promotion of tobacco products.15
PUBLIC HEALTH IMPLICATIONS
Opponents to this strategy may suggest this policy is an overregulation that impinges on individual decision making. While it may not be news to any adult that smoking is a health hazard, those who currently smoke in our target neighborhoods report a similar desire to quit to many of their White, suburban counterparts who successfully have.7 Reducing retailer density and increasing resident-to-retailer distance would make it more possible for these individuals to avoid incessant tobacco exposure in their daily lives and increase their probability of quitting, while also reducing the likelihood that Wilmington’s youth become the next generation of tobacco industry customers.
For these reasons, cities around the country have introduced a number of policies to reduce retailer density, including schoolbased buffer zones, district population rate caps, and bans on tobacco sales in pharmacies.12 Of these, we have found schoolbased buffer zones to be the most effective policy for reducing tobacco retailer density and increasing average resident-to-retailer distance. These impacts have a demonstrable effect on smoking
Figure 1. Wilmington Policy Context and Solution Mapped
As expected, banning tobacco sales within pharmacies had the least impact on both density and distance in all of Wilmington and its medium- and high-density residential zones, with zero impact on density in those zones and a meager 3.4% decrease in citywide density. The impact on distance is negligible.
Given these findings, a compelling case can be made for banning tobacco sales within 500 meters of K-12 schools. Not only is this policy highly effective in other places,12 including Philadelphia,13 but it demonstrably achieves the largest impact on retailer density and resident-to-retailer distance in Wilmington and its mediumand high-density neighborhoods. Figure 1 provides a useful visualization of the locations of tobacco retailers, medium- and high-density neighborhoods, and the places where tobacco sales would be eliminated if tobacco sales were banned within 500 meters of a school.
The literature tells us that retailer density and proximity are strongly correlated with smoking initiation among youth,11 and with a lower likelihood of quitting.8 Easy access to cigarettes can be a temptation, but repetitive exposure to in-store advertising makes tobacco nearly impossible to avoid.7 This plays out both nationally and locally as members of low-SES, dense urban communities of color tend to smoke later into their lives than their White suburban counterparts.3
There are demonstrable disparities in smoking-related health outcomes in New Castle County. Brooks et al. have shown that those who currently smoke disproportionately live in Wilmington, and the majority of those individuals live in Wilmington’s densest, lowest-income, and most racially segregated neighborhoods.5 These neighborhoods contain the densest concentrations of tobacco retailers of any residentially zoned areas in New Castle County.4
22 Delaware Journal of Public Health - August 2022
effective solution examined, by far, is banning tobacco sales within 500 meters of a school. Eliminating tobacco sales within 500 meters of a school in Wilmington would reduce density city-wide by 78.2% and by 73.3% in medium- and highdensity residential zones. Average resident-to-retailer distance is increased by 115% in the city as a whole and by a whopping 141.5% in medium- and high- density residential zones. In both, the average distance increases to more than 500-meters, which is associated with a greater likelihood of quitting.8
In keeping with the benchmark set by Combs et al., we projected the impact of a 50% reduction in retailers within medium- and high-density residential zones.6 Reducing retailer density by half increases the average resident-to-retailer distance by 12.1% in medium- and high-density residential zones and by 6.4% in all of ImposingWilmington.adensity cap of one retailer per 1,000 residents would have an even greater impact on retailer density and distance, reducing the city’s overall density to one from 2.38 tobacco retailers and increasing the average distance by 41.2%. Even more significantly, this policy is projected to increase resident-toretailer distance in medium- and high-density residential zones by The62%.most
15. Healthy Corner Store Initiative | Overview. (2014). The Food Trust. http://thefoodtrust.org/uploads/media_items/healthy-corner-storeoverview.original.pdf
23
13 Lawman, H. G., Henry, K. A., Scheeres, A., Hillengas, A., Coffman, R., & Strasser, A. A. (2020, April). Tobacco retail licensing and density 3 years after license regulations in Philadelphia, Pennsylvania (2012–2019). American Journal of Public Health, 110(4), 547 553. https://doi.org/10.2105/AJPH.2019.305512
5. Brooks, M. M., Siegel, S. D., & Curriero, F. C. (2021, March). Characterizing the spatial relationship between smoking status and tobacco retail exposure: Implications for policy development and evaluation. Health & Place, 68, 102530 https://doi.org/10.1016/j.healthplace.2021.102530
1. United States Surgeon General. (2014). The health consequences of smoking -- 50 years of progress: a report of the Surgeon General: (510072014-001) [Data set]. American Psychological Association. https://doi.org/10.1037/e510072014-001
7 Twyman, L., Bonevski, B., Paul, C., & Bryant, J. (2014, December 22). Perceived barriers to smoking cessation in selected vulnerable groups: A systematic review of the qualitative and quantitative literature. BMJ Open, 4(12), e006414 https://doi.org/10.1136/bmjopen-2014-006414
14. Porter, I. (2019, July 16). It’s official—Delaware raises smoking age from 18 to 21. The News Journal. https://www.delawareonline.com/story/news/2019/07/16/delawareraises-smoking-age-18-21/1738717001/
cessation and uptake prevention among youth. Cigarette smoking remains the leading modifiable cause of early death in America,1 and the impacts of tobacco retailer density and proximity are visited disproportionately on Delaware’s most vulnerable populations.4,5 We believe it is long past time to redress this disparity and hope lawmakers invested in Wilmington find our recommendations useful.
3 Holford, T. R., Levy, D. T., & Meza, R. (2016, April). Comparison of smoking history patterns among African American and White cohorts in the United States Born 1890 to 1990. Nicotine Tob Res, 18(Suppl 1), S16 S29 https://doi.org/10.1093/ntr/ntv274
6 Combs, T. B., Ornstein, J. T., Chaitan, V. L., Golden, S. D., Henriksen, L., & Luke, D. A. (2022, May). Draining the tobacco swamps: Shaping the built environment to reduce tobacco retailer proximity to residents in 30 big US cities. Health & Place, 75, 102815 https://doi.org/10.1016/j.healthplace.2022.102815
2. Levinson. (2017). Where the U.S. tobacco epidemic still rages: Most remaining smokers have lower socioeconomic status. Journal of Health Care for the Poor and Underserved, 28(1), 100–107. https://doi.org/10.1353/hpu.2017.0012
9. Marsh, L., Vaneckova, P., Robertson, L., Johnson, T. O., Doscher, C., Raskind, I. G., Henriksen, L. (2021, January). Association between density and proximity of tobacco retail outlets with smoking: A systematic review of youth studies. Health & Place, 67, 102275. https://doi.org/10.1016/j.healthplace.2019.102275
11. Rodriguez, D., Carlos, H. A., Adachi-Mejia, A. M., Berke, E. M., & Sargent, J. D. (2013, September). Predictors of tobacco outlet density nationwide: A geographic analysis. Tobacco Control, 22(5), 349 355 https://doi.org/10.1136/tobaccocontrol-2011-050120
Dr. Bourke may be contacted at jbourke@desu.edu
4. Siegel, S. D., Brooks, M., Bourke, J., & Curriero, F. C. (2021). Reducing exposure to tobacco retailers with residential zoning policy: Insights from a geospatial analysis of Wilmington, Delaware. Cities & Health, 1 13. https://doi.org/10.1080/23748834.2021.1935141
10 Robertson, L., McGee, R., Marsh, L., & Hoek, J. (2015, January). A systematic review on the impact of point-of-sale tobacco promotion on smoking. Nicotine Tob Res, 17(1), 2 17. https://doi.org/10.1093/ntr/ntu168
12 Glasser, A. M., & Roberts, M. E. (2021, January). Retailer density reduction approaches to tobacco control: A review. Health & Place, 67, 102342 https://doi.org/10.1016/j.healthplace.2020.102342
REFERENCES
8 Pulakka, A., Halonen, J. I., Kawachi, I., Pentti, J., Stenholm, S., Jokela, M., Kivimäki, M. (2016, October 1). Association between distance from home to tobacco outlet and smoking cessation and relapse. JAMA Intern Med, 176(10), 1512 1519. https://doi.org/10.1001/jamainternmed.2016.4535
Ages 50+ or those who are immunocompromised can get their second booster (fourth) dose four months after receiving the initial booster.
• The Hepatitis A and B vaccines protect the liver from serious infection, failure, and death.
For the greatest protection against serious illness, hospitalization, and death, DPH urges people to get all booster doses for which they are eligible now; do not wait for a fall booster. Fully boosted eligible Delawareans can still get a fall booster dose. To find vaccination sites, visit de.gov/getmyvaccine
In mid May, the Delaware Public Health Laboratory detected the BA.5 variant in less than 1% of the test results sequenced. By the end of June, the BA.5 variant was detected in 45.3% of sequenced tests.
Individuals eligible for a booster dose
• Ages 19 through 64 should get the Measles, Mumps, and Rubella vaccine.
August is National Immunization Awareness Month. The Division of Public Health (DPH) reminds adults that only up to date immunizations protect them from diseases. Follow this advice from DPH:
• Complete the COVID 19 vaccination series, including eligible booster doses.
• Get a flu shot every fall.
• The Zoster vaccine protects adults 50 and older from shingles when chickenpox reactivates.
Visit de.gov/immunizations for the adult vaccine schedule or use the Adult Vaccine Assessment Tool at www2.cdc.gov/nip/adultimmsched/ Contact the Delaware Immunization Program at 1 800 282 8672 weekdays between 8:00 a.m. and 4:30 p.m.
• The Varicella vaccine protects adults with severe immunodeficiency, HIV, and pregnant individuals and health care workers without immunity.
Ages 5+ and five months since the second dose of AgesPfizer.18+ and five months since the second dose of AgesModerna.18+and two months since the initial dose of Johnson & Johnson.
Those who qualified for an "additional/third" dose of Pfizer or Moderna because of certain immunocompromising conditions.
24 Delaware Journal of Public Health - August 2022
Nationwide, the emergence of the highly transmissible BA.5 variant and other variants has caused an increase in COVID 19 cases and fluctuations in community risk levels
• First year college students living in residential housing and individuals with HIV and other conditions need the Meningococcal vaccine.
From the Delaware Division of Public Health August 202
Receiving all eligible doses of COVID-19 vaccine provides the best protection
• The pneumococcal vaccine protects adults ages 65 and older against pneumonia and meningitis.
Individuals with general questions about COVID-19 should call Delaware 2-1-1. Individuals who are deaf or hard of hearing can text their ZIP code to 898-211 or email delaware211@uwde.org. Hours of operation are Monday through Friday, 8:00 a.m. to 9:00 p.m. and Saturday, 9:00 a.m. to 5:00 p.m.
DPH reported on My Healthy Community that on July 24, 2022, Delaware’s seven-day average of new positive COVID-19 cases was 358.9, compared to 59.3 on March 21, 2022 and 241.9 on June 25, 2022. As of July 24 in Delaware, there were 132 current hospitalizations and 3,021 deaths due to COVID 19, and 623,250 Delawareans were fully vaccinated.
• The Human Papilloma Virus vaccine protects against viruses that cause cancer.
Immunizations aren’t only for kids
• Adults who did not get a Tetanus, Diphtheria, and Pertussis vaccine as an adolescent should get one dose and then a booster shot every 10 years.
DPH believes everyone regardless of race, religion, and economic or social condition has the right to a standard of living adequate for health and necessary social services. In recent years, DPH has strived to improve health equity with the help of many community leaders, non profit organizations, state agencies, and stakeholders. One example is improving prenatal education and care to reduce the infant mortality rate. Another is educating parents and guardians how to protect children with asthma to keep them in school and out of the hospital.
Schools, workplaces, businesses, places of worship, health and social service providers, and lawmakers can adopt policies that focus on health promotion. To understand Delaware’s health inequities, read The Health Equity Guide for Public Health Practitioners and Partners, Second edition. To learn about issues impacting state communities, visit My Healthy Community Delaware myhealthycommunity.dhss.delaware.gov/homeat.
Our health depends on conditions where we live, learn, work, and play and not just on the medical treatment we receive.
Healthy People is the longest running disease prevention and health promotion initiative within the federal government. It focuses on reducing morbidity, mortality, and infectious diseases, prevention, chronic diseases, health care associated infections, and opioid use. Several goals apply to long-term risk factors such as tobacco use, obesity, and social determinants of health.
areas/social determinants health 25
The Office of Disease Prevention and Health Promotion within the U.S. Department of Health and Human Services (HHS) named the Delaware Division of Public Health a Healthy People 2030 Champion for its commitment to furthering health and well being.
“More than ever, strengthening health and prosperity is a shared responsibility,” says Vice Admiral Jerome M. Adams, MD, MPH, former U.S. Surgeon General, in a YouTube video. “It happens at the local, state, tribal, and national levels and involves public, private, and non profit sectors.”
DPH: a Healthy People 2030 champion
The DPH Bulletin – August 2022 Page 2 of 4
Identifying upstream social and environmental conditions that cause health inequities leads to a more effective, inclusive, and comprehensive delivery of care.
The Social Determinants of Health greatly impact health and longevity
HHS releases 10 year objectives with specific targets that set a shared vision for the nation and a society in which all people can achieve their full potential and well being across the lifespan. The federal government hopes to achieve its goals through multi sector partnerships in public health.
Delawareans have less risk of disease, disability, and injury when they engage in healthy behaviors. They can reach their full health potential with a better quality of life when they live, work, and play in communities with good social, economic, and environmental conditions.
Well paying and available jobs, a strong education system, affordable housing, and accessible health care are examples of preferred Social Determinants of Health. In contrast, poverty, high drop out rates, crime, homelessness, and discrimination are dangerous Social Determinants of Health.
To learn more about Healthy People 2030, visit https://health.gov/healthypeople.Source:https://health.gov/healthypeople/priority
AmericanWhites,HispanicamongaresuicideIn2510peopleofleadingsecondcausedeathforages-14and34.theU.S.,rateshighestnon
Kent and Sussex County: 800 287 6423
Know the warning signs of suicide
Septemberhere
Contact Lifeline Suicide Hotline
Individuals in the U.S. experiencing thoughts of suicide, a mental health or substance use crisis, or any other kind of emotional distress can call the National Suicide & Crisis Lifeline at 988.
Newark meetings: held on the second and fourth Thursdays of the month from 7:00 p.m. to 8:30 p.m. at Newark United Methodist Church, 62 E. Delaware Avenue, Newark, Delaware 19711.
National Suicide & Crisis Lifeline
Zoom meetings are held every Thursday from 7:00 p.m. to 8:00 p.m. To receive a Zoom link, contact Rochelle Balan at 302-654-6833 or rbalan@mhainde.org
Suicide Support Groups and Community Resources
Dial 988 toll free, 24/7. Calls are confidential.
New Castle County: 302 761 9100
Read more about groups at high risk for suicide
Every day, approximately 105 Americans of all ages die by suicide, according to the Centers for Disease Control (CDC). In 2020, suicide was the
Increased alcohol or drug use is another warning sign To connect to treatment services, visit Chttps://www.helpisherede.com/onnectionstofamily,community support, and easy access to health care can decrease suicidal thoughts and behaviors. If you or someone you care about feels overwhelmed with sadness, depression, or anxiety, or if you want to harm yourself or others, call the Delaware Hope Line at 1 833 9 HOPEDE or 833 946 7333, or text DEHOPE to 55753.
26 Delaware Journal of Public Health - August 2022
The DPH Bulletin – August 2022 Page 3 of 4
Assists those 18 years and older with severe personal, family, or marital problems 24/7.
4 10, 2022 is National Suicide Prevention Week. Be concerned if someone you know talks about committing suicide, has attempted suicide, seems preoccupied with death, and gathers dangerous items such as pills or a weapon. Those at risk of suicide may have experienced recent difficult life events such as relationship or financial trouble, have a terminal or chronic illness, or have a disability. Other signs are trouble eating or sleeping, lack of personal hygiene, a history of mental illness, and drastic changes in behavior such as acting aggressively and driving recklessly. At-risk individuals may withdraw from friends or social activities, give away prized possessions, and lose interest in school, work, or hobbies
1 800 969 HELP (4357)
Northern Delaware: 1 800 652 2929
Southern Delaware: 1 800 345 6785
Kent and Sussex counties: 1 800 262 9800
Delaware 24/7 Youth Crisis Support
Crisis Intervention Services
Crisis Text Line: Text DE to 741741
Indians, and Alaska Natives. Also at risk are veterans, those living in rural areas, and young people who identify as lesbian, gay, or bisexual, and individuals who experienced violence, including child abuse, bullying, sexual violence, or physical abuse
Wilmington meetings: held on the first Monday of the month (or the third if there's a holiday), 7:00 p.m. to 8:30 p.m. For locations, contact information@mhainde.org
Emergency Response: Dial 911
Survivors of Suicide Mental Health Association of Delaware Newwww.mhainde.orgCastleCounty: 302 654 6833
• Check the manufacturer’s site online for formula availability before going to a store to purchase.
Monkeypox spreads by direct contact with the infectious rash, scabs, or body fluids or indirectly, such as by touching contaminated clothing or linens.
• Consult your pediatrician to discuss the best options to meet the infant’s medical and nutrition needs. Ask about alternatives.
Monkeypox is a zoonotic disease caused by infection with the Monkeypox virus (MPX). It may cause flu like illness with fever, headache, muscle aches, backache, swollen lymph nodes, chills, and exhaustion, followed by a blister like rash one to four days later. The illness lasts two to four weeks and is rarely fatal Prior to 2022, monkeypox cases rarely occurred in the United States and were associated with international travel or importing animals from countries where the disease is more common.
by avoiding people with monkeypox rashes, not handling bedding, towels, or clothing of infected people, not sharing eating utensils or cups with an infected person, and wash hands often with soap and water. Individuals concerned about symptoms or possible exposure can call the DPH hotline, 866-408-1899, Monday through Friday from 8:30 a.m. to 4:30 p.m. Visit www.cdc.gov/poxvirus/monkeypox/ and de.gov/monkeypox for more information.
State announces first monkeypox cases
• When possible, breastfeed your child. Breastfeeding is the healthiest option for children under age 1. Delaware WIC provides peer counselors, lactation consultants, support groups, and manual breast pumps. Details about WIC’s breastfeeding programs can be found here. DPH offers a breastfeeding guide.
For more information about the supply of infant formula, visit dethrives.com or follow DPH on Facebook and Instagram.
• Do not make or use homemade formula, which lacks inadequate amounts of critical nutrients Low calcium can lead to hospitalization.
• WIC, SNAP, TANF, and local food banks can help with the cost of buying formula and finding other infant supplies Individuals can check with their local hospital to see what breastfeeding support is offered.
The state’s first-ever monkeypox cases in people were announced by the Division of Public Health (DPH) on July 12 and 21. The cases, which are considered probable pending confirmatory testing by the Centers for Disease Control and Prevention (CDC), were reported in each county in a 41-yearold New Castle County man, a 25-year-old Kent County man, and a 46 year old Sussex County man.
More U.S. households should be able to find infant formula after the federal government imported shipments and worked with key manufacturers. Supply chain issues caused a national shortage DPH and the U.S. Department of Health and Human Services shares the following guidance to families and maternal child health stakeholders:
Monkeypox also spreads from respiratory secretions during prolonged, face to face contact, or during intimate physical contact, such as kissing, cuddling, or sex. Pregnant people can spread the virus to their fetus through the placenta. People can get monkeypox from a scratch or bite from an infected animal, and preparing or eating meat, or using products from an infected animal.
27
The DPH Bulletin – August 2022 Page 4 of 4
As national infant formula shortage eases, DPH guides families
• Never dilute formula because that can be dangerous and life-threatening.
Individuals with symptoms should immediately contact their health care provider and self isolate until all lesions have resolved, the scabs have fallen off, and a fresh layer of intact skin has formed. Avoid being intimate with
Preventothers.infection
AGING IN PLACE
Aging in place is defined as remaining in a community-based dwelling during one’s late years in life. The home may be one where an individual spent most of their adulthood, perhaps rearing a family and establishing deep roots, or it may be a “downsized” space, such as an apartment, mobile home, or condo, that offers the appeal of independent living without the
AGING IN PLACE: THE BENEFITS
While aging in place is preferred by the vast majority of adults and can bring a host of psychological and physical benefits, older adults require community support in order to age in place safely and with dignity. In this commentary, we review the demographic changes and characteristics of older adults nationally and in Delaware, highlight some of the benefits and challenges to aging in place, and discuss the individual and system-level strategies that are needed to help older adults successfully age in place. Finally, we provide an overview of one creative solution that addresses instrumental and social needs among individuals aging in place with chronic illness.
ABSTRACT
Shay Lukas, B.S.
Maggie Ratnayake, L.P.C.M.H., A.T.R., N.C.C. Executive Director, Lori’s Hands
Lori’s Hands Student Executive Board
According to the AARP in 2021, if given the choice, 77% of adults over 50 would prefer to age in place.6 This personal preference is reflected in the data: in the past 20 years, the number of community-dwelling adults in traditional housing has increased, while those living in nursing homes has declined,7 and in 2020 only 1.2 million adults over 65 were nursing home residents.8 In Delaware, public nursing home utilization has been declining since 2011 and private nursing home utilization began declining in 2020.2 As nursing homes are less utilized, the burden of care is shifted to community-based caregivers, both paid/formal and unpaid/informal. In the United States in 2020, there were approximately 53 million informal caregivers, which translates to one in five American adults.9 While caregivers provide critical support to allow an individual to age in place, this unpaid care can have deleterious effects on the caregiver’s own health, finances, and emotional wellbeing.9
28 Delaware Journal of Public Health - August 2022
maintenance, expense, and potential dangers of remaining in a larger home. For some, aging in place may even mean moving in with a family member or friend to maintain some independence while also enjoying the benefits - and supports - of co-housing.
DOI: 10.32481/djph.2022.08.007
Harshitha Henry, B.S.-c
The United States is facing a “gray tsunami” as the baby boomer generation ages and fertility rates decline. In 2010, there were 40.3 million Americans over 65, a number that is expected to grow to 80 million by 2030.1 Delaware is not isolated from this trend: it is predicted that the Delaware over-65 population will increase 48.6% between 2020 and 2050, from 183,822 to 273,105.2
Program Assistant, Lori’s Hands
Aging in Place: Are We Prepared?
As the age and health status of the population shift, we are also seeing changes in family systems and dynamics. Increasingly, older adults in the U.S. are unlikely to live with extended family or even to live less than one hour away from family members who provide at least intermittent care.1 While proximity to adult children can be a source of support for many, 15.2 million older adults have no children, and 22% of adults are or will be on their own in old age.5 With research showing that at least half of older adults 65 or older can expect to be in need of care during their older years, the availability of caregivers is an important consideration.5
With so many individuals choosing to age in place, it is undeniable that there are many perceived benefits. The advantages, however, may not be as understood and documented as one might expect. Many older adults associate “aging in place” with positive attributes such as maintaining one’s autonomy and independence in a community that offers social connections and access to services.10 When an individual is able to age in their own home, they are granted a daily sense of familiarity, whether that consists of morning greetings from a household pet, contact with neighbors, or the ability to surround themselves with physical objects that represent cherished memories.
For many older adults, managing a chronic disease will be a central part of the aging experience. Nationwide, 78% of adults over 55 have a chronic condition (e.g., arthritis, asthma, cancer, cardiovascular disease, chronic obstructive pulmonary disease, or diabetes), a rate that swells to 85% in adults over 65.3 In Delaware, four of the top five leading causes of death are chronic diseases.4
Jessica Neave, M.S.
Public Health/Physician Assistant Student, Lori’s Hands Student Executive Board Alumna Sachi Brathwaite, M.S.
Chapter Manager, Lori’s Hands
AGING IN THE UNITED STATES
Health and financial considerations may also factor into the perceived benefits of aging in place. For many, the perceived financial advantages of aging in place are a motivator to delay or avoid institution-level care. While the costs of all forms of long term care are undeniably increasing, research does suggest that providing care at home to those aging in place may be a more cost-effective option.13 Research also shows that millions of health care associated infections occur in long-term care facilities in the U.S. each year.14 Aging in one’s home can provide an alternative to nursing homes or long-term care facilities, therefore protecting older adults from health care associated infections that could negatively impact their health and/or shorten their lifespan.
Despite the noted preference among adults for aging in place, barriers to doing so safely do exist. One of the key components of aging in place, one’s home, tops the list. A 2020 report estimated that only 10% of American homes are “aging ready,” with a step-free entryway, a bedroom and bathroom on the first floor, and at least one bathroom accessibility feature.15 While home modifications that could enable individuals to age in place safely do exist, they are often not known about or are out of reach financially for older adults on a limited budget.16 With roughly one third of adults over the age of 65 experiencing a fall each year and up to two thirds of these falls taking place in and around the home, the importance of appropriate home modifications to reduce fall risk cannot be understated.11
A variety of strategies - both on individual and community levels - can be implemented to create a supportive environment conducive to aging in place. The foundational aspects of these strategies include improving education, advocacy, and infrastructure to foster independence for the aging population. In considering community efforts, literature suggests that programs and policies directed toward mitigating physical barriers, such as creating a built environment that promotes connectedness and providing transportation supports, are beneficial in supporting an aging population within a community.22 Community-wide strategies to address accessibility, mobility, and supportive services that are linked with financial support from local and national governments along with continuous advocacy are most likely to produce lasting change.
Successful and dignified aging in the home is not brought about only by an individual’s surroundings - how one interacts with their community is equally important. Educational initiatives for
AGING IN PLACE: THE CHALLENGES
For older adults aging in place, the safety and accessibility of one’s neighborhood is also of paramount importance. While exercise is recognized as important for physical and social health, activities such as walking outdoors can produce anxiety due to concerns about sidewalk safety and corresponding fall risks. Research indicates that older individuals are 18% more likely to be mobile when their community environment is accessible.17 In addition to concerns about safety and accessibility in their neighborhoods, older adults who are continuously exposed to built environments with fewer support services (ex: pharmacies, senior centers) and more businesses like fast food restaurants and liquor stores, are more likely to self-report poor health.18
A lack of transportation options can also be a barrier to aging in place. Transportation-disadvantaged older adults experience social isolation and obstacles to accessing a variety of goods and services essential to quality of life.19 The most-used form of transportation among American adults is the private vehicle.
While aging in place may be more affordable than institutional care, it remains expensive and can be inaccessible to some. It is found that the wealthiest of Americans are able to afford care and the poorest are able to receive some degree of subsidized care. It is middle class Americans, then, who often struggle the most: they may be unable to afford adequate care and may be ineligible for public assistance to supplement the costs.1
AGING IN PLACE: STRATEGIES
Many older adults share that one of their greatest concerns in regard to aging in place is the lack of someone to make a social call to check on them.11 More than one third of adults over 45 report feeling lonely, and research suggests that social isolation and loneliness are associated with increased rates of mortality, dementia, heart disease, stroke, anxiety, depression, and suicide.20
For older adults, loneliness may increase due to mobility and transportation changes that come with age and which impact one’s ability to engage in the community.21
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As individuals age and lose the ability to drive, they must rely upon other forms of transportation to access essential services. Alternatives such as walking, public transportation, ridesharing and paratransit services do not come without their pitfalls such as accessibility, effectiveness, and efficiency.11
A familiar environment and place can contribute to an older adult’s sense of identity, can promote successful utilization of neighborhood services, and can help one remain socially connected thanks to the proximity of friends.11 Research indicates that higher satisfaction with one’s social network and neighborhood integration is directly correlated with decreased feelings of loneliness.12 In addition, perceived safety and sufficiency of neighborhood services is also linked to an older adult’s experience of loneliness.12 It is important to note that the opposite may also be true - if a person is less satisfied with their social network, is less engaged with neighborhood resources, and feels generally less connected to their surroundings, a person may actually feel more isolated and lonely and less satisfied with their aging in place experience.
Aging in place affects not only the individuals choosing to remain in their homes but also the informal support systems they rely upon as they age and their health declines. The United States is increasingly depending on informal caregivers to deliver essential support to older adults aging in place11: it is estimated that the value of care provided by informal caregivers is $470 billion annually.9 While many individuals enjoy aspects of caring for an aging loved one, the potential threats to caregivers’ health and wellbeing are real. Research demonstrates that spousal caregivers reporting associated strain are nearly two thirds more likely to die within four years than non-caregivers.11 Yet, without a support system that provides direct assistance (such as with transportation, housekeeping, organizing pills, sometimes even bathing), care coordination (scheduling appointments and facilitating communication between providers), and patient advocacy (ensuring the individual receives the care and resources they need), aging in place can quickly become fraught with challenges, if not outright dangers.11
The benefits of participation in Lori’s Hands to both students and clients have been documented through both internal and independent evaluation.25 Benefits for clients include decreased loneliness, emotional fulfillment and connection, intergenerational understanding, and assistance with daily tasks. Among students, reported benefits include solidifying career interests, a deepening knowledge of chronic illness, and intergenerational understanding. Since Lori’s Hands’ inception, more than 1500 student volunteers and 400 community members have benefited from participation. Lori’s Hands has developed partnerships with more than 13 colleges and universities to create meaningful service learning opportunities across its three locations. In 2020, Lori’s Hands received federal funding from the Administration for Community Living’s Community Care Corps to support program expansion. Intergenerational service learning programs like Lori’s Hands have tremendous potential to deliver impactful support to community members aging in place while also preparing a next-generation health care workforce to deliver care with empathy, insight, and creativity.
Lori’s Hands’ unique intergenerational model addresses many of the challenges faced by older adults and individuals with chronic illness who are aging in place. Lori’s Hands trains and equips college student volunteers to make weekly visits to help community members with day-to-day tasks (such as grocery shopping, organizing a closet, or running the vacuum cleaner) that can be made challenging by chronic disease. While improving clients’ independence, students also provide essential social support, increasing community connectedness and reducing loneliness. As clients experience these benefits, they educate students about their experiences living with chronic illness, navigating the health care system, aging, and more, providing a real-world education to pre-health professionals.
Lori’s Hands’ services are available to adult community members living with chronic illness in Newark, DE, Baltimore, MD, and Metro Detroit, MI. Among the most common client diagnoses are arthritis, diabetes, hypertension, pulmonary disease, cancer, depression or anxiety, and stroke. Eighty-three percent of clients live with multiple chronic conditions. Thirty one percent of clients are people of color, 76% are female, and 88% are over the age of 65. The majority (61%) of clients are single or widowed. While Lori’s Hands has no income eligibility criteria, 63% of clients report having “not enough” or “just enough” money left over at the end of each month.
2. Delaware Department of Health and Social Services. (2022, May). 2021 nursing home utilization statistical report. https://dhss.delaware.gov/dhcc/hrb/files/nursinghomeutilization2021.pdf
INTERGENERATIONAL SERVICE LEARNING: A UNIQUE APPROACH
30 Delaware Journal of Public Health - August 2022
Many communities and organizations are working to creatively address some of the challenges facing those striving to age in place. From home repair programs, to home-based care teams, to senior centers, to Meals on Wheels, to Villages, and more, these initiatives are making aging in place a more realistic option for some. Nevertheless, a more unified statewide and national approach as well as further research on the effectiveness of existing programs and areas of opportunity are needed to support a growing older adult population’s goal to age in place with dignity and independence 1
CONCLUSION
older adults that aim to increase awareness of what supportive services are available and how to use them are integral to aging in the community setting. It is also essential to consider the social determinants of health and how they impact each individual23 and for the voices of those actually affected to be heard. When the citizens of an aging community are involved and passionate in advocacy efforts, change is more easily instigated.22
REFERENCES
Lori’s Hands student volunteers are currently enrolled in an undergraduate or graduate course of study. While the majority of student volunteers are preparing for a career in health care, participation is open to students from any academic major. The most frequently reported barrier to participation for students is in regard to transportation to client homes. Currently, students must find their own means of transportation to make client visits. To attempt to reduce this barrier, Lori’s Hands always pairs students together to make client visits, guaranteeing at least one student has a vehicle and students can carpool. Due to issues like limited public transportation, high gas prices, and less frequent car ownership in urban environments, Lori’s Hands is continuing to develop creative solutions to reduce barriers to participation for prospective student volunteers.
1. Bookman, A., & Kimbrel, D. (2011, Fall). Families and elder care in the twenty-first century. The Future of Children, 21(2), 117–140. https://doi.org/10.1353/foc.2011.0018
As the number of older adults in the United States continues to increase and the aging in place movement maintains popularity, we must take a critical look at how our communities are equipped to support this growing population. Many factors should be considered when we assess the suitability of both our built and social environments for aging in place, recognizing that these elements can have a direct effect on physical and social health and wellbeing. Creative solutions do currently exist to address some of the needs of those who are aging in place. Additional research needs to be conducted to more fully understand the challenges and benefits of aging in place and to guide efforts to continue to support the aging community’s independence, health, and wellbeing.
Ms. Ratnayake may be reached at maggie@lorishands.org
Intergenerational service learning is one promising solution to the challenges facing older adults aging in place. Research suggests that intergenerational service learning not only improves young people’s attitudes towards aging and the older generation, but also has a positive impact on the older adult participants’ quality of life, physical health, generativity, and a lessening of depressive symptoms.24 Lori’s Hands is a Delaware-based community health service learning nonprofit that jointly aims to improve the wellbeing of community-dwelling adults with chronic illness while also preparing a next-generation health care workforce to care for an aging population. Established as a student club at the University of Delaware in 2009, Lori’s Hands is now a 501(c)3 nonprofit organization spanning three states (Delaware, Maryland, and Michigan).
14 Smith, P. W., Bennett, G., Bradley, S., Drinka, P., Lautenbach, E., Marx, J., Stevenson, K., & the Society for Healthcare Epidemiology of America (SHEA), & the Association for Professionals in Infection Control and Epidemiology (APIC). (2008, September). SHEA/APIC Guideline: Infection prevention and control in the longterm care facility. American Journal of Infection Control, 36(7), 504 535. https://doi.org/10.1016/j.ajic.2008.06.001
https://www.census.gov/content/dam/Census/library/publications/2020/demo/p23-217.pdf
25 Karpyn, A., Kim, J., Larock, J., Silberg, T., Tracy, T., & Seibold, M. (2021, January). Lori’s Hands: Impacts on participating clients. Final evaluation report. Publication #T21-003. University of Delaware Center for Research in Education & Social Policy.
6 American Association for Retired People. (2021). Where we live, where we age: Trends in home and community preferences. https://livablecommunities.aarpinternational.org
13. Marek, K. D., Stetzer, F., Adams, S. J., Popejoy, L. L., & Rantz, M. (2012, April). Aging in place versus nursing home care: Comparison of costs to Medicare and Medicaid. Research in Gerontological Nursing, 5(2), 123 129 https://doi.org/10.3928/19404921-20110802-01
21 Smith, J. M. (2012, May-June). Toward a better understanding of loneliness in community-dwelling older adults. The Journal of Psychology, 146(3), 293 311. https://doi.org/10.1080/00223980.2011.602132
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4 Delaware Department of Health and Social Services. (2019, November). Chronic disease in Delaware: Facts and figures. https://www.dhss.delaware.gov/dhss/dph/dpc/files/2019chronicdiseasefactsfigures.pdf
16 Fausset, C. B., Kelly, A. J., Rogers, W. A., & Fisk, A. D. (2011, Spring). Challenges to aging in place: Understanding home maintenance difficulties. Journal of Housing for the Elderly, 25(2), 125 141 https://doi.org/10.1080/02763893.2011.571105
17. Clarke, P., & Gallagher, N. A. (2013, December). Optimizing mobility in later life: The role of the urban built environment for older adults aging in place. J Urban Health, 90(6), 997 1009 https://doi.org/10.1007/s11524-013-9800-4
15 Vespa, J., Engelberg, J., & He, W. (2020). Old housing, new needs: Are US homes ready for an aging population? Current Population Reports, 23-217. U.S. Census Bureau.
12 Kemperman, A., van den Berg, P., Weijs-Perrée, M., & Uijtdewillegen, K. (2019, January 31). Loneliness of older adults: Social network and the living environment. International Journal of Environmental Research and Public Health, 16(3), 406 https://doi.org/10.3390/ijerph16030406
7 Toth, M., Palmer, L., Bercaw, L., Voltmer, H., & Karon, S. L. (2022, February 3). Trends in the use of residential settings among older adults. J Gerontol B Psychol Sci Soc Sci, 77(2), 424 428. https://doi.org/10.1093/geronb/gbab092
9. Centers for Disease Control and Prevention. (2021, November). Supporting caregivers. Alzheimer’s Disease and Healthy Aging. https://www.cdc.gov/aging/publications/features/supporting-caregivers.htm
22 Lehning, A. J. (2012, June). City governments and aging in place: Community design, transportation and housing innovation adoption. The Gerontologist, 52(3), 345 356. https://doi.org/10.1093/geront/gnr089
23. Fulmer, T., Reuben, D. B., Auerbach, J., Fick, D. M., Galambos, C., & Johnson, K. S. (2021, February). Actualizing better health and health care for older adults. Health affairs (Project Hope), 40(2), 219 225 https://doi.org/10.1377/hlthaff.2020.01470
3 National Center for Health Statistics. (2009). Percent of U.S. adults 55 and over with chronic conditions. https://www.cdc.gov/nchs/health_policy/adult_chronic_conditions.htm
https://www.cresp.udel.edu/wp-content/uploads/2021/01/UD-CRESP_ LH-Client-Report_Final_1.21.21.pdf
24. Petersen, J. (2022). A meta-analytic review of the effects of intergenerational programs for youth and older adults. Educational Gerontology, 1 15 https://doi.org/10.1080/03601277.2022.2102340
5 Valerio, T., Knop, B., Kreider, R. M., & He, W. (2021). Childless older Americans: 2018. Current Population Reports, 70-173. U.S. Census Bureau. https://www.census.gov/content/dam/Census/library/publications/2021/demo/p70-173.pdf
8. Administration for Community Living. (2021, May). 2020 profile of older Americans. https://acl.gov/sites/default/files/Aging%20and%20Disability%20in%20 America/2020ProfileOlderAmericans.Final_.pdf
19 Adorno, G., Fields, N., Cronley, C., Parekh, R., & Magruder, K. (2018). Ageing in a low-density urban city: Transportation mobility as a social equity issue. Ageing and Society, 38(2), 296 320 https://doi.org/10.1017/S0144686X16000994
10. Wiles, J. L., Leibing, A., Guberman, N., Reeve, J., & Allen, R. E. (2012, June). The meaning of “aging in place” to older people. The Gerontologist, 52(3), 357 366 https://doi.org/10.1093/geront/gnr098
20. National Academies of Sciences, Engineering, and Medicine. 2020 Social isolation and loneliness in older adults: Opportunities for the health care system. The National Academies Press. https://doi.org/https://doi.org/10.17226/25663
18 Spring, A. (2018, January 18). Short- and long-term impacts of neighborhood built environment on self-rated health of older adults. The Gerontologist, 58(1), 36 46. https://doi.org/10.1093/geront/gnx119
11 Dye, C. J., Willoughby, D. F., & Battisto, D. G. (2010). Advice from rural elders: What it takes to age in place. Educational Gerontology, 37(1), 74 93 https://doi.org/10.1080/03601277.2010.515889
32 Delaware Journal of Public Health - August 2022
The Changing Landscape of Healthcare and the Need to Focus on Local Geography
Over a hundred years later, Beebe Healthcare – now an integrated healthcare delivery system – is still providing local care for people who live, visit, work, and seek care here in southern Delaware. During the pandemic, we mobilized resources to ensure that the community had dependable quality healthcare that they could rely on for COVID care and all the other services needed to live in our geographic region.
A healthcare system, even one as committed to focusing on our county as Beebe, cannot address these issues alone. In order to improve the health of our community, collaboration and cooperation are critical. Improving the community’s health will require close alignment with important organizations like First State Community Action Agency, La Red, La Esperanza, the Nanticoke Indian Tribe, and many more. We must work together with local government, our schools, nonprofit organizations, and other healthcare systems to align on health improvement targets and seek consensus on what collective impacts we can make together. Ideas like transforming our community into a “Blue Zone” or increasing economic opportunities by focusing on healthcare and education growth to combat poverty and housing will require working together.
David Tam, M.D., M.B.A., C.P.H.E., F.A.C.H.E. President & CEO, Beebe Healthcare
And as Beebe Healthcare’s Board and Leadership now launch our new five-year strategic plan, the emphasis will still be on the care of our community as defined by geography – Sussex County. We refer to our plan as “One Beebe,” emphasizing our commitment to focus the combined efforts of our hospitals, clinics, emergency rooms, walk-in care sites, providers of our medical staff, nursing school, residency training program, and medical foundation – every part of Beebe Healthcare – on caring for the people who live in, work in, and visit our county. We will develop and implement new technologies and advanced methods to care for the people who need care in our geographic region. And even though people may access healthcare in different ways – on a digital device, in new medical office and hospitals, free standing emergency departments and cancer centers, and even admitted to your own home for inpatient care – we will ensure that the compassionate and personalized care people have received from their local community health system, often delivered by family, friends, or neighbors, will continue.
Upon my arrival in March 2020 as the new President & CEO of Beebe Healthcare in Sussex County, Delaware, I had the opportunity to see the landscape of healthcare with an outsider’s perspective during a crisis that we have not seen in generations. And as a member of the Sussex County community for almost three years, I clearly see the impact of geography on healthcare – landmarks like the Mispillion River, the Chesapeake Bay, the beaches of the coast, and even the rapidly evolving distribution of farmland and residential developments – all have changed how Beebe Healthcare has changed the way we are delivering healthcare services to our community.
But it’s not just healthcare that is influenced by our geography. It is also about health. And Beebe’s strategic plan is also focused on improving the health of the people who live in Sussex County. And, in many ways, this is what excites me about the future of Beebe Healthcare and Sussex County. Because our geography also defines, in many ways, the health of the people who live, work, and visit here. The diversity of density of homes and populations impact access – not just to healthcare – but to other important determinants of health like places to obtain fresh fruits and vegetables, clean water, internet and wi-fi, and opportunities for social and community interaction. As our population ages, the need to connect people with social and emotional support and opportunities to address issues such as depression, anxiety, and dementia grow, and our geography can sometimes make that a challenge.
DOI: 10.32481/djph.2022.08.008
All three counties of Delaware have unique geographic features that have impacted the population and their health. For centuries, the people of Sussex County and what they did were shaped by our geography. The land provided opportunities for farming and agriculture. The ocean, bays, and rivers made access to waterways a boon for fishing and industrial development. And the beauty of our coasts has brought greater development and growth. Healthcare as an industry – as a profession – must refocus our efforts to serve our local communities, often defined by our geographies, and work together with others to align, collaborate, and cooperate to improve the health of the people we serve.
For Beebe Healthcare, geography is part of our heritage – our DNA. In 1916, two brothers – Drs. James and Richard Beebe – returned home after attending medical school in Philadelphia to open a hospital to serve the people living a significant distance from cities with more healthcare options.
The theme of this edition of the Delaware Journal of Public Health is “Place Matters: Geography and Health.” It is a most appropriate topic of public discourse following our recent experiences with the COVID-19 pandemic.
Senator Tip O’Neill of Massachusetts used to say that “all politics is local.” And all health is “local.” As the only health system headquartered in Sussex County for over a century, Beebe Healthcare will be relentless in our efforts to “be the partner of choice” for people who are driven to make our geographic region healthier.
Dr. Tam may be contacted at dtam@beebehealthcare.org.
Please wash your hands for at least 20 seconds. Use warm water and soap. Turn off the faucet with a paper towel if available. Use hand sanitizer when you cannot wash your hands. Thank you. For more information please visit: de.gov/coronavirus WASH YOUR HANDS Updated 5/21/2021 33
Households that face eviction often face an uphill battle to gather the resources required (e.g., first and last month’s rent, security deposits, utility deposits, moving expenses, etc.) to relocate into other housing. Furthermore, the mark of an eviction on their credit report makes it more difficult to find landlords that are willing to rent to them.4 Many evicted households will find temporary, makeshift accommodations with family or friends, or take up other precarious living situations. Some will, upon eviction, immediately become homeless and seek shelter and other homeless services. However, a longer trajectory from eviction to homeless shelter is more common, where households move to other living arrangements and these arrangements fall apart as combinations of economic and interpersonal strain intensify over time.
This study differs from the survey-based studies as it determines the extent of eviction experiences among a homeless population solely through matching administrative records. This standardizes
ABSTRACT
DOI: 10.32481/djph.2022.08.009
Eviction is frequently a precursor to homelessness. This is an exploratory study that looks at a group of homeless adults who stayed in Delaware homeless shelters in 2019 and the extent by which their homelessness is preceded by an eviction filing. Specifically, we match records of homeless shelter use with records from a court-based database of eviction filings, both in Delaware, to determine the frequency and correlates of prior eviction among adults staying in Delaware shelter and/or transitional housing facilities in 2019. Results show that 21 percent of the people in the study group had records of eviction filings in the 2-year period prior to initial homeless services use. Recent history of eviction filings was much more prevalent among study group members who were homeless with their children (i.e., with families), who were Black, and/or who were female. These findings are consistent with prior research and demonstrate the potential of interventions designed to mitigate eviction to also reduce homelessness, especially among families with children.
BACKGROUND
Olivia Mwangi, M.S.
INTRODUCTION
Prior Evictions Among People Experiencing Homelessness in Delaware
Director, Center for Community Research & Service, Joseph R. Biden, Jr. School of Public Policy and Administration; Associate Professor, Public Policy; University of Delaware
Previous reports that included findings on the extent to which evictions have preceded homelessness have typically come from surveys of people experiencing homelessness. These studies have indicated that homeless households often had prior experiences of eviction and that such eviction experiences served as a primary catalyst for subsequent spells of homelessness. For example, separate studies reported that 11 percent each of surveyed homeless adults in Los Angeles5 and homeless families in San Francisco6 cited evictions (legal or extralegal) as a primary cause of their homelessness. Reports based upon surveys of homeless populations in other parts of the country found corresponding proportions as high as 30 percent in the Houston area and 45 percent across Massachusetts.7
Stephen Metraux, Ph.D.
Eviction and homelessness are related in that eviction precipitates displacement and homelessness frequently sustains it. These two phenomena combine to first remove and then deprive households (single individuals or families) of their rootedness in place, and the resulting disequilibrium contributes to a range of adversities, including an array of undesirable health outcomes and inequities.1–3
Center for Community Research & Service, Joseph R. Biden, Jr. School of Public Policy and Administration; University of Delaware James McGuire Center for Community Research & Service, Joseph R. Biden, Jr. School of Public Policy and Administration; University of Delaware
Here we provide an exploratory study that looks at a group of homeless adults who stayed in Delaware homeless shelters in 2019 and the extent by which their homelessness is preceded by an eviction filing. Specifically, we match records of homeless shelter use with records from a court-based database of eviction filings, both in Delaware, to determine the frequency and correlates of prior eviction (within two years of first using homeless services) among adults staying in shelter and/or transitional housing in 2019.
These findings are based largely upon the responses of individuals experiencing homelessness and carry distinct limitations. Respondents may have differing understandings of what constitutes an eviction, such as whether “eviction” is limited to formal, court-filed evictions or also includes other, less formal actions or threats from landlords.8,9 Problems with memory recall may distort the time between when an eviction occurred and how much time subsequently elapsed until the onset of homelessness. People may underreport their experiences with eviction due to the stigma related to being evicted, or may overreport them in the hope that this may render them eligible for housing or other services.10 Respondents may not make connections between eviction and homelessness when they initially find alternative housing to avoid homelessness–like moving in with family or friends–and then become homeless.6
34 Delaware Journal of Public Health - August 2022
Based on this match with the eviction filings, a subgroup of the study group with a matching eviction record is identified and the characteristics of the individuals in this subgroup is compared to the characteristics of the study group as a whole.
DATA AND METHODS
The basis for this study is a merge of two administrative datasets. The first is the Community Management Information System (CMIS), a repository of data on homeless services provided in Delaware and the families and individuals who use these services. The Housing Alliance Delaware (HAD) manages the CMIS and has provided access to it for this study. The second database, maintained by Delaware’s Justice of the Peace (JP) court system, contains legal filings for evictions in Delaware. These eviction records are publicly accessible in a searchable online database.
the definition of eviction to instances when an eviction is formally filed in the court system. It also operationalizes homelessness to an instance where a household received shelter from a homeless services provider. The records provide much more specific time frames between the date of eviction filing and the subsequent date of shelter entry. However, despite the greater precision involved here, the evictions identified in this study do not include situations where a household is forced or coerced out of their rental arrangements by extra-legal means, and thus will provide conservative assessments of the connection between eviction and homelessness that do not include instances in which it is the threat of eviction, in the absence of a legal filing, that displaces people. What results is a different perspective from those provided by surveys, and an approach that is unique among the research that we are able to locate. Taken together, this study promises to broaden (and not replace) the understanding of how extensive eviction histories are among homeless populations, and identifies associations between individual characteristics and the relative likelihoods of having experienced an eviction filing prior to Delawarehomelessness.hashigh levels of both evictions and homelessness. From 2020 to 2022, the state’s homeless population has more than doubled.11 Prior to the COVID-19 pandemic, there were approximately 18,000 evictions filed annually in Delaware’s Justice of the Peace court system. Based upon this, Princeton University’s Eviction Lab reported an annual eviction filing rate of 16%, as compared to a national eviction filing rate of 2%.7 Low filing fees and plaintiffs’ ability to pursue evictions without obtaining legal representation are among the factors that account for high eviction filing rates in Delaware.12 By looking at the extent to which eviction filings preceded the onset of homelessness, this study provides a foundation for assessing whether and to what extent policy interventions to provide legal and financial assistance to mitigate evictions could potentially impact the numbers of people subsequently experiencing homelessness.
Risk ratios and chi-square tests of difference are used to assess individual differences between those with and without prior eviction records, and a multivariate logistic regression model is fitted to systematically assess the associations between individual characteristics and having a recent (within two years of earliest homeless services receipt) record of an eviction filing.
RESULTS
The CMIS database yielded records for 1,052 adults for whom the earliest record of a shelter or a transitional housing stay (i.e., index stay) occurred in 2019. Of these, 221 (21 percent) had a matching record of a JP Court eviction filing that occurred within a 2- year period prior to the index stay.
For this study, we identify, using records in the CMIS, a study group of adults who have an initial record of receiving emergency shelter or transitional housing (i.e., homeless services) sometime in 2019. These records are matched with the JP Court database based on first and last name for cases when an eviction filing was initiated within a two-year period preceding the date of the initial record of homeless services use. Eviction records in which a name matches one from the CMIS study group, but which either have a longer gap between the filing date and the earliest homeless services date, or where the eviction filing date follows the earliest date of homeless services receipt, were not considered for this study.
This study was approved as exempt from full review by the Institutional Review Board of the University of Delaware.
Table 1 shows the differential distributions of individual characteristics between the study group as a whole and the subgroup of 221 people with recorded eviction histories (i.e., eviction subgroup). Chi-square tests showed statistically significant differences (p< 0.05) for the eviction subgroup in the distributions by race, gender, household type and disability.
Table 2 shows the extent to which the proportions of those with recent eviction histories vary based upon selected characteristics and then combinations of these characteristics. In this respect, the substantial differences between Black and White races (27 percent and 14 percent); men and women (25 percent and 16 percent); and family (with children) and individuals (34 percent and 16 percent) mirror the findings from Table 1. Combining these characteristics to construct even more precisely defined subgroups underscores how differences can layer upon each other, such as with gender and household type. However, such combinations only marginally raise the rates of recent eviction history among a particularly defined subgroup from the 34 percent rate shown among adults in families.
35
While 58 percent of the overall study group was comprised of Black race, that proportion rose to 74% among the eviction subgroup, yielding a 1.98 risk ratio (RR) when compared to those in the study group of White race. The study group was just over half female (51 percent), while that proportion rose to 62 percent among the eviction subgroup (RR=1.55). Only 27% of the study group were experiencing homelessness as part of a family (i.e., accompanied by minor children), while 43% of the adults in the eviction subgroup were part of a family (RR=2.06). Along with these significant bivariate differences in race, gender, and household composition, the difference in rates of identified disability is substantively similar (48 percent and 47 percent) but marginally significant (p=0.04) due to different levels of missing data.
The logistic regression results on Table 3 demonstrate the robustness of the impacts associated with race, gender and household type on the odds of having a recent eviction history. In addition, the two older age groups are associated with significantly higher odds of having an eviction history than the youngest age group, a relationship that did not manifest itself in
In the eviction literature, these characteristics are commonly associated with higher risk for eviction. Desmond, in his study of eviction in Milwaukee, finds that “Black women disproportionately experienced the mark and the material hardship of eviction” (p. 112) and argues that “eviction is to women what incarceration is to men: a typical but severely consequential occurrence contributing to the reproduction of urban poverty” (p. 88).13
While this study cannot conclusively show that eviction filings led to subsequent homelessness among the study group members, circumstances would suggest that the two phenomena are related and that intervening with housing assistance and other measures to mitigate evictions could also prevent subsequent homelessness among some proportion of those assisted. Given that one-third of the adults in families in this study received an eviction notice prior to their homelessness, tenant assistance measures that allow households to maintain stable housing represent a potential means to markedly reduce the number of families who become homeless, and thereby would prevent the onset of two experiences that are often devastating and traumatic, especially among children.16
A data match between eviction and homeless services records show that, among the 1,024 people whose initial Delaware homeless services use was recorded sometime in 2019, 21 percent were defendants in evictions filed in the Delaware JP Courts during the 2-year period prior to initial homeless services use. Such eviction filings were much more prevalent among study group members who were homeless with their children (i.e., with families), who were Black, and/or who were female.
No (reference) 90% 90%
Veteran (chisq=0.07; d.f.=1) p=0.78
Race (chisq=23.99; d.f.=3) p<0.001
Sex (chisq=8.91; d.f.=2) p=0.01
Null 17% 11% 0.54
Household Type (chisq=22.97; d.f.=1) p<0.001
bodies of literature showing homelessness as disproportionately affecting women or families. Instead, there is a consensus that dynamics and experiences of homelessness are qualitatively different among women, who are most often homeless as single parents accompanied by children, and men, whose homelessness is experienced predominantly as a single adult.15 Among the homeless population, adults in families are more likely to have had spells in which they lived in leased housing and as such were more vulnerable to eviction, whereas unaccompanied adults, due to higher prevalence of disability, more institutional placements, and a greater flexibility with sleeping arrangements, are less likely to enter into leasing arrangements and face eviction.
Hispanic 7% 5% 0.76
Table 1. Finally, adding interaction terms to the model between race, gender and household type measures did not contribute measurably to the interpretability of these results and are not included in the Table 3 results.
Male (reference) 49% 38%
White (reference) 38% 25%
55+ 23% 24% 1.26
35-54 39% 44% 1.36
Disability (chisq=6.52; d.f.=2) p=0.04
Age (chisq=3.24; d.f.=2) p=0.20
Other 0.10% 0%
Yes 48% 47% 0.81
Black 58% 74% 1.98
Adults in Study Group with Previous Eviction Filing Risk Ratio
Other 2% 1% 0.61
Adults in Study Group
Total 1052 221
36 Delaware Journal of Public Health - August 2022
Yes 10% 10% 1.07
With Family 27% 43% 2.06 Without Family (reference) 73% 57% Characteristics for the Overall Study Group and the Subgroup with Recent Histories of Eviction Filing
18-34 (reference) 38% 32%
DISCUSSION & CONCLUSION
Unknown 2% 0%
Table 1. Individual
Female 51% 62% 1.55
No (reference) 35% 42%
Racial disparities in who becomes homeless are also well documented in the homeless literature.14 In contrast, there are no
Ethnicity (chisq=0.74; d.f.=1) p=0.39
Race
1. The Network For Public Health Law. (2021). The public health implications of housing instability, eviction, and homelessness. The Network for Public Health Law. Retrieved from: https://www.networkforphl.org/resources/legal-and-policy-approachestowards-preventing-housing-instability/the-public-health-implicationsof-housing-instability-eviction-and-homelessness/
Black Woman with Family 177 63 36% White Woman with Family 48 12 25% Proportions of the Study Group with a Recent Eviction Filing Broken Down by Select Individual Characteristics
Accompanied by Children 286 96 34% Unaccompanied by Children 766 125 16% Race and Household Type
REFERENCES
with greater propensity to have an eviction history are consistent with both the homeless and eviction literatures. Given this, the findings of this study establish a link between homelessness and prior eviction, although it leaves much to be further explored. And finally, in Delaware, this study bolsters efforts to pass statewide right to counsel legislation for tenants facing eviction,7 as this study suggests that such legislation can have the effect of reducing homelessness, especially among families, women, and racial minorities.
ACKNOWLEDGMENTS
Woman with Family 234 76 32% Man with Family 52 20 38% Woman Unaccompanied 304 76 25% Man Unaccompanied 460 64 14% Gender, Race, and Household Type
Table 2.
Total 1,052 221 21%
A second limitation is that the CMIS dataset has large enough gaps in its coverage of homeless services to preclude having a comprehensive dataset of Delaware’s entire homeless population. This means that we were unable to use this data to determine how many people with eviction filings subsequently became homeless and that the study group we created does not include everyone receiving homeless services for the first time in 2019. Thus, the study group, while at 1,024 persons is of substantial size, has qualities of a convenience sample. More broadly, the generalizability of such a sample, from a small state, is limited, especially given the variation in eviction laws and policies across Evenstates.with these limitations, the extent of evictions experienced in the study group is consistent with the range of findings in previous studies, and the individual characteristics associated
Adults with a Recent Eviction Filing Proportion with Recent Eviction Filing
Black 604 164 27% White 401 55 14% Gender
The authors are grateful for support for this study from Delaware Community Legal Aid Society, Inc.; the Delaware Combined Campaign for Justice, and the Summer Undergraduate Fellowship Program of the Joseph R. Biden, Jr. School of Public Policy & Administration at the University of Delaware, and for data support from James Teufel and Ben Coleman at Moravian University; Housing Alliance Delaware; and the Justice of the Peace Court of the Delaware Courts.
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Dr. Metraux may be contacted at metraux@udel.edu
Black with kids 216 80 37% White with kids 61 15 25% Black without kids 388 84 22% White without kids 340 40 12% Gender and Household Type
This study has limitations that must be taken into account when considering the results. First, matching criteria were limited to first and last name, creating a situation where matches are prone to both type 1 and type 2 errors, as different people may share common names, and spelling inconsistencies may preclude a person’s records from being matched across data systems. While there is no way to systematically validate matches, the datasets that were matched were relatively small in size, which reduces the incidence of separate people having identical names, and the sequencing guidelines (evictions preceding homelessness) provides some safeguard against type 1 error. The datasets were also small enough to permit manual review of the matches, the great majority of which involved names that appeared likely to be unique to one person.
Female 538 137 25% Male 512 84 16% Household Type
Adults in Study Group
10. García, I., & Kim, K. (2021). Many of us have been previously evicted: Exploring the relationship between homelessness and evictions among families participating in the rapid rehousing program in Salt Lake County, Utah. Housing Policy Debate, 31(3-5), 582–600. https://doi.org/10.1080/10511482.2020.1828988
Veteran Status (non-Veteran as reference category)
16. Holl, M., van den Dries, L., Wolf, J.R.L.M. (2016). Interventions to prevent tenant evictions: a systematic review. Health & Social Care in the Community, 24(5), 532-546. doi: / https://doi.org/10.1111/hsc.12257
Gender (male/other as reference category)
Yes 0.35 1.42 -0.32-1.02
2. Kapadia, F. (2022, March). Ending homelessness and advancing health equity: A public health of consequence. American Journal of Public Health, 112(3), 372–373. https://doi.org/10.2105/AJPH.2021.306704
Household type (unaccompanied adult as reference category)
12. Guterbock, A., & Metraux, S. (2020). Eviction and legal representation in delaware: an overview. University of Delaware, Center for Community Research & Service. Retrieved from: https://udspace.udel.edu/handle/19716/26352
Hispanic -0.19 0.83 -1.06-0.67 Age (18-34 as reference category)
7. Steinkamp, N., & DiDomenico, S. (2021). The economic impact of an eviction right to counsel in Delaware. Stout LLC. Retrieved from: https://www.stout.com/-/media/pdf/evictions/report-cost-benefitdelaware-right-counsel-evictions-defense-5-5-2021.pdf
Female* 0.39 1.47 1.03-2.11
6. San Francisco Right to Civil Counsel. (2014). Pilot program documentation report. John and Terry Levin Center for Public Service and Public Interest Stanford Law School. Retrieved from: https://sfbos.org/sites/default/files/FileCenter/Documents/49157San%20Francisco%20Right%20to%20Civil%20Counsel%20 Pilot%20Program%20Documentation%20Report.pdf
Healthcare Coverage (no coverage as reference category)
Table 3.
Veteran 0.33 1.39 -0.21-0.87
35-54*** 0.75 2.11 0.36-1.13 55+*** 0.83 2.28 0.35-1.30
13. Desmond, M. (2012). Eviction and the reproduction of urban poverty. American Journal of Sociology, 118(1), 88–133. https://doi.org/10.1086/666082
Disability Indicator (no disability and missing data as reference category)
Other -1.07 0.343 -2.53-0.39
Ethnicity (non-Hispanic as reference category)
11. Housing Alliance Delaware. (2022). Point in time count & housing inventory count: 2022 report. Housing Alliance Delaware. Retrieved from: https://www.housingalliancede.org/housing-alliance-publications
14. Housing Alliance Delaware. (2020). Racial disparities and equity: homelessness in Delaware. Housing Alliance Delaware. Retrieved from: https://www.housingalliancede.org/housing-alliance-publications
Coefficient
Black*** 0.77 2.12 0.4-1.140
Disability Indicator -0.01 0.99 -0.34-0.32
3. Himmelstein, G., & Desmond, M. (2021). Eviction and health: a vicious cycle exacerbated by a pandemic. Health Affairs Health Policy Brief
8. Collinson, R., & Reed, D. K. (2018). The effects of evictions on low-income households. Working paper, New York University, Wagner School. Retrieved from: https://economics.nd.edu/assets/303258/jmp_rcollinson_1_.pdf
15. Metraux, S., & Culhane, D. P. (1999). Family dynamics, housing and recurring homelessness among women in New York City homeless shelters. Journal of Family Issues, 20(3), 371–396. https://doi.org/10.1177/019251399020003004
38 Delaware Journal of Public Health - August 2022
5. Flaming, D., Burns, P., & Carlen, J. (2018). Escape routes: meta-analysis of homelessness in Los Angeles. Economic Roundtable. Retrieved from: https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3202467
Covariate
Race (White as reference category)
In a Family (w children)*** 0.93 2.53 0.54-1.31
doi: https://doi.org/10.1377/hpb20210315.747908
9. Desmond, M., & Gershenson, C. (2016). Housing and employment insecurity among the working poor. Social Problems, 63(1), 46–67. https://doi.org/10.1093/socpro/spv025
4. Cookson, T., Diddams, M., Maykovich, X., & Witter, E. (2018). Losing home: the human cost of eviction in Seattle. Seattle Women’s Commission. Retrieved from: https://www.seattle.gov/Documents/Departments/ SeattleWomensCommission/LosingHome_9-18-18.pdf
* p<0.05; ** p< 0.01; *** p<0.001 Logistic Regression Results for Independent Impacts of Individual Characteristics Upon the Likelihood of having a Prior Eviction History
Odds Ratio Confidence Interval
COVID-19 vaccines are now available for infants and children 6 months to 5 years old. Federal agencies have authorized the Pfizer and Moderna mRNA COVID vaccines for use in these populations. Both vaccines provide some protection against infection with the Omicron variant, and stronger protection against hospitalization and death.
For more information about vaccines, visit de.gov/immunizations and visit the CDC’s webpage for parents. The Child and Adolescent Vaccine Assessment Tool provides personalized immunization schedules; find it www.cdc.gov/vaccines/partners/childhood/index.htmlImmunizationhttps://www2a.cdc.gov/vaccines/childquiz/atpartnerscanfindresourcesat
The Division of Public Health (DPH) reminds parents and guardians to schedule children’s wellness visits before the school year begins so their vaccinations are current. August is National Immunization Awareness “UnvaccinatedMonth.kids are vulnerable to diseases such as the flu, measles, mumps, rubella, chickenpox, pertussis, and hepatitis,” said James Talbott, manager of DPH’s Immunization Program. “These diseases can have serious complications resulting in blindness, deafness, and even death.”
Infants and children 6 months to 5 years can now receive their COVID-19 vaccines
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Modernainfection
’s pediatric vaccine consists of two doses spaced 28 days (four weeks) apart. The Moderna vaccine was estimated to be between 37% and 50% effective, depending on age, at preventing infection and is likely more effective at preventing hospitalization and death. Experts say a Moderna booster could elevate the level of protection against infection to 80%
Before the school year begins, children’s other vaccinations should be up-to-date
Immunizations keep children healthy, in school, and learning. They reduce the number of days parents and guardians take off from work to care for sick children. Keeping children’s vaccinations current also lessens disease in the community.
For more information about the pediatric vaccines and to find vaccination sites, visit de.gov/youthvaccine.
From the Delaware Division of Public Health July 202
The Delaware Immunization Program provides children’s immunization records upon phone, e mail request, and through the public access portal betweenContact(www.dhss.delaware.gov/dhss/dph/ipp/portalflyer.pdf).theprogramat18002828672weekdays8:00a.m.and4:30p.m.U
ninsured and underinsured children up to age 18 can get vaccinated at Public Health clinics.
Pfizer’s pediatric vaccine is a three-dose vaccine, with the second dose given 21 days after the first dose, and the third dose given at least eight weeks (two months) after the second dose The Pfizer vaccine is about 80% effective at preventing
A tutorial about preventing heat related illness is www.cdc.gov/nceh/hsb/extreme/heat_illness_training.htmat.
It’s important to avoid heat related illnesses by practicing good hydration. The Division of Public Health (DPH) recommends drinking plenty of water, even if you are not thirsty, to prevent dehydration
Prepare before a doctor’s appointment
• Consider bringing a family member or friend. Your companion can take notes, remind you of what you wanted to discuss, and help you remember what the doctor said. Ask the family member or friend to wait in the waiting room if you need to discuss private issues.
When preparing to see a doctor, follow these tips from the National Institutes of Health (NIH):
The DPH Bulletin – July 2022 Page 2 of 3
For more information and to read these recommendations in Spanish, visit the NIH at appointmenthttps://www.nia.nih.gov/health/how-prepare-doctors-.
40 Delaware Journal of Public Health - August 2022
Drink plenty of water in summer heat
• Request an interpreter if you need one before the appointment. By making that request in advance, the office can make arrangements
• Keep your doctor up to date. Tell the doctor what happened since your last visit, such as pain, fever and other symptoms, difficulty sleeping or walking, and changes in your appetite, weight, or energy level, or medications.
• Take a list of topics you want to discuss. Bring up the most important matters first.
• Take information with you to the doctor. Bring a list of your medications and the dosage you are taking. Include over-the-counter medicines, vitamins, and herbal remedies or supplements. Also bring your insurance cards, names and phone numbers of your other doctors, and your medical records if the doctor doesn’t have them.
• Wear your glasses or hearing aids. Let the doctor and staff know if you have trouble seeing or hearing, or if you do not understand their diagnosis or instructions.
Individuals with diabetes need to take special care in the heat. The CDC warns that if their blood vessels and nerves are damaged, their bodies are unable to cool effectively To combat the summer heat and humidity, individuals with diabetes should drink enough water, test their blood sugar often, and stay inside in air conditioning especially when it reaches 80°F in the shade with 40% humidity or higher. They should not store insulin or oral diabetes medicine in direct sunlight or in a hot car. They should have a plan on how to refrigerate their medications in case they lose power, and they should have a go bag packed in case of emergency
The Centers for Disease Control and Prevention (CDC) defines dehydration as “a condition that can cause unclear thinking, result in mood change, cause your body to overheat, and lead to constipation and kidney stones.” Another way to prevent dehydration is to avoid sugary drinks, alcohol, and drinks with caffeine such as coffee and energy or sports drinks.
The CDC recommends that athletes schedule workouts and practices early in the morning or in the evening when the temperature is cooler and to begin exercising slowly. Athletes should drink more water than usual and know that muscle cramping may be an early sign of heat-related illness.
• Do not touch or otherwise handle wild or unfamiliar animals, including cats and dogs, even if they appear friendly.
• Keep garbage securely covered.
Prevent damaging kitchen fires, burns, and scalds by following these safe cooking tips from the American Burn Association (ABA):
• Turn pot or pan handles to the back of the stove so they cannot be pulled down.
• Have a licensed veterinarian vaccinate all dogs, cats, and ferrets 6 months of age and older against rabies, as required by state law.
On June 28, the Delaware Public Health Laboratory (DPHL) confirmed rabies in a stray cat in the area of Smyrna Landing Road in Smyrna, Delaware. DPH advised two potentially exposed individuals to begin post exposure prophylaxis treatment. Anyone who thinks they might have been bitten, scratched, or have encountered a cat in this area should immediately contact their health care provider or call the DPH Rabies Program at 302 744 4995. An epidemiologist is available 24/7. Anyone in the area who thinks a cat may have bitten their pet should immediately call their private veterinarian to have their pet examined and treated.
• When simmering, baking, roasting, or boiling food, check it regularly.
• Cover the burn with a clean, dry cloth. Do not apply creams, ointments, or sprays.
To prevent rabies exposure, take these steps:
• Keep pets indoors. Do not let them roam. Spaying or neutering your pet may reduce the tendency to roam or fight
• Keep a pan lid near you every time you cook and use it when frying to prevent grease splatter. If food catches fire, cover the pan, let it cool in place, and turn the heat off.
• Allow food to rest before removing it from the microwave.
• Stay in the kitchen when frying, grilling, or broiling food.
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• Remove all clothing, diapers, jewelry, and metal from the burned area, as they can hide underlying burns and retain heat.
To date in 2022, DPHL has confirmed eight cases of rabies in two raccoons, three foxes, and three cats.
• Keep pet food and water dishes indoors.
Report sick stray domestic animals, such as a cat or dog, to DPH’s Office of Animal Welfare at 302 255 4646. Report wild animals that behave aggressively or are sick or injured to the Delaware Department of Natural Resources and Environmental Control's Wildlife Section at 302 739 9912 or 302 735 3600.
If a burn or scald occurs, take these first aid steps:
The DPH Bulletin – July 2022 Page 3 of 3
• Cook when you are wide awake and not drowsy from medications or alcohol.
• Always wipe the stove, oven, and exhaust fan clean to prevent grease buildup.
• After cooking, turn off all burners and appliances.
• Have a “kid free zone” of at least three feet around the stove.
• Use dry (not damp) oven mitts or potholders to prevent burns. Keep them nearby.
• Remain in the home while food is cooking and use a timer to remind you to check on your food.
• Right away, put the burn in cool water for three to five minutes.
• Do not feed feral animals, including cats.
For more information about rabies, visit DPH www.dhss.delaware.gov/dhss/dph/dpc/rabies.htmlat or call 1-866-972-9705; or visit the Centers for Disease Control and Prevention at www.cdc.gov/rabies/.
Cook safely to prevent fires and burns
• Wear short, close fitting, or tightly rolled sleeves when cooking.
Prevent rabies: do not touch stray or wild animals
The Division of Public Health (DPH) reminds Delawareans not to touch stray or wild animals to avoid rabies, a fatal yet preventable disease
For more information about fire prevention, visit ABA at https://ameriburn.org/ and the Delaware State Fire School at https://statefireschool.delaware.gov/.www.usfa.fema.gov
Eric Plautz, M.S.
Department of Human Development and Family Sciences, University of Delaware
One promising approach to supporting FCC providers is building peer support. FCC professionals typically work alone, or with one other adult, and have infrequent contact with other ECE professionals. Health research shows that increasing social support can have significant positive impacts on changing and maintaining health behaviors.7 In the field of early childhood, peer support has been shown to serve as a mediating factor for other behavior and practice-based changes in ECE settings,8 especially with FCC professionals.9 Thus creating peer support may be an effective mechanism for health behavior change with this population.
INTRODUCTION
Delaware Institute for Excellence in Early Childhood, University of Delaware
Rena Hallam, Ph.D.
DOI: 10.32481/djph.2022.08.010
Department of Behavioral Health and Nutrition, University of Delaware
Kyma Fulgence-Belardo, B.A.
Workplaces are an important determinant of health status across professions and workplace health promotion efforts can contribute to reducing socioeconomic inequalities.1 Research shows that the early care and education (ECE) workforce, particularly family child care (FCC) educators, who care for a small group of mixed aged children in a home setting, struggle with wellbeing, mental and physical health.2 For example, one study of FCC educators showed that 62% had high stress scores and nearly 90% were overweight or obese.3 In addition, the demographics of the FCC workforce – disproportionately composed of low-income women of color - place them at higher risk for chronic diseases.2
The Create Health Futures program, a web-based intervention focused on healthy eating among ECE professionals, had no significant impact on diet quality or dietary behaviors.5 In contrast, the Cultivating Healthy Intentional Mindful Educators (CHIME) program, which focuses on the social-emotional health of ECE professionals, has been shown to increase emotional wellbeing and mindfulness in pilot studies.6 These past studies show an ongoing need to design and successfully implement interventions with this population.
ABSTRACT
For example, the Care2BWell program was a worksite health intervention designed to increase ECE professionals’ physical activity. Process evaluation data from an initial study showed that implementation varied significantly across sites and no improvements in physical activity were observed in participants.4
Objective: To design and assess the effectiveness of an evidence-based intervention to improve the health and wellbeing of family child care professionals. Methods: The early care and education (ECE) workforce, and family child care (FCC) educators in particular, face challenges to their wellbeing, mental and physical health. In addition, the demographics of the FCC workforce – disproportionately composed of low-income women of color - are associated with higher risk for chronic diseases. The Shining the Light on You program is designed to address FCC professional wellbeing in a feasible, evidence-based manner. The program includes weekly virtual sessions co-facilitated by a Board-Certified Health and Wellness Coach (HWC) and a Technical Assistance Coach (Early Childhood Specialist) and three individual coaching sessions with the HWC. HWC is built upon a foundation of behavior change theories, motivational strategies and effective communication approaches from psychology, medicine, public health and related fields. Using a mixed methods approach to gather data, participants from three initial cohorts of the program (n=33) implemented in Delaware reported improvement in health and wellbeing indicators. Results: Participants reported improvements in social support, physical activity and water consumption from pre- to post-program surveys. In interviews conducted with the participants following the program, participants consistently commented on the connections between all components of wellbeing and the importance of self-care. Conclusions: This model demonstrates the potential of integrating best practices from HWC and the ECE system.
42 Delaware Journal of Public Health - August 2022
Department of Behavioral Health and Nutrition, University of Delaware
Shining the Light on You: An Evidence-Based Program Designed to Improve the Health and Wellbeing of Family Child Care Professionals
Department of Behavioral Health and Nutrition, University of Delaware
Laura Lessard, Ph.D., M.P.H.
Despite this need, few evidence-based interventions have been developed or feasibly implemented with this population.2
Sarah Albrecht, M.S.
METHODS
SHINING THE LIGHT ON YOU: PROGRAM COMPONENTS
Health and Wellness Coaching Construct Intervention Application
Data presented in this report was collected from three previous cohorts of the Shining the Light on You program (n= 33) conducted in Delaware. Cohorts took place via Zoom during
the Fall of 2020, Spring of 2021 and Spring of 2022. Participants were recruited through the Delaware Institute for Excellence in Early Childhood (DIEEC), a statewide organization that provides training, technical assistance and support for child care educators. DIEEC staff circulated flyers and emails describing the program to all FCC professionals in the county, and interested professionals were referred to program staff for more information.
Qualitative Interviews
This report describes the conceptual model and preliminary results for the Shining the Light on You program which is designed to address wellbeing among FCC professionals in a feasible, evidence-based manner.
The program has a research-based, mixed-methods evaluation approach that includes pre- and post-program surveys and postprogram interviews. This report includes data from post-program interviews with cohorts 1 and 2 (total n=18), pre-program survey data from all three cohorts (n=33) and linked pre- and postprogram survey data from cohort 3 (n=15).
Measures
The Shining the Light on You FCC Wellbeing Initiative is a 15week virtual program that integrates evidence-based practices from the Health and Wellness Coaching field10,11 and Early Childhood Education sector.9 The program includes weekly virtual sessions co-facilitated by a Board-Certified Health and Wellness Coach (HWC) and an Early Childhood Technical Assistance Coach, and three individual coaching sessions with the HWC (one at the beginning, middle and end of the program). The weekly sessions include introductions to the group and the tenets of health coaching, discussion of habits, the importance of self-care, goal setting and several weeks of topic-specific sessions with guest speakers. Topics are chosen by the group and have included mindful eating, stress reduction and management, sleep, financial literacy and physical activity. Each week, participants share their progress on their goals, talk through barriers and celebrate successes.
The sessions are specifically designed to 1) develop individual and group wellbeing goals; 2) provide ongoing monitoring and support; and 3) connect participants with one another and with existing community resources to meet goals. HWC is built upon a foundation of behavior change theories, motivational strategies and effective communication approaches from psychology, medicine, public health and other related fields. Table 1 illustrates how program components match best practices from the HWC field.11,12
Participants
Pre- and Post-Program Surveys
Participant-Centered Approach - Co-facilitation with early childhood technical assistance coach who has experience with the FCC setting - Initial survey and intake forms to assess participant needs - Regular check-ins to assess program satisfaction - Non-judgmental approach to goal setting and support Participants set goal(s) - Participants set their own goal(s) that are articulated to the Coaches and peers Self-discovery or active learning - Sessions are engaging, involve small group/pair discussion and activities, exercise and/or practice Content education - 12 weeks dedicated to participant-chosen wellbeing topics (e.g. mindful eating, physical activity, financial stress) - Expert guest speakers and connection to relevant community resources Self-monitoring of progress - Weekly check-ins with peers - Text message reminders to monitor progress Trusted relationship with Health and Wellness Coach - Icebreakers with Coaches and peers - Individual Coaching sessions with HWC Table 1. Shining the Light on You, Program Components Mapped to Health and Wellness Coaching Best Practices 43
The post-program qualitative interview guide was designed to gather information about participant experience and suggestions for future improvements. The interview guide also included questions pertaining to participants’ experience with the individual health coaching sessions, as well as their perceptions of the impact of the program on their health and the health of the children and families they serve. The interview guide was developed using best practices from the field of qualitative research13 and reviewed by experts in the field of evaluation and early childhood education before use.
Participants complete pre- and post-program surveys online via the Qualtrics platform. Survey questions were drawn from validated survey instruments, where possible. Social Support was measured using the ten-item Social Provisions Scale (SPS)14; physical activity, healthy days and chronic disease status were measured using items from the Behavioral Risk Factor Surveillance system15; water consumption was measured using a single item from the Food Attitudes and Behaviors Survey16 (“On average, about how many cups of bottled or tap water do you drink each day? 8 oz of water is equal to one cup. One standard 16 oz bottle of water equals 2 cups”).
commented on the connections between all components of wellbeing and the importance of self-care. One participant explained, “I’m more aware how important it is what I feed my body, not just food, you know… And how important it is to care for me so I can care for everybody else.” Similarly, another participant said, “It’s just about the focus on me and you know taking care of me. Like because that’s where it all begins, you know. [If] we’re not taking care of ourselves then I mean daycare, personal, everything can kind of go down the drain.”
Pre- and Post-Program Survey Results
Number of days physical health not good in the past
For cohort 3 (n=15), total mean score on the Social Provisions Scale (SPS) increased from pre- to post-program (paired t-test; p=0.028). Participants reported more frequent engagement in physical activity and greater water consumption. Before the program, six participants (50% of those with paired surveys) reported never engaging in moderate physical activity. After the program, all six of these participants reported engaging in moderate PA at least once per week, with three of those original
The one-on-one qualitative interviews were conducted via Zoom by a trained staff member in the weeks following the end of each cohort. After each interview, detailed notes with direct quotes were taken from the video recording. Thematic analysis13 was conducted using the detailed notes, with illustrative quotes identified for each theme. Participants received a $25 gift card for participating in the interview. All study related procedures were reviewed by the Institutional Review Board of the University of Delaware.
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Impact on Children and Families
Participant Characteristics
The 18 FCC participants from cohorts 1 and 2 were female, identified as primarily non-Hispanic Black or White, with ages ranging from 39 to 61 years. For cohort 3, all fifteen participants were female and 60% identified as Black or African American. On average, participants reported working more than 56 hours per week and serving about eight children in their programs. More than half of participants (54.5%) reported having diagnosed high blood pressure and only 9.4% of participants reported five or more days of moderate physical activity per week. More information about participants from baseline are provided in Table 2.
30 6.31 days Number of days mental health not good in the past 30 7.43 days High Blood Pressure 54.5% Diabetes 9.1% Pre-Diabetes or borderline Diabetes 18.8% Asthma 6.1% No participation in physical activity or exercise in past month 25.0% Participation in 5+ days per week of moderate physical activity 9.4%
six participants engaging in PA three or more days per week. A similar pattern emerged with water consumption; half of participants reported infrequent water consumption (1-3 cups per day) at the beginning of the program and all of these respondents increased their water consumption by the end of the program.
Impact on Health
RESULTS
Participants also mentioned that the program positively influenced the ways they engage with the children and families they serve. One participant described, “Because when you’re stressed and you feel like everything’s falling apart in the house, it’s really hard to be pleasant and want to, you know, sit and read books and enjoy time with the kids. So I do feel like it has put me in a better frame of mind, which makes me react to the children in a much better way.” Many participants also discussed how specific program topics, such as nutrition and physical activity, influenced how they care for the children. As one participant explained, “Now since I’m eating more vegetables and stuff during the day, they’re getting healthier snacks and things too.”
Importance of Connecting with Other Providers
11.8%
Number of paid days off built into contracts each year (both vacation and sick time) days
Health Status Indicators
Qualitative Interview Results
44 Delaware Journal of Public Health - August 2022
Twelve of eighteen participants from cohorts one and two engaged in the post-program interviews. Participants from both cohorts described how participating in the program positively influenced their health, their role as a FCC provider, and how they engage with the children they serve. Many also described the positive impact of being surrounded by other FCC providers throughout the program.
(MeanPre-ProgramorFrequency)
Interview Procedures
Hours worked per week hours
Received SNAP benefits within the past year
9.89
Table 2. Characteristics of Program Participants at Baseline, Delaware Shining the Light participants (2020-2022) (all cohorts, n=33)
Improvements in areas of nutrition, physical activity, sleep, and stress were commonly mentioned throughout the interviews. As one participant remarked, “I’m sleeping more, I’m drinking more water, and I’m losing weight.” Another participant expressed a similar sentiment and built upon the importance of her changes, “Well, I’m working out now… three times a week I have to do it or I have to do it. I don’t have any choice because it’s good for me. It’s good for my mind. It’s good for… everyone around me too… it takes the stress out.”
One final theme that was common throughout the interviews was the importance of having the opportunity to share and feel connected with other FCC providers. One participant remarked, “It let me know that I wasn’t the only one going through what I was going through and listening to the other providers, it made me feel as though, okay, I can get through this… Listening to some of the stories and everybody opening up and sharing with one another.” Similarly another participant said, “Listening to everybody’s story made me realize mine wasn’t so bad, it doesn’t seem. And that we’re all going through this together. We’re all going through something and having that group felt like, okay I can say this and I feel good about it.”
Dr. Lessard may be contacted at llessard@udel.edu
This study had significant strengths, including multiple cohorts over several years, connection to the evidence-base from both health coaching and early childhood and use of validated survey instruments. That said, the study had several limitations that should be considered. First, all cohorts were implemented in Delaware with licensed professionals, the majority of whom were already connected to ECE systems. Thus, our results may not translate to intervention effectiveness in unlicensed care settings or among professionals who are not connected to systems. Secondly, while the pre- and post-program survey results were triangulated with qualitative interviews, the lack of a comparison/ control group limits our ability to assess causality. Future studies of Shining the Light will include more robust research designs (e.g. experimental designs) that will allow the research team to continue to develop evidence of effectiveness along with establishing mediating factors for health behavior change.
DISCUSSION
REFERENCES
7 Hurdle, D. E. (2001, May). Social support: A critical factor in women’s health and health promotion. Health & Social Work, 26(2), 72 79 https://doi.org/10.1093/hsw/26.2.72
Combining Health and Wellness Coaching practices with ECE Technical Assistance is a promising approach for engaging with the FCC community in a meaningful and impactful way. Participants reported improvements in a variety of health and wellbeing indicators both for themselves and for the children in their care. In particular, participants reported increases in social support, physical activity levels and water consumption in both surveys and interviews. Our results contrast with the lack of impact found from other worksite wellbeing programs for this population, though these other programs were narrowly focused on a sub-set of health behaviors (e.g. nutrition, physical activity) and did not include explicit focus on peer support.4,5
3 Tovar, A., Vaughn, A. E., Grummon, A., Burney, R., Erinosho, T., Østbye, T., & Ward, D. S. (2017). Family child care home providers as role models for children: Cause for concern? Preventive Medicine Reports, 5, 308 313. https://doi.org/10.1016/j.pmedr.2016.11.010
11 Wolever, R. Q., Simmons, L. A., Sforzo, G. A., Dill, D., Kaye, M., Bechard, E. M., Yang, N. (2013, July). A systematic review of the literature on health and wellness coaching: Defining a key behavioral intervention in healthcare. Glob Adv Health Med, 2(4), 38 57. https://doi.org/10.7453/gahmj.2013.042
PUBLIC HEALTH IMPLICATIONS
5. Mofleh, D., Chuang, R. J., Ranjit, N., Cox, J. N., Anthony, C., & Sharma, S. V. (2022, June 27). A cluster-randomized controlled trial to assess the impact of a nutrition intervention on dietary behaviors among early care and education providers: The Create Healthy Futures study. Preventive Medicine Reports, 28, 101873. https://doi.org/10.1016/j.pmedr.2022.101873
12 Armstrong, C., Wolever, R. Q., Manning, L., Elam, R., III, Moore, M., Frates, E. P., . . . Lawson, K. (2013, May). Group health coaching: Strengths, challenges, and next steps. Glob Adv Health Med, 2(3), 95 102 https://doi.org/10.7453/gahmj.2013.019
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1. van de Ven, D., Robroek, S. J. W., & Burdorf, A. (2020, September). Are workplace health promotion programmes effective for all socioeconomic groups? A systematic review. Occupational and Environmental Medicine, 77(9), 589–596. https://doi.org/10.1136/oemed-2019-106311
4 Neshteruk, C. D., Willis, E., Smith, F., Vaughn, A. E., Grummon, A. H., Vu, M. B., . . . Linnan, L. (2021, July 29). Implementation of a workplace physical activity intervention in child care: Process evaluation results from the Care2BWell trial. Translational Behavioral Medicine, 11(7), 1430 1440 https://doi.org/10.1093/tbm/ibab034
6 Hatton Bowers, H., Calvi, J., Chen, F., Foged, J., Gottschalk, J., & Werth, L. (2018). A multidimensional perspective of the effects of a mindfulness intervention on the well-being of early childhood teachers. presented at: International Society of Psychoneuroendocrinology, Irvine, CA.
9. Hallam, R., Hooper, A., Buell, M., Zigler, M., & Han, M. (2019). Boosting family child care success in quality rating and improvement systems. Early Childhood Research Quarterly, 47(2), 239 247 https://doi.org/10.1016/j.ecresq.2018.12.008
Data from the first three cohorts of the program further underscored FCC providers’ need for health promotion. Providers struggle with nutrition, physical activity and stress levels that contribute to their overall wellbeing and can influence their ability to provide high quality care. Emerging research across ECE settings suggests that poor provider wellbeing can contribute to lower classroom quality, including increased conflict and negative reactions in relationships with children, and decreased job commitment.17–19 Poor provider wellbeing may also influence children’s social-emotional development.20
2 Lessard, L. M., Wilkins, K., Rose-Malm, J., & Mazzocchi, M. C. (2020, January 8). The health status of the early care and education workforce in the USA: A scoping review of the evidence and current practice. Public Health Reviews, 41, 2. https://doi.org/10.1186/s40985-019-0117-z
10 Olsen, J. M., & Nesbitt, B. J. (2010, September-October). Health coaching to improve healthy lifestyle behaviors: An integrative review. Am J Health Promot, 25(1), e1 e12 https://doi.org/10.4278/ajhp.090313-LIT-101
Despite widespread call for an increase in workforce wellbeing initiatives, few feasible and effective programs have been designed for this population. Thus far, The Shining the Light on You program has shown that focusing on the unique needs of FCC providers can result in the adoption of healthy lifestyle behaviors that improve their quality of life and the ways they interact with the children and families they serve. Future research is underway to further document the impact of the intervention on the health of the providers.
8 Rojas, J. P., Nash, J. B., & Rous, B. S. (2019, March). Discovering childcare providers’ coaching needs with design thinking techniques. Early Child Development and Care, 189(4), 613 624 https://doi.org/10.1080/03004430.2017.1336166
13 Creswell, J., & Poth, C. (2018). Qualitative inquiry and research design: Choosing among five approaches (4th edition). SAGE Publications, Inc.
14 Cutrona, C., & Russell, D. (1987). The provisions of social relationships and adaptation to stress. Advances in personal relationships, 1(1), 37-67.
17 Whitaker, R.C., Dearth-Wesley, T., Gooze, R.A. (2015). Workplace stress and the quality of teacherchildren relationships in Head Start, 30, 57-69. https://doi.org/10.1016/j.ecresq.2014.08.008
18 Buettner, C. K., Jeon, L., Hur, E., & Garcia, R. E. (2016, October). Teachers’ social-emotional capacity: Factors associated with teachers’ responsiveness and professional commitment. Early Education and Development, 27(7), 1018 1039. https://doi.org/10.1080/10409289.2016.1168227
19. Luckey, S. W., Lang, S. N., & Jeon, L. (2021, November). Examining associations among provider-family relationships, provider coping strategies, and family child care providers’ relationships with children. European Early Childhood Education Research Journal, 29(6), 877 894 https://doi.org/10.1080/1350293X.2021.1985556
16. Erinosho, T. O., Pinard, C. A., Nebeling, L. C., Moser, R. P., Shaikh, A. R., Resnicow, K., . . . Yaroch, A. L. (2015, February 23). Development and implementation of the National Cancer Institute’s Food Attitudes and Behaviors Survey to assess correlates of fruit and vegetable intake in adults. PLoS One, 10(2), e0115017 https://doi.org/10.1371/journal.pone.0115017
20 Roberts, A., LoCasale-Crouch, J., Hamre, B., & DeCoster, J. (2016, July). Exploring teachers’ depressive symptoms, interaction quality, and children’s social-emotional development in Head Start. Early Education and Development, 27(5), 642 654. https://doi.org/10.1080/10409289.2016.1127088
15 Centers for Disease Control and Prevention. (2020). Behavioral risk factor surveillance system survey questionnaire. U.S. Department of Health and Human Services.
46 Delaware Journal of Public Health - August 2022
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Visit http://www.dhss.delaware.gov/dhss/dph for more information on DPH programs. Visit HealthyDelaware.org for information on free or low-cost cancer screenings, blood pressure screenings, free or low-cost diabetes programing, and information and tips on leading a healthy lifestyle.
DOVER (July1, 2021) —
The goals of the national program are to:
“I am pleased that DPH is participating in the Healthy People 2030 program,” said DPH Director Dr. Karyl Rattay. “A good life starts with good health and that is what DPH strives to deliver to all Delawareans through its programs and partnerships. DPH o ers a full range of free to low-cost programs aimed at reducing chronic diseases such as diabetes, cancer and high blood pressure. Participating in this initiative will help us reach more people.”
As a Healthy People 2030 Champion, DPH has demonstrated a commitment to helping achieve the Healthy People 2030 vision of a society in which all people can achieve their full potential for health and well-being across their lifespan.
The Delaware Division of Public Health (DPH) is pleased to be recognized by the O ce of Disease Prevention and Health Promotion (ODPHP) within the U.S. Department of Health and Human Services (HHS) as a Healthy People 2030 Champion.
Date: July 1, DHSS-6-20222022
Jill Fredel, Director of Communications
Molly Magarik, Secretary
ODPHP recognizes DPH as part of a growing network of organizations partnering with it to improve health and well-being at the local, state, and tribal levels.
Attain healthy, thriving lives and well-being free of preventable disease, disability, injury, and premature death. Eliminate health disparities, achieve health equity, and attain health literacy to improve the health and well-being of all. Create social, physical and economic environments that promote attaining the full potential for health and well-being for all. Promote healthy development, healthy behaviors, and well-being across all life stages. Engage leadership, key constituents and the public across multiple sectors to take action and design policies that improve the health and well-being of all.
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Email:302-255-9047jill.fredel@delaware.gov
2030 is the fth iteration of the Healthy People initiative, which sets 10-year national objectives to improve health and well-being nationwide. Healthy People 2030 Champions are public and private organizations that are working to help achieve Healthy People objectives. Healthy People 2030 Champions receive o cial support and recognition from ODPHP.
DELAWARE DIVISION OF PUBLIC HEALTH RECOGNIZED AS A HEALTHY PEOPLE 2030 CHAMPION
“ODPHP is thrilled to recognize DPH for its work to support the Healthy People 2030 vision,” says Rear Admiral Paul Reed, MD, ODPHP Director. “Only by collaborating with partners nationwide can we achieve Healthy People 2030’s overarching goals and Healthyobjectives.”People
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• one or two doses for the primary cohort ages 9 to 14
The World Health Organization announced in April that it will consider changing its regimen recommendation for the Human Papillomavirus (HPV) vaccine, which protects against cervical cancer, the fourth most common cancer in
HPV vaccination campaigns have seen slow uptake in many low- and middle-income countries. Moving from a two- or three-dose regimen to a one- or two-dose one could help reach the goal of 90% vaccination by 2030.
Following its evaluation, SAGE suggested the WHO update its dose schedules for HPV as follows:
WHO considers single-dose HPV vaccine schedule
policy advises two doses of the vaccine for 9to 14-year-old girls, while girls 15 and older as well as the immunocompromised, beginning at age 9, should receive three doses. The Strategic Advisory Group of Experts (SAGE) on Immunization, which advises the WHO on global vaccine policies and strategies, recently evaluated evidence that single dose regimens are equally effective as two and three dose regimens. One Costa Rica study conducted by researchers from the National Cancer Institute and other institutions found women who received either one or two doses of the vaccine had the same protection against HPV infections as a three-dose group.
•
MATTERSHEALTHGLOBAL
• two doses with a 6-month interval for women older than 21.
Thewomen.current
• one or two doses for young women ages 15 to 20
Inside this issue
Lowycancer.noted
Following its evaluation, SAGE suggested the WHO update its dose schedules for HPV as follows:
In 2018, an estimated 570,000 women worldwide received a diagnosis of cervical cancer and about 311,000 women died from the disease, according to the WHO. Almost all cervical cancer cases are linked to infection with high-risk HPV, an extremely common virus transmitted through sexual contact. Most HPV infections resolve spontaneously and cause no symptoms, yet persistent infection can cause
Further evidence is needed to show that the reduced dose schedule provides protection for immunocompromised individuals, according to SAGE. A high incidence of HPV-related cancers has been seen in those who are immunocompromised or living with HIV as well as in girls who face sexual abuse.
Fogarty’s
• one or two doses for the primary cohort ages 9 to 14
• one or two doses for young women ages 15 to 20
HPV vaccination campaigns have seen slow uptake in many low- and middle-income countries. Moving from a two- or three-dose regimen to a one- or two-dose one could help reach the goal of 90% vaccination by 2030.
Lowycancer.noted
The WHO will conduct a stakeholder consultation before revising its position paper on HPV vaccination. A decision is expected in October.
“The HPV vaccine is highly effective for the prevention of HPV serotypes 16 & 18, which cause 70% of cervical cancer,” said Dr. Alejandro Cravioto, SAGE Chair.
policy advises two doses of the vaccine for 9to 14-year-old girls, while girls 15 and older as well as the immunocompromised, beginning at age 9, should receive three doses. The Strategic Advisory Group of Experts (SAGE) on Immunization, which advises the WHO on global vaccine policies and strategies, recently evaluated evidence that single dose regimens are equally effective as two and three dose regimens. One Costa Rica study conducted by researchers from the National Cancer Institute and other institutions found women who received either one or two doses of the vaccine had the same protection against HPV infections as a three-dose group.
policy advises two doses of the vaccine for 9to 14-year-old girls, while girls 15 and older as well as the immunocompromised, beginning at age 9, should receive three doses. The Strategic Advisory Group of Experts (SAGE) on Immunization, which advises the WHO on global vaccine policies and strategies, recently evaluated evidence that single dose regimens are equally effective as two and three dose regimens. One Costa Rica study conducted by researchers from the National Cancer Institute and other institutions found women who received either one or two doses of the vaccine had the same protection against HPV infections as a three-dose group.
• Building a bench of researchers in post-Ebola Liberia • Partnering
www.fic.nih.govFOGARTY INTERNATIONAL CENTER • NATIONAL
Further evidence is needed to show that the reduced dose schedule provides protection for immunocompromised individuals, according to SAGE. A high incidence of HPV-related cancers has been seen in those who are immunocompromised or living with HIV as well as in girls who face sexual abuse.
www.fic.nih.govFOGARTY INTERNATIONAL CENTER • NATIONAL INSTITUTES OF HEALTH • DEPARTMENT OF HEALTH AND HUMAN SERVICES Inside this issue FOCUS
•
JULY/AUGUST 2022
“The HPV vaccine is highly effective for the prevention of HPV serotypes 16 & 18, which cause 70% of cervical cancer,” said Dr. Alejandro Cravioto, SAGE Chair.
that “the vaccine has very high efficacy,” but it only prevents new infections. “As most women are exposed to HPV soon after initiating sexual activity, it is important to vaccinate them before they become sexually active.”
Fogarty fellow Abigail Link evaluates causes of meningitis in patients in Uganda…p. 4
www.fic.nih.govFOGARTY INTERNATIONAL CENTER • NATIONAL
• Partnering
FOCUS
In 2018, an estimated 570,000 women worldwide received a diagnosis of cervical cancer and about 311,000 women died from the disease, according to the WHO. Almost all cervical cancer cases are linked to infection with high-risk HPV, an extremely common virus transmitted through sexual contact. Most HPV infections resolve spontaneously and cause no symptoms, yet persistent infection can cause
Further evidence is needed to show that the reduced dose schedule provides protection for immunocompromised individuals, according to SAGE. A high incidence of HPV-related cancers has been seen in those who are immunocompromised or living with HIV as well as in girls who face sexual abuse.
Thewomen.current
Following its evaluation, SAGE suggested the WHO update its dose schedules for HPV as follows:
HPV vaccination campaigns have seen slow uptake in many low- and middle-income countries. Moving from a two- or three-dose regimen to a one- or two-dose one could help reach the goal of 90% vaccination by 2030.
“Giving a single dose is less expensive and logistically easier compared with multiple doses,” said Dr. Doug Lowy, Deputy Director of the National Cancer Institute. “Single dose vaccination will make it more feasible to vaccinate more women in low- and middle-income countries.”
•
Read
WHO considers single-dose HPV vaccine schedule
WHO considers single-dose HPV vaccine schedule
In 2018, an estimated 570,000 women worldwide received a diagnosis of cervical cancer and about 311,000 women died from the disease, according to the WHO. Almost all cervical cancer cases are linked to infection with high-risk HPV, an extremely common virus transmitted through sexual contact. Most HPV infections resolve spontaneously and cause no symptoms, yet persistent infection can cause
MATTERSHEALTHGLOBAL
Read more on pages 6 – 9
The World Health Organization announced in April that it will consider changing its regimen recommendation for the Human Papillomavirus (HPV) vaccine, which protects against cervical cancer, the fourth most common cancer in
Lowycancer.noted
•
The WHO will conduct a stakeholder consultation before revising its position paper on HPV vaccination. A decision is expected in October. INSTITUTES OF HEALTH DEPARTMENT OF HEALTH AND HUMAN SERVICES
•
WHOofCourtesyPhoto
The World Health Organization announced in April that it will consider changing its regimen recommendation for the Human Papillomavirus (HPV) vaccine, which protects against cervical cancer, the fourth most common cancer in
• two doses with a 6-month interval for women older than 21.
51 Read More on pages 53-59 48 Delaware Journal of Public Health - August 2022
Fogarty’s response to Ebola: Where are we now? Building a bench of researchers in post-Ebola Liberia to fight against viral disease in West Africa Developing a new generation of researchers in Sierra Leone more pages
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Inside this issue FOCUS
• one or two doses for young women ages 15 to 20
• two doses with a 6-month interval for women older than 21.
“The HPV vaccine is highly effective for the prevention of HPV serotypes 16 & 18, which cause 70% of cervical cancer,” said Dr. Alejandro Cravioto, SAGE Chair.
JULY/AUGUST 2022 response to Ebola: Where are we now? to fight against viral disease in West Africa Developing a new generation of researchers in Sierra Leone
that “the vaccine has very high efficacy,” but it only prevents new infections. “As most women are exposed to HPV soon after initiating sexual activity, it is important to vaccinate them before they become sexually active.”
“Giving a single dose is less expensive and logistically easier compared with multiple doses,” said Dr. Doug Lowy, Deputy Director of the National Cancer Institute. “Single dose vaccination will make it more feasible to vaccinate more women in low- and middle-income countries.”
that “the vaccine has very high efficacy,” but it only prevents new infections. “As most women are exposed to HPV soon after initiating sexual activity, it is important to vaccinate them before they become sexually active.”
“Giving a single dose is less expensive and logistically easier compared with multiple doses,” said Dr. Doug Lowy, Deputy Director of the National Cancer Institute. “Single dose vaccination will make it more feasible to vaccinate more women in low- and middle-income countries.”
Fogarty fellow Abigail Link evaluates causes of meningitis in patients in Uganda…p. 4
Fogarty fellow Abigail Link evaluates causes of meningitis in patients in Uganda…p. 4
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Fogarty’s response to Ebola: Where are we now? • Building a bench of researchers in post-Ebola Liberia • Partnering to fight against viral disease in West Africa • Developing a new generation of researchers in Sierra Leone Read more on pages 6 – 9 MATTERSHEALTHGLOBAL
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• one or two doses for the primary cohort ages 9 to 14
The WHO will conduct a stakeholder consultation before revising its position paper on HPV vaccination. A decision is expected in October. INSTITUTES OF HEALTH DEPARTMENT OF HEALTH AND HUMAN SERVICES
The world is falling short in reducing premature deaths from noncommunicable diseases (NCDs), and the Assembly approved several recommendations to address them. The WHO estimates that every minute, 28 lives between the
The action plan highlights the importance of a strengthened workforce to benefit overall health and economic prosperity of all societies. The “Working for Health” model shows how progress can be made by optimizing existing healthcare systems to build more capacity and by strengthening the protection and performance of health care workers.
in health systems to treat NCDs has been a major contributor to this issue. The UN Health Agency reports spending $0.84 per person per year could prevent and treat these diseases and conditions and so save nearly 7 million lives between now and 2030. Delegates approved a new implementation roadmap to accelerate action on NCDs that aims to help member states achieve the NCD-related targets in the United Nation’s Sustainable Development Goals (SDGs).
The Working Group on Strengthening WHO Preparedness and Response to Health Emergencies (WGPR), first established in 2021, issued its final report, “Strengthening WHO preparedness for and response to health emergencies.” The report proposes a variety of actions, including boosting manufacturing capacity for countermeasures (vaccines, therapeutics, diagnostics, essential supplies) and supporting regional manufacturing and diversification of production of countermeasures. The WGPR report also recommends developing processes for the transfer of technology and know-how to developing countries, strengthening whole genomic sequencing and analysis capability, and investing in health infrastructure workforce education, skills, and jobs. The intention is to engage local communities in health emergency prevention, preparedness, and response.
In conclusion, the WGPR proposed a working group on the International Health Regulations, which will help guide discussions on changes to protocols.
Actions on noncommunicable diseases
Emergency preparedness and response
WHA seeks to strengthen global health workforce
JULY/AUGUST 2022
One strategic roundtable at the 75th World Health Assembly discussed health emergency preparedness, response, and resilience.
The WGPR acknowledged the importance of rapid and broad sharing of pathogens for effective disease surveillance but called attention to the sustainability of recently established initiatives, such as the WHO BioHub and WHO Hub for Pandemic and Epidemic Intelligence. The BioHub is a global system for sharing biological materials with epidemic or pandemic potential while the WHO Pandemic Hub focuses on detecting new events with pandemic potential, monitoring disease control measures for pandemic risk management, and leveraging innovations in data science for public health surveillance using a methodology called “pandemic and epidemic intelligence.”
The Assembly also supported the creation of first-ever global targets for addressing diabetes, a global strategy on oral health, and new recommendations to prevent and manage obesity, among other key actions.
The 75th World Health Assembly (WHA) addressed pressing global health challenges at their May 2022 meeting. These challenges include supporting the global health care workforce, acting against noncommunicable diseases (NCDs), strengthening health emergency preparedness, improving clinical trials, preparing urban areas for emergencies, preventing and controlling infection, and revitalizing responses to HIV, viral hepatitis and sexually transmitted infections. Delegates of the 194 member states of the WHA, the main decision-making body of the WHO, meet annually to agree on priorities and policies.
Supporting the health workforce
The WHA adopted the Working for Health Action Plan (2022-2030) which recommends ways to optimize, build, and strengthen the global health care workforce. Measures taken since 2016 to address health workforce shortages have generated progress in many areas. For example, the global shortfall of workers is projected to drop from 18 to 10 million by 2030. Still, gains have been uneven across regions and the impact of the pandemic is still being felt in terms of health care system disruptions and added workload for medical and health staff.
CiprianiLaurent/WHO 49
ages of 30 and 70 are cut short by cardiovascular disease, cancer, diabetes, chronic respiratory diseases, or mental health conditions. Twenty-five of those deaths occur in UnderinvestmentLMICs.
a stepping-stone for budding researchers who aspire to conduct independent research addressing chronic conditions. “Our partners in Ethiopia and India tell us that opportunities for post-doctoral training that support the transition to independence are lacking,” said Patel. Without that support, early career researchers stagnate or leave research after years of assisting senior investigators instead of pursuing their own interests.
director, I saw the Ethiopian fellows improve their abilities to think through scientific questions and present to scientific audiences. On the Indian side, I saw
Researchers2022 in Ethiopia and India find common ground
EmilyPatel.Chuba,
“In our first year, on the Ethiopian side we had more clinicians, whereas on the Indian side we had more researchers,” said Patel. These differences in background and needs led to terrific conversations and diverse
In addition to learning from expert researchers, COALESCE trainees will engage with health care stakeholders and representatives from the Ethiopian and Indian Ministries of Health. This added dimension should help to advance policies and enhance scientific capabilities in both countries, said Chuba. Meanwhile, the program will continue to provide a platform for previous Emory global health trainees to become mentors. “Our global health scholars see the value of capacity building and want to contribute to their home countries. Past trainees, who have returned to their institutions and worked their way up, are now poised to serve as mentors for a new generation.”
SheCOALESCE.envisions
The result, the COllaborative Research, Implementation, And LEadership Training to AddresS Chronic Conditions across the Life CoursE (COALESCE) program, seeks to facilitate locally driven research and implementation by training 116 researchers and practitioners from India and
DOI: 3 JULY/AUGUST
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India’s Centre for Chronic Disease Control is a collaborator in the COALESCE program. Pictured: Participants learn about a study at the Centre.
Learning to lead
Global health research trainees rarely encounter opportunities to develop their own South-South collaborations. The lucky few who fleetingly meet their counterparts from other countries usually do so at consortium meetings tacked onto the end of their training programs. “They always get a lot of value from talking to each other, there’s a lot of opportunity for growth and learning there,” said Dr. Shivani Patel of Emory University. Recognizing this, she partnered with colleagues to create a program that brings scholars together from the very start of their training.
program manager, said that, though COALESCE is strengthened by Emory’s “strong strategic partnerships” and previous global health programs, its scope is more expansive than those of the past because it emphasizes professional development. “We’re focused on the part of science that’s ‘team’—how do you collaborate with others?” For example, trainees undergo assessments to gain self-awareness of how they communicate and “show up” as a team member, said Chuba. “They learn to lead.”
pairing of countries and continents it would appear. Yet the collaboration includes two of Emory’s long-standing institutional partners, India’s Centre for Chronic Disease Control and Ethiopia’s Addis Ababa University. “COALESCE is about creating a space to invest in yourself, right? In your daily life, no one’s going to say: ‘let’s talk about how to build a network’ or ‘let’s talk about how to seek mentorship,’” said Patel, associate director of
50 Delaware Journal of Public Health - August 2022
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fellows build networks and grow collaborations.” Papers, pilot proposals, and other deliverables—all delayed by the pandemic—are now coming to fruition. One trainee has already received funding from Wellcome Trust. Other indicators of the program’s success are the quality of applicants received in the second and third round and the number of applications, which “nearly doubled,” according to
“If we want science that addresses the needs of diverse populations across the globe, then we need to support scientists in becoming independent researchers.” This is “critically important” for growing local capacity and developing North-South and South-South collaborations, she said.
The pandemic stymied the first (2019) class of COALESCE, yet an innovative remote program still benefitted trainees.
Working in Lira prior to her Fogarty project helped her “get buy-in and partners because people have seen me here for the past five years in different roles. In any society it’s about making connections so that was definitely advantageous for me,” said Link.
Evaluating meningitis causes patientsamonginUganda
PROFILE
meningitis cases. She also plans to further train her team, which now includes a manager, three nurses, and three medical officers, to help collect and analyze new data. “They’ve begun to see the fruits of their labor in the form of findings from the patients that have come in over the past five to six years.”
Fogarty’s staff and project management lessons taught her much-needed organizational skills. She also praised the networking opportunities provided by Fogarty. “Other fellows working in your same country can be great guides and mentors. I’ve asked other Ugandan researchers, ‘I’m thinking about this for a project — what kind of cultural differences should I be aware of?’” Most of all she appreciated the amount of time provided by a Fogarty fellowship. “Unfortunately, we global health researchers tend to form a research question based on what we feel is the need. But it’s more important to interact with the people and understand what gaps they Lookingsee.”
Foreign institution: Makerere University in Kampala
COVID-19 delays prevented her from completing her project in 2021 as planned. Though a disruptive force, the pandemic also brought unexpected insight. “I learned how much I can rely on the people on the ground,” she said. Though her work is ongoing, Link already has published an evaluation of cryptococcal
Abigail Link, RN, MPH, PhD
Link decided to continue this research for a Fogarty project by answering the question: If not CM, what other types of meningitis are making these Ugandan patients sick? Using data from a regional hospital, she will determine disease causes and conduct surveys and interviews with both patients and providers to understand their experiences as well as the barriers to improving health outcomes. “We’re in the middle of that right now, enrolling patients in the program, and, come September, we’ll do a preliminary analysis,” she said.
to the future, Link plans to apply for NIH funding to “develop a mental health screening tool that will be implemented in HIV clinics in Lira.” She also plans to collaborate with Lira University on a training grant. “I chose nursing versus medicine because I wanted to have quality time with patients and take on the role of a caregiver versus the role of a person who diagnosis and prescribes,” said Link.
Fogarty Fellow: 2020-2021
Research topic: Meningitis surveillance and outcomes in Uganda
4
PROFILE
Evaluating meningitis causes patientsamonginUganda
U.S. institution: University of Minnesota
Research topic: Meningitis surveillance and outcomes in Uganda
U.S. institution: University of Minnesota
Fogarty Fellow: 2020-2021
Link decided to continue this research for a Fogarty project by answering the question: If not CM, what other types of meningitis are making these Ugandan patients sick? Using data from a regional hospital, she will determine disease causes and conduct surveys and interviews with both patients and providers to understand their experiences as well as the barriers to improving health outcomes. “We’re in the middle of that right now, enrolling patients in the program, and, come September, we’ll do a preliminary analysis,” she said.
meningitis cases. She also plans to further train her team, which now includes a manager, three nurses, and three medical officers, to help collect and analyze new data. “They’ve begun to see the fruits of their labor in the form of findings from the patients that have come in over the past five to six years.”
Working in Lira prior to her Fogarty project helped her “get buy-in and partners because people have seen me here for the past five years in different roles. In any society it’s about making connections so that was definitely advantageous for me,” said Link.
Seeing this gap, her former colleague, Dr. Paul Bohjanen, who had been researching CM in Kampala, helped start a program where Lira patients could get treated even if unable to pay. “For my Ph.D. dissertation, I helped analyze that program. What we found is about half of the patients with symptoms did not have a diagnosis of CM.” An opportunistic infection that afflicts people living with HIV, cryptococcal meningitis symptoms include fever, intense headache, stiff neck, nausea, vomiting, sensitivity to light, drowsiness, and confusion.
51
Seeing this gap, her former colleague, Dr. Paul Bohjanen, who had been researching CM in Kampala, helped start a program where Lira patients could get treated even if unable to pay. “For my Ph.D. dissertation, I helped analyze that program. What we found is about half of the patients with symptoms did not have a diagnosis of CM.” An opportunistic infection that afflicts people living with HIV, cryptococcal meningitis symptoms include fever, intense headache, stiff neck, nausea, vomiting, sensitivity to light, drowsiness, and confusion.
Abigail Link, RN, MPH, PhD
In northern Uganda, little is known about meningitis— its specific causes, the number of people affected, the impact of prevention measures. Meningitis is an infection and inflammation of the fluid and membranes around the brain and spinal cord caused by viruses, bacteria, or fungi. Dr. Abigail Link became interested in how cryptococcal (fungal) meningitis (CM) was diagnosed and treated in the region when a scientist friend visited her in Lira, where she worked as a lecturer. “Here in the north, if the hospital is out of stock, costs are shifted to patients. Those who can’t afford the diagnostic test or medication don’t get treated,” explained Link.
Foreign institution: Makerere University in Kampala
Fogarty’s staff and project management lessons taught her much-needed organizational skills. She also praised the networking opportunities provided by Fogarty. “Other fellows working in your same country can be great guides and mentors. I’ve asked other Ugandan researchers, ‘I’m thinking about this for a project — what kind of cultural differences should I be aware of?’” Most of all she appreciated the amount of time provided by a Fogarty fellowship. “Unfortunately, we global health researchers tend to form a research question based on what we feel is the need. But it’s more important to interact with the people and understand what gaps they
Lookingsee.”
4
In northern Uganda, little is known about meningitis— its specific causes, the number of people affected, the impact of prevention measures. Meningitis is an infection and inflammation of the fluid and membranes around the brain and spinal cord caused by viruses, bacteria, or fungi. Dr. Abigail Link became interested in how cryptococcal (fungal) meningitis (CM) was diagnosed and treated in the region when a scientist friend visited her in Lira, where she worked as a lecturer. “Here in the north, if the hospital is out of stock, costs are shifted to patients. Those who can’t afford the diagnostic test or medication don’t get treated,” explained Link.
to the future, Link plans to apply for NIH funding to “develop a mental health screening tool that will be implemented in HIV clinics in Lira.” She also plans to collaborate with Lira University on a training grant. “I chose nursing versus medicine because I wanted to have quality time with patients and take on the role of a caregiver versus the role of a person who diagnosis and prescribes,” said Link.
COVID-19 delays prevented her from completing her project in 2021 as planned. Though a disruptive force, the pandemic also brought unexpected insight. “I learned how much I can rely on the people on the ground,” she said. Though her work is ongoing, Link already has published an evaluation of cryptococcal
degrees, yet we also graduated 23 Ph.D. students, among them nine Indonesians. When our AITRP trainees returned to their countries, they trained the next generation of HIV investigators. They also persuaded scientists and faculty from their home institutions to join them in AIDS research.
What’s ahead for you?
In Indonesia, returning UIC-AITRP trainees founded AIDS research programs at both AJCU and the College of Nursing, University of Indonesia. Later, Professor Irwanto, our first postdoc, partnered with me to successfully develop AJCU’s existing AIDS research program into an AIDS Research Center (ARC) serving faculty, students, and researchers across the archipelago. Based on ARC’s success— buttressed by continuing Fogarty training and capacity-building—Dr. Evi Sukmaningrum, who earned her doctorate as a UIC-AITRP trainee, spearheaded the effort to have ARC formally designated a “Center of Excellence” in research and training by the Indonesian Ministry of Education and Culture. This designation recognizes ARC’s contributions to AIDS research in health policy and social innovation.
A second project involves a Tajikistan/UIC partnership that is conducting a NIAID-funded clinical trial to test the effectiveness of a peer prevention model for HIV. The model we developed is designed to reduce drug and sexual HIV risk behaviors among social networks of Tajik labor migrants who inject drugs while working in Moscow. The pilot study and first half of the clinical trial have shown positive results. If success continues, the model could be culturally adapted and tested for use in Indonesia where drug use fuels the epidemic.
A second project involves a Tajikistan/UIC partnership that is conducting a NIAID-funded clinical trial to test the effectiveness of a peer prevention model for HIV. The model we developed is designed to reduce drug and sexual HIV risk behaviors among social networks of Tajik labor migrants who inject drugs while working in Moscow. The pilot study and first half of the clinical trial have shown positive results. If success continues, the model could be culturally adapted and tested for use in Indonesia where drug use fuels the epidemic.
degrees, yet we also graduated 23 Ph.D. students, among them nine Indonesians. When our AITRP trainees returned to their countries, they trained the next generation of HIV investigators. They also persuaded scientists and faculty from their home institutions to join them in AIDS research.
Why is it important to study HIV in Indonesia?
A&Q 5
A
Tell us about your accomplishments in Indonesia. For nearly 23 years, I directed the UIC AIDS International Training and Research Program (the UIC-AITRP) with six universities in four countries: Indonesia, Chile, Malawi, and China. The program included short-term and MPH
A central question of sociology asks: How and why do people come together collaboratively to form cities, communities, neighborhoods, and extended families? My research extends these questions to explore community-based models, peer prevention strategies, and culturally acceptable norms to promote and reinforce safer sex and drug practices within key populations and across their social networks.
What’s ahead for you?
As to why global health research, I grew up on the islands of Maui and Oahu in pre-state Hawaii. The islands’ rich cultural heritage and blending of many ethnic and racial populations greatly influenced the tenor and direction of my research. Also, at the start of the AIDS pandemic, I participated on the advisory team that WHO convened to develop what were then the first guidelines for studying HIV risk behavior in multiple countries. The natural next step was to conduct my own international research while encouraging others to do so.
HIV incidence continues to climb in many regions of Indonesia. The country has many talented clinicians and university faculty capable of leading and conducting effective HIV research that could inform public policy, prevention, and clinical practice. They just need the advanced theoretical and methodological skills to do so. Fogarty-sponsored training provides that.
A central question of sociology asks: How and why do people come together collaboratively to form cities, communities, neighborhoods, and extended families? My research extends these questions to explore community-based models, peer prevention strategies, and culturally acceptable norms to promote and reinforce safer sex and drug practices within key populations and across their social networks.
Why is it important to study HIV in Indonesia?
Papua New Guinea has the highest rates of HIV infection in Indonesia. Prevention efforts among indigenous populations have little success due to geographic, socioeconomic, and cultural barriers. Through NIAID funding, Drs. Robert Bailey (UIC), Ignatius Praptoraharjo (AJCU/ARC), and I are partnering with the Papua indigenous community to develop and pilot a voluntary, indigenous model of medical male circumcision. This onetime prevention method is well-suited for a population that cannot consistently access prevention supplies and distrusts outside efforts to promote safer behavior.
JUDITH LEVY, PHD &Q
Why sociology, why global health research?
Why sociology, why global health research?
JUDITH LEVY, PHD
My own research in Indonesia has benefited greatly from UIC’s long history of HIV research and interventions within the archipelago. Building on these established relationships, in 2003, my colleagues at UIC and Atma Jaya Catholic University (AJCU) in Jakarta and I received funding from the World AIDS Foundation to conduct HIV prevention workshops in four Indonesian cities. Other projects and studies, including an AIDS International Training and Research (AITRP) grant and my current Fogarty training program in HIV translational science, grew from there.
My own research in Indonesia has benefited greatly from UIC’s long history of HIV research and interventions within the archipelago. Building on these established relationships, in 2003, my colleagues at UIC and Atma Jaya Catholic University (AJCU) in Jakarta and I received funding from the World AIDS Foundation to conduct HIV prevention workshops in four Indonesian cities. Other projects and studies, including an AIDS International Training and Research (AITRP) grant and my current Fogarty training program in HIV translational science, grew from there.
5 52 Delaware Journal of Public Health - August 2022
HIV incidence continues to climb in many regions of Indonesia. The country has many talented clinicians and university faculty capable of leading and conducting effective HIV research that could inform public policy, prevention, and clinical practice. They just need the advanced theoretical and methodological skills to do so. Fogarty-sponsored training provides that.
Tell us about your accomplishments in Indonesia. For nearly 23 years, I directed the UIC AIDS International Training and Research Program (the UIC-AITRP) with six universities in four countries: Indonesia, Chile, Malawi, and China. The program included short-term and MPH
Judith Levy is Associate Professor Emerita in Health Policy and Administration at University of Illinois in Chicago (UIC) and Director of the Fogarty UIC/Atma Jaya Catholic University Training Program in Advanced Research Methods and Translational Science. She earned a Ph.D. in sociology from Northwestern University. Her pioneering work in HIV/AIDS research over the last four decades has appeared in prestigious journals and publications.
Papua New Guinea has the highest rates of HIV infection in Indonesia. Prevention efforts among indigenous populations have little success due to geographic, socioeconomic, and cultural barriers. Through NIAID funding, Drs. Robert Bailey (UIC), Ignatius Praptoraharjo (AJCU/ARC), and I are partnering with the Papua indigenous community to develop and pilot a voluntary, indigenous model of medical male circumcision. This onetime prevention method is well-suited for a population that cannot consistently access prevention supplies and distrusts outside efforts to promote safer behavior.
Judith Levy is Associate Professor Emerita in Health Policy and Administration at University of Illinois in Chicago (UIC) and Director of the Fogarty UIC/Atma Jaya Catholic University Training Program in Advanced Research Methods and Translational Science. She earned a Ph.D. in sociology from Northwestern University. Her pioneering work in HIV/AIDS research over the last four decades has appeared in prestigious journals and publications.
As to why global health research, I grew up on the islands of Maui and Oahu in pre-state Hawaii. The islands’ rich cultural heritage and blending of many ethnic and racial populations greatly influenced the tenor and direction of my research. Also, at the start of the AIDS pandemic, I participated on the advisory team that WHO convened to develop what were then the first guidelines for studying HIV risk behavior in multiple countries. The natural next step was to conduct my own international research while encouraging others to do so.
In Indonesia, returning UIC-AITRP trainees founded AIDS research programs at both AJCU and the College of Nursing, University of Indonesia. Later, Professor Irwanto, our first postdoc, partnered with me to successfully develop AJCU’s existing AIDS research program into an AIDS Research Center (ARC) serving faculty, students, and researchers across the archipelago. Based on ARC’s success— buttressed by continuing Fogarty training and capacity-building—Dr. Evi Sukmaningrum, who earned her doctorate as a UIC-AITRP trainee, spearheaded the effort to have ARC formally designated a “Center of Excellence” in research and training by the Indonesian Ministry of Education and Culture. This designation recognizes ARC’s contributions to AIDS research in health policy and social innovation.
T
ministry of health in 2014, helped accelerate the development and clinical research of vaccines and therapeutics for Ebola. This program has been instrumental in testing vaccine candidates and developing therapeutics and has contributed to many of the research findings we have today. Fogarty has been able to leverage what NIAID started in West Africa to help build longterm sustainable capacity for research in the region.
So far in 2022, an Ebola outbreak was declared in the DRC, a small outbreak of leptospirosis is being tracked in Tanzania, and Marburg was reported in Ghana. This while the world is still grappling with the effects of the COVID-19 pandemic and the expanding monkeypox global health emergency. Capacity-building projects like the ones Fogarty funded in West Africa after the 2014-2016 Ebola outbreak can help meet this global need to prevent future epidemics.
Elizabethresearchers.Higgs, a Global Health Science Advisor with NIAID, who was part of the team that initially launched the PREVAIL study in Liberia, said, “There is no quick fix, but this is how it starts. Ten years from now West Africa could be in a very different place due to these investments.”
Fogarty’s response to Ebola: Where are we now?
T
The research community has learned much more about Ebola since 2014. This colorized micrograph shows Ebola virus particles (blue) budding from an infected cell (yellow-green).
So far in 2022, an Ebola outbreak was declared in the DRC, a small outbreak of leptospirosis is being tracked in Tanzania, and Marburg was reported in Ghana. This while the world is still grappling with the effects of the COVID-19 pandemic and the expanding monkeypox global health emergency. Capacity-building projects like the ones Fogarty funded in West Africa after the 2014-2016 Ebola outbreak can help meet this global need to prevent future epidemics.
6
FOCUS FOCUS
The research community has learned much more about the Ebola virus since 2014. Today, we have an Ebola vaccine that has already been used to help control outbreaks in the Democratic Republic of Congo (DRC) and monoclonal antibody therapeutics to treat the virus and prevent new outbreaks in the region. Scientists are now even looking at the potential of using the Ebola virus to benefit cancer patients, as some studies have shown that elements of the virus can be used to treat glioblastomas, a deadly brain tumor for which there is currently no cure.
Many healthcare workers who participated in the initial Ebola efforts and the PREVAIL studies have become trainees in Fogartyfunded programs, pursuing higher education and conducting independent research. Four of Fogarty’s capacity-building programs in the region—the Mali-Guinea Emerging Infectious Disease Research Training Program, the Training in Clinical and Epidemiological Research for Liberia (TRACER) program, the Boston University and University of Liberia Partnership to Enhance Emerging Epidemic Virus Research (BULEEVR), and the Partnership for Research in Emerging Viral Infections-Sierra Leone (PREVSL) — all aim to help West Africa grow the next generation of infectious disease
“
he public health system in West Africa was simply not built to combat a virus like Ebola in 2014. Without any approved vaccines or therapeutics at the time, the lack of medical personnel, supplies, and personal protective equipment meant that fighting an outbreak of this magnitude would be an uphill battle without intervention from outside the region. Liberia, Guinea, and Sierra Leone were the three countries most impacted by the outbreak, and in total more than 11,300 lost their lives.
ministry of health in 2014, helped accelerate the development and clinical research of vaccines and therapeutics for Ebola. This program has been instrumental in testing vaccine candidates and developing therapeutics and has contributed to many of the research findings we have today. Fogarty has been able to leverage what NIAID started in West Africa to help build longterm sustainable capacity for research in the region.
FOCUS 6 FOCUS
The research community has learned much more about Ebola since 2014. This colorized micrograph shows Ebola virus particles (blue) budding from an infected cell (yellow-green).
he public health system in West Africa was simply not built to combat a virus like Ebola in 2014. Without any approved vaccines or therapeutics at the time, the lack of medical personnel, supplies, and personal protective equipment meant that fighting an outbreak of this magnitude would be an uphill battle without intervention from outside the region. Liberia, Guinea, and Sierra Leone were the three countries most impacted by the outbreak, and in total more than 11,300 lost their lives.
Unfortunately, we have also learned that Ebola can linger in disease-privileged sites like the eye, brain, and urogenital system for several years after infection and, in some cases, has reinfected survivors. Ebola’s longterm side effects include fertility issues, cataracts, and
Unfortunately, we have also learned that Ebola can linger in disease-privileged sites like the eye, brain, and urogenital system for several years after infection and, in some cases, has reinfected survivors. Ebola’s longterm side effects include fertility issues, cataracts, and
NIAIDofcourtesyPhoto
Theblindness.National
Theblindness.National
Fogarty has been able to leverage what NIAID started in West Africa to help build long-term sustainable capacity for research in the region. ”
Fogarty’s response to Ebola: Where are we now?
Fogarty has been able to leverage what NIAID started in West Africa to help build long-term sustainable capacity for research in the region.
“ ” 53
Institute of Allergy and Infectious Diseases (NIAID) Partnership for Research on Ebola Virus in Liberia (PREVAIL) program developed with the Liberian
The research community has learned much more about the Ebola virus since 2014. Today, we have an Ebola vaccine that has already been used to help control outbreaks in the Democratic Republic of Congo (DRC) and monoclonal antibody therapeutics to treat the virus and prevent new outbreaks in the region. Scientists are now even looking at the potential of using the Ebola virus to benefit cancer patients, as some studies have shown that elements of the virus can be used to treat glioblastomas, a deadly brain tumor for which there is currently no cure.
NIAIDofcourtesyPhoto
Institute of Allergy and Infectious Diseases (NIAID) Partnership for Research on Ebola Virus in Liberia (PREVAIL) program developed with the Liberian
a Global Health Science Advisor with NIAID, who was part of the team that initially launched the PREVAIL study in Liberia, said, “There is no quick fix, but this is how it starts. Ten years from now West Africa could be in a very different place due to these investments.”
Elizabethresearchers.Higgs,
Many healthcare workers who participated in the initial Ebola efforts and the PREVAIL studies have become trainees in Fogartyfunded programs, pursuing higher education and conducting independent research. Four of Fogarty’s capacity-building programs in the region—the Mali-Guinea Emerging Infectious Disease Research Training Program, the Training in Clinical and Epidemiological Research for Liberia (TRACER) program, the Boston University and University of Liberia Partnership to Enhance Emerging Epidemic Virus Research (BULEEVR), and the Partnership for Research in Emerging Viral Infections-Sierra Leone (PREVSL) — all aim to help West Africa grow the next generation of infectious disease
When the Ebola epidemic first hit Liberia in late 2013, there were fewer than 200 medical doctors, let alone researchers in the country to manage or survey the outbreak, according to the WHO. At that time, Dr. Soka Moses had just completed his medical degree at the University of Liberia and was volunteering at the John F. Kennedy Hospital in Monrovia. “There was so much panic,” said Moses. “Health facilities were closed, and many doctors were getting infected.” That initial outbreak lasted until 2015 and led to more than 5,000 deaths in the Sincecountry.then,
Dr. Jeffrey Martin is a principal investigator on the TRACER program and Chief of the Division of Clinical Epidemiology and Health Services Research at UCSF, co-directing TRACER alongside his UCSF colleague Dr. Krysia Lindan, a professor of epidemiology and biostatistics. Dr. Martin says, “If our ultimate goal is to promote equity in education and develop a workforce of independent investigators and researchers who can study the issues in countries like Liberia, we need to ensure that local emerging scientists have access to the same level of training that we have in the U.S. It is our responsibility as scientists in the U.S. to give back to our profession and train others who do not have the same infrastructure and opportunity.”
BULEEVR is fostering a culture of science in Liberia by increasing human capacity in the country to support new and existing research initiatives focused on emerging pathogens. Through training boot camps and mentorship for health care professionals, technicians, educators, and future researchers, leaders of the BULEEVR partnership
his colleagues exemplify what the future could hold for TRACER and similar programs in Liberia. “I am learning skills that strengthen my research abilities with this program for the first time,” said Moses. “It has given me the skills I need to conduct rigorous high-quality research that holds up to the international standard.”
are identifying candidates for doctoral-level training in translational research, public health, and basic sciences.
TRACER provides emerging researchers in Liberia with lecture-based, mentored, and experiential training in clinical and epidemiological research targeting Ebola, Lassa fever, malaria, and other infectious diseases. Trainees work on research projects happening in-country while working on their master’s in clinical research at UCSF, taking the knowledge learned in the classroom to inform their protocols.
Liberia has been focused on rebuilding its medical and research infrastructure with support and funding from the NIH, CDC, USAID, and other institutions. Two critical building blocks in that research infrastructure are the Training in Clinical and Epidemiological Research (TRACER) program, in which Dr. Moses is currently a research scholar, and the Boston University and University of Liberia Partnership to Enhance Emerging Epidemic Virus Research (BULEEVR).
7 FOCUS ON EBOLA 54 Delaware Journal of Public Health - August 2022
Dr. Soka Moses poses with volunteers as they prepare to discharge Ebola-nega tive patients at Ebola treatment unit one at John F. Kennedy Memorial Hospital in Monrovia, Liberia in 2014.
TRACER is a collaboration between the University of California San Francisco (UCSF), the National Public Health Institute of Liberia, the University of Liberia, and the Partnership for Research on Vaccines and Infectious Diseases in Liberia (PREVAIL), a U.S.-Liberia project managed by the National Institute of Allergy and Infectious Diseases (NIAID).
Training programs like TRACER, though small, are essential to ensure there are trained researchers and medical research infrastructure in those countries hardest hit by the ever-growing risk of viral diseases and to prevent future endemics and pandemics.
FOCUS ON COVID AWARDS
MosesSokaDr.ofcourtesyPhoto
Building a bench of researchers in post-Ebola Liberia
TRACER currently has three trainees, Dr. Cozie Gwaikolo, Dr. Soka Moses, and Mr. Moses Badio, all of whom are participating in PREVAIL projects during their training. Dr. Gwaikolo and Mr. Badio are both engaged in a PREVAIL project studying short- and long-term symptoms associated with COVID-19. Dr. Moses has been involved in several Ebola-related research projects, including a study funded by the National Institute on Minority Health and Health Disparities (NIMHD), which found that age was one of several risk factors contributing to Ebola persistence in Hesemen.and
“After years of intentional investment in the region, Mali has become a scientific powerhouse in terms of malaria research,” said Elizabeth Higgs, a Global Health Science Advisor with NIAID, who was part of the team who initially launched the Partnership for Research on Vaccines and Infectious Diseases in Liberia (PREVAIL) study. “Fogarty programs like these [planning grants] are essential to building capacity and developing this cadre of scientists, prepared to fight future outbreaks.”
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Between the two nations, there were over 3,800 confirmed cases of Ebola and almost 2,600 deaths. Of these, only eight cases (and six deaths) occurred in Mali, according to the CDC. During the Guinea outbreak, Mali supported Guineans wherever possible, forging a collaborative partnership between the two nations.
Dr. Seydou Doumbia working in the UCRC laboratory, an initiative of the Malian government, the University of Science, Techniques, and Technologies of Bamako, and NIAID.
PartneringEBOLA to fight viral diseases in West Africa
The Mali-Guinea Emerging Infectious Disease Research Training Program (Mali-Guinea EID-RTP) is a new program funded by Fogarty and the National Institute of Allergy and Infectious Diseases (NIAID) that will strengthen this ongoing South-South collaboration between the University of Science, Techniques, and Technologies of Bamako (USTT-B) in Mali and the University of Conakry in Guinea. The program will also draw on the expertise of researchers from NIAID, Johns Hopkins University, and Northwestern University. The program will be run by principal investigators (PIs) who worked on the front lines of the Ebola outbreak.
Dia/UCRCIbrahimaofcourtesyPhoto FOCUS ON
The first case of the 2014-2016 Ebola outbreak was traced back to a child in Guinea who was infected with the virus three months before an outbreak was declared. Guinea was one of the countries hardest hit by the virus. Another West African nation, Mali, was able to contain the virus much faster than their neighbors to the north.
This partnership came to fruition through the Fogartyfunded planning grants established in 2016. Because of the geographic and cultural proximity of the two nations, it was a natural fit. Culturally Mali and Guinea have many similarities as both are francophone nations in a region where English is the predominant language in academia. The program anticipates that the research landscape for the next disease outbreak will look very different in Guinea by building up the research infrastructure there. Mali is a prime example of how that could look.
The Mali-Guinea Emerging Infectious Disease Research Training Program was met with enthusiasm from ministers of health across the region and aims to train six doctoral students and 15 master’s students over the next five years. Doumbia says, “This program will be a tremendous resource. Not only for Mali and Guinea but for West Africa and other francophone countries throughout the continent.”
“A unique factor of this program is that we will be performing genomic surveillance of emerging infectious pathogens, something we have not been able to do with previous grants,” said Dr. Seydou Doumbia, a PI in the training program. Doumbia is the Dean of the Faculty of Medicine and Odontostomatology at USTT-B. He is also
the Director of the University Clinical Research Center (UCRC) at Bamako.
Mali faired far more favorably during the Ebola epidemic in comparison to its neighbors due to almost 30 years of investment into malaria research and the establishment of the Malaria Research and Training Center (MRTC) at the National School of Medicine and Pharmacy, which has facilitated research with NIAID and other international partners. “Having the NIH lab there allowed us to avoid delays in diagnosis, prevent the spread of disease, and prepare for future cases,” said Doumbia.
The UCRC laboratory was initially established to study malaria and tuberculosis. However, because of the existing infrastructure, they could quickly switch gears to test and isolate Ebola cases and conduct contact tracing, further discouraging the spread of the disease in the country.
Dr. John S. Schieffelin, associate professor of pediatrics and medicine at Tulane University, is a co-PI on the project. He explains, “Programs like this are so important in a country where there just aren’t enough doctors, even the ones who are interested in research have so much clinical work it's hard for them to find the time, and it's understandably not a priority.”
Fogarty developed a targeted planning grant during that initial outbreak to encourage increasing scientific capacity in Liberia, Sierra Leone, and Guinea. That planning grant revealed that one of the most significant issues beyond the lack of physical infrastructure to do research in the region was the absence of trained researchers. Dr. Troy Moon, a professor of pediatrics in the Division of Infectious Diseases at Vanderbilt University Medical Center, is a principal investigator (PI) in the Partnership for Research in Emerging Viral Infections-Sierra Leone, or PREVSL, program who has worked on capacity-building projects in Mozambique throughout much of his career. “The Ebola outbreak highlighted that Sierra Leone and much of West Africa had not benefited from the same health system strengthening activities that occurred in other African countries,” he said. “We were starting from scratch in many ways.”
DevelopingEBOLA a new generation of researchers in Sierra Leone
56 Delaware Journal of Public Health - August 2022
Leone had almost 600 doctors, and its public health system has been bolstered by investment in the region. While this is a positive change in the healthcare workforce since 2014, there is still plenty of work to be done to serve the almost 8 million people living in the country today.
is currently involved in a project studying how antibiotics were prescribed to patients co-infected with malaria and Ebola during the 2014-2016 outbreak. Dr. Samuels, a physician-scientist at the Kenema Government Hospital (KGH), has completed a study looking at the prevalence of respiratory syncytial virus (RSV) and influenza in hospitalized infants and toddlers in Sierra Leone. He also recently completed another study on preexisting humoral immunity to human coronaviruses and/or SARS-CoV-2. Dr. Samuels says one of PREVSL’s biggest benefits was the mentorship. “Because of my mentors, I felt empowered to translate science, write proposals, and be an independent Asresearcher.”of2018,Sierra
9 FOCUS ON
master's in clinical investigations from Vanderbilt University School of Medicine along with a concurrent vaccine fellowship at the Vanderbilt Vaccine Research Dr.Program.Morovia
So far, PREVSL has had two trainees, Dr. Foday Morovia and Dr. Robert Samuels, who has already received his
PREVSL has enrolled another student on track to start the degree portion of their training in late 2022, along with several new staff members. Incremental progress from programs like PREVSL moves the needle and gets other physicians in the region excited and interested in research that can have a long-term impact. Dr. Samuels remarked, “I implore young researchers to consider these viral hemorrhagic fevers like Ebola and Lassa fever so that we can build researchers in this area and strengthen our knowledge. These outbreaks mostly affect low- and middle-income countries and can have devastating consequences.”
The Fogarty-funded PREVSL program is a partnership between Tulane University, Vanderbilt University Medical Center, the University of Sierra Leone, and Kenema Government Hospital (KGH). The program aims to train a new generation of researchers in implementation science while strengthening clinical trial capacity. PREVSL also aims to advance clinical and translational research on delivering quality health services for endemic viral hemorrhagic fevers like Lassa fever while simultaneously building the knowledge and skills of trainees in-country to conduct higher-level clinical trial research during an epidemic like Ebola.
Dr. Robert Samuels (second from left), a former PREVSL trainee, meets with patients as part of his study on preexisting immunity in Ebola and Lassa fever survivors.
Sierra Leone, with an estimated 134 doctors for almost 7 million people at the time, severely lacked the infrastructure needed to fight a deadly virus like Ebola in 2014. Nearly 4,000 died of the disease before the country was declared Ebola-free in November 2015.
SamuelsRobertDr.ofcourtesyofPhoto
Training in Clinical and Epidemiological Research for Liberia program coalesces University of California San Francisco, the National Public Health Institute of Liberia, the University of Liberia, and Partnership for Research on Ebola Virus in Liberia, an NIH initiative. This four-part alliance trains Liberian early-career investigators who are focused on epidemiological research of Ebola, acute febrile illness, and malaria. The curriculum strengthens research skills in Liberia while improving the country’s ability to respond to infectious disease threats.
Fogarty’s support of Ebola research is a point of pride
The focus of this edition of Global Health Matters is the scientific lessons learned since the devastating Ebola outbreak of 2014–2016. Unlike the previous known occurrences of Ebola, the outbreak which began in 2014 struck countries recovering from conflict and lacking the health infrastructure and numbers of trained personnel to effectively deal with the problem. When the epidemic ended more than two years later, suspected and confirmed cases rose above 28,600, while reported deaths topped 11,300.
OPINION
University of Bamako in Mali, University of Conakry in Guinea, Johns Hopkins University, and the National Institute of Allergy and Infectious Diseases joined forces to create the Mali-Guinea Emerging Infectious Disease Research Training Program. This Fogartysupported endeavor provides high-level training in field and laboratory epidemiology, translational clinical research, public health emergency management, and genomic characterization and surveillance of emerging
From the start, Fogarty recognized that the greatest contribution we could make would be a commitment to ongoing, long-term strengthening of research capacity and health systems in West Africa through training. We believe even a modest investment in training can provide the tools low-resource countries require to halt outbreaks and prevent the need for large-scale emergency efforts like the one assembled to fight Ebola. Fogarty understands that preparedness is always less costly than an emergency Inresponse.theyears
Fogarty’s support of Ebola research is a point of pride
Finally,pathogens.our
of Medicine and Allied Health Sciences, Kenema Government Hospital, Vanderbilt Institute for Global Health, and Tulane University. This training partnership emphasizes clinical and translational research focused on the delivery of quality health services for endemic viral hemorrhagic fevers, like Lassa fever. The intention is to develop the capability to conduct clinical trial research during epidemics and outbreaks, as was done during the Ebola crisis.
University of Bamako in Mali, University of Conakry in Guinea, Johns Hopkins University, and the National Institute of Allergy and Infectious Diseases joined forces to create the Mali-Guinea Emerging Infectious Disease Research Training Program. This Fogartysupported endeavor provides high-level training in field and laboratory epidemiology, translational clinical research, public health emergency management, and genomic characterization and surveillance of emerging
Finally,pathogens.our
By Dr. Roger I. Glass, Director, Fogarty International Center
By Dr. Roger I. Glass, Director, Fogarty International Center
since the Ebola crisis ended—in the years when most others looked away—we have continued to support the development of West African health infrastructure through training. One Fogarty supported program unites Boston University (BU), University of Liberia (UL), and regional affiliates. The BU-UL Partnership to Enhance Emerging Epidemic Virus Research in Liberia includes a bootcamp to develop basic, translational, and clinical research skills in Liberia. From there, select candidates pursue an advanced degree at BU before returning to Liberia to conduct research projects that build sustainability while retaining intellectual capital
57
The impact of this outbreak on West Africa was momentous. Initially, health officials and care providers in the hardest hit countries of Liberia, Sierra Leone, and Guinea were overwhelmed by the record numbers of people sickened by the hemorrhagic virus and could pay little attention to studying the epidemiology of the outbreak.
The focus of this edition of Global Health Matters is the scientific lessons learned since the devastating Ebola outbreak of 2014–2016. Unlike the previous known occurrences of Ebola, the outbreak which began in 2014 struck countries recovering from conflict and lacking the health infrastructure and numbers of trained personnel to effectively deal with the problem. When the epidemic ended more than two years later, suspected and confirmed cases rose above 28,600, while reported deaths topped 11,300.
West Africa’s Ebola epidemic showed all the world the value of training scientists and research professionals who will then be capable of studying and responding to future emerging infectious disease outbreaks. Meanwhile, the ongoing COVID-19 pandemic has shown us that the training done in West Africa provided the foundation we hoped for. One example is Dr. Christian Happi, who, following the Ebola crisis, established a metagenomic platform that enabled his team to sequence the whole genome of the first SARS-CoV-2 in Africa. Global health security requires trained scientists and robust health and research systems across the globe. We at Fogarty are proud to contribute to this mission by continuously strengthening local health research through training.
10
of Medicine and Allied Health Sciences, Kenema Government Hospital, Vanderbilt Institute for Global Health, and Tulane University. This training partnership emphasizes clinical and translational research focused on the delivery of quality health services for endemic viral hemorrhagic fevers, like Lassa fever. The intention is to develop the capability to conduct clinical trial research during epidemics and outbreaks, as was done during the Ebola crisis.
Training in Clinical and Epidemiological Research for Liberia program coalesces University of California San Francisco, the National Public Health Institute of Liberia, the University of Liberia, and Partnership for Research on Ebola Virus in Liberia, an NIH initiative. This four-part alliance trains Liberian early-career investigators who are focused on epidemiological research of Ebola, acute febrile illness, and malaria. The curriculum strengthens research skills in Liberia while improving the country’s ability to respond to infectious disease threats.
Anotherin-country.ofour
West Africa’s Ebola epidemic showed all the world the value of training scientists and research professionals who will then be capable of studying and responding to future emerging infectious disease outbreaks. Meanwhile, the ongoing COVID-19 pandemic has shown us that the training done in West Africa provided the foundation we hoped for. One example is Dr. Christian Happi, who, following the Ebola crisis, established a metagenomic platform that enabled his team to sequence the whole genome of the first SARS-CoV-2 in Africa. Global health security requires trained scientists and robust health and research systems across the globe. We at Fogarty are proud to contribute to this mission by continuously strengthening local health research through training.
programs, the Partnership for Research in Emerging Viral Infections-Sierra Leone, forms a collaboration among the University of Sierra Leone College
OPINION
programs, the Partnership for Research in Emerging Viral Infections-Sierra Leone, forms a collaboration among the University of Sierra Leone College
since the Ebola crisis ended—in the years when most others looked away—we have continued to support the development of West African health infrastructure through training. One Fogarty supported program unites Boston University (BU), University of Liberia (UL), and regional affiliates. The BU-UL Partnership to Enhance Emerging Epidemic Virus Research in Liberia includes a bootcamp to develop basic, translational, and clinical research skills in Liberia. From there, select candidates pursue an advanced degree at BU before returning to Liberia to conduct research projects that build sustainability while retaining intellectual capital
From the start, Fogarty recognized that the greatest contribution we could make would be a commitment to ongoing, long-term strengthening of research capacity and health systems in West Africa through training. We believe even a modest investment in training can provide the tools low-resource countries require to halt outbreaks and prevent the need for large-scale emergency efforts like the one assembled to fight Ebola. Fogarty understands that preparedness is always less costly than an emergency Inresponse.theyears
10
The impact of this outbreak on West Africa was momentous. Initially, health officials and care providers in the hardest hit countries of Liberia, Sierra Leone, and Guinea were overwhelmed by the record numbers of people sickened by the hemorrhagic virus and could pay little attention to studying the epidemiology of the outbreak.
Anotherin-country.ofour
HIV testing and case identification among children and adolescents in 22 PEPFAR-supported countries decreased by between 29% to 40% in October 2019–September 2020. The analysis, published in the CDC Morbidity and Mortality Weekly Report (MMWR), suggests that progress toward UNAIDS targets has been negatively affected by the COVID-19 pandemic.
Dr. Ann Kurth, an epidemiologist and Dean of the Yale School of Nursing, will lead the New York Academy of Medicine, the first nurse to hold the position. Dr. Kurth's research focuses on HIV/ reproductive health and global health system strengthening in the context of pandemics, climate change, and other stresses. She also co-founded the Yale Institute for Global Health.
Former CUGH chair to lead NY Academy of Medicine
Fogarty grantee wins maternal health challenge
The CDC approved the establishment of the Office of the Associate Director for Global Health Diplomacy and Strategy (CAE) in July. The new office will advise and represent the CDC Director on agency-wide global health strategies and coordinate policies and priorities focused on achieving maximum public health impact in support of the agency mission.
HEALTH Briefs GlobalPEOPLE
The GW Milken School of Public Health launched a new center dedicated to addressing health disparities and improving public health in the Caribbean and Latin America. One of the center’s goals is to provide training opportunities for students, scientists, and organizations serving Caribbean and Latin American communities.
Professor Clement Adebamowo received the Jeff Cohen Service Award from Public Responsibility in Medicine & Research (PRIM&R) in recognition of his work in research ethics. He is the Director for Global Health Cancer Research at the University of Maryland School of Medicine and directs the Fogarty-funded Eastern Nigeria Research Ethics Training (ENRICH) Program.
El-Sadr to lead new global program
Long-time grantee receives PRIM&R service award
58 Delaware Journal of Public Health - August 2022
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New center for Caribbean/Latin American health
WHO publishes mental health report
Dr. Bethany Hedt-Gauthier, Associate Professor of Global Health & Social Medicine at Harvard T.H. Chan School of Public Health, won first place in the NIH Maternal Health Diagnostics Challenge for mHealth tools developed by her Fogarty-funded project enabling community health workers to monitor postpartum recovery by women following cesarean delivery in Rwanda.
Sewankambo recognized for his work in global bioethics
Professor Nelson Sewankambo received the inaugural GLIDE Global Health Ethics Leadership Award in recognition of his contributions to global bioethics. Sewankambo, a long-time Fogarty grantee, helped build the THRiVE research capacity strengthening consortium and is director of the Fogarty-funded Makerere University International Bioethics Research Training Program.
Vanderbilt names new Global Health Director
The Stop TB Partnership unveiled their Global Plan to End TB 2023-2030 which outlines priority actions–including early diagnosis, scaling up prevention efforts, and developing a TB vaccine–and estimates financial resources needed to end TB as a global health threat by 2030.
Former Fogarty board member Dr. Wafaa El-Sadr was appointed Executive Vice President for Columbia Global at Columbia University. This new umbrella program will bring together the university’s global projects including Columbia’s Global Centers. Dr. El-Sadr is Founder and Director of ICAP.
Dr. Muktar Aliyu has been named Director of the Vanderbilt Institute for Global Health. Aliyu, a renowned physician and epidemiologist born and raised in Nigeria, led several Fogartyfunded programs at Vanderbilt, including the Building Research Capacity in HIV/Non-communicable Diseases program in Nigeria.
CDC establishes global health diplomacy office
TB Partnership releases plan to end TB by 2030
Pandemic led to less child HIV testing
The World mental health report: transforming mental health for all, the WHO’s largest review of mental health in 20 years, provides guidance for governments, academics, health professionals, and others; showcases examples of good practice from around the world; and outlines global threats to mental health.
July/August 2022
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Designer: Carla Conway
Japanese Research Fellowships (JSPS)
The UN Sustainable Development Goals did not achieve its target of halving the number of road traffic deaths by 2020, explained the authors led by Fogarty grantee Dr. Adnan Hyder of the George Washington University Milken Institute School of Public Health. In fact, no low-income country and less than a quarter of middle-income countries have seen a decrease in the number of road deaths over the past decade.
Preventing road injuries saves countless lives
Writer/editor:Judith.Coan-Stevens@nih.govCoan-StevensMariahFelipeMariah.Felipe@nih.govWriter/editor:SusanScuttiSusan.Scutti@nih.gov
The study data include first-ever nation-specific estimates (for 185 countries) of the positive effects of addressing road safety. These estimates can be used as a starting point for public officials to change policies and shape priorities, the authors stated.
Funding Opportunity Announcement Deadline Details
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The global toll of road traffic injuries is immense, causing more than 50 million injuries and disabilities and ending 1.35 million lives each year, according to a series of articles published in The Lancet.
Worse, 104 countries showed an increase in deaths during that period. The authors estimate that proven interventions—such as reducing speed limits and drunk driving incidents, along with using helmets, seatbelts, and child restraints—could prevent 25-40% of fatal road injuries. These measures would especially benefit low- and middle-income countries, where more than 90% of road traffic deaths occur. While prevention is the cornerstone for saving lives, improved post-crash care could also reduce mortality by 35%.
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Volume 21, No. 4 ISSN: 1938-5935
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The risk of road traffic deaths is nearly three times higher in low-income countries than highincome ones.
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Fulbright-Fogarty Fellowships in Public Health
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Objective: The DSU COVID-19 study aims to understand the response to and impact of COVID-19 in nine underserved communities in Delaware and to inform public health messaging. In this article, we describe our community engaged research approach and discuss the benefits of community engaged research in creating place-based health interventions designed to reduce entrenched health disparities and to respond to emerging or unforeseen health crises. We also highlight the necessity of sustained community engagement in addressing entrenched health disparities most prevalent in underserved communities and in being prepared for emerging and unforeseen health crises. Method: Our study is a longitudinal study comprised of three waves: initial, six months follow-up, and twelve months follow-up. Each wave consists of a structured survey administered on an iPad and a serology test. Through community engaged research techniques, a network of community partners, including trusted community facilities serving as study sites, collaborates on study implementation, data interpretation, and informing public health messaging. Results: The community engaged approach (CEnR) proved effective in recruiting 1,086 study participants from nine underserved communities in Delaware. The research team built a strong, trusting rapport in the communities and served as a resource for accurate information about COVID-19 and vaccinations. Community partners strengthened their research capacity. Collaboratively, researchers and community partners informed public health messaging. Conclusion: The partnerships developed through CEnR allow for place-based tailored health interventions and education. Policy Implications: CEnR continues to be effective in creating mutually beneficial partnerships among researchers, community partners, and community residents. However, CEnR by nature is transactional. Without sustained partnerships with and in underserved communities, we will make little progress in impacting health disparities and will be ill-prepared to respond to emerging or unforeseen health crises. We recommend that population health strategies include sustainable research practice partnerships (RPPs) to increase their impact.
The Benefits of Community Engaged Research in Creating Place-Based Responses to COVID-19
Matthew Billie Delaware State University
Studies within states highlight the race/ethnic groups most impacted by COVID-19. In Massachusetts, infection and death rates were “highly correlated with race and poverty.”4 An analysis of COVID-19 death rates among Latinx in California found that COVID-19 mortality rates were highest among the poorest.4 Similar trends are evident in Delaware. Early in the pandemic (July 2020), the COVID-19 infection rate was 129/10,000 with Blacks three times as likely and Hispanic seven times as likely to contract COVID-19 than were non-Hispanic Whites. COVID-19 also showed a differential impact by location and race/ethnicity. In New Castle County, the overall infection rate was 95/10,000 but only 58.6 among Whites compared to 150 among Blacks and an astonishing 387.2 among Hispanics. In Kent County, the overall rate was 100/10,000, with a 53.7 positive rate among Whites yet 145.2 among Blacks and a 180.6 among Latinx. The overall COVID-19 infection rate was 2.5 times higher in Sussex County than either Kent or New Castle counties. Similarly, the race/ethnic disparities were also exacerbated with an 80.9 rate among Whites, 294.9 among Blacks, and a staggering 928/10,000 among Latinx.5
DOI: 10.32481/djph.2022.08.011
Sharron Xuanren Wang, Ph.D.
60 Delaware Journal of Public Health - August 2022
ABSTRACT
INTRODUCTION
The COVID-19 pandemic has affected poor people of color disproportionately. From the onset of the pandemic, racial/ethnic disparities in both cases and deaths were evident.1 Differences have persisted as new variants of COVID-19 have emerged. What may look like small differences when aggregated within race/ethnic groups is large when cumulative mortality rate ratios are considering. Bassett and colleagues2 found that the risk of dying from COVID-19 was greater among Blacks and Hispanics than among non-Hispanic Whites. Further analysis revealed that Blacks and Hispanics younger than 65 years dying as the result of COVID-19 were deprived of almost seven more years of life than non-Hispanic Whites younger than 65 years who died of COVID-19. These disparities by race/ethnicity are more significant than other major causes of death. Feldman and colleagues3 analyzed CDC data for all 50 states. They concluded that if COVID-19 mortality rates had been equal across race/ ethnic categories and income levels, COVID-19 deaths among race/ethnic groups would have been 71% lower.
Department of Sociology and Criminal Justice, Delaware State University
Delaware Institute of Science & Technology, Delaware State University
Dorothy Dillard, Ph.D.
Melissa A. Harrington, Ph.D.
Center for Neighborhood Revitalization and Research, Delaware State University
Nicole Bell-Rogers, Ed.D., F.N.P.-C., R.N.
Department of Nursing, Delaware State University
In response to the early signs of COVID-19’s disproportionate impact on lower income communities with a large proportion of Black and Brown residents, we initiated a longitudinal study to examine the impact of and response to COVID-19 in nine underserved communities in Delaware. We have completed the first wave of surveying and serology testing, successfully recruiting 1,085 respondents and building a strong network of community partners. Our experience highlights the role of community engaged research in addressing COVID-19 in underserved communities. More importantly, it underscores the necessity of maintaining partnerships with and in underserved communities if progress is to be made on reducing health disparities and if we are to be prepared for emerging or unforeseen health issues.
Our study, “Social and Behavioral Implications for COVID-19 Testing in Delaware’s Underrepresented Communities,” aims to understand the impact of and response to COVID-19 and to share what we learn with state and community partners to improve and tailor COVID-19 public health messaging. We selected nine underserved communities based on the Community Health Index (CHI), coupled with incidence of COVID-19 and COVID-19 testing rates. The CHI is a score calculated for each census tract by the Delaware Division of Public Health (DPH) based on health indicators. The CHI score ranges from 12.3 (better) to 208.6 (worse). DPH created a color-coded scoring mechanism to identify and track COVID-19 testing and positive rates by census tracts. Table 1 provides an overview of our study communities. All nine communities have high CHI scores, indicating higher rates of health issues among residents, and were ranked as medium or high priority by DPH’s COVID-19 response.
As of July 2022, the state-wide COVID-19 death rate/10,000 persons was 24.2. The rates by county were similar in New Castle County (22.6/10,000) and Sussex County (23.6/10,000) and slightly higher in Kent County (31.5/10,000),5 A closer look at the COVID-19 related death rates in underserved communities indicates alarming disparities. Looking at a selection of poorer communities, as indicated by Social Vulnerability Index scores of .90 or greater, the COVID-19 death rate is at least double and, in some cases, greater than four times the state rate. Although the factors affecting these disparities are many and complex, the impact of COVID-19 has mirrored that of many other health issues, disproportionately affecting poor communities of color. Research has established that zip code is a greater determinant of health than genetic code.6 We also know that access to healthcare and other services is more difficult for the poor, particularly for poor minorities.7 These realities are exacerbated by a justified mistrust of both science8 and medicine9 among Black and Brown Americans. Given these realities, understanding the impact of and response to COVID-19 in underserved communities requires a place specific approach.
Our study design is longitudinal with surveying and serology testing conducted at initial enrollment (Wave 1), six (6) months after enrollment (Wave 2), and 12 months after enrollment (Wave 3). Data collection includes the administration of a survey and a serology test. The Wave 1 survey, adapted from the COVID-19 Community Response Survey developed by Johns Hopkins University, includes questions about demographics, socioeconomic characteristics, COVID-19-related beliefs and practices, general health, and COVID-19 testing and vaccination. We revised the survey for Waves 2 and 3 to include additional vaccination questions. The serology test provides data on exposure to the COVID-19 infection, allowing for an objective measure of exposure. The study team is comprised of a project manager, DSU graduate nursing students, and DSU undergraduate students. The study team reflects the community in terms of race and ethnicity, including several DSU bilingual students.
STUDY DESIGN
KENT COUNTY SUSSEX COUNTY NEW CASTLE COUNTY Census Tracts 420 W.Camden BorderMD 418.02 DoverW. 430 Harrington 504.06 Seaford 503.01 Bridgeville 505.03 Georgetown 6.02 RunPricesNE 24&2322, Westside 30.02 Riverside Race Ethnicity& WhiteHispanicBlack 89.4%6.5%4.6% 30.9%11.4%60.2% 68.8%31.6%4.6% 59.5%37.8%13.9% 20%13%78% 48.9%12.6%73.7% 90.9%1.3%7.6% 50%45%30% 76.5%8.8%21.5% CHI 184.3 168 164 173 194.6 156 208.6 204.3 203.5 PriorityCOVID-19DPH Medium High High Medium High High Medium High Medium PartnerCommunity Study Facilities)(TrustedSites Sussex County Health Coalition Dover Education and Child Care Center; Solid Rock Baptist Church; Harrington VWF; Harrington Public Library Sussex County Health Coalition First State CAA; Miracle Revival Center; Seaford Public Library; Coverdale Community Center; Bridgeville Volunteer Fire Department Wilmington HOPE Commission WHC; Latin American Community Center; The Teen Warehouse Table 1. DSU COVID-19 Study Sites 61
Oursite.
Our proposal included SCHC as our community partner in Kent and Sussex Counties. WCAC was not able to take on the community partner role but remained a key partner in our research and dissemination efforts. Another community partner, the Wilmington HOPE Commission (WHC) agreed to serve as our community partner in New Castle County. SCHC and WHC are different in that SCHC is a coalition with an extensive network of partners and WHC is a service agency in direct contact with potential study participants. Both types of organizations benefit recruitment. SCHC relies on it network of service providers to advertise the study and recruit participants; whereas, WHC uses word of mouth and its clients to recruit. It is important to note that we compensate our community partners. Monetary compensation creates equity with community partners.
We have grown our network to include additional host sites, allowing the study team to work directly in several isolated rural communities. We have also partnered with two libraries, the Seaford and Harrington public libraries. Establishing study sites at these libraries allowed us access to potential study participants from our communities of interest. We extended our network to include two churches, both located directly in study communities and providing community outreach. Our community partners also identified individuals from the community who we compensated to translate the recruitment materials, consent forms, and survey into Spanish and Haitian Creole. Several community residents were hired to assist at the study sites, serving as translators and being a familiar face at the study
62 Delaware Journal of Public Health - August 2022
SCHCsite.and
CEnR is an essential component of translational research, primarily because it aims to include the subjects of research as participants making findings directly relevant and accessible to the target population. Much attention has been given to the importance of CEnR, including the DJPH September 2018 issue. However, less attention is paid to the difficulty of conducting community engaged research in the academic environment. CEnR emphasizes building capacity, improving trust, and translating knowledge to action. To build the trusting mutually beneficial relationship between research and community takes time and effort that is rarely funded, making it low priority and often discouraged. But without these relationships academic researchers are left flat footed when the race to secure funding starts because the time between funding announcement and proposal submission does not allow for building relationships with community partners. CEnR also emphasizes the involvement of community members in all stages of research, from framing the issue, creating the data collection instruments, and designing the study. This too is frequently not feasible in the timeframe for responding to research funding opportunities. Another set of issues emerges from the proposal review process. Proposal review panels frequently expect validated instruments or surveys in the public domain, prohibiting community input on the information collected. Validated instruments also lean toward generic and frequently academic language that excludes culturally and geographically relevant phrasing, increasing the likelihood of respondent misunderstanding. Review panels tend to score quantitative studies with large samples and sophisticated data analysis plans highest, forcing researchers to prioritize reviewer preferences over community needs. The publish or perish culture of academia coupled with its growing expectation of contributing to the institution’s research portfolio by securing external funding exacerbate the barriers to CEnR. We faced these common challenges as we responded to the NIH call for rapid response proposals to COVID-19. Although we were not able to fully engage our study communities during proposal development, we did rely on our existing community
partners, Sussex County Health Coalition (SCHC) and the Wilmington Community Advisory Council (WCAC), to help us shape our recruitment and participant engagement protocol and to connecting us to trusted facilities. Through their extended networks, SCHC and WCAC identified ten trusted facilities willing to serve as study sites.
WHC have primary responsibility for recruiting back and scheduling participants for Wave 2 and Wave 3, six and twelve months after initial enrollment. Our community partners lead the development of recruit-back processes, tailoring them for the study communities. Several techniques were employed, including phone calls and text messages. Participants were contacted for two weeks before and after their return date. With each contact, they are provided a study site schedule, allowing them to complete Wave 2 and Wave 3 at the most convenient
community partners also provide a platform to disseminate information about the study and findings. One of our primary study aims was to inform public health messaging by sharing findings continuously with our community and state partners. We have been fortunate to expand our network to include the Division of Public Health, university based cooperative extension programs, hospitals and COVID-19 response coalitions. We present findings as they become available, shortening the gap between research and practice. We work directly with DPH and two university cooperative extension teams informing tailored public health messaging. We also respond to partners’ request for information, allowing the community to identify the topics of concern and interest.
Using a community engaged approach, we leveraged existing partnerships with access to trusted service providers located in our study communities. Community-engaged research (CEnR) recognizes the historical mistreatment of marginalized groups in research and places the community first by involving research participants in all aspects of the research process (CEnR).10 It is an essential approach to understanding and addressing health issues because it focuses on research participants living in close proximity and sharing similar situational characteristics affecting their health. As such, CEnR is responsive to the centrality of place in addressing health disparities.
The study team employs COVID-19 safety protocol, including wearing masks, using partitions to separate participants while completing the survey and during serology testing and results discussion, and wiping down surfaces and iPads. Prior to entering the study site, the nurse screens potential participants for COVID-19 using CDC recommended screening procedures. If the screen indicates exposure to COVID-19 or COVID-19 symptoms, the potential participant is encouraged to get tested, provided with testing information, and asked to return to the study site when COVID-19 negative or when symptoms have resolved.
Both researchers and community partners benefit from community engaged research approaches. By leveraging the expertise of our community partners, we successfully recruited 1,086 study participants, 91% of our 1,200 participant target, in eight months during COVID-19 resurgences causing site closures. The differences in our recruitment rates by county underscore the importance of our partners. Our strongest partnerships are in New Castle County and in Sussex County. The recruitment rates in both those counties (103% in each county) were over twice the recruitment rate in Kent County (48%) where our community partners took longer to establish and were fewer than in the other two counties.
The study team’s consistent presence in the underserved communities increases trust of researchers. Building trust requires commitment and patience. As an example, the study team was at one remote community site for three weeks with no community participation despite extensive recruitment efforts. The third week a trusted member of the community came to the site to inquire about the activities. She participated in the study and the next week eight additional community members enrolled. The composition of the study team which reflects the residents of many of the study communities has also been key to building trust within the community. Participants have tracked their return dates and returned without reminders. Participants come by the study sites to confirm return dates and volunteer for future studies. Our study bolsters the participants’ confidence in COVID-19 initiatives such as masking, vaccination, and routine testing. We serve as a liaison to local health care resources and combat COVID-19 misinformation. The serology testing component of the study aids participants in gauging previous contact/infection and making decisions about vaccination.
DISCUSSION
One effective mechanism to maintain and strengthen community partnerships is to build on the foundation established by CEnR by supporting sustainable research practice partnerships (RPPs). Educational research has relied heavily on RPPs to improve teaching and learning.12 RPPs are designed explicitly to address persistent or entrenched problems by creating equitable partnerships between researchers and practitioners. Through these mutually respectful partnerships, researchers understand practice context (or community) making the research more relevant and practitioners understand and participate in research increasing data informed interventions. In RPPs, researchers support practice partners in achieving their service goals. They are less about peer reviewed publications and more focused on providing practice partners data designed for decision-making. Practice oriented analysis makes RPPs key in translational research. Research partners’ commitment to rigorous, scientifically sound research methodology ensures findings are valid and reliable and increases the likelihood findings are generalizable to similar contexts and populations. The methodological sound research strategy enables RPPs to inform academic and practice disciplines. RPPs offer a transformational partnership between researchers and practitioners, significantly shortening the science to practice translational gap.
THE BENEFITS OF COMMUNITY ENGAGED RESEARCH
Our CEnR approach has strengthened our community partners’ research muscle. Presentations educate our partners on community engaged research design and implementation, they provide a platform for community partners to ask questions and provide insight and more contextual, community-specific understanding of our research findings. They encourage community partners to ask questions, guiding our analyses and producing more community relevant findings. For example, our early analyses highlighted vaccine hesitancy.11 When we presented these early findings, community partners were interested in the reasons why participants were not vaccinated, more specific race/ethnic group analyses, and COVID-19 information sources used by study participants. We updated our vaccine hesitancy analyses addressing these community driven requests. We are currently engaging in small group discussions about the findings so we, research and community in collaboration, can focus on the implications of the findings for specific communities. This example also underscores how CEnR strengthens translational research. Our COVID-19 study includes an explicit aim to inform public health messaging, translating science to practice in real time. Frequent communication with community partners, provides the outreach workers critical information to better educate and advocate for their constituents.
Research practice partnerships (RPPs) are a natural outcome of CEnR and offer a sustainable strategy to address entrenched health disparities and to be positioned to respond to emerging and unforeseen health crises. The reality is that some health crises are unpreventable and, in some cases, unpredictable. However, we can be better prepared to respond to the unpredictable health crises and more effective in addressing the entrenched health disparities by responding to what we know and building on what we have.
As with most CEnR, significant effort has been extended to implement this study. And, we have once again been reminded that community engagement of any type requires time and patience and for it to be mutually beneficial it must put community first. We also learned that CEnR, as a form of community engagement, is worth the effort for researchers, community partners, and community residents. However, CEnR by nature is transactional. It exists as long as the study is funded, creating a new challenge: maintaining and strengthening community partnerships that are necessary to address health disparities in a tailored place/community specific approach. Without sustained partnerships with and in underserved communities, we will make little progress in impacting health disparities and will be ill-prepared to respond to emerging or unforeseen health crises.
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Our collaboration with study site host agencies has allowed us to respond to two new requests for proposals, both employing CEnR. During proposal development, we solicited input from an expanded network. The community partnerships we developed while implementing the COVID-19 study allowed us to engage two new community serving partners in these proposals. Both new partners are located in communities of interest and directly serve residents in these communities, strengthening our community focus as well as strengthening community research capacity.
Dr. Dillard may be contacted at ddillard@desu.edu
8. Scharff, D. P., Mathews, K. J., Jackson, P., Hoffsuemmer, J., Martin, E., & Edwards, D. (2010, August). More than Tuskegee: Understanding mistrust about research participation. Journal of Health Care for the Poor and Underserved, 21(3), 879 897 https://doi.org/10.1353/hpu.0.0323
ACKNOWLEDGEMENTS
12 Sjölund, S., Lindvall, J., Larsson, M., & Ryve, A. (2022) Mapping roles in research-practice partnerships – a systematic literature review. Educational Review, DOI: https://doi.org/10.1080/00131911.2021.2023103 https://www.tandfonline.com/doi/full/10.1080/00131911.2021.2023103
This project is supported by the National Institute of Health (Grant number: 3 P20 GM103653-09S1).
DISCLOSURES
11 Wang, S. X., Bell-Rogers, N., Dillard, D., & Harrington, M. A., & the FNP-c. (2021, September 27). COVID-19 vaccine hesitancy in Delaware’s underserved communities. Delaware Journal of Public Health, 7(4), 168 175 https://doi.org/10.32481/djph.2021.022
2. Bassett, M. T., Chen, J. T., & Krieger, N. (2020, October 20). Variation in racial/ethnic disparities in COVID-19 mortality by age in the United States: A cross-sectional study. PLoS Medicine, 17(10), e1003402 https://doi.org/10.1371/journal.pmed.1003402
4 Chen, J.T., Testa, C.,Waterman, P., Krieger, N. (2021). Intersectional inequities in COVID-19 mortality by race/ ethnicity and education in the United States, January 1, 2020–January 31, 2021. Harvard Center for Population and Development StudiesWorking Paper, 21(3)
5. Delaware. (2020). Coronaviruse Disease (COVID-19). Retrieved from https://coronavirus.delaware.gov/
This study could not have been implemented without the continuous assistance and support of our community partners and host sites. We are grateful for their collaboration. We also thank our students and nurses who have created a community friendly COVID-19 safe research environment.
REFERENCES
6. Lakhani, C. M., Tierney, B. T., Manrai, A. K., Yang, J., Visscher, P. M., & Patel, C. J. (2019, February). Repurposing large health insurance claims data to estimate genetic and environmental contributions in 560 phenotypes. Nature Genetics, 51(2), 327 334 https://doi.org/10.1038/s41588-018-0313-7
1. Mackey, K., Ayers, C. K., Kondo, K. K., Saha, S., Advani, S. M., Young, S., . . . Kansagara, D. (2021, March). Racial and ethnic disparities in COVID-19–related infections, hospitalizations, and deaths: A systematic review. Annals of Internal Medicine, 174(3), 362–373. https://doi.org/10.7326/M20-6306
7 Lazar, M., & Davenport, L. (2018, January-March). Barriers to health care access for low income families: A review of literature. Journal of Community Health Nursing, 35(1), 28 37. https://doi.org/10.1080/07370016.2018.1404832
10. Balls-Berry, J. E., & Acosta-Pérez, E. (2017, June). The use of community engaged research principles to improve health: Community academic partnerships for research. Puerto Rico Health Sciences Journal, 36(2), 84 85 https://pubmed.ncbi.nlm.nih.gov/28622404
We know that zip codes are a stronger determinant of health than genetic codes, underscoring the centrality of location in addressing health disparities and emphasizing the need to put location and, thus, community, first in all public health responses. We also know that mistrust of medicine and research continues to inhibit response to health disparities and health emergencies. A sustained partnership between researchers, community serving organizations and community residents through RPPs is necessary to create trust as well as produce and implement community defined responses to health disparities. Community engaged research techniques have proven effective as a research strategy and offer a starting point to create sustainable research practice partnerships that can advance science and improve the health conditions in underserved communities. Including RPPs in all population health strategies would increase the likelihood of decreasing health disparities and increase our preparedness to address emerging and unforeseen health crises.
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3 Feldman, J. M., & Bassett, M. T. (2021, November 1). Variation in COVID-19 mortality in the US by race and ethnicity and educational attainment. JAMA Network Open, 4(11), e2135967 https://doi.org/10.1001/jamanetworkopen.2021.35967
9 Birkhäuer, J., Gaab, J., Kossowsky, J., Hasler, S., Krummenacher, P., Werner, C., & Gerger, H. (2017, February 7). Trust in the health care professional and health outcome: A meta-analysis. PLoS One, 12(2), e0170988. https://doi.org/10.1371/journal.pone.0170988
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Make a family emergency communication plan and emergency wallet cards Tell relatives and friends where your family will relocate or if you will stay and shelter in place
• Non perishable food supply for three days, for humans and pets
June 1 marked the start of the 2022 hurricane season. As storms increase in severity, prepare in advance and heed the advice of emergency preparedness officials. Follow this guidance:
Create a household supply kit in case you lose power and water for several days, or if flooded or blocked roads prevent you from leaving. Include these contents:
Find vaccination and testing sites at https://coronavirus.delaware.gov/.
• Towels or rags, plastic sheeting, and duct tape For recommended supply lists, visit Ready.gov and PrepareDE.org or use the Federal Emergency Management Agency (FEMA) app.
• Water (at least one gallon per person per day) for three days. Remember drinking water for pets.
From the Delaware Division of Public Health June 202
• Battery-powered or hand crank radio, extra batteries, flashlight, utility knife, pliers
• First aid kit and medicines
Know Delaware’s evacuation routes. Visit deldot.maps.arcgis.com Have a plan for where you can stay.
The Division of Public Health (DPH) anticipates that the first shipments of pediatric COVID 19 vaccine will be delivered to requesting providers on June 20, with the first doses potentially being administered as early as June 21.
Prepare now for hurricanes
Stay informed. Sign up for Emergency Alerts and listen to local broadcasts. https://www.preparede.org/stayVisitinformed/
First shipments of pediatric COVID-19 vaccine expected in Delaware June 20
DPH asks Delawareans to stay one step ahead of COVID 19 by getting vaccinated and boosted when eligible and staying home if you are sick. Get tested if you have symptoms or were exposed. If you test positive, ask your health care provider if you should get treatment. Use a mask in public indoor spaces with poor ventilation and if you have a weakened immune system or live with someone who does.
The U.S. Food & Drug Administration’s Vaccines and Related Biological Products Advisory Committee meets June 15 to discuss amending two Emergency Use Authorizations: 1) to include infants and children 6 months through 5 years of age in the Moderna COVID 19 mRNA vaccine’s primary series; and 2) to include infants and children 6 months through 4 years of age in the Pfizer BioNTech COVID 19 mRNA vaccine’s primary series. The Centers for Disease Control and Prevention (CDC) then must approve their recommendations. Find the latest information on de.gov/youthvaccine. Consistent with other Northeastern states, Delaware’s seven-day average of new positive COVID 19 cases rose from 157.1 on April 22, 2022 to 356.4 on June 9, 2022, according to DPH. Community levels of COVID 19 were high in New Castle and Kent counties as of June 13 and had improved to medium in Sussex County, according to the CDC’s COVID Data Tracker at www.cdc.gov/covid data tracker
Assemble a go-bag such as a backpack to grab during an evacuation. Pack a flashlight with batteries, cash, first aid supplies, and medications. Also include copies of your family’s health insurance, homeowner’s or renter’s policies, and prescriptions in a waterproof bag. Pets need their own go-bag with non-perishable food, food and water dishes, leash, carrier, and favorite toy.
The DPH Bulletin – June 2022 Page 2 of 3
Tickborne illness in Delaware: more than just Lyme disease
• After you come indoors, check your clothing for ticks, shower, and perform a thorough tick check.
• Prevent ticks on your pets and in your yard. Visit a health care provider if you become sick after a tick bite, especially if you have a rash, fever, or alarming symptoms. The Centers for Disease Control and Prevention offers a comprehensive tick guide at https://www.cdc.gov/ticks/
Tobacco use is Delaware’s leading cause of preventable death
66 Delaware Journal of Public Health - August 2022
Lone Star Tick www.CDC.gov/ticks
• Avoid grassy, brushy, and wooded areas.
• Treat clothing and gear with permethrin or buy pretreated items.
• Remove ticks immediately. (See removal tips attachedMosthttps://www.cdc.gov/ticks/removing_a_tick.htmlat:.)diseasesaretransferredafterbeingtothebodyforlongerthan24hours.
The Lone Star tick is commonly found in Delaware. It can carry pathogens that cause ehrlichiosis and AGS, a rare but potentially life threatening allergic reaction. AGS occurs two to six hours after a person bitten by a Lone Star tick eats red meat or other products containing alpha gal, a sugar molecule found in most mammals. AGS symptoms include hives or itchy rash, nausea or vomiting; heartburn or indigestion; diarrhea; cough, shortness of breath, or difficulty breathing; drop in blood pressure; swelling of the lips, throat, tongue, or eye lids; dizziness or faintness; and severe stomach pain.
If you have life-threatening symptoms, immediately call 911. If you have signs of a tickborne disease, do not delay visiting a health care provider. If you have questions about tickborne illness including Lyme disease, contact DPH’s Office of Infectious Disease Epidemiology at 302-744-4990 or visit Followhttps://dhss.delaware.gov/dhss/dph/epi/lyme.htmlthesetipstopreventtickbites:
DPH’s PreventionTobacco and Control Program offers strategiesresourcescessationtobaccoandonthe
Delaware is home to various species of ticks, all of which can carry diseases that cause illness. Tickborne illnesses reported to the Division of Public Health (DPH) are ehrlichiosis, anaplasmosis, babesiosis, Spotted Fever Rickettsioses, tularemia, and a condition called Alpha gal Syndrome (AGS).
• Use Environmental Protection Agency (EPA) registered insect repellants.
Healthy Delaware https://www.healthydelaware.org/Individualswebsite,. DPH’s anti Vape Toolkit is also on HealthyDelaware.org and available at VapeFreeDE.com.
The Delaware Quitline, an evidence based best practice, has served more than 65,000 Delawareans since it began in 2001. Callers are offered the option to receive free motivational support over the phone, online, or in person from a local health care professional trained in tobacco use cessation. The Quitline now serves Delaware residents ages 13 years and older free of charge. Individuals ages 18 and older may receive free pharmaceutical smoking cessation aids such as nicotine patches and gum. Reach the Delaware Quitline at 1-866-409-1858 startquitTservice.vapingtobaccoAnotherhttps://www.dhss.delaware.gov/dph/dpc/quitline.htmloroptionistouseQuitsupport.com,anonlineandcessationhebestwaytoistonotTohelpyouthandyoungadultstonotbeginusingtobaccoproducts,
To generate more calls to the Delaware Quitline, the state’s smoking cessation program, DPH has a new campaign. Developed by Aloysius Butler & Clark with input from current tobacco users, it features a man trapped in a maze; the Quitline is his way out. There are television, radio, billboard, and other ads.
Over the last 10 years, cigarette use among Delaware adults has decreased 30.7 percent, from 21.8 percent in 2011 to 15.1 percent in 2020, according to the Division of Public Health (DPH). However, tobacco use is still the leading preventable cause of death in Delaware.
For more information on birth control and to access the birth control campaign resources, visit https://dethrives.com/healthy women or call 211.
To reduce the state’s unintended pregnancy rate, the Division of Public Health (DPH) is providing access to the full range of contraception through a Birth Control Awareness Campaign.
Delaware WIC has new website
Senior meal boxes. If you are over the age of 60, you may be eligible for the Senior Nutrition Program. Call 2-1-1 or 302-444-8129.
DPH’s June 2020 Reproductive Health data brief reports that between 2012 and 2018, of Delaware women aged 15 to 44 with a recent live birth, there was a 17 percent increase among women indicating their pregnancy as “wanted then or sooner” and an approximate 29 percent decrease among women indicating their pregnancy as “wanted later or unwanted.” There was a 107 percent increase in reversible methods of contraception, an 89 percent increase in intrauterine devices, and a 162.5 percent increase in contraceptive implants. Contraceptive implant use was highest among Hispanic women, Medicaid clients, women with less than 12 years of school, and those living in Sussex County. IUD use was highest among white non Hispanics and women with more than 12 years of education.
“Close to half of all unplanned pregnancies occur to women using a birth control method that doesn’t work well for them, or there is inequitable access to a full range of contraceptives,” said DPH Family Planning Administrator Yvonne Fletcher. “It is our goal to provide information and resources so Delawareans can choose a birth control method that is right for them and feel empowered to make their own contraceptive choices.”
Delaware WIC’s new educational website provides evidence-based information on breastfeeding, nutritional feeding practices, and programming that supports the short- and long-term health of eligible pregnant, postpartum, and breastfeeding women, infants and children up to age 5.
WIC, also known as the Special Supplemental Nutrition Program for Women, Infant and Children, is a federal program that serves approximately 6.3 million people nationally, including about half of all infants born in the United States. In Fiscal Year 2021, the Delaware WIC program served 17,199 participants.
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DPH launches birth control campaign
“BC Works For Me” promotes information on access to the full range of contraceptive methods and highlights 53 different options, including long-acting reversible contraceptives (LARCs). It highlights benefits beyond pregnancy prevention and shares tips on having birth control conversations with parents, children, friends, partners, and providers.
Access a food pantry. Dial 2 1 1 or 1 800 560 3372. Text your ZIP Code to 898 211. Visit www.delaware211.org
Apply for SNAP benefits online at Assist.dhss.delaware.gov or visit a Division of Social Services office. If questions, call 302-571-4900 and select ‘Customer Relations.’
The DPH Bulletin – June 2022 Page 3 of 3
Apply for WIC benefits. Learn how to apply at Delaware.WICresources.org
How to get food help
The site, Delaware.WICresources.org, also features a link to information and contact numbers related to the baby formula shortage and information on the Delaware WIC Farmers’ Market Nutrition Program which began June 1 and ends October 31. The Farmers’ Market Nutrition Program materials guide participants on how and where to redeem their one time $30 nutrition coupon provided by the program.
Visit Delaware.WICresources.org or follow Delaware WIC on Facebook, Instagram, or YouTube to find information on Delaware WIC’s programs and healthy recipes using WIC approved ingredients.
DOI: 10.32481/djph.2022.08.012
Principal Investigator, Department of Communication; Undergraduate Research Assistant, Center for Research in Education and Social Policy, University of Delaware Lindsay Hoffman, Ph.D.
68 Delaware Journal of Public Health - August 2022
INTRODUCTION
Prior studies of the COVID-19 impact on college students reveal many concerning effects resulting from the pandemic.
Environment and setting have a large influence on matters of population health, and college is a critical place for students, shaping both health and education. College students across the nation were impacted by the COVID-19 pandemic, and changes at universities left many anxious, isolated, and coping with social, emotional, and educational impacts. Objective: To perform a data analysis of the qualitative responses garnered through the Student Return to Campus Survey administered at the University of Delaware (UD) in Spring 2020, and to identify common themes of student experiences and priorities during the pandemic years to inform future recommendations for health crisis management. Methods: The study utilized secondary data analysis from an online student experience survey of 2,941 Freshman, Sophomore, and Junior students from the 2020-2021 academic year. Results: Qualitative analysis revealed a set of common outstanding themes influencing the college pandemic experience, including: Quality and Accessibility of Education in a Virtual Learning Environment; Quality of Student Life; Mental Health During the Pandemic; Thoughts and Attitudes About Vaccination Policies, Masking, Testing, and COVID Guidelines; Priorities and Considerations About the Return to Campus; and Overall Feelings About the Pandemic at UD. Conclusions: Student experiences were influenced by academic, social, emotional, and financial factors, which were often described with great intensity, and were at times contradictory. Students emphasized struggles with transitioning to and with virtual learning, the quality of campus resources, financial responsibilities, family health, and personal health. The results also shed light on the importance of communication with the campus community and the desire for students to express opinions during a crisis. Health Policy Implications: The results of this study have implications for crisis management for college campuses and planning for future responses to unanticipated events and ongoing COVID-19 mitigation efforts.
Professor of Communication, Department of Communication, University of Delaware Allison Karpyn, Ph.D.
A
Associate Professor of Communication, Department of Communication, University of Delaware Amy Bleakley, Ph.D., M.P.H.
Professor of Education and Behavioral Health & Nutrition, College of Education and Human Development; Associate Director, Center for Research in Education and Social Policy, University of Delaware
The COVID-19 pandemic caused substantial disruptions to college students’ experiences of place and health. On January 31st, 2020, the World Health Organization (WHO) declared the novel coronavirus outbreak, later officiated as COVID-19, as a Public Health Emergency of International Concern.1 By March 2020, public school systems and institutions of higher education began to declare emergency closures and shut down with the intent to bring infection spread under control. On March 15, 2020, the University of Delaware officially suspended in-person classes, non-essential research, and University-sponsored travel, as well as vacated residence halls to prepare to transition to fully remote teaching, working, and learning environments until further notice.2 As was the case across the nation and the world, the sudden school closures had unique consequences for student
The shift in the University environment for many students was profound, and resulted in not only changes to their daily routines, learning remotely rather than in-person, but it also resulted in physical movement to their homes or to relatives’ homes, isolation in dorms if students were unable to relocate, elimination of oncampus social activities, and drastic reduction in accessibility of mental health resources, including shifts in access to care when moving across state lines.
populations and their families. Whether students were learning on campus, at home, or through hybrid modalities, the changing nature of academic environments during the pandemic impacted student health and well-being.
ABSTRACT
Abhigna Rao, B.A.
Reflection on the Relationship Between Place and Health: Understanding Undergraduate Student Experiences and Priorities During the COVID-19 Pandemic
In Spring 2020, the Center for Research in Education and Social Policy (CRESP) at the University of Delaware, in concert with the University administration, formulated and launched several targeted surveys related to the impact of COVID-19. One survey was disseminated to full-time Freshmen, Sophomores, and Juniors in the 2020-2021 academic year via an email link through their university-affiliated email. Students were asked about their experiences during the pandemic, their opinions about how mandates were enforced at the institution, and their concerns and priorities regarding a full return to campus in Fall 2021.
In total, 2,941 undergraduate students completed the survey, which reflects a 25% response rate. Of those, 1,858 responded to the open-ended question, “Is there anything else you want the administration to know about your experiences or feelings this past year?” The open-ended nature of this question, and its robust response, enabled a more in-depth understanding of the experiences of students during this time, and they are the focus of this article. Sixty-eight percent of the survey-takers identified as female, with 32% identifying as male. Seventy percent of respondents were White, 5.4% were Asian, 4.6% were Black, and 7.6% were Hispanic. Our sample is similar to the actual demographic breakdown of full-time undergraduates at UD: 58% female, 43% male; 63.9% identify as White, 5.26% as Asian, 6.31% as Black, and 8.19% as Hispanic.
The responses from this question were uploaded to, and analyzed with, Dedoose Version 9.0.46 (SocioCultural Research Consultants, LLC; Los Angeles, CA, USA), a data analysis software that is programmed to code common themes of qualitative data. Responses were systematically examined using
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The spread of COVID-19, one of the largest health crises of our time, brought about an entirely new culture for living and learning. In college settings, adapting to this new way of experiencing college as a place had implications for students’ immediate and long-term health, including their educational attainment (an important social determinant of health)5, mental health, and exposure to the COVID-19 virus.
Evidence of impact on student mental health is also documented.7,8 Studies considering the impact of online learning, quarantine, and the health fears associated with COVID-19 on student mental health report concerning outcomes. For example, a COVID-19 impact study conducted at Arizona State University revealed that students experienced delayed graduation, job losses, economic disparities, and health “shocks” such as hospitalization or fear of becoming sick.9 In another example, the American College Health Association, in partnership with The Healthy Minds Network, explored students’ experiences, attitudes, concerns, and perceived support of universities during the pandemic across 14 colleges and universities. Researchers found that mental health in college students was negatively impacted, and major associated factors included financial stress, racebased discrimination, and access to healthcare, which in turn affected their academic performance.10
BACKGROUND
differences in students’ learning styles.17 These implications include accommodating students with visual or auditory disabilities,18,19 or those that require more varied support, from reading and writing assignments to hands-on experiences.20
Academically, students experienced challenges in adjusting to online learning, and often were unable to engage with and retain content at the same pace online, as had occurred in person.3,4 Studies demonstrate that education is a critical determinant of health.5 Prior research suggests that declines in academic achievement pertaining to reading, mathematics, and by GPA were likely.6 However, it is also clear that measuring how much, and in what ways, academic outcomes were impacted by school closures and virtual learning is not straightforward and is complicated by the unique and ubiquitous nature of the pandemic.6
METHODS
The pandemic required a shift to online learning, resulting in drastic increases in the use of hybrid and fully virtual teaching since the invention of the platform.4 On one hand, teaching and learning through virtual platforms can be more accessible as well as cost-effective, especially for those who might not otherwise be able to attend an in-person class.11 On the other hand, while virtual learning has strengths, it also posed many challenges, including unanticipated consequences. For example, unlike in-person learning, which encourages physical activity and social interaction, both important components of strong mental health,12–15 support for these areas are not easily able to be achieved in a virtual learning environment.16 Virtual learning may also have implications for instructors’ ability to accommodate
Given the breadth of concern for the potential impacts of COVID-19 on the health of students in higher education environments, we sought to better understand the ways in which the University as a place impacted undergraduate student well-being in Delaware. Our analysis examines the thoughts, needs, concerns and experiences of undergraduate students in Delaware whose living and social environment was impacted by a global health pandemic.
Prior research to understand student needs during the pandemic has also focused on stressors experienced with regard to COVID-19.21,22 These studies report that student worries about campus return varied widely, from vaccination statistics to classroom instruction and infrastructure. Students were also concerned about the safety of themselves and their families, especially where increased exposure to the virus was a risk.23 A cross-sectional survey conducted among clinical students across six medical schools in the United States from April to May of 2020 asked students about pandemic-related stressors: 84% of respondents reported that they felt an increase in stress due to the pandemic; other symptoms experienced by students were severe anxiety and PTSD-risk symptoms.24 Research shows that increased stress in these areas was related to significant negative effects on the perceived psychophysical health among students.22 One study shows that one-third of students who were mandated to relocate during a semester reported higher levels of grief, loneliness, generalized anxiety, and PTSD related to the pandemic than those who did not have to move.25 The disruption to academia and social life brought about issues with students’ mental health, accessibility to mental health services, and outreach to students in special circumstances, such as those with pre-existing conditions, financial barriers, and international backgrounds.8
Theme 4. Thoughts and Attitudes About Vaccination Policies, Masking, Testing, and COVID Guidelines
Findings emerged as six qualitative themes, with representative quotes summarized in Table 1, Table 2, and Table 3. In presenting these findings, and interpreting the data, we recognize that while students reported significant impacts attributable to specific issues (such as virtual learning), there were simultaneously profound shifts taking place in all environments due to the COVID-19 pandemic. It is likely that while respondents described isolated concerns, the thoughts and feelings reflected in the data were influenced by multiple contextual factors. We further recognize that the PI for this study is a former University of Delaware student, who identifies as female and a person of color, and who experienced COVID-19 as a college student, and that these lived experiences likely influenced the lenses through which the data was interpreted.
As a student, college policies had a strong influence on student’s experiences of place and connection to others, and because policies were in direct relation to a health pandemic, had immediate impacts on student health, both mental and physical as well. A wide variety of student opinions and feelings were expressed about the mandates that UD put in place to prevent the spread of infection on campus, and no one perspective stood out above the rest. Most notable across all comments was the strength, or passion, behind the perspective. Table 2 articulates the variation in students’ opinions about COVID regulations on campus. Moreover, the theme also encompasses student activities pertaining to adherence to university rules, and student responses show that the behavior of other people was a large, influential factor that shaped student attitudes about pandemic guidelines at the University and led to feelings of anxiety about eventually returning to campus.
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Theme 1. Quality and Accessibility of Education in a Virtual Learning Environment
For instance, some students experienced a decline in on-campus housing security and affordability, which resulted in students having to arrange alternative housing plans at the last minute, translating to an additional stressor amidst the pandemic. Student quality of life was further impacted by financial difficulties during the pandemic. In particular students reported challenges related to having to financially support themselves in a particularly stressful and limited retail environment, having to face unexpected unemployment for themselves and their families, leaving hardships with regard to university tuition costs, and not qualifying for aid and grant money despite expressing a need. Furthermore, students faced difficulties with connecting to their peers while learning online, and were at times challenged to feel that there was a sense of safety and equality on campus. Students also had to provide care to loved ones at home and cope with having relatives who were suddenly very sick. Exemplary quotes supporting the categorization approaches for Themes on Quality and Accessibility of Education as well as Student Quality of Life and related sub-themes on these topics are presented in Table 1
Quality of life is a critical factor for mental and physical health. Students experiencing displacement from the college campus, or alienation from its resources, described impacts on their quality of life. Factors included financial burdens, social activities, fear for their safety, and the stress of family challenges and other external factors (factors away from school grounds that impacted students’ pandemic experiences). Many quotes about campus services referenced the need for access to more local resources
One of the most frequently discussed influences of the pandemic on college students was the quality and accessibility of the education that they received following the transition to virtual learning platforms during the pandemic year. As a social determinant of health, the way that students experience education, and their likelihood to continue forward with college, is of critical health concern.5 Students reported a wide range of virtual learning challenges, including their course infrastructure, technological issues (including utilizing the Zoom conferencing platform for class attendance and participation), networking opportunities, lack of diversity, equity, and inclusion across individual learning differences, and difficulties with managing academic lifestyles. Virtual learning benefits were also expressed, which involved more efficiency with workload, better time management, and the ability to focus on personal and family health while at home, which students believed contributed positively to mental health. Challenges experienced when transitioning between learning modalities and working with UD’s modified grading policy were also noted. Exemplary quotes on these topics are presented in Table 1.
Theme 2. Quality of Student Life
an inductive approach. The themes of the qualitative data were developed with a focus placed on understanding the student experience during the COVID years. Initially, a draft of codes was developed by the Principal Investigator (PI) of the study (the undergraduate student) and was refined alongside the Thesis Director. As the Principal Investigator is an undergraduate student, the coding process was vetted and discussed with the Thesis Director throughout the process, with discrepancies resolved collectively. However, primary coding activities were engaged by the PI. This study was designated exempt by the Institutional Review Board of the University of Delaware, and the research team has no conflicts of interest to declare.
Theme 3. Mental Health During the Pandemic
RESULTS
and for those resources to be open and available to them. These include spaces like the Center for Counseling and Student Development, Residence Life and Housing, and Career Services, Student Financial Services, funding for student organizations, COVID testing centers, parking expenses, interfaith prayer spaces on campus, and dining hall hours and services.
Students described how the intersection of being a student and displaced or isolated while at the same time struggling with many new stressors brought forth by the pandemic created heightened mental health needs. Examples of mental health concerns are shown in Table 2 and cover a variety of issues, including stress from academic workload, concerns about faculty accommodations for students, feelings about canceled school breaks, lack of motivation, and coping with personal health issues. Many students found that the amount of work assigned, despite the virtual landscape of classes, was overwhelming and presumptive that students had more time, though that was not the case. Students also reported feeling less motivated to put in effort on assignments since learning online brought about fatigue and modalities that were not inclusive of all learning styles.
Virtual Learning Challenges
Allowing/encouraging socialization (in a safe manner) I think would significantly improve the overall state of student mental health. There was a lack of in-person opportunities that could have happened while still being safe. It was very di cult to connect with my peers outside of class or even to form new relationships with others in our community.
Theme: Quality & Accessibility of Education
If the classes are mixed, I may need to find somewhere quiet to sit down for an hour to watch a lecture if it is in-between two in-person classes. Finding a place where I can work and won’t be asked to leave has been an issue.
Transition Between Learning Modalities
Representative Quotes
Sub-Themes
The modified grading and extra support to students has been beneficial. I was disappointed that they removed the modified pass option. We are still struggling in this pandemic, so it is not fair that we are being treated as if things are back to normal for us academically when they clearly are not.
Challenges with Campus Services & Student Resources
The financial burden you have placed on students of the university is astounding given the recession and job losses many families including mine are struggling with. I wish UD could give us more grant money for students with financial need.
Social Activities & Student Events
External Student Circumstances
Learning in a classroom versus at home is a completely di erent experience, and many students, including myself, will struggle.
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Theme: Quality of Student Life
I myself am very much a hands-on learner, and I learn best when I am able to talk to my peers and professors, which has been extremely di cult in the completely online format. All year, I have had trouble with my computer. When I use zoom and chrome at the same time my computer overheats and my mic stops working. It has been very di cult to actually absorb and have new information stick in this online environment.
Table Representative quotes related to Quality and Accessibility of Education in a Virtual Learning Environment and Quality of Student Life
I enjoy Zoom more than in-person class. It’s easier, I can go to class o of my phone. It saves time from traveling to school and then to work. Working remotely allowed me to maximize my learning potential and focus more on my Iacademics.strugglewith social anxiety, so the remote learning option is much better for me.
There are armed robberies, break-ins, and stalkers- and somehow the school/police force is more concerned with suspending kids for doing things every college kid does.
Virtual Learning Benefits
Campus Safety & Social Unrest
Sub-Themes Representative Quotes
Modified Grading Policy
As a low-income student, I’m constantly worried about what happens if I can’t work (due to COVID) and can’t support myself.
Housing has been very stressful because the communication about the availability of oncampus housing came too late in the year to find a ordable o -campus housing. There has been little help when it comes to advising and career advisement virtually. I have been utterly crushed by online classes and the removal of normal resources (library, library cafe, student centers, etc.). I went from a straight-A student to a B’s and C’s student.
1.
My family is immunocompromised. I have to help my disabled mother. I do not want to risk exposing her to covid because a school opened too early. I am unemployed and so are my parents and this year has been incredibly frustrating and di cult.
Financial Burdens & Responsibilities
Blue lights on Main Street would help make me feel more comfortable with the amount of violence that has been going on.
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The pandemic response was way overreacted. I think the college implemented unnecessary rules and policies for something that, objectively, is not that dangerous.
Table 2. Representative quotes related to Mental Health During the Pandemic and Thoughts and Attitudes About Vaccination Policies, Masking, Testing, and COVID Guidelines
Representative Quotes
My sleeping schedule has been a mess since the Fall 2020 semester. I usually sleep at 11:30 PM or 12:30 AM by the latest, but now it has become a habit for me to sleep at 3 AM or 4 AM.
Theme: Thoughts & Attitudes About Vaccination Policies, Masking, Testing, and COVID Guidelines
I love that my professors were willing to work with me and that we had the online classes [through] Zoom. I feel like although this pandemic has been hard, some teachers have not changed their teaching styles to accommodate the students as they’ve [the students] had to accommodate to remote learning.
Faculty Accommodations for Students
Sub-Themes Representative Quotes
I think replacing the spring break week with sporadic re-coop days was not the best option. We/I count a lot on this week to catch up on some assignments and the final papers, and most important issue is that this week can balance out stress and help to maintain mental health.
Students should be required to get vaccinated in order to attend in-person classes. We need to get vaccines to be on campus regardless, and these vaccines extremely important in the context of eliminating the spread of COVID-19.
Academic Workload
Additional Student Needs
School Breaks
Sub-Themes
Theme: Mental Health During the Pandemic
Being online does not mean that learning becomes easier or faster. Personally, I have found that the lack of in-person classes makes it di cult to fully digest lecture material, and it takes more time to understand new concepts in such a stressful time. Professors should have been much more lenient when it comes to late work. Being online consumes my day from 4 AM – 7 PM with class and homework and I am in a constant cycle of waking up and then working until exhaustion.
This semester is the most stressed I have ever been and the fact that I wasn’t allowed a spring break to mentally prepare myself for the remainder of the semester has severely impacted my academic performance, motivation, and mental health.
It a ected my productivity throughout the day and I am having a hard time fixing my sleeping schedule. I ended up with a rotated hip from sitting in-front of my computer every day for months on end.
Student Lack of Adherence to University Rules
Mindsets About Pandemic Regulations
I sit for hours in my room on my laptop, and then I am supposed to do more and more hours of online homework…my life is standing still.
The breaks that we have had this semester have not been enough. I still had assignments due that night and an exam at 8 AM the next morning.
Motivation
I live in Newark and have a job on Main Street and the amount of people I see every day still not wearing masks, not social distancing, partying every single day, etc. is really worrisome and makes me very uncomfortable.
In my in-person classes I often feel uncomfortable because kids choose not to sit where the socially distanced stickers are in the lecture hall.
I used to love attending lectures and interacting with professors and classmates. Since things have gone online, I have lost all my enthusiasm for my work and it [has] reflected in my performance. It is harder to pay attention in virtual classes…it is particularly frustrating that most students will not engage or even turn on their cameras during the class.
Theme 6. Overall Feelings About the Pandemic
Theme: Overall Feelings About the Pandemic at the University of Delaware
The first section of Table 3 showcases student priorities and considerations when thinking about a full campus return during Fall of 2021. Thoughts and feelings reflect upon a significant shift in place and its relationship to their health. Students expressed a spectrum of concerns, thoughts and emotions regarding vaccine and masking policies, how UD administration policies should shift if an outbreak of COVID-19 resulted, the importance of University policy on impacts on the legacy of the institution and the way that students viewed their importance to the school, and the importance of streamlined and consistent health policy communication with the campus community.
Representative Quotes
Priorities for Campus Return
If mostly everyone is vaccinated and we do daily health checks, regular testing, and contact tracing, I think we will be okay to go back to school normally.
Representative Quotes
Everybody is trying to do their best in finding ways and making things work. We have to remain flexible and supportive of each other and keep the dialogue going. COVID-19 has sort of a ected everyone in one way or the other. This year has been hard for everyone, and there is obviously no right answer or way to please everyone 100%.
Table 3. Representative quotes related to Priorities and Considerations About the Return to Campus and Overall Feelings About the Pandemic at the University of Delaware
Some of the feedback provided by students expressed only generalized feelings about their experiences related to the health pandemic at the University of Delaware that did not fit into any other specific category. These are captured in Table 3 under the theme “Overall Feelings.”
Pandemic Planning
Sub-Themes
There was a lot of back and forth with reports of what the plan was as far as allowing research to continue, if it could be done socially distanced, when certain decisions would be made, etc.
I am uncomfortable in the idea of being back on campus. I feel pressured to be on campus because of the housing contract.
DISCUSSION
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This will likely not be the last global pandemic in our lifetime so focusing on what safety/ disciplinary measures worked and what didn’t will be needed for next time.
Communication with Campus Community
University Legacy & Retention
Theme 5. Priorities and Considerations About the Return to Campus
I would just like to highly encourage the administration to return 100% back to normal in Fall 2021 semester and so on because we UD students need to be back in the classroom with proper learning and teaching and having the ability to ask professor questions.
Theme: Priorities and Considerations About the Return to Campus
I think some more student input in the future can help make easier and better decisions for students on campus.
I know many people transferring because of what student life has looked like here. Many students plan to transfer because of the lack of care UD has shown toward its students.
I think UD needs to be better and more cohesive in their decision-making process for similar situations to COVID.
Our data suggest that University students attending school during the COVID-19 pandemic had experiences unique to a University context (place), both in-person and virtually, and that those experiences have important implications for their educational attainment, short-term health, and long-term health.
I wish that the administration (particularly earlier in the pandemic) had been more forthcoming and transparent with information about changes to on campus guidelines. It often felt as if we were kept in the dark until the last minute of decisions regarding teaching and Despiteresearch.somuch of this virus being out of an individual’s person’s control, the University phrased many of its messages in ways that blamed the students.”
our study was that policies around vaccinations, masking, testing, and general guidelines for COVID safety were very polarizing social health issues across the UD campus, and often, students that wanted more social interaction also wanted stricter pandemic guidelines; again these findings have important inferences for discussions of how we consider policy, and health behavior in a place and health context. Some felt that vaccinations should be required in order to return to campus (“Students should be required to get vaccinated in order to attend in-person classes. We need to get vaccines to be on campus regardless, and these vaccines are extremely important in the context of eliminating the spread of COVID-19.”), while others felt strongly about personal choice with vaccines and masking. Some felt that the current campus regulations were overreacted (“I think the college implemented unnecessary rules and policies for something that, objectively, is not that dangerous.”), while others believed they would help control the spread of infection. Regardless of the view, comments were often articulated with strong conviction. Political polarization regarding major public health issues was very prevalent across the nation as well, according to several other studies.32,33 While there was a diverse array of perspectives about any topic surrounding mandates and policies, one major concern that was prevalent in the data was regarding other students and their lack of adherence to the rules. Our study shows that students felt anxious and unsafe returning to campus because of the potential for others’ behavior
At the same time that technology and educational approaches concerned students, students craved more of a social student life, which again was moderated in part by their association with the University as a place, which historically was a foundation of social connectedness. In particular, the data reflects a need for greater availability, adaptability, and accessibility of campus and departmental resources. Communication about resources and support for students was often reported as vague and intermittent, leaving students without adequate information about the ways in which they could navigate University spaces (another aspect of place) while maintaining their health (i.e., reduced COVID exposure, testing on campus, mental health services, and visiting with friends and family.) Of particular note was students’ need for more information about mental health counseling, financial, and career services: “There has been little help when it comes to advising and career advisement virtually.” Major restrictions were placed on student activities after the campus reopen, so although students were returning back to campus, there were limited engagements to get involved and socialize, which impacted students’ academics and mental health. Students expressed anger and frustration toward university fees and other costs that at the time required students to pay for resources and services that they were unable to access. While previous research also highlights the issue of students facing greater responsibilities with fewer campus resources and support,29 there is a need for further exploration of the specific impact of the pandemic on financial challenges faced and personal lives of students.
On the other hand, not all student experiences of University changes were negative. Students also reported educational benefits including greater efficiency, time management, and a sense of safety from the virus: “I feel like I would have struggled with completing much of my school work if I had to deal with commute times on top of attending classes.” Especially for students who were holding down a full-time job, caring for family members at home, or had other demands on their time, remote work offered them more flexibility with their schedules: “I enjoy Zoom more than in-person class. It’s easier, I can go to class off of my phone. It saves time from traveling to school and then to work.” Such benefits have been identified in other studies.28
Mental health issues related to academic stress and the changes in setting and social access were particularly heightened during the pandemic. Students expressed that many of their professors were reluctant to adapt their teaching styles, and that they often made assumptions about the time that students had to dedicate to schoolwork, which led to a major increase in the amount of workload and time commitment needed to complete assignments. As illustrated in this quote from the data: “Being online does not mean that learning becomes easier or faster. Personally, I have found that the lack of in-person classes makes it difficult to fully digest lecture material, and it takes more time to understand new concepts in such a stressful time.” Prior research further supports this finding, and reports that academic workload and being away from a school environment lead to negative impacts on the level of stress experienced by college students.21 One pivotal mental health-related policy decision made by University administration which was critically described by students was the cancellation of a traditional spring break, replacing it with two weekdays in the middle of the semester on which no classes were to be held. Students were unhappy with the lack of a reprieve from the rigor of the semester, and that the two well-being days that were implemented in place of the spring break were neither effective in reducing stress nor useful in catching up on work, as many professors still administered exams and assigned homework: “I count a lot on this week to catch up on assignments and final papers, and most important…balance out stress and help to maintain mental health.” Several studies in the literature also emphasize the importance of school breaks and their role in preventing build-up of anxiety, stress, and restlessness.30 Moreover, students who attended schools that did not administer a spring break due to pandemic health experienced declines in mental health, creativity, and productivity, alongside a decrease in overall Anotherhappiness.31findingof
We found that many students struggled to feel that the quality and accessibility of the education that they were receiving across virtual formats was aligned with what they received when there was not a pandemic. Many students were frustrated with technological issues, lack of student social networking opportunities, and difficulty with managing academic workload. Such concerns are particularly alarming given the importance of education as a social determinant of health. Our finding that students experienced challenges in meeting academic expectations aligns with prior research demonstrating that the online environment presents barriers to participation in group work activities, lack of certain technological competencies in students, and “one-size-fits-all approaches” to education that lacks inclusivity of different learning styles.26 Such findings, while the first of their kind for Delaware, are well-aligned with other investigations about the social impacts of the pandemic on students in higher education, which showed that the interruption to daily routines led to lowered motivation, declines in mental health, and a lack of interpersonal connection.27
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on the study data, issues with communication of safety mandates, academic workload, and financial burdens all contributed to the quality of students’ mental health during the pandemic years. Student comments highlighted gaps within the University’s network of mental health resources (such as adequate on-campus counseling services) that heightened isolation and feeling a lack of support from college administrators. Moving forward, it may be a valuable step for administrators to solicit input from current students and maintain an ongoing mechanism for insight related to mental health service needs, such as a mental health advisory group. While every student has a unique set of needs, starting an open dialogue with students during more certain and stable times, may help to create a precedent for consistent feedback during less certain times, and perhaps a sense of unity when facing adversity as an institution. Student feedback suggests that while a central hub to support students is critical, spokes from that hub must also reach into other facets of the student environment, including but not limited to instructors, the classroom, and classroom policies.
Based on the findings, several suggestions for future approaches to support students in University settings, during or in preparation for crises, emerged. University policy was recognized by students as a driving factor in their education, quality of life, and mental health. As a place, the University encompassed both immediate physical parameters, as well as virtual and logistical experiences which drove health outcomes. While these
to put them in danger: “The amount of people I see every day still not wearing masks, not social distancing, [and] partying every single day is really worrisome and makes me very uncomfortable.” Of note, this finding has not been explicitly reported in other similar studies.
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most profoundly, the study revealed insight into the passionate and contradictory nature of perspectives during the COVID-19 pandemic. Student views often clashed with regard to how the University as an environment should protect health or enable social normalcy. For instance, although the sentiments expressed about the campus reopening were reluctant about returning (see Table 3), these thoughts are contradicted by Table 1, which outline students’ thoughts on Quality of Education and Quality of Student Life, respectively; in these, there is more of an eagerness and urgency to return due to the detriment of online education and lack of access to student resources; for more elaboration, see Table 1. Additionally, there were several student responses that articulated a more overarching point of view concerning the pandemic at the University of Delaware, as illustrated by this quote: “This year has been hard for everyone, and there is obviously no right answer or way to please everyone 100%.” Times of health crises make way for various uncertainties, not just in the way that the crisis will evolve, but also in the needs that individuals determine for themselves. Therefore, it is important to include key stakeholders in data collection efforts and feedback in decisions regarding their own health and lifestyles as much as possible, being mindful to develop solutions that are intentional and individualized.
recommendations serve to inform future policy changes, we recognize that our findings are contextual and specific to a certain time, place, and population.
Student comments indicate that institutional communication strategies are important mechanisms that either enhance or detract from student experiences during crises, particularly with regard to health policy. As such, attention is needed to ensure messaging is consistent and provided across multiple platforms to the greatest extent possible. Students indicated experiencing some confusion understanding rapidly shifting policies with delays in updates across platforms (ie. email, social media, and university-affiliated websites). Further students cautioned that communications should err on the side of encouragement and positive tones rather than harsh, or fearful tones. Administrations of higher education may be well served to have mechanisms in place to ensure consistency and clarity across platforms, as well as enforce those regulations in a way that encourages students rather than creating additional anxiety and worry.
A fifth finding centered on what students’ priorities and considerations were when thinking about a full campus reopening. Again, there was an assortment of viewpoints and perceptions expressed. Some comments conveyed that the University should perform a full evaluation of what worked and did not work, for administrators operationally and for students experientially, in order to determine what measures to put in place for the coming semester. A staggering perspective held by many students was the reluctance to advocate for the University of Delaware as a whole as a result of how they felt treated as students. In fact, many students at the time shared declarative views that they wanted to transfer schools: “I know many people transferring because of what student life has looked like here.” Furthermore, communication between administration and the students about regulations and pandemic planning were two other areas of concern, with inconsistency and lack of clarity being the main issue noted. While other research confirms that navigating the pandemic did cause tensions for school leaders,34,35 there is much more to be explored regarding the specific relationships and perspectives between college students and administrations during the Finally,pandemic.andperhaps
Because student educational experiences are often driven by faculty interaction and capacity, efforts to incentivize and increase resources to implement more specific opportunities for teaching faculty are recommended to prepare for times of crisis in a proactive way. Student comments also suggested future efforts to incorporate in-person and virtual flexibilities to allow for greater student agency with learning. Therefore, faculty training could include (but is not limited to) expanding resources for faculty to increase their awareness of how to accommodate a variety of student learning needs in virtual and in-person environments, as well as supporting student mental health during times of high Basedstress.
FUTURE DIRECTIONS
Many student comments urged administration to balance student experiences with fiscal recovery in order to optimize the quality of student treatment and value. Students experienced a number of financial burdens during the pandemic and expressed sensitivities to additional fees and costs, especially when they were charged with expenses that they felt were unjustified. Taking the time to reflect on how and when Universities should approach student financial burdens during crises may be worthwhile to prevent future stressors. Conversations between administrators and the
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11. O’Leary, R., & Ramsden, A. (2002). Virtual learning environments. The Handbooks for Economic Lecturers. https://www.igi-global.com/gateway/book/56017
12. Biddle, S. (2016, June). Physical activity and mental health: Evidence is growing. World Psychiatry, 15(2), 176–177. https://doi.org/10.1002/wps.20331
The Student Return to Campus Survey (Fall 2021) provided the opportunity for public health practitioners and educators alike to understand, with considerable detail, how students responded to drastic shifts in their experience of University life (place) resulting from a global pandemic (health). Findings showed that students experienced both benefits and challenges in their transition to new learning modalities, influencing their quality and accessibility of education. They also experienced dramatic shifts in student life, including engagement with the University’s resources and social milieu, underwent considerable financial challenges, had strong reactions and preferences regarding pandemic mandates and returning to campus, and ultimately experienced changes in quality of life and mental health as a result. As institutions reflect and plan for future unexpected health and environmental events, such data and recommendations as described here can support efforts related to communication strategies, faculty training efforts, mental health resources, and social service provisions. Ms. Rao may be contacted at abhiarao@unc.edu.
7. Grubic, N., Badovinac, S., & Johri, A. M. (2020, August). Student mental health in the midst of the COVID-19 pandemic: A call for further research and immediate solutions. The International Journal of Social Psychiatry, 66(5), 517–518. https://doi.org/10.1177/0020764020925108
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10. Martinez, A., & Nguyen, S. (2020). The impact of COVID-19 on college student well-being. Health Minds Network. https://vtechworks.lib.vt.edu/handle/10919/99741
14. Pachucki, M. C., Ozer, E. J., Barrat, A., & Cattuto, C. (2015, January). Mental health and social networks in early adolescence: A dynamic study of objectively-measured social interaction behaviors. Soc Sci Med, 125, 40–50. https://doi.org/10.1016/j.socscimed.2014.04.015
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CONCLUSIONS
8. Liu, C. H., Pinder-Amaker, S., Hahm, H. C., & Chen, J. A. (2022, July). Priorities for addressing the impact of the COVID-19 pandemic on college student mental health. J Am Coll Health, 70(5), 1356–1358. https://doi.org/10.1080/07448481.2020.1803882
9. Aucejo, E. M., French, J., Ugalde Araya, M. P., & Zafar, B. (2020, November). The impact of COVID-19 on student experiences and expectations: Evidence from a survey. Journal of Public Economics, 191, 104271. https://doi.org/10.1016/j.jpubeco.2020.104271
2. University of Delaware. (2020). Coronavirus updates archive. University of Delaware. Retrieved from: https://www.udel.edu/home/coronavirus/covid-updates/
student body should be open and ongoing to identify effective strategies and areas for improvement such that measures are not reactive when a crisis arises and additional costs to students mitigated. An increase in the need for resources and funding may be unavoidable when forming crisis management plans, but universities should strive to recognize student needs and prepare to provide additional services and resources.
16. Korioth, T. (2021, July 18). AAP urges in-person learning, masking in updated guidance on safe schools. AAP News. Retrieved from: https://publications.aap.org/aapnews/news/17241
17. Asim, S., Ponners, P. J., Bartlett, C., Parker, M. A., & Star, R. P. (2020). Differentiating instruction: for middle school students in virtual learning environments. Indiana University Southeast.
13. Orben, A., Tomova, L., & Blakemore, S.-J. (2020, August). The effects of social deprivation on adolescent development and mental health. The Lancet. Child & Adolescent Health, 4(8), 634–640. https://doi.org/10.1016/S2352-4642(20)30186-3
18. Greer, D., Rowland, A. L., & Smith, S. J. (2014). Critical considerations for teaching students with disabilities in online environments. Teaching Exceptional Children, 46(5), 79–91. https://doi.org/10.1177/0040059914528105
19. Thornton, C. P., Ruble, K., & Jacobson, L. A. (2022, April 1). Education for children with chronic illness. JAMA Pediatrics, 176(4), 341–342.
5. Telfair, J., & Shelton, T. L. (2012). Educational attainment as a social determinant of health. North Carolina Medical Journal, 73(5), 358–365. https://doi.org/10.18043/ncm.73.5.358
32 Allcott, H., Boxell, L., Conway, J., Gentzkow, M., Thaler, M., & Yang, D. (2020, November). Polarization and public health: Partisan differences in social distancing during the coronavirus pandemic. Journal of Public Economics, 191, 104254. https://doi.org/10.1016/j.jpubeco.2020.104254
34 Netolicky, D. M. (2020). School leadership during a pandemic: Navigating tensions. Journal of Professional Capital and Community, 5(3/4), 391 395 https://doi.org/10.1108/JPCC-05-2020-0017
20 KIPP Texas Public Schools. (2021, August 17). Four benefits of in-person learning. KIPP Texas Public Schools. Retrieved from: https://kipptexas.org/4-benefits-of-in-person-learning/
26. Gillett-Swan, J. (2017). The challenges of online learning: Supporting and engaging the isolated learner. Journal of Learning Design, 10(1), 20 https://doi.org/10.5204/jld.v9i3.293
28 Allan, B. (2007). Time to learn? Management Learning, 38(5), 557 572 https://doi.org/10.1177/1350507607083207
29 Telli, O., Mountcastle, L., Jehl, B. L., Munoz-Osorio, A., Dahlquist, L. M., Jayasekera, A., Miner, K. (2021). Impact of COVID-19 campus closure on undergraduates. Teaching of Psychology https://doi.org/10.1177/00986283211043924
27 Chaturvedi, K., Vishwakarma, D. K., & Singh, N. (2021, February). COVID-19 and its impact on education, social life and mental health of students: A survey. Children and Youth Services Review, 121, 105866 https://doi.org/10.1016/j.childyouth.2020.105866
25 Conrad, R. C., Hahm, H. C., Koire, A., Pinder-Amaker, S., & Liu, C. H. (2021, April). College student mental health risks during the COVID-19 pandemic: Implications of campus relocation. Journal of Psychiatric Research, 136, 117 126 https://doi.org/10.1016/j.jpsychires.2021.01.054
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23. Haughey, D., Vaughn, J., & Kalman, M. (2021, September). Stronger together: The student experience during the onset of COVID-19. The Journal of Nursing Education, 60(9), 517 521. https://doi.org/10.3928/01484834-20210708-06
30. Camacho, T. (2020, Oct 7). How a canceled spring break will affect students. The Famuan. Retrieved from: http://www.thefamuanonline.com/2020/10/07/how-a-canceled-springbreak-will-affect-students/
35 Śliwa, S., Saienko, V., & Kowalski, M. (2021, November). Educating students during a pandemic in the light of research. International Journal of Educational Development, 87, 102504. https://doi.org/10.1016/j.ijedudev.2021.102504
33. Cornelson, K., & Miloucheva, B. (2022, September). Political polarization and cooperation during a pandemic. Health Economics, 31(9), 2025 2049 https://doi.org/10.1002/hec.4560
21. Yang, C., Chen, A., & Chen, Y. (2021, February 10). College students’ stress and health in the COVID-19 pandemic: The role of academic workload, separation from school, and fears of contagion. PLoS One, 16(2), e0246676 https://doi.org/10.1371/journal.pone.0246676
31. Copeland, W. E., McGinnis, E., Bai, Y., Adams, Z., Nardone, H., Devadanam, V., . . . Hudziak, J. J. (2021, January). Impact of COVID-19 pandemic on college student mental health and wellness. Journal of the American Academy of Child and Adolescent Psychiatry, 60(1), 134 141.e2. https://doi.org/10.1016/j.jaac.2020.08.466
22. Zurlo, M. C., Cattaneo Della Volta, M. F., & Vallone, F. (2020, October 22). COVID-19 student stress questionnaire: Development and validation of a questionnaire to evaluate students’ stressors related to the coronavirus pandemic lockdown. Frontiers in Psychology, 11, 576758. https://doi.org/10.3389/fpsyg.2020.576758
24 Lee, C. M., Juarez, M., Rae, G., Jones, L., Rodriguez, R. M., Davis, J. A., Harries, A. J. (2021, July 29). Anxiety, PTSD, and stressors in medical students during the initial peak of the COVID-19 pandemic. PLoS One, 16(7), e0255013 https://doi.org/10.1371/journal.pone.0255013
INTRODUCTION
Green benefits to health from nature-based interventions, like a wetland park, can include increased self-esteem and lower levels of stress, depression, and anxiety.12 Moreover, green infrastructure can have positive impacts on the cardiovascular system and pregnancy health, though less is known about the health benefits from green stormwater management systems.13 Other benefits can include increased physical activity14 and lower exposure to air pollution and other toxics,15 though findings on self-reported health are mixed.16,17
Creating green spaces in urban areas that lack them, as well as improving the quality of and access to existing green spaces, can positively impact the social, economic, and health outcomes of nearby residents.1–4 Socially disadvantaged communities (i.e., low-income communities of color) have generally had the least access to urban green amenities like community gardens, resilient parks, rain gardens, and flood control mitigation, and are disproportionately vulnerable to climate change hazards, as well as other environmental injustices like toxic waste and water pollution.1,2,5 Paradoxically, however, these communities are also more vulnerable to “residential and social displacement” when the introduction of green infrastructure to mitigate environmental hazards does not account for downstream, unintended consequences. These consequences can include potential changes in racial makeup and housing affordability, including an influx of Whites and higher rent and general cost of living, which can accompany revitalization and enhanced resilience to environmental and climate hazards.1,2,5–9
ABSTRACT
and plants, while also serving as a space for walking, biking, and enhancing commercial and residential economic activity via its connection to the Riverfront.10 Though the wetland park has only recently been opened to the public (June 2022), it is a major, community-generated greening effort happening in tandem with significant Riverfront development in South Wilmington.11
78 Delaware Journal of Public Health - August 2022
Victor W. Perez, Ph.D. Associate Professor, Sociology, University of Delaware William Swiatek, M.A., A.I.C.P. Principal Planner, WILMAPCO
Our goal in this analytic essay is to underscore that any community health benefits that come from enhanced access to green space, efforts to remediate known environmental hazards, and efforts to mitigate climate change impacts must be examined in the context of community revitalization and social change.2,5 The newly opened Wilmington Southbridge Wetlands Park is a prime example of a large, urban, green infrastructure project that is aimed at controlling historic flooding in the community of Southbridge. South Wilmington, DE generally encompasses Census tract 19.02 and is made up of 2,113 residents, according to the 2020 Census. The core community of Southbridge, located in Census tract 19.02, has 1,430 residents and is roughly 86% African-American. As one of the largest brownfields in the City of Wilmington, the transformation of the wetland into an attractive and functional environmental amenity is aimed at reducing flooding and introducing ecosystems for native wildlife
DOI: 10.32481/djph.2022.08.013
This essay begins with a review of some relevant literature on the relationship between greening and community health. Next, we briefly present findings from our examination of community demographic change using data at both the Census tract and block group level for Census tract 19.02, which contains the community of Southbridge and neighboring Christina Landing. Future Riverfront East development will be located in the same Census tract next to Christina Landing. We show some of the chief demographic characteristics of the area, currently and historically, to illustrate significant recent social changes. Our analysis also explores the same data for the discrete community of Southbridge, which we have determined by matching Census blocks to the common locally perceived neighborhood boundary to explore how any demographic shifts in the area can be isolated as within or outside of the core community of Southbridge (see the 2006 SAMP and 2021 SNAP for some details on these community data). Lastly, we present health data that helps to focus attention on the relationship between greening, revitalization, and health in the area.
Greening, Revitalization, and Health in South Wilmington, Delaware
We highlight the potential for paradoxical impacts of green infrastructure integrated with urban redevelopment. Absent directly addressing social inequalities in parallel efforts, green infrastructure may lead to negative health outcomes of disadvantaged residents, including eventual displacement. We present the research literature and reviews on this topic. We next highlight the case of recent in-migration of higher-income Whites and others in South Wilmington, Delaware, spurred on by high-end Riverfront redevelopment at Christina Landing. This migration may obscure how greening efforts—such as a new wetlands park to control area flooding—influence health outcomes in Southbridge, a low-income, African American neighborhood also within South Wilmington. The area’s Census tract boundary, often used in both health and equity assessments, is shared by these distinctive communities. When viewed through the lens of inequality, greening can have multi-faceted impacts that structure health outcomes. We underscore the importance of the mitigation of its potentially harmful effects.
GREENING AND COMMUNITY HEALTH
Cole and colleagues note that “gentrification itself may have no effect or even a positive effect on the health of the population as a whole while its effect on the health of underprivileged residents may be detrimental” (p. 159).5 This underscores the importance of knowing what the intended and unintended health consequences are for areas experiencing greening coupled with significant economic revitalization and development, like South Wilmington. Gentrification need not involve the swift, outright displacement of underprivileged residents, but could involve processes of “intimate segregation” from more privileged residents moving into the same area, with different groups utilizing different parts of the green space and not directly interacting.10 The variety of negative outcomes of displacement notwithstanding, without attention to community change in this context, health improvements may be attributed to greening when, in fact, they may be due to processes of in- and outmigration of different residents over time and when measured using Census Tract boundaries.
GREENING AND COMMUNITY CHANGE IN THE CONTEXT OF REDEVELOPMENT AND REVITALIZATION
Between 2000 and 2020, there has been a significant change in the White demographic residing in Census tract 19.02. Table 1 below shows the number of White residents in the tract and in the core community of Southbridge over time. These data illustrate the significant increase of White residents in Christina Landing, a Riverfront development to the west of Southbridge, but not directly into Southbridge itself (see the 2021 SNAP for more information).
Table 1. White Resident Influx into South Wilmington from 2000-2020 Year 2000 2010 2020 Tract 19.02 91 393 394 Southbridge NA 43 49
Unfortunately, health data for specific racial groups within any
social and economic shifts heightens disadvantaged residents’ vulnerability to displacement and other social disruptions.16,17 Investment in affordable, mixed-income housing and encouraging homeownership by longtime residents, as well as ensuring that any investments in the area related to housing benefit longtime residents, is crucial to ensuring equitable outcomes and community sustainability.22 However, revitalization and development can be seen as a paradox by local residents of color, as it may create fears of gentrification, racial exclusion, and a loss of social ties, but is also necessary as an external source of “top down” revitalization and urban economic development.7,23 (p.294),24 Indeed, data suggest a growing trend of socio-economic and racial disparities across the City of Wilmington as a whole. For example, median household income disparities across White and Black Wilmington residents show that, in 1980, White Wilmingtonians earned $46,380 and Black Wilmingtonians earned $35,380; in 2015-2019 (2017 inflation-adjusted dollars), White Wilmingtonians earned $65,087 and Black Wilmingtonians earned $31,629. In South Wilmington, where a single Census tract 19.02 houses a relatively wide range of economic disparities and dimensions of racial exclusion and segregation, this is even more pronounced. White median household income in Census tract 19.02 was $62,723 in 2000, while the Black median household income for the tract was $38,207 (both inflation-adjusted). In 2020, the Census reported median household incomes for the tract as $143,333 and $31,875, respectively, reflecting a substantial increase for White households and a decrease for Black households.
These newer White residents also reflect a significant increase in White wealth in the tract, with more than a doubling of the median White household income between 2000 and 2020 (in inflation-adjusted dollars). This influx will likely increase dramatically over the next 10 years with the buildout of the Riverfront East. The number of Black residents in Southbridge today (n = 1236) is largely the same as in 2010 (n = 1212), but the tract has seen a 12% decrease in total Black residents since the year 2000, totaling 1426 today.
Figures 1 and 2 (on the following page) illustrate the geographic boundary for Census tract 19.02 and the blocks used in our estimation of the core community of Southbridge, using 2020 Census data, respectively.
By focusing on South Wilmington (broadly) and Southbridge (specifically) as a case study where equitable health outcomes can flow both up and downstream, we highlight the need to mitigate potential for displacement of longtime residents because the health benefits of greening for them may only be temporary; by contrast, greening can enhance and elevate the generally better levels of health that in-migrants may have.5 Efforts to revitalize and enhance the environmental resilience of vulnerable communities through green-integrated development may widen the gap of inequality via wealthier in-migrants and may not have the intended effects, health and otherwise. In light of this, health measures that assess the beneficial impact of greening must parse out the overall better health that may accompany new residents moving into the area, especially if the area encompasses a single geographic unit (i.e., Census tract) but contains significant levels of socioeconomic disparities across it and may be gentrifying. These health differences reflect broader patterns of the profound impacts of social determinants of health and are well-documented.18
Research literature that examines the relationship between gentrification and health helps to understand community redevelopment and economic revitalization (as well as any negative impacts of gentrification on health) as a multistage process.19 With intensive Riverfront redevelopment having occurred and set to expand in South Wilmington and comparatively little redevelopment within Southbridge,20 we suggest that racial disparities will continue to be a key driver of change in wealth, and possibly health, evident in South Wilmington’s Census tract data. Several of these changes are apparent in demographic, wealth, and health data already. Greening initiatives, by themselves, are often beneficial for all residents, existing and new, wealthy and not. Too often, however, green and climate resilience initiatives in urban areas with environmental disamenities and socially disadvantaged residents cater to the interests of residential and commercial real estate development that attracts new residents that can afford to live in the local area.21 With this, the potential for significant
79
Figure 2. Core Community of Southbridge by Blocks
80 Delaware Journal of Public Health - August 2022
Figure 1. Geographic Boundary of Census Tract 19.02
Higher HouseholdMedianIncome Higher % BlackNon-Hispanic Higher %WhiteNon-Hispanic Physical inactivity (-.28) 0.08 (.75) 0.56 (-.71) 0.50 Obesity (-.32) 0.10 (.82) 0.67 (-.75) 0.57 Asthma (-.57) 0.33 (.86) 0.74 (-.73) 0.53 Poor reported mental health (-.59) 0.35 (.58) 0.34 (-.53) 0.28 Poor reported health (.22) 0.05 (.22) 0.05 (-.10) 0.01 Table 2. Pearson’s r and R-Squared Values Between Population Groups and Health Behaviors and Outcomes in the Wilmington, DE Region 81
Localized greening and other improvements ought to benefit both existing and new residents across South Wilmington.
The data in Table 2 are coefficients of determination, or R-squared, that measure the association between racial and income concentration with health behaviors and outcomes. Higher values have greater association, with 1 being a complete correlation and 0 none. These data are for Census tracts across the Wilmington region – New Castle County, DE and Cecil County, MD and are based on a deeper analysis of Behavioral Risk Factor Surveillance System (BRFSS) health data recently analyzed by WILMAPCO.25 Demographic and socio-economic data cited are from the American Community Survey, 2015-19.
Census tracts with stronger concentrations of Whites or Blacks show fairly strong–and disparate–correlations to various health behaviors and outcomes. Table 2 below shows the Pearson’s r and R-squared correlations between higher median household income, higher percentages of non-Hispanic Blacks, and higher percentages of non-Hispanic Whites and various health data. Higher percentages of Blacks are, for example, correlated with increasing physical inactivity (the estimated percentage of adults reporting to be physically inactive over the past 30 days).
Stronger White presence, meanwhile, and to a lesser extent, higher median incomes, are linked to declining levels of physical inactivity, estimated obesity, asthma and poor reported mental health. While it is an obvious measure to include, we found poor reported health to be weakly correlated to racial or income conditions; it is more strongly correlated (0.18) with advancing median age in a tract.
But, as the data above suggest, caution is needed. Aggregate health improvements across the tract may be largely due to the recent and the likely, future, in-migration of wealthier Whites, and not positive greening efforts, such as the development and revitalization of parks and trails alone. As noted earlier, these patterns are indicative of the complex relationship between race and the social determinants of health, and play out in greening and other community development policies.
CONCLUSION AND PUBLIC HEALTH IMPLICATIONS
Post-industrial urban spaces provide ample opportunity for the remediation of brownfields and other “vacant and derelict land,” often disproportionately located nearby or within socially disadvantaged and marginalized communities, and recreate them into green spaces such as urban agriculture and recreation spaces (p. 2233).7 Often, though, this movement towards cleanup and re-use is driven by economic and profit-based incentives, due in part to the costliness of brownfield redevelopment, but also because of the need for external sources of investment.7 When deeply intermixed with higher cost residential and commercial development that takes into account climate-change impacts like sea level rise and increased storm surges, these efforts can also be seen as ways to enhance resilience to climate change, or what Anguelovski and colleagues (2019) call “a new type of climate planning: green climate resilience” (p. 26139).1
given Census tract are not readily available. These data are, instead, aggregated to all populations within a Census tract, and they are difficult to assess historically. This makes tracking health improvements within a given tract for a given group impossible without a local survey. Examining the correlations between regional Census tracts with increasing concentrations of demographic groups and increasing concentrations of health conditions is, however, possible. These correlations may offer some insight into health improvements a tract experiencing heavy racial and income change, like South Wilmington (19.02), has and may continue to experience.
The “green and resilient orthodoxy” that “integrates nature-driven solutions into urban sustainability policy” (p. 26140)1 underlies much of the integrated residential and commercial development and green infrastructure enhancement being implemented in South Wilmington. This integration might downplay the potential negative impacts on the most vulnerable residents in the area, while, as Anguelovski and colleagues remark, “selling a new urban brand of greening and environmentally resilient 21st-century city to investors, real estate developers, and new sustainability class residents” (p. 26140).26 It is important, further, to better understand the sequencing of green infrastructure and revitalization through development, in order to determine if it leads revitalization and redevelopment efforts or if it is integrated within it.26
Moreover, greening and redevelopment processes should feature not just initial, but iterative community engagement. In their review of literature surrounding green gentrification and health, Jelks and colleagues observed:
In urban areas with significant greening and redevelopment growth intertwined, there may be a need to adjust the geographic boundaries that obfuscate explanations for improvements in community health and allow for more precise and intentional policies to prevent social displacement and the loss of those benefits. The SNAP recommends doing just that in South Wilmington. In the meantime, it is imperative to study communities within these formal geographic boundaries with more precision in order to best understand the impact green infrastructure has had on the health and well-being of any socially disadvantaged residents that tend to reside outside of Christina Landing and other areas to the west of Southbridge. Further, the formal geographic boundaries should be assessed as to their utility, strengths, and weaknesses for data-driven policymaking in a rapidly-changing urban area experiencing significant development and growth. This type of assessment will provide the acumen necessary to equitably distribute any benefits of development, revitalization, and greening, and help to mitigate the potential for displacement of socially and economically disadvantaged residents in the area.
Policy interventions, however, are often not nuanced enough to target distinct places within a tract, such as Southbridge. Thus, under the banner of addressing historic social inequities, market-rate luxury high-rise development outside of Southbridge qualifies for Opportunity Zone tax credits. In a similar vein, a project to construct a street grid at Riverfront East, a planned high-end development more than a half mile from Southbridge, has received millions of dollars in funding through a Rebuilding American Infrastructure with Sustainability and Equity (RAISE) grant where equity benefits were highlighted based on tract data. Paradoxically, by themselves and without incorporating direct benefits to neighboring disadvantaged places, such projects simply do not just fail to address but may widen Wilmington’s growing socio-economic and health divisions.
Dr. Perez may be contacted at victorp@udel.edu
CONCLUSION
Existing community planning and organizing efforts in Southbridge – like the SWPN and the SBCA – can support wider community engagement of residents and ensure new efforts are in line with the SNAP. The key is for redevelopment efforts to engage with these groups and to stay engaged. The concept for Southbridge’s wetland park originated in the 2006 Plan and early development and implementation efforts sought resident support and direction through workshops and meetings. However, a pair of offshoot implementation efforts–the placement of a large sports field adjacent to the community and the decision to connect Southbridge to the new Christina River Bridge via trail and not road–sped forward without stopping for community direction and support. These can be contrasted against other area efforts that have, such as the development of a neighborhood park revitalization plan at Hicks Park grounded in door-to-door surveying and iterative engagement with community leaders surrounding streetscape and bridge replacement plans. We must be cognizant of the possibility that demographic and health data, when organized by geographic boundaries that contain a wide variety of social and economic disparities and are experiencing significant revitalization to attract new residents, may be illusionary; that is, the positive health impacts of any greening may be obscured by the influx of wealthier residents who tend to have better health, overall, and the upand downstream benefits to health unequal. These geographic boundaries, moreover, present critical implications for policy. The common overreliance on Census tracts to represent place is especially problematic in areas like South Wilmington (Census tract 19.02) with sharp racial and class divisions within its boundary.27,28 Today, South Wilmington often rightfully surfaces
We would like to thank Maddy Starling at the University of Delaware for assistance with demographic data and geographic boundaries. This paper is partially the result of research sponsored by the Delaware Sea Grant College Program with funds from the National Oceanic and Atmospheric Administration (NOAA) Office of Sea Grant, U.S. Department of Commerce, under NOAA grant number NA22OAR4170094. The statements, findings, conclusions, and recommendations are those of the author(s) and do not necessarily reflect the views of the DESG or the U.S. Department of Commerce.
With the support of Healthy Communities Delaware, the South Wilmington Planning Network (SWPN) and Southbridge Civic Association (SBCA) produced the Southbridge Neighborhood Action Plan (SNAP) late last year. An update to a 2006 Neighborhood Plan, the SNAP offers a comprehensive approach to community revitalization grounded in the needs of existing residents. While greening and climate adaptation efforts feature prominently in the plan, so too–equally–do the need for mixedincome housing development, hammering out community benefit agreements with private developers, and addressing other community needs such as the betterment of health and improved mobility. Pursuing multi-pronged, community-driven revitalization alongside greening and resilience efforts should help inhibit unintended green gentrification, which can come about through siloed greening efforts.9
82 Delaware Journal of Public Health - August 2022
as a socio-economically disadvantaged tract in any number of indices incorporating measures such as poverty and non-White racial concentrations. But, in South Wilmington, this designation is made on the strength of data emanating from Southbridge, an historically Black, lower-income neighborhood within the tract, and not Christina Landing, a racially mixed but predominantly White, upper middle-income community.
. . . parks and greenways in gentrifying communities are most often designed to meet the needs and aesthetic preferences of affluent White newcomers, as opposed to longtime low income BIPOC residents. To this extent, early, meaningful, and consistent engagement of residents of communities targeted for urban greening projects is critical to ensure that long-time residents have a voice in designing green spaces that they would like to use...14
ACKNOWLEDGMENTS
8 Rigolon, A., & Nemeth, J. (2018). “We’re not in the business of housing:” Environmental gentrification and the nonprofitization of green infrastructure projects. Cities (London, England), 81, 71 https://doi.org/10.1016/j.cities.2018.03.01680.
4 Zhang, Y., van Dijk, T., Tang, J., & van den Berg, A. E. (2015, November 12). Green space attachment and health: A comparative study in two urban neighborhoods. International Journal of Environmental Research and Public Health, 12(11), 14342 14363 https://doi.org/10.3390/ijerph121114342
18. National Academies of Sciences, Engineering, and Medicine. (2017). The root causes of health inequity. In J.N. Weinstein, A. Geller, Y. Negussie, & A. Baciu, (Eds.), Communities in action: Pathways to health equity (chapter 3). National Academies Press.
16 Gibbons, J., & Barton, M. S. (2016, December). The association of minority self-rated health with Black versus White gentrification. J Urban Health, 93(6), 909 922 https://doi.org/10.1007/s11524-016-0087-0
13. Suppakittpaisarn, P., Jiang, X., & Sullivan, W. C. (2017). Green infrastructure, green stormwater infrastructure, and human health: A review. Current Landscape Ecology Reports, 2, 96 110 https://doi.org/10.1007/s40823-017-0028-y
5 Cole, H. V. S., Mehdipanah, R., Gullón, P., & Triguero-Mas, M. (2021, June). Breaking down and building up: Gentrification, its drivers, and urban health inequality. Current Environmental Health Reports, 8(2), 157 https://doi.org/10.1007/s40572-021-00309-5166
2 Cole, H. V. S., Triguero-Mas, M., Connolly, J. J. T., & Anguelovski, I. (2019, May). Determining the health benefits of green space: Does gentrification matter? Health & Place, 57, 1 https://doi.org/10.1016/j.healthplace.2019.02.00111.
11. South Wilmington SAMP Neighborhood Plan Work Group. (2006). South Wilmington Neighborhood Plan. Retrieved from http://www.wilmapco.org/Southbridge/files/SAMPFinalDraft_Jun06.pdf
7 Maantay, J. A., & Maroko, A. R. (2018, October 12). Brownfields to greenfields: Environmental justice versus environmental gentrification. International Journal of Environmental Research and Public Health, 15(10), 2233 2249. https://doi.org/10.3390/ijerph15102233
21 Garcia Lamarca, M., Anguelovski, I., Cole, H. V. S., Connolly, J. J. T., Perez-del-Pulgar, C., Shokry, G., & Triguero-Mas, M. (2022). Urban green-grabbing: Residential real estate developers discourse and practice in gentrifying Global North neighborhoods. Geoforum, 128, 1 https://doi.org/10.1016/j.geoforum.2021.11.01610.
6. Gould, K. A., & Lewis, T. L. (2018). Green gentrification: Urban sustainability and the struggle for environmental justice. Routledge.
20. Healthy Communities Delaware, & the Southbridge Civic Association. South Wilmington Planning Network; & Robinson, A. (2021). The Southbridge neighborhood action plan. Retrieved from: https://wilmapco.sharefile.com/share/ view/88d0f1c7cc9342648c589a08cda2f8cf
22. Centers for Disease Control and Prevention. (2013). Healthy places: Strategies to minimize the adverse effects of gentrification. Retrieved from: https://www.cdc.gov/healthyplaces/healthtopics/gentrification_ strategies.htm
14 Jelks, N. O., Jennings, V., & Rigolon, A. (2021, January 21). Green gentrification and health: A scoping review. International Journal of Environmental Research and Public Health, 18(3), 907 https://doi.org/10.3390/ijerph18030907929.
3 Rigolon, A., Browning, M. H. E. M., McAnirlin, O., & Yoon, H. V. (2021, March 4). Green space and health equity: A systematic review on the potential of green space to reduce health disparities. International Journal of Environmental Research and Public Health, 18(5), 2563 https://doi.org/10.3390/ijerph180525632589.
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9. Shokry, G., Connolly, J. J. T., & Anguelovski, I. (2020). Understanding climate gentrification and shifting landscapes of protection and vulnerability in green resilient Philadelphia. Urban Climate, 31(100539), 1 10https://doi.org/10.1016/j.uclim.2019.10053921.Harris,B.,Schmalz,D.,Larson,L.,Fernandez, M., & Griffin, S. (2020). Contested spaces: Intimate segregation and environmental gentrification on Chicago’s 606 trail. City & Community, 19(4), 933 https://doi.org/10.1111/cico.12422962
15. Cole, H. V. S., Garcia Lamarca, M., Connolly, J. J. T., & Anguelovski, I. (2017, November). Are green cities healthy and equitable? Unpacking the relationship between health, green space and gentrification. Journal of Epidemiology and Community Health, 71(11), 1118 https://doi.org/10.1136/jech-2017-2092011121
17 Izenberg, J. M., Mujahid, M. S., & Yen, I. H. (2018, July). Health in changing neighborhoods: A study of the relationship between gentrification and self-rated health in the state of California. Health & Place, 52, 188 https://doi.org/10.1016/j.healthplace.2018.06.002195.
12 Maund, P. R., Irvine, K. N., Reeves, J., Strong, E., Cromie, R., Dallimer, M., & Davies, Z. G. (2019, November 11). Wetlands for wellbeing: Piloting a nature-based health intervention for the management of anxiety and depression. International Journal of Environmental Research and Public Health, 16(22), 4413 4429 https://doi.org/10.3390/ijerph16224413
19 Tulier, M. E., Reid, C., Mujahid, M. S., & Allen, A. M. (2019, September). “Clear action requires clear thinking”: A systematic review of gentrification and health research in the United States. Health & Place, 59, 102173 https://doi.org/10.1016/j.healthplace.2019.102173102182.
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REFERENCES
28 Schnake-Mahl, A. S., Jahn, J. L., Subramanian, S. V., Waters, M. C., & Arcaya, M. (2020, February). Gentrification, neighborhood change, and population health: A systematic review. J Urban Health, 97(1), 1 https://doi.org/10.1007/s11524-019-00400-125
23 Chronopoulos, T. (2016). African Americans, gentrification, and neoliberal urbanization: The case of Fort Greene, Brooklyn. Journal of African American Studies, 20, 294 322. https://doi.org/10.1007/s12111-016-9332-6
27. Smith, G. S., Breakstone, H., Dean, L. T., & Thorpe, R. J., Jr. (2020, December). Impacts of gentrification on health in the US: A systematic review of the literature. J Urban Health, 97(6), 845 https://doi.org/10.1007/s11524-020-00448-4856
24. Danley, S., & Weaver, R. (2018). “They’re Not Building It for Us”: Displacement pressure, unwelcomeness, and protesting neighborhood investment. Societies (Basel, Switzerland), 8(3), 74 https://doi.org/10.3390/soc803007489
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25. Wilmapco. (2022). Health Behaviors & Outcomes: Transportation and Land Use Correlations. Retrieved from http://www.wilmapco.org/data/Health_Data_Report_May_2022.pdf
26 Anguelovski, I., Connolly, J. J. T., Cole, H., Garcia-Lamarca, M., Triguero-Mas, M., Baró, F., Minaya, J. M. (2022, July 2). Green gentrification in European and North American cities. Nature Communications, 13(1), 3816 https://doi.org/10.1038/s41467-022-31572-13828.
Feeling better starts with feeling
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Prabhdeep Uppal, D.O., M.S.
GFR tells us how well the kidneys are working, and is used to estimate kidney function and thus chronic kidney disease (CKD). While estimated GFR (eGFR) can decline with age, CKD risk factors include diabetes and hypertension. GFR is not only important for evaluation of chronic kidney disease but is also considered while ordering medications that could be renally Sinceeliminated.3measured
The use of race in medicine implies that we are physiologically different based on our outward, physical characteristics. However, race is not based in genetics, nor in physiology, but is entirely a social construct based on characteristics, physical locations, and behavioral patterns.1
President & CEO, Delaware Health Sciences Alliance; Physician Leader, Partnerships and Academic Programs, ChristianaCare M. Burday, M.D.
GFR is expensive and lengthy, we currently use creatinine as a filtration marker to estimate GFR using the CKD-EPI and Modification of Diet in Renal Disease (MDRD) equations.4 Both equations include adjustments based on age, sex,
Adjusting for Black race using the MDRD and CKD-EPI equations accounts for an approximately 18% and 16% increase in eGFR, respectively. It was assumed that Black people have a higher average muscle mass (possibly due to diet or genetic differences), which has never been proven by any reputable research. While dietary differences can be cultural, they are also influenced by socioeconomic status, so this is likely a confounder and poor surrogate marker of directly influencing creatinine. It is an inappropriate generalization to assume Black people have more muscle mass. One cannot even measure muscle mass on living humans; it can only be measured on a cadaver.
DOI: 10.32481/djph.2022.08.014
Doctors for Emergency Services, ChristianaCare Omar A. Khan, M.D., M.H.S.
We have incorporated race into multiple clinical equations despite unclear evidence for doing so. We also recognize that the effects of racism and other social determinants of health, rather than race itself, are responsible for disparities in health outcomes.
Director, Medical Student Programs, Hospitalist, ChristianaCare
BACKGROUND
Emergency Medicine & Family Medicine Resident, ChristianaCare Benjamin L. Golden, M.D.
and race. An eGFR of less than 90 mL/min/1.73 m2 is categorized into five stages of chronic kidney disease with initiation of dialysis at stage 5 (Figure 1).
The Case Against Race-Based GFR
WHY GFR MATTERS FOR KIDNEY DISEASE
These eGFR equations are based on small and flawed studies published between the 1970s and 1990s. The MDRD equation was developed in 1999 using data from 1628 patients; of those, 197 Black men and women were included in the cohort.5 During the study, there was an incidental finding that Black men and women had higher creatinine excretion rates compared to their White counterparts. This happened to coincide with a report from the preceding year from the National Health and Nutrition Examination Survey, which also suggested the same but did not have any objective data on GFR and prevalence of CKD.5 The coincidental findings led researchers to conclude that Black race was an independent predictor of GFR, leading to the addition of the race coefficient to the equation without accounting for social factors or other independent predictors of CKD including hypertension and diabetes.
Figure 1. Stages of Chronic Kidney Disease
86 Delaware Journal of Public Health - August 2022
We highlight in this paper the use of race-based glomerular filtration rate (GFR). It has been suggested that the current racebased algorithm incorporating GFR is delaying diagnosis and treatment of worsening chronic kidney disease.2
Doctors for Emergency Services, ChristianaCare Ashley Panicker, M.D.
PUBLIC HEALTH & CONSIDERATIONSPOLICY
For example, a 55-year-old woman with a serum creatinine of 2.8 comes to the clinic for evaluation. If she is a White woman, she would be referred for a transplant due to an eGFR of 20 mL/min/1.73 m2 using the CKD-EPI equation. A Black woman with the same weight, height, body surface area and creatinine would not be referred because her GFR using CKD-EPI would be calculated as 23 mL/min/1.73 m2 (Figure 2). In nephrology, an eGFR 20 mL/min/1.73 m2 or less is the threshold for referral in the United States. Kidney transplant is the optimal treatment with ESRD, yet Black patients are less likely to be referred for transplant, and once on the list, wait longer than their White counterparts. A recent study at Brigham and Women’s hospital showed that removing the race coefficient would reclassify 3.1% of Black patients from eGFR > 20 mL/min/1.73 m2 to eGFR ≤ 20 mL/min/1.73 m2, making them eligible for a transplant referral.2
Figure 2. Comparison of MDRD and CKD-EPI Values for White and Black Women.
Despite the Black population constituting only 13% of the overall US population, Black patients account for more than 35% of all patients in the United States receiving dialysis for kidney failure.7 The disproportionate number of Black patients receiving dialysis further supports that the Black population has worse outcomes for chronic kidney disease, yet we continue to calculate and assign a higher GFR value with the current equations.
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Aside from the obvious delays in care for CKD, there are multiple other issues with using the race coefficient. For example, one obvious issue lies in the following question –how do providers categorize individuals with a heterogenous heritage? Currently, there is no guidance in this area. In the United States, whether you have one-fourth, one-eighth, or less Black ancestry, you are considered Black. During the Jim Crow segregation era, the South had the “one drop rule,” which meant a single drop of “Black blood” makes a person Black.9 Similarly, medicine is making arbitrary distinctions that are not based in science. It is left to the provider’s discretion to decide which race category to use based on his or her understanding of a patient’s race or the patient chooses which one they self-identify with the most. This, again, subverts the concept that race is a legitimate scientific variable. As Yearby wrote, “The genome between socially constructed racial groups is 99.5%-99.9% identical; the 0.1%-0.5% variation between any two unrelated individuals is greatest between individuals in the same racial group; and there are no identifiable racial genomic clusters.”10 In our view, this suggests that structural racism continues to affect modern medicine. This will become a more pressing issue as there was a 276% increase in individuals identifying as mixed race in recent years, which is predicted to increase 11
Addressing such disparities in health is not only important from a social justice and equity standpoint but also for improving the nation’s overall health and economic prosperity. A national study updated in 2018 by the W.K. Kellogg Foundation showed that there is a potential economic gain of $135 billion per year if racial disparities in health care were eliminated.8 This includes $93 billion in excess medical care costs and $42 billion in untapped productivity.8 As our population becomes more diverse, it is important to address these disparities.
RACISM & HEALTH
Physicians are failing to diagnose early stages of CKD in the Black population, which leads to a delay in secondary prevention.2 The leading causes of chronic kidney failure include diabetes and hypertension, both which can be controlled with the appropriate treatment regimens to prevent further progression of CKD. While early-stage kidney disease can be asymptomatic, it can progress to later stages without appropriate treatment and lead to fatigue, swelling in the extremities, muscle cramps and oliguria.6 Diagnosing CKD at earlier stages is critical so physicians can evaluate underlying causes and control risk factors.
Table 1. Status of eGFR Race Correction Factor Elimination Hospital System Status
The National Kidney Foundation and the American Society of Nephrology (NFK-ASN) created a task force that recently completed a 10-month review process with social and scientific evidence, testimonies from patients, providers and trainees including 97 experts representing 21 US states and seven other countries.13 They examined in detail twenty-six eGFR approaches with the intent to eliminates bias and shortened the initial twenty-six approaches to six by eliminating those that would be difficult to implement or have significant barriers in terms of standardizing in labs. Creatinine, for example, is widely used and standardized while cystatin C is only available in some labs and would be difficult to immediately implement.
REFERENCES
Tidal Health/Nanticoke
https://www.ncbi.nlm.nih.gov/books/NBK560512/
FUTURE DIRECTIONS: TOWARDS A RACE-NEUTRAL CONSIDERATION OF KIDNEY DISEASE
Wilmington VA In process of moving to eliminate the correction factor and should be completed soon. Working on computer testing. ChristianaCare Removed 4/12/22 Nemours Children’s Health No current plan to eliminate the correction factor
88 Delaware Journal of Public Health - August 2022
No current plan to eliminate the correction factor
1. Witzig, R. (1996, October 15). The medicalization of race: Scientific legitimization of a flawed social construct. Annals of Internal Medicine, 125(8), https://doi.org/10.7326/0003-4819-125-8-199610150-00008675–679.
Removal of race from eGFR is an opportunity for physicians to help reduce inequalities in treatment and outcomes. Instead of assuming biologic causes of health inequities, we can focus on social determinants of health that lead to disparities. Dr. Clive Callender, founder of the Howard University Hospital Transplant Center, once said “Institutionalized racism is the elephant in the room that has not been addressed. We have put this social construct, as enormous as it is, to become an obstacle to everything that we do, and we pay the price.” As current and future providers for many of these patients, we can help reduce these health inequities by advocating for our patients, looking at GFR when making clinical decisions, and supporting the elimination of race based GFR.
Eliminating the correction factor late summer or fall
Working on eliminating the correction factor. No date in place, target: June/July 2022
3. Kyriakopoulos, C., & Gupta, V. (2022, Jan). Renal failure drug dose adjustments. StatPearls. Treasure Island (FL): StatPearls Publishing.
Dr. Uppal may be contacted at Prabhdeep.uppal@christianacare.org
Beebe Healthcare Removed 3/2022
Of the twelve approaches that did not include race as a variable, seven were not developed in a population that included Black individuals. This led to a final five approaches for further review to find an accurate, non-racially based, and feasible cost-effective measurement for GFR. The committee then divided the potential clinical consequences into general medical care and nephrology care with general medical care being medication initiation and dosing. Based on patient testimonies and research, it was determined that we need earlier CKD detection, transparent communication about detection, tracking eGFR trajectory and rapid referral to nephrology including transplants.13 It was important to minimize bias and Theinaccuracy.grouplooked for an approach that would not disproportionately affect any one group of individuals, and found that of the five different approaches, CKD-epi using creatinine without the race coefficient was recommended because it included diversity during development as 31% of the participants within the CKD-EPI studies were identified as Black.13 It is also immediately available in all labs in the United States and does not disproportionately affect any group of individuals. While cystatin is not currently used, its routine use is encouraged as a combination of both creatinine and cystatin are more accurate and would support better clinical decisions. In Delaware, significant headway has occurred as regards to eliminating the correction factor in 2022 as compared to 2021. In a phone survey to all the Delaware hospital systems conducted April 2022, many were moving to eliminate or had already eliminated the correction factor. Conversations were held with pathologists, laboratory supervisors, pharmacy,
St. Francis Hospital/ Trinity Health
What happens if we eliminate the race coefficient? A recent cross-sectional study showed that removing race as a factor in recommending care resulted in one third of Black patients reclassified to a more severe stage of CKD.12 This initiative will improve the quality of life for one third of the population with CKD and prevent early progression to ESRD. Physicians can order early referrals and transplant evaluations. While some may argue that ending the race adjustment can lead to overdiagnosis and overtreatment, as medical professionals we should be favoring practices that alleviate health inequities over those that will exacerbate them.
CONCLUSION
2 Ahmed, S., Nutt, C. T., Eneanya, N. D., Reese, P. P., Sivashanker, K., Morse, M., Mendu, M. L. (2021, February). Examining the potential impact of race multiplier utilization in estimated glomerular filtration rate calculation on African-American care outcomes. Journal of General Internal Medicine, 36(2), 464 https://doi.org/10.1007/s11606-020-06280-5471.
Bayhealth
information technology and chemistry personnel; all were familiar with the eGFR race correction. While some systems have dropped the correction or are moving ahead in the process, two systems have no plans at present to eliminate it (see Table 1). The significance of this is unclear, especially considering the recommendation by the National Kidney Foundation-American Society of Nephrology.
13 Delgado, C., Baweja, M., Crews, D. C., Eneanya, N. D., Gadegbeku, C. A., Inker, L. A., Powe, N. R. (2022, February). A unifying approach for GFR estimation: Recommendations of the NKF-ASN task force on reassessing the inclusion of race in diagnosing kidney disease. Am J Kidney Dis, 79(2), 268 https://doi.org/10.1053/j.ajkd.2021.08.003288.e1
4 Mula-Abed, W. A., Al Rasadi, K., & Al-Riyami, D. (2012, March). Estimated glomerular filtration rate (eGFR): A serum creatinine-based test for the detection of chronic kidney disease and its impact on clinical practice. Oman Medical Journal, 27(2), 108 https://doi.org/10.5001/omj.2012.23113.
6. Stenvinkel, P. (2010, November). Chronic kidney disease: A public health priority and harbinger of premature cardiovascular disease. Journal of Internal Medicine, 268(5), 456 467 https://doi.org/10.1111/j.1365-2796.2010.02269.x
7. Kidneyfund.org. (2016). Kidney disease and African-Americans. https://www.kidneyfund.org/kidney-today/kidney-disease-africanamericans.html
8 Turner, A. (2018). The business case for racial equity: A strategy for growth. W.K. Kellogg Foundation. https://altarum.org/sites/default/files/uploaded-publication-files/ WKKellogg_Business-Case-Racial-Equity_National-Report_2018.pdf
10. Yearby, R. (2021, February). Race based medicine, colorblind disease: How racism in medicine harms us all. Am J Bioeth, 21(2), 19 27. https://doi.org/10.1080/15265161.2020.1851811Epub2020Dec5.
9 Sharfstein, D. J. (2007). Crossing the color line: Racial migration and the one-drop rule, 1600-1860, 91 Minnesota Law Review, 592. Retrieved from http://scholarship.law.vanderbilt.edu/faculty-publications/386
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11. Jones, N., Marks, R., Ramirez, R., & Rios-Vargas, M. (2022). 2020 Census Illuminates Racial and Ethnic Composition of the Country. Census.gov https://www.census.gov/library/stories/2021/08/improved-raceethnicity-measures-reveal-united-states-population-much-moremultiracial.html
5. Levey, A. S., Bosch, J. P., Lewis, J. B., Greene, T., Rogers, N., & Roth, D., & the Modification of Diet in Renal Disease Study Group. (1999, March 16). A more accurate method to estimate glomerular filtration rate from serum creatinine: A new prediction equation. Annals of Internal Medicine, 130(6), 461 https://doi.org/10.7326/0003-4819-130-6-199903160-00002470.
12 Bragg-Gresham, J., Zhang, X., Le, D., Heung, M., Shahinian, V., Morgenstern, H., & Saran, R. (2021, January 4). Prevalence of chronic kidney disease among Black individuals in the US after removal of the Black race coefficient from a glomerular filtration rate estimating equation. JAMA Network Open, 4(1), https://doi.org/10.1001/jamanetworkopen.2020.35636e2035636
These three Delawareans are united by their diagnosis of intellectual/developmental disability (IDD) and by the safe and healthy environments in which they live. As a central tenet of the strategy to make Americans healthier, we are motivated to
For those individuals with IDD, assistance is needed at home to complete both activities of daily living (bathing, toileting, dressing, eating, moving) as well as instrumental activities of daily living (shopping, transportation, preparing meals, managing medications, using the phone, cleaning, running errands, and managing finances). Thousands of Delawareans with IDD rely on individuals known as direct support professionals (DSPs) to provide support in completing these activities of living throughout their day. These individuals help with life’s essential activities and are integral to healthy living conditions. DSPs perform “some of the functions of clinicians, service coordinators, managers, maintenance, and clerical personnel. They have a code of ethics and a set of core competencies.”2 DSPs make it possible for adults with IDD to live a more typical life in the community, such as holding a job, going to the store, taking a vacation, or visiting the doctor’s office. They also support independence in residential situations. Without these individuals, Delawareans with IDD and their families would not have a choice of safe and healthy environment in which they would like to live. Whether in a parent’s apartment, a long-term care facility, or in an apartment with peers also affected by IDD, each location requires DSPs to assist in maintaining the independence and health of the individual.
Research Nurse Supervisor, ChristianaCare
K.B. is a 28-year-old female with moderate autism. She uses verbal words to communicate and lives in an apartment with three roommates and full time DSPs who serve as house managers and staff. She works 20 hours per week at a supermarket and another DSP serves as her job coach. Her house staff accompanies her to all doctor’s appointments and errands including a weekly physical therapy session and an outing with a friend. When shopping, they assist with helping her pay and accept change. As she navigates going on a date for the first time, her DSP accompanies her to a healthy relationship class.
90 Delaware Journal of Public Health - August 2022
C.T is a 43-year-old female with quadriplegic spastic cerebral palsy. She lives in a long-term care facility and relies on a DSP called a residential technician. This individual makes sure she is bathed, dressed, and safely in her wheelchair from which she communicates via an augmentative and alternative communication system (AAC) and moves throughout the campus independently using head and foot controls. Her DSP ensures her choice of clothing and the color of her lighting in the room, gets her to appointments, and assists with technology support when her Facetime, email, or Alexa is not working. CT enjoys spending time with her parents on the weekend and her DSP ensures she is packed and has everything she needs for trips home.
Charmaine Wright, M.D., M.S.H.P.
The Where and the How: Ensuring those with Disabilities have the People Power for Healthy Living
Yet the DSP workforce has never been more challenged. For the 1.7 million adults with disabilities living in the US, there has been a shortage of support staff for many years because of inadequate funding and high turnover. However, the COVID-19 pandemic has raised it to epic proportions. In 2021, more than half of Delaware agencies serving people with IDD had vacancies for 20-50% of their necessary workforce.3 As a
A.S. is a 33-year-old autistic man who rents the apartment above his parents’ garage. He is competitively employed at a 20 hour/week job where he is entitled, through Medicaid, to have the support of a Direct Support Professional (DSP), who serves as his job coach. With the money he earns at his job and his monthly disability payment, he pays for his transportation to and from work and DSP’s to support him in community activities after work and on weekends. The rent he pays to his parents covers room and board. His parents support him in kind with oversight of all of his finances, medical care to include daily medications, meals, laundry, housekeeping, coordination of caregivers and ensure his safety in the apartment with the help of a security system. He is currently eligible through the Medicaid Lifespan Waiver to access benefits of $2700 per year to help him with the cost of personal care or pay for respite services like camp.
Medical Director, Center for Special Health Care Needs, ChristianaCare Verna Hensley
Vice President, Public Affairs, Easterseals Delaware and Maryland’s Eastern Shore Neal Emery, M.D.
look closely at the environment and other social determinants that account for health. The environment includes a person’s living conditions, their access to transportation, and safety. In clinical settings, we often monitor the health of an individual’s living conditions by asking about housing, homelessness, ambulatory status, and isolation.1 Nationally, 59% of those with IDD live with a family member, while 16% live in a group home (a residential setting with six or fewer individuals), 11% live in their own home, and 9% live in a long-term care facility (a residential setting with seven or more individuals). When we focus on the population with IDD, we cannot look at living situations nor discuss housing without noting the necessity of those hearts and hands who make it possible.
DOI: 10.32481/djph.2022.08.015
Attending Physician, ChristianaCare Pat Swanson, B.S.N., R.N.
Lack of career advancement is another reason often cited for workers leaving the caregiving industry. To create awareness about the career pathway and advancement, many states are sharing successful strategies on a broader scale at conferences and meetings. Sharing best practices regarding continuing education and leadership roles are a great step in bolstering states who may have lagging knowledge. DSP apprenticeships have been implemented to help create this career ladder, demonstrating that the profession is vibrant, and worthy of commitment. Currently, the Ability Network of Delaware, an association of community-based disability and behavioral health services providers, is advocating for the establishment of a Healthcare Workforce Center which would create an apprenticeship program for DSPs in Delaware. This apprenticeship model, which would create an employment pipeline for this career out of vo-tech and other high schools and adult education programs, is already in place in 19 other states. Federal and state governments can also assist with retention by helping support the career ladder in financial and operational ways.9
result of labor shortages, half of these agencies were unable to take on new clients and one quarter had to reduce services to existing clients. Government entities, family caregivers and a broad spectrum of disability organizations readily cite the workforce shortage as one of the most urgent challenges facing people with all types of disabilities.
Already, efforts are underway to begin to address the funding of the IDD system which impacts DSP wages in Delaware.
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Besides championing higher wages, another solution for the crisis is to recruit and retain the best workforce possible. Delaware’s turnover rate for DSPs was reported as 36% in 2020, slightly below the national rate of 43%.4 However, it is likely much higher now due to the pandemic. As hundreds of thousands of workers leave the caregiving industry, it is important to focus on renewed and innovative recruitment strategies. Collaborating with community colleges and offering loan forgiveness are two strategies to recruit the best caregivers. New York, for example, trains and certifies DSPs for free through in person or online courses through the state university system.5 California offers licensing to more than 5,000 new DSPs each year through free training courses run by the state Department of Education or through “challenge exams” that let experienced caregivers codify their skills.6
The direct support workforce crisis relates directly to the inadequate funding of services by government, because chronic underfunding translates to low wages for these workers. Just two years ago, State funding in Delaware supported a wage of approximately $9.00 an hour for these essential workers, who bear enormous responsibility in the care of the people they support. Inflation, a rising caseload, and most recently, a pandemic, has further exacerbated the ability of service providers to hire and retain direct support staff. Both in community settings and in long term care facilities, the vacancies for these positions are staggering.
In 2019, a partnership formed by the family advocacy group A-Team Delaware and disability service providers joined together and made history by advocating for the successful passage of the Michael McNesby Full Funding for Adults with Intellectual Disabilities Act. This law mandated the State to fully-fund day and residential services for adults with intellectual disabilities in Delaware based on a 2018 market study. Between 2018 and 2022, The Delaware General Assembly approved $42 million in State dollars, which will draw more than $59 million in federal matching Medicaid collars to fund service providers under contract by the Delaware Division of Developmental Disabilities (DDDS). This combined investment of more than $101 million is welcome news to meet the increasing needs of Delawareans with IDD and their caregivers. However, even with these additional dollars, the State funding only supports a $14/hour wage for Direct Support Professionals – far below a livable wage here. The Delaware Division of Disability Services (DDDS) will undertake an updated market study in the coming year which should reflect the need for higher wages for Direct Support Professionals.
Focusing on labor and immigration policy is a necessity. For decades, home health care in the U.S. has been bolstered by an immigrant workforce.7 This caregiving, which is often seen as
As labor markets reach a new normal with the COVID pandemic, the strain on the DSP workforce faces a new challenge: aging caregivers. Those who live with a family member often share a home with a parent who themselves are aging, and often over the age of 60 years. As individuals with IDD and their parents age in place, two crises are compounded: both need direct support professionals to be companions, makeup artists, chefs, Facetime operating system fixers, walking buddies, cheerleaders, anxiety-busters, friends, and guardians of health. Without these individuals, people requiring DSP services would suffer the threat of loneliness and even loss of life. It is extremely sobering that the waitlist of people who are disabled and need home and community-based services is growing rapidly at the very time the staffing shortage has reached an all-time high. Many private agencies who provide services through DSPs have closed their doors as these agencies say that America’s system for the disabled is nearing collapse.10 Delaware must build on the success of advocacy around the McNesby Act to ensure DSP staffing in all areas that those with IDD dwell. Now is the time to infuse the DSP industry with innovative ideas and energy in addition to new funding streams. For those with IDD, now is the time to be sure the question “who helps you live” receives as much attention as “where do you live.”
Dr. Wright may be contacted at: Charmaine.s.wright@christianacare.org.
low skill and not adequately respected, falls overwhelmingly on marginalized groups: in Delaware 76% of DSPs are women and more than 70% belong to a minority group.4 Until the recent workforce crisis, immigration policy and labor policy have not valued these positions. According to the Bureau of Labor Statistics, home health and personal care aides are the fastest growing industry, projected to grow 33 percent in the next decade, much faster than all occupations. But there still simply aren’t enough workers to fill the demand.8 Providing a new category of visa for DSPs may allow those who have caregiving skill to immigrate and start working faster and easier.
1. Linguamatics. (n.d.). Social determinants of health. Retrieved from: https://www.linguamatics.com/solutions/social-determinants-health-sdoh
5. State University of New York. (n.d.). Tuition-free health care certification programs. Retrieved from: https://www.suny.edu/otc/opwdd/
7. Martin, S., Lowell, L., Gozdziak, E. M., Bump, M., & Breeding, M. E. (2009, Dec). The role of migrant care workers in aging societies: Report on research findings in the United States. LTSS Center. Retrieved from: http://www.ltsscenter.org/resource-library/Role_of_Migrant_Care_ Workers_in_Aging_Societies.pdf
2. Regional Centers for Workforce Transformation. (2017). RCWT and core competencies at 2017 NYSACRA conference. Retrieved from: https://workforcetransformation.org/core-competencies-2017-nysacra/
LOWERING YOUR HIGH BLOOD PRESSURE IS EASIER THAN YOU THINK. There are FREE classes to help you get healthier and stay that way. HealthyDelaware.org/HealthyHeart 302-208-9097 92 Delaware Journal of Public Health - August 2022
10. Goldberg, D. (2022, Aug 10). ‘People will die waiting’: America’s system for the disabled is nearing collapse. Politico. Retrieved from: https://www.politico.com/news/2022/08/10/americas-system-for-thedisabled-is-nearing-collapse-00050713
4. National Core Indicators. (2022). Staff stability survey report. Retrieved from National Core Indicators. (2022). Staff stability survey report. https://www.nationalcoreindicators.org/resources/staff-stability-survey
REFERENCES
8. U.S. Bureau of Labor Statistics. (n.d.). Occupational outlook handbook: Home health and personal care aides. Retrieved from: https://www.bls.gov/ooh/healthcare/home-health-aides-and-personalcare-aides.htm
9. Moe, A. (2022, Jul). The crisis facing nursing homes, assisted living and home care for America’s elderly. Politico Magazine. Retrieved from: https://www.politico.com/news/magazine/2022/07/28/elder-careworker-shortage-immigration-crisis-00047454
3. Delaware Division of Developmental Disabilities Services. (2021). Summary results of DDDS staff vacancy survey. Retrieved from: https://dhss.delaware.gov/dhss/ddds/files/ DDDSStaffVacancySurvey_SummaryResults.pdf
6. California Department of Education. (2022). Neilson T. Direct Support Professional Program Summary. Retrieved from: https://www.cde.ca.gov/ci/ct/rp/dsp07summary.asp
30+ SPF wayssmaRttoblocktheRays ProtectYourSkinDE.com LATHER THE LOTION. SPORT THE SHADES. COVER UP WITH CLOTHES. SEEK LESS SUN.WEAR A WIDE BRIM. 93
When certain geographic areas within the United States lack resources to supply their residents with healthy food due to limited access to affordable and high-quality food stores, the area can be defined as a food desert.1 Research suggests that neighborhoods with better access to supermarkets and limited access to convenience stores tend to have healthier diets and lower levels of obesity and obesity-related chronic diseases.2–4 In neighborhoods without larger supermarkets, the smaller stores charge higher prices for fresh produce and sometimes completely lack other food items like nonfat milk or whole grain bread.5
ABSTRACT
the impoverished, predominantly Black communities doubly afflicted by supermarket inaccessibility.8 A number of projects and initiatives have since been implemented in an effort to improve access to healthier food options in disadvantaged neighborhoods with mixed results.2,9,10 In this study, we sought to evaluate interval change in food store accessibility based on neighborhood sociodemographic characteristics using the newly available 2020 US census data.
This problem directly affects those 39.5 million Americans living in low-income and low-access areas, with socioeconomic status playing a key role in determining the quality and quantity of food in close proximity.6 A White neighborhood has four times the supermarkets a predominantly Black neighborhood contains.7 Using the 2000 Census data, a research study reported that the number of supermarkets (a surrogate marker for access to high quality, healthful food) decreased, while grocery and convenience stores (representing lower quality food) increased with increasing level of neighborhood poverty, with
Background: It has been previously reported that access to quality food is greatly impacted by neighborhood food store quality and availability, which in turn is determined by a complex interplay of sociodemographic factors. Lowincome predominantly Black neighborhoods face the most limited access to quality food. The purpose of this study was to examine the newly available 2020 Census to see if any significant change has occurred to this pattern and if any new insights can be gained by analyzing these data. Methods: 2020 US Census and current ReferenceUSATM food store data were merged and multivariate Negative Binomial Count Regression Models were used to establish the relationship between different types of food stores (high, medium, and low quality) and neighborhood characteristics including urbanicity, poverty level, and race/ethnicity. Results: 11.5% of the predominantly NonHispanic (NH) White census tracts (CT) (6,486 out of 56,192), 61.3% (4,002 out of 6,531) of the predominantly NonHispanic Black CTs, and 44.1% (3,644 out of 8,258) of the predominantly Hispanic CTs were in the high poverty category. Compared to the reference group of NH White/low-poverty group, the incident rate ratio (IRR) and 95% Confidence interval [CI] of having access to high quality food stores for NH Black was significantly lower starting at the low poverty level (0.57 [0.48, 0.67], p<0.001) and decreasing further with increasing poverty: NH Black/ medium poverty (0.48 [0.42, 0.55], p<0.001); NH Black/high poverty (0.38, [0.34, 0.42], p<0.001). A similar pattern was seen with the Hispanic groups as well, though to a lesser degree. We further examined access to computer/ electronic devices including smartphones from 2017 to 2020. High poverty NH Black households experienced the fastest growth from 73.6% access rate in 2017 to 82.6% in 2020, compared with 87.0% to 92.0% in the total population. Conclusion: Analyses of the 2020 Census data reveal that access to high-quality food stores in high-poverty minority neighborhoods, NH Black neighborhoods in particular, remains severely limited. Innovative interventions and emerging technologies, online grocery shopping for example, warrant further evaluation as potential strategies to improve access and decrease disparities in social determinants of healthy eating.
The Lawrenceville School, Lawrenceville, New Jersey
Impact of Neighborhood Sociodemographic Characteristics on Food Store Accessibility in the United States Based on the 2020 US Census Data
INTRODUCTION
Allison Y. Zhu
94 Delaware Journal of Public Health - August 2022
2020 US Census data were obtained through the US Census Bureau website.11 Neighborhoods were represented as census tracts (CT). Food store information was obtained via ReferenceUSATM, a nationwide business and residential information database that contains real-time updated comprehensive business information including street address, phone number, hours of operation, number of employees, online presence, Standard Industrial Classification (SIC) codes, business contacts, etc.12 Census data and various grocery store data from ReferenceUSATM were merged by business address, SIC code or both.
DataMETHODSSources
DOI: 10.32481/djph.2022.08.016
STUDENT SPOTLIGHT
Rural CTs had more convenience stores (2.22±2.10), fewer Grocery stores (0.78±1.05) and fewer Supermarkets (0.14±0.41) than Urban CTs. Both convenience stores and grocery stores increased in number with increasing level of poverty, while the average number of supermarkets per CT exhibited a reverse trend, decreasing in low poverty CTs (0.28±0.60), followed by medium poverty (0.24±0.55), with the lowest number in high poverty CT (0.18±0.47) (see Table 2)
NH: non-Hispanic; SD: standard deviation
1. Race and ethnicity: five race and ethnicity categories were constructed based on the standard guideline for reporting race and ethnicity in research.13 A CT was defined as predominantly Non-Hispanic (NH) White, NH Black, Hispanic or Asian if greater than or equal to 50% of the population was of that particular race and ethnicity. The remaining CTs were classified as Integrated when no predominant group existed.
Statistical Analysis
Results from the negative binomial regression models (Table 3) demonstrated that with predominantly NH White/low poverty CTs as reference, supermarkets decreased with rising poverty levels within NH Black and Hispanic CTs, while no significant differences were observed within NH White low and medium poverty CTs (p=0.651), high poverty group and reference group Asian CTs (p=0.223), or low poverty group and reference group Integrated CTs (p=0.30). NH Black CTs were more severely impacted than the Hispanic CTs, with the lowest IRR among each poverty level. The NH Black/low poverty CTs (IRR 0.57 [0.48, 0.67]) had the fewest supermarkets among the low poverty and medium poverty CTs, only statistically non-significantly better than the Hispanic/high poverty group (IRR 0.55 [0.50, 0.60]).
Predominantly NH Black CTs had the most convenience stores the and lowest number of Supermarkets when compared to each of the other groups with Bonferroni correction. For small grocery stores, Hispanic CTs had the most grocery stores and NH White CTs had the fewest, while the mean numbers of small grocery stores in NH Black (1.06±1.39), Asian (1.13±1.92) and Integrated CTs (1.06±1.49) were statistically non-significantly different from each other (see Table 2). Store statistics for each of the 15 combined Race/Ethnicity/Poverty subgroups are shown in Figures 1-3 Regression Models
Independent Variables
Dependent Variable
DescriptiveRESULTS Summary Statistics
4. CTs were categorized as urban if they fell within a metropolitan Statistical Area (MSA). All others were considered rural.
95
The analysis included 83,350 CTs. Table 1 summarizes CT distribution based on poverty levels (low, medium, and high), urbanicity (urban vs rural), and the five major race/ethnic groups (NH White, NH Black, Hispanic, Asian, and Integrated).
2. Poverty: a CT was classified as high poverty if greater than or equal to 20% of households residing within the CT reported an income below the federal poverty level (FPL); medium poverty if between 10-20% of the households reported below FPL income; low poverty if <10% of the households residing within the CT reported below PFL income.
The findings for grocery stores were uniform: for all 15 subgroups, the number of grocery stores increased in stepwise fashion with increasing levels of poverty among each race/ethnic subgroup. At low poverty level, Hispanic/Low poverty CTs had the highest grocery store IRR at 1.28 [1.19, 1.37], while NH Black/ low poverty CTs (IRR 1.06 [0.96, 1.17]) were not significantly different from the reference group (p= 0.287). Asian/medium poverty had the highest IRR at 2.24 [1.92, 2.63], and Asian/ high poverty had the highest IRR at 3.89 [3.23, 4.70] within the medium and high poverty groups, respectively.
The dependent variables were the counts of high, medium, and low-quality food stores in each CT. High-quality food stores (collectively named “supermarkets”) included wholesale clubs (SIC code 531110) and big grocery stores (SIC codes 541101, 541104-541108 and >=50 employees); medium-quality food stores included small grocery stores (SIC codes 541101, 541104-541108 and < 50 employees); low-quality food stores included convenience stores (SIC 541103), service/gas stations (SIC 554101, 554103), and variety stores (SIC 533101).
3. A 15-category combined race/ethnicity and poverty variable was constructed, combining each race/ethnic group with a poverty level as a composite variable for use in regression analysis.
Compared to 2000 Census data,8 NH White CT decreased from 69.9% to 67.4% of all CTs, NH Black CTs remained stable at 7.8%, while Hispanic CTs increased from 4.7% in 2000 to 9.9% in 2020.
Eleven and a half percent of all NH White CTs (up from 7.9% in 2000), 61.3% of all NH Black CT (70.7% in 2000), and 44.1% of all Hispanic CT (71.5% in 2000) fell within the High poverty category. While 38.0% of NH White CTs were rural, Black (88.9%) and Hispanic (90.5%) CTs were predominantly in urban areas.
All continuous variables, presented as mean +/- standard deviation, were compared by using analysis of variance (ANOVA) with Bonferroni post hoc correction. Categorical variables were expressed as percentages and were compared with the use of the Chi-square test. For all tests, significance was accepted as p value <0.05.
Multivariable count regression models were employed to examine the association between the counts of three types of food stores with neighborhood characteristics including total population, poverty level, as well as the combined poverty/ race and ethnicity variable. Negative binomial logarithmic regression models with custom estimate Dispersion Parameters were used instead of Poisson regression models (with fixed Dispersion Parameter of 1) due to over-dispersion of our count data.14 Incident rate ratio (IRR) and 95% confidence interval (CI) were reported as the main output of the regression models. All statistical analyses were performed using SPSS version 22 software (IBM, Armonk, New York).
As online grocery ordering becomes an increasingly common grocery access strategy, the percentage of households with one or more types of computing devices including smartphones within each major race/ethnic group was tallied from 2017 to 2020 (Figure 4). NH Black/high poverty led all subgroups with the largest absolute increase of 9.02% from 73.56% in 2017 to 82.58% in 2020, followed by the Hispanic/high poverty group with an 8.90% absolute increase (from 77.63% in 2017 to 86.52%).
In this study, the IRR [95% CI] for Black/high poverty CTs was 0.38 [0.34, 0.42], compared to the reference group of White/ low poverty CTs, a 62% lower accessibility. Even the Black/low
Multiple studies have shown that living in neighborhoods without access to high-quality food (“food deserts”) predisposes residents to worse dietary intake and consequently diet-related adverse health outcomes such as obesity, hypertension, type 2 diabetes, and other cardiovascular diseases.2,15 Policy action and intervention strategies have been implemented to achieve equitable access to healthy foods across the U.S. Most notable is the Healthy Food Financing Initiative.16 Authorized by the 2014 Farm Bill, and reauthorized by the 2018 Farm Bill,17 HFFI has been funding innovative food retail and food system enterprises that seek to improve access to healthy food in underserved areas. The results of both research and policy interventions were mixed, with some reporting positive changes while others did not.18 It was noted that stores in high-poverty, non-White neighborhoods often survived for a shorter duration of time than those in wealthy neighborhoods.10 One study reviewed six cases of failed food store interventions in food deserts9 but could not identify a unifying rationale to explain why inner-city grocery store interventions were not successful. For those that did survive, one study reported that supermarkets opening in a food desert led to little improvement in the net availability of healthy foods, thus challenging the underpinnings of policies such as the HFFI.2 The concept of geographic food access was further challenged by a study reporting that supermarket access actually improved though income did not, resulting in a net increase in low-income, lowaccess census tracts observed between 2010 and 2015,6 suggesting that income and resource constraints may be greater barriers to accessing healthy food retailers than simple proximity.
For all racial/ethnic groups, the number of convenience stores increased with rising levels of poverty. NH White/high poverty had the highest IRR (1.92 [1.88,1.98]), followed by NH Black/ high poverty (1.77, [1.71, 1.83]), Integrated/high poverty (1.69, [1.63, 1.76]), and Hispanic/high poverty (1.40, [1.36, 1.45]). Asian neighborhoods at all poverty levels had significantly lower numbers of convenience stores, including the Asian/High poverty group with IRR of 0.59 [0.46, 0.76], p<0.001, when compared to the reference group.
DISCUSSION
Computer and Smartphone Access
Trends in urban samples (including 59,106 CTs) were similar to the nationwide sample and were not reported. The rural sample (including 24,244 CTs), NH White CTs made up 88% of the group, NH Black represented 4%, Hispanic 3.3%, Asian 0.1%, and Integrated 5.7%, respectively. Given the skewed distribution and suboptimal model fit parameters, multivariate count regression modeling was not performed on rural samples alone.
poverty group, despite being at the same level in terms of income as the reference group, had significantly lower IRR (0.57 [0.48, 0.67]). The IRRs based on the 2000 US census data from the Bower study8 were 0.30 [0.26, 0.34] (Black/high poverty) and 0.59 [0.45, 0.77] (Black/low poverty), respectively, indicating minimal improvement over the past 20 years. This pattern was also seen in Hispanic groups as well, albeit to a lesser degree. Despite 20 years of intense policy and community interventions aimed at improving food access equity, and despite a notable improvement in poverty in minority groups (61.3% of all NH Black CTs and 44.1% all Hispanic CTs belonged to the high poverty categories in 2020, an improvement from 70.7% and 71.5%, respectively), the lack of significant improvement to supermarket accessibility in the most vulnerable neighborhoods warrants close examination and creative rethinking of current strategies and policies. Challenges of opening and maintaining supermarkets in food desert neighborhoods are multifactorial and have shown resistance towards interventions. Innovative strategies are urgently needed to address this national health disparity. The COVID-19 pandemic-related rise in unemployment, volatility in supply chains and lost access to school meals all led to a doubling of food insecure households in 2020.19 According to a Pew Research Survey, though the digital lives of Americans with lower and higher incomes remain markedly different, smartphone ownership has stood out with the highest and fastest growth in low-income individuals (at 76% in those making <$30,000/year household income, as compared to 59% for desktop or laptop computer, and 57% for home Smartphonesbroadband).20havethe potential to close or at least narrow the digital divide among low-income, minority individuals with traditionally low technology adoption rate. With the 2020 Census data, our analyses observed the same trend. Ownership of any type of computing device including smartphones in predominantly Black/high poverty areas saw the largest absolute increase from 73.6% of households in 2017 to 82.6% in 2020. The implication of this trend is profound. With the challenges of opening and retaining a traditional supermarket store in low-income minority neighborhoods, online grocery shopping (e-grocery), which received an unforeseen boost from the COVID-19 pandemic, appears to offer a unique opportunity for exploration. Online grocery sales jumped from $53.19 billion in 2019 to $110.72 billion in 2020, a 108.2% increase.21 Of the 2,500 participants surveyed, 78% used their mobile devices when placing orders and 77% ordered from big box retailers like Costco, Wal-Mart, or Kroger. Online grocery shopping appears well positioned to serve the low-income minority residents living in food deserts; the e-grocery platforms are less location sensitive and technology dependent, two major hurdles for these communities to adopt this new way of grocery shopping. Significant knowledge and measurement gaps exist in terms of consumer behavior towards online grocery shopping and logistical constraints of delivery zone coverage. Further feasibility/cost-effectiveness evaluation, education, outreach, and policy changes are needed to assess whether app-based online grocery shopping is a viable option to overcome the multiple challenges posed by the lack of easy access to brick-and-mortar supermarkets in food desert neighborhoods.
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Integrated 1.69±1.95 1.06±1.49 0.28±0.60
Count % Count % Count % Count % Count % Count %
Convenience stores (mean±SD)
Medium Poverty 2.11±2.06 0.96±1.27 0.24±0.55
Full sample 1.80±1.94 0.87±1.26 0.24±0.56
Table
Grocery stores (mean±SD)
Low poverty 1.41±1.64 0.64±1.01 0.28±0.60
Figure 1. Average Count of Supermarkets by Census Tract Poverty Level and Racial/Ethnic Composition, 2020 US Census.
Hispanic 1.70±1.87 1.31±1.68 0.20±0.50
Rural 2.22±2.10 0.78±1.05 0.14±0.41
Urban 1.62±1.84 0.90±1.33 0.29±0.60
Low 32182 57.3 893 13.7 1588 19.2 533 61.1 4568 39.7 39764 47.7 Med 17524 31.2 1636 25.0 3026 36.6 217 24.9 3843 33.4 26246 31.5 High 6486 11.5 4002 61.3 3644 44.1 123 14.1 3085 26.8 17340 20.8 Rural 21344 38.0 723 11.1 785 9.5 19 2.2 1373 11.9 24244 29.1 Urban 34848 62.0 5808 88.9 7473 90.5 854 97.8 10123 88.1 59106 70.9 1. Summary of United States 2020 Census Tract Characteristics by Poverty, Urbanicity and Race/Ethnicity
** represents p≤0.001 when compared to the Reference Group.
Supermarkets (mean±SD)
Predominantly NH White 1.83±1.92 0.74±1.06 0.25±0.57
Total (N=83,350)
High poverty 2.20±2.18 1.25±1.58 0.18±0.47
Asian 0.68±1.06 1.13±1.92 0.26±0.64
Census tracts NH 67.4%)(N=56,192,White NH (N=6,531,Black 7.8%) (N=8,258,Hispanic 9.9%) Asian (N=873, 1.0%) (N=11,496,Integrated 13.8%)
Predominantly NH Black 1.92±2.14 1.06±1.39 0.12±0.39
Table 2: Number of Each Category of Food Stores per Census Tract Based on Urbanicity, Poverty Level and Race/Ethnicity.
Poverty
97
Figure 3. Average Count of Convenience Stores by Census Tract Poverty Level and Racial/Ethnic Composition, 2020 US Census.
98 Delaware Journal of Public Health - August 2022
** represents p≤0.001 when compared to the Reference Group.
** represents p≤0.001 when compared to the Reference Group.
Figure 2. Average Count of Grocery Stores by Census Tract Poverty Level and Racial/Ethnic Composition, 2020 US Census.
Figure 4. Percentage of Households with at Least One Computing Device Including Smart Phone Based on Race, Ethnicity and Poverty Levels, From 2017 to 2020. NH: non-Hispanic; LP: low poverty; MP: medium poverty; HP: high poverty. Predominant Race/ Ethnic Group Convenience IRR (95% CI) Grocery IRR (95% CI) Supermarket IRR (95% CI) NH White/ low poverty Ref p-value Ref p-value Ref p-value NH White/ medium poverty (1.59,1.62 1.65) <0.001 (1.48,1.52 1.56) <0.001 (0.97,1.01 1.05) 0.651 NH White/ high poverty (1.88,1.92 1.98) <0.001 (1.73,1.79 1.85) <0.001 (0.87,0.93 0.99) 0.016 NH Black/ low poverty 1.021.01 (0.94, 1.09) 0.741 (0.96,1.06 1.17) 0.287 (0.48,0.57 0.67) <0.001 NH Black/ medium poverty (1.36,1.43 1.51) <0.001 (1.57,1.67 1.79) <0.001 (0.42,0.48 0.55) <0.001 NH Black/ high poverty (1.71,1.77 1.83) <0.001 (2.07,2.16 2.25) <0.001 (0.34,0.38 0.42) <0.001 Hispanic/ low poverty (0.89,0.94 0.99) 0.028 (1.19,1.28 1.37) <0.001 (0.61,0.68 0.77) <0.001 Hispanic/ medium poverty (1.15,1.19 1.24) <0.001 (1.77,1.85 1.94) <0.001 (0.59,0.64 0.70) <0.001 Hispanic/ high poverty (1.36,1.40 1.45) <0.001 (2.58,2.68 2.79) <0.001 (0.50,0.55 0.60) <0.001 Asian/ low poverty (0.39,0.45 0.51) <0.001 (1.09,1.22 1.38) <0.001 (0.66,0.79 0.95) 0.011 Asian poverty/medium (0.53,0.63 0.75) <0.001 (1.92,2.24 2.63) <0.001 (0.48,0.65 0.89) 0.007 Asian/ high poverty (0.46,0.59 0.76) <0.001 (3.23,3.89 4.70) <0.001 (0.52,0.78 1.16) 0.223 Integrated/ low poverty (0.85,0.88 0.91) <0.001 (1.15,1.21 1.26) <0.001 (0.88,0.93 0.99) 0.30 Integrated/ medium poverty (1.29,1.33 1.38) <0.001 (1.80,1.88 1.96) <0.001 (0.84,0.90 0.97) 0.004 Integrated/ high poverty (1.63,1.69 1.76) <0.001 (2.22,2.32 2.43) <0.001 (063,0.69 0.75) <0.001 Table 3: Incidence rate ratios (IRR) for three types of food stores in 83,350 nationwide US Census tracts, 2020 99
ACKNOWLEDGMENTS
7 Morland, K., Wing, S., Diez Roux, A., & Poole, C. (2002, January). Neighborhood characteristics associated with the location of food stores and food service places. American Journal of Preventive Medicine, 22(1), 23 29 https://doi.org/10.1016/S0749-3797(01)00403-2
6. Rhone, A., ver Ploeg, M., Dicken, C., Williams, R., & Breneman, V. (2017, Jan). Low-income and lowsupermarket-access census tracts, 2010-2015. USDA Economic Research Service. https://www.ers.usda.gov/publications/pub-details/?pubid=82100
4 Testa, A., & Jackson, D. B. (2019, June). Food insecurity, food deserts, and waist-to-height ratio: Variation by sex and race/ethnicity. Journal of Community Health, 44(3), 444 450. https://doi.org/10.1007/s10900-018-00601-w
Limitations
16 Healthy Food Financing Initiative. (2021). Rural Development. https://www.rd.usda.gov/about-rd/initiatives/healthy-food-financing-initiative
REFERENCES
8. Bower, K. M., Thorpe, R. J., Jr., Rohde, C., & Gaskin, D. J. (2014, January). The intersection of neighborhood racial segregation, poverty, and urbanicity and its impact on food store availability in the United States. Preventive Medicine, 58, 33 39. https://doi.org/10.1016/j.ypmed.2013.10.010
3 Gittelsohn, J., & Trude, A. (2017, January). Diabetes and obesity prevention: Changing the food environment in lowincome settings. Nutrition Reviews, 75(suppl 1), 62 69 https://doi.org/10.1093/nutrit/nuw038
The author would like to thank Raymond Xu (of Carnegie Mellon University) for his assistance in data curation and processing. Ms. Zhu may be contacted at allisonyzhu@gmail.com
2. Ghosh-Dastidar, M., Hunter, G., Collins, R. L., Zenk, S. N., Cummins, S., Beckman, R., . . . Dubowitz, T. (2017, July). Does opening a supermarket in a food desert change the food environment? Health & Place, 46, 249 256 https://doi.org/10.1016/j.healthplace.2017.06.002
15. Kelli, H. M., Hammadah, M., Ahmed, H., Ko, Y.-A., Topel, M., Samman-Tahhan, A., . . . Quyyumi, A. A. (2017, September). Association between living in food deserts and cardiovascular risk. Circ Cardiovasc Qual Outcomes, 10(9), e003532. https://doi.org/10.1161/CIRCOUTCOMES.116.003532
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There are several limitations of this study. First, this study is based on the assumption that individuals prefer to shop at the food store closest to their homes. Recent research, however, has shown that the average American household often bypasses the closest stores in favor of their preferred store further away,19 thus challenging the validity of traditional food access mapping and analysis, this study included. Second, commercial databases like ReferenceUSATM have potential classification biases and lack complete information on certain proprietary, privately owned franchises. Furthermore, community-driven food security measures such as fruit stands, farmers’ markets, and community gardens are often not included in traditional food access classification systems. Lastly, using census tracts to map food stores may run into classification ambiguity problems as food retailers tend to run along census tract boundaries adjacent to busy and easily accessible roads, resulting in potential undercounting of stores in certain neighborhoods.8 Despite these limitations, this study highlights the persistent disparities of food store accessibility as a function of neighborhood socio-economicdemographic characteristics and the urgent need for intervention.
Our findings suggest that, similar to 2000 Census data, neighborhood poverty status and racial/ethnic composition are independently associated with accessibility of high, medium, and low-quality grocery stores. Poor predominantly Black neighborhoods remain most limited in their access to highquality food items from Supermarket stores, despite improved poverty levels in minority groups and 20 years of targeted policy interventions. Fast-rising smartphone ownership in low-income minority residents offers the promise to explore online grocery shopping as an alternative to overcome the hurdles posed by poor access to traditional offline stores.
CONCLUSIONS
5 Rose, D. (2010, June) Access to healthy food: A key focus for research on domestic food insecurity. The Journal of Nutrition, 140(6), 1167 1169 https://doi.org/10.3945/jn.109.113183
10 Warren, J. L., & Gordon-Larsen, P. (2018, June). Factors associated with supermarket and convenience store closure: A discrete time spatial survival modelling approach. Journal of the Royal Statistical Society. Series A, (Statistics in Society), 181(3), 783 802. https://doi.org/10.1111/rssa.12330
9 Engler-Stringer, R., Fuller, D., Abeykoon, A. M. H., Olauson, C., & Muhajarine, N. (2019, October). An examination of failed grocery store interventions in former food deserts. Health Educ Behav, 46(5), 749 754 https://doi.org/10.1177/1090198119853009
11. Census Bureau Tables. Retrieved from https://data.census.gov/cedsci/table
12 Reference, U. S. A. (1999). http://0-www.referenceusa.com.catalog.sjlibrary.org
1. Beaulac, J., Kristjansson, E., & Cummins, S. (2009, July). A systematic review of food deserts, 1966-2007. Preventing Chronic Disease, 6(3), A105. https://pubmed.ncbi.nlm.nih.gov/19527577
13. Flanagin, A., Frey, T., & Christiansen, S. L., & the AMA Manual of Style Committee. (2021, August 17). Updated guidance on the reporting of race and ethnicity in medical and science journals. JAMA, 326(7), 621 627. https://doi.org/10.1001/jama.2021.13304
14 Long, J. S. (1997, Jan). Regression models for categorical and limited dependent variables. SAGE Publications Inc. https://us.sagepub.com/en-us/nam/regression-models-forcategorical-and-limited-dependent-variables/book6071
19 George, C., & Tomer, A. (2021, Aug). Beyond ‘food deserts’: America needs a new approach to mapping food insecurity. Brookings.
18. National Research Council (US). (2009). The public health effects of food deserts: workshop summary. National Academies Press (US). http://www.ncbi.nlm.nih.gov/books/NBK208019/
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20. Vogels, E. A. (2021, Jun). Digital divide persists even as Americans with lower incomes make gains in tech adoption. Pew Research Center. https://www.pewresearch.org/fact-tank/2021/06/22/digital-dividepersists-even-as-americans-with-lower-incomes-make-gains-in-techadoption/
https://www.brookings.edu/research/beyond-food-deserts-americaneeds-a-new-approach-to-mapping-food-insecurity/
17 Johnson, R., Becker, G. S., Capehart, T., Chite, R. M., Cowan, T., Gorte, R. W., Jickling, M. (2008, Jun). The 2008 farm bill: a summary of major provisions and legislative action. Congressional Research Service. https://www.everycrsreport.com/files/20080619_ RL33934_614d6a0faf11fe1b17757b3ceff90babdaa67bde.pdf
21. Spryker. (n.d.). More than a fifth of Americans expect to do most or all grocery shopping online by 2024. https://spryker.com/us-online-grocery-report/
DOI: 10.32481/djph.2022.08.017
Let It End With Us
INTRODUCTION
This aligns with the Delaware Academy of Medicine/Delaware Public Health Association because it works to educate the population about school shootings, a public health concern. This is an issue that has been a problem for decades and is likely to be a serious issue for decades to come, unless strong action is actually and finally taken by state and federal legislatures.
BACKGROUND
The Delaware Academy of Medicine/Delaware Public Health Association allows our student interns to choose a public health issue of their choice to research and offer a solution to that problem. The following research is being published due to the timing of the Robb Elementary School shooting in Uvalde, TX. The editors would like to note that the larger the primacy of mental illness as a driver of mass shootings should not be generalized. While it may have an effect, focusing on mental illness can increase stigma, lead to unintended consequences, and distract from other factors that may be at play in individual situations.
102 Delaware Journal of Public Health - August 2022
School (21). Internationally, the United States stands alone in the number, magnitude and frequency of these unimaginable events. School shootings typically occur because a person is dealing with a mix of suicidal thoughts, despair and anger and has access to guns.1 Each of the decades since the 1990’s have had a major school shooting resulting in the death of at least ten people.2 The Columbine High School Shooting was the first school shooting that gained wide media attention which resulted in the death of thirteen people: twelve students and one teacher.2 Research has been done in order to study the perpetrators of these horrific crimes. Bonanno and Levinson researched shootings up to the Sandy Hook Tragedy in 2012. In this study they determined that 95% of school shooters were current students and 5% former students and that the perpetrators came from a variety of different backgrounds. Some had high grades, some were failing, some were popular, others social outcasts: some had a good family situation where others came from broken families or were in the foster system. Although shooters came from a variety of backgrounds it was reported that 93% had engaged in concerning behaviors that could have been predictive of them planning a violent event.2 Sixty-eight percent of gun incidents at schools involve a weapon a student got from home, family member or friend, and almost half of parents who own a gun incorrectly assume their children don’t know where the guns are stored.3
Kelly Shannon University of Delaware; Student Intern, Delaware Academy of Medicine/Delaware Public Health Association
Mass shootings can occur anywhere but the ones occurring in schools are often the most emotionally charged. School shootings have been occurring in the United States for decades. Due to the media coverage, the first school shooting people tend to remember is the Columbine High School Shooting in 1999. Since then, hundreds of school shootings have occurred, including ones with a high number of casualties such as Virginia Tech (32), Sandy Hook Elementary School (26), Marjorie Stoneman Douglas High School (17) and most recently Robb Elementary
I choose to address this problem because children should not have to constantly be aware of where to hide just in case a shooter comes into their school. The United States is the land of the free, yet nearly every day school or mass shootings chip away at this freedom, leaving students to live in fear and uncertainty. Gun violence and school gun violence affect everyone whether directly or indirectly, and are things that almost everyone agrees need to be stopped. Mental health plays a role in some of this violence, but so does easy access to a large variety of guns. My program focuses on providing increased access to mental health resources and stricter gun regulation to help prevent school shootings in Delaware and potentially across the nation.
STUDENT SPOTLIGHT SECTION
School shootings are all too common in the United States of America. Solutions to this problem have been successfully accomplished in many other countries. Unfortunvately, the United States stands alone with the frequency of school and mass shootings.
Many programs currently exist to minimize the possibility of school shootings, but the number of school shootings is still very high because little has been done at the governmental level. I chose this topic to suggest a logical process in order to help prevent these tragic events from ever occurring again.
From 1994-2004 the United States instituted a ban on assault weapons. This law banned the possession, manufacturing and transferring of semi-automatic firearms designated as assault weapons that hold more than ten rounds of ammunition at a time.5 This expired after ten years, with many arguing it took away second amendment rights and did not accomplish much.5 Both the Sandy Hook and Marjorie Stoneman
Everytown has been collecting school gun violence statistics since the Sandy Hook Elementary school shooting in 2012. Sixty-three percent of guns fired were in K-12 schools.4 Large scale shootings such as Sandy Hook and Marjorie Stoneman Douglas make up roughly 1% of school shootings that occur.4 Gun violence can lead to more than death or physical injuries; it can lead to psychological trauma, difficulty concentrating and decreased standardized test scores. Although large scale mass shootings are rare, over 500 school shootings have occurred between 2013-2019.4 These shootings are psychologically damaging, and have long term effects on the students and teachers.4
STUDENT SPOTLIGHT
After mass shootings in Canada, Australia and the United Kingdom, gun laws were quickly put in place that included laws that increased background checks, had a waiting period to purchase a gun, required mandatory safety courses and instituted a gun buyback program.7 In the UK, these new stricter regulations were passed less than two weeks after a deadly school shooting in Scotland in 1996. Since that time, zero school shootings have occurred in the UK.7 These countries show that common sense laws can greatly reduce the number of all kinds of mass shootings.
INTERPERSONAL FACTORS
The final construct that has a role in school shootings is public policy. Mental health is a large factor that contributes to school shootings, but the majority of those with mental health issues, both treated and untreated, do not participate in violent acts. Thus, better mental health resources are necessary but not enough. Let It End With Us will work with the Delaware Legislature to put in place policies that
In 2020, there was a decrease in school shootings (likely due to the COVID- 19 pandemic), but that year also had the highest rate of overall gun violence in U.S. history.7 The U.S. has less than 5% of the world’s population, but over 40% of the world’s total guns.7 The solution is not a one step process; an effective intervention needs both gun control laws and more readily available mental health resources.
Children who are exposed to violence and bullying may be at an increased risk for violent behavior. Let It End With Us will provide schools with the tools necessary to create an anti-bullying environment where students feel safe and accepted.
Douglas shooters used assault style weapons in the years after the ban was lifted.6 This ban was not perfect and did not decrease overall gun violence, but did drastically reduce the death toll in mass shootings.6
Although mental health has a role in mass shootings and every country has mental health issues within its population, the United States is the only country that has hundreds of school shootings each year. Many states in the United States allow easy access to guns for everybody, even those with a history of violence.
Intrapersonal factors are characteristics that an individual holds; one’s knowledge, beliefs and attitudes. Interpersonal processes and primary groups are social interactions and social support systems such as relationships and communication with family, friends and coworkers. Institutional factors are social institutions with rules and regulations such as schools. Community factors are the relationships among different organizations and institutions. The final construct is public policy which are laws and policies at the local, state and federal level.
Most recently, the mass shooting at Robb Elementary School on May 24, 2022, left nineteen students and two teachers dead. Since the Columbine shooting in 1999, one hundred sixty-nine students in America have been killed in mass school shootings (defined as four or more deaths).11
The constructs of intrapersonal factors, interpersonal processes and primary groups, institutional factors and public policy all have a role in the occurrence of school shootings and must be analyzed in order to create an effective intervention. In order to increase awareness of mental health issues and their role in school shootings Let It End With Us will include solutions for each of these constructs.
The Social Ecological Model (SEM) was created by a team of researchers including K.R. McLeroy and was based on Uri Broffenbrenner’s Ecological Model, but the SEM was adjusted to be used for health promotion instead of child development. The SEM is made up of five constructs: intrapersonal factors, interpersonal processes and primary groups, institutional factors, community factors and public policy.12
Common sense laws like the assault weapon ban are important to implement and surveys show that the majority of the U.S. population is in favor of such laws. Numerous common sense laws were implemented after mass shootings in countries such as the United Kingdom, Canada and Australia and these countries have since seen a large reduction in the number of mass shootings.7
Unlike many other countries, the United States has not put any stricter gun control laws or regulations into place, and the country continues to see gun tragedy after gun tragedy. No assault weapon bans currently exist in the U.S., despite the overwhelming approval of a majority of Americans.7 Legislature at the federal level cannot agree on the appropriate steps to take on this issue.7 The Trump administration even rolled back gun regulations by removing an Obama administration act that prevented those with mental illness from buying a gun.7
INTRAPERSONAL FACTORS
INSTITUTIONAL FACTORS
School administrations and teachers need to be diligent in noticing students engaging in suspicious activities and unusual behavior. Students who see these behaviors should feel confident in their school administration in taking the necessary action to stop and seek help for the student(s) showing these behaviors. Let It End With Us will educate both students and teachers on warning signs that can often lead to school shootings.
SOCIAL-ECOLOGICAL MODEL
Mental health illnesses in the context of school shootings can be due to interpersonal factors like genetics, lacking access to treatment, and lack of education. There are also environmental factors (history of child abuse or adverse childhood advents (ACEs) that can lead to mental health issues or amplify existing ones. Let It End With Us will create and implement a mass media campaign to provide education about mental health and decrease its stigma. It will also provide resources and qualified guidance counselors to students to increase access to treatment.
PUBLIC POLICY
The idea that the mentally ill are violent is stigmatizing and creates a dangerous and harmful bias that can lead people to not seek mental health resources.10 It is not easy to determine if people with mental illness have any of the red flags indicating they may have the potential to commit a school or mass shooting so although improved mental health resources and education are important, a multipronged approach to prevention is necessary.
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Studies have found that a number of school shooters have had an untreated mental illness.8 Dr. Ira Glick from Stanford University studied thirty-five mass shootings that occurred where the shooter survived. Her team was able to use medical evidence to determine twenty-eight had mental illnesses including schizophrenia and personality disorders, for which none of those studied were being medicated.8 Increasing mental health resources in schools might be very beneficial, especially since the COVID-19 pandemic added the stress of social isolation and loss of loved ones to many individuals; certain companies such as Mental Elephant exist in order to provide these resources. New legislation called the Mental Health Reform Reauthorization Act of 2022 is being considered in the federal government. This act would further add to similar mental health legislation from 2016, but include the effects of COVID-19.
History of violence is another cause of mass shootings. Serious mental disorders are believed by many to be the main contributor to mass shootings, but only 5% of all mass shootings are performed by people with a mental disorder.9 A majority of mass shootings are perpetrated by those who have a history of legal violence, desire to be remembered, and feelings of emptiness.
The last goal is arguably the most important: affecting change in public policy. These policies include gun regulations that would put common sense gun laws and an assault weapon ban into place. Other laws will deal with access to mental health care and work on increasing the availability and affordability of mental health resources both in and out of schools.
Let It End With Us uses the social-ecological model of change to address school shootings in Delaware and the United States and how to prevent them. The intrapersonal, interpersonal, institutional and public policy constructs of the SEM will inform the Let It End With Us program on the three main goals that allow schools, school staff, government and students to work together to end this epidemic (See Appendix A)
Health in all policies integrates health considerations into policy making in order to improve the health of a population.14 Part of decreasing school gun violence, and gun violence in general, is accomplished by creating laws. These laws would involve limiting those who can own a gun and restricting the type of guns people can own. Decreasing gun deaths, especially of young people, will improve both the physical and mental health of the population.
These three goals all work together to prevent school shootings by focusing on education, mental health resources and public policy. Delaware is a small state and itself has not had a lot of school shootings, but states could learn from Delaware and implement similar programs in order to decrease the number of school shootings, and other shootings, they have to help stop the gun violence epidemic throughout the United States of America.
Implementing school education programs to promote awareness and provide resources are crucial for success. However, education programs and increased mental health resources will only go so far. A major national gun law, the bipartisan 2022 gun law, was developed in response to the Buffalo and Uvalde shootings. This bill expands background checks for those under twenty-one, gives authorities ten days to look at mental health records, and sets aside money for states to provide better mental health programs and put in place red flag laws which allows a gun to be taken away from someone deemed dangerous.9 Continued pressure on Congress and a focus on education and mental health will hopefully move the US towards a more peaceful and healthier society.
CONCLUSION
No matter how much research or statistics show the damage guns have in schools, nothing has changed, even after major school shootings such as Sandy Hook Elementary School, Marjorie Stoneman Douglas High School, and most recently Robb Elementary School. Although I learned what could be done to stop these tragedies, they will still occur, and anyone’s school could be next initiating fear in students, parents and the community.Ms.Shannon may be contacted at krooshan@gmail.com.
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Social determinants of health (where a person is born, lives, grows and works) include aspects such as health care access and quality, education access and quality, economic stability, social and community context and
Implementing programs, laws and policies to educate and treat mental health and to make guns harder to buy has been shown to have a large impact on reducing school shootings, and mass shootings in general.
address mental health and provide better resources, both in and out of school. It will also work to make guns harder to obtain for this population, ban the sale and possession of assault weapons, create common sense gun laws that prevent those with obvious mental health issues from purchasing a gun, and advocate for detailed background checks, mandatory registration of guns, and safety courses required before a gun can be purchased.
School gun violence and gun violence in general is a public health issue. Gun violence relates to the social determinants of health, health in all policies and health promotion. School gun violence does not just affect those who are injured, but all the students in the school as well as the community as a whole.
Educating about gun violence and gun safety is promoting the health of the population. Education is necessary for people to understand the impact guns continue to have on individuals, families and communities. Health promotion programs aimed to reduce school gun violence could focus on gun safety, mental health and ways to protect yourself in the case of an active shooter.
neighborhood and built environment.13 Certain areas, communities and schools have increased use of firearms and shootings. This can not only lead to an increased risk of premature death, but also to psychological trauma to both children, adolescents and adults. Where a person lives and their socioeconomic status can determine the amount of violence they will see or be a victim of in their lifetime.
LET IT END WITH US
I learned a lot from completing this internship. Gun violence has become increasingly prevalent in our society and is a major issue in the United States. What makes the U.S. an outlier to the rest of the world is critical to understand in order to take the steps needed to reduce the number of deaths and improve our public health. It is beneficial to look at the statistics to determine what other countries are doing to successfully reduce or eliminate these events from occurring. Although this is a heartbreaking topic, it is something everyone should educate themselves about no matter where they stand on gun rights and regulations. School shootings in the US affect everyone and are a critical public health issue. Gun regulations and mental health problems need to be seriously addressed to really make a substantial difference.
There are many other aspects of public health that contribute to school shootings, but social determinants of health, health and policy and health promotion are the three major parts of what makes school gun violence a public health issue. Policies, education and increased access to certain resources could decrease the number of shootings, thereby allowing more children to have long lives without the long-lasting trauma that shootings can cause.
DISCUSSION
The first goal of the program is education. This entails increasing awareness of gun violence and signs of potential school shooters by putting posters up in Delaware schools, educating about the correlation between mental health and school shooters, educating students so that they can get involved and work to end school gun violence, and work to create better safety programs and drills to practice for students, teachers, and staff (See Appendix B). These actions will allow people who might be directly involved in school shootings to be more prepared to potentially stop a shooting before it Thehappens.nextgoal is a communication plan which involves creating social media platforms such as Instagram and Tik Tok. The social media accounts will have posts that educate on school gun violence, show school gun violence statistics, talk about mental health and talk about signs of a school shooter and what people can do to prevent them. Social media allows for the fast distribution of messages and a larger reach.
Half10/15/22ofall K-12 DE schools will have programsambassadorstudent 75%1/15/23ofall DE K-12 schools will have student ambassador program
5. Update school safety plans and security regarding school shootings
Long Term Outcomes
Posters8/31/22 created K-12inPosters10/15/22available½ofDelawareschools
3. Educate students, teachers and staff on signs of a potential school shooter
1. Reach out to legislators in RegardingDE gun laws
Posters1/15/23 available in all Delaware K-12 schools
2. Increase gunparticipationstudentinendingviolenceinschools
Education 1. Create posters for schools in Delaware showing shootingsschoolstatistics
Create8/31/22videos, social media posts and posters everyoneavailablepostedInformation9/30/22andfor
3. Increase training for guidance counselors in schools regarding mental health Determine9/30/22 appropriate training resources counselorsschooltrainingHave12/15/22betterforguidance
2. Increase mental health resources available to all Delawareans
APPENDIX A: LOGIC MODEL 105
Pass1/31/23policy that makes mental health resources more affordable in DE
75%10/31/22ofDelawareans are aware of the correlation between mental health and school shootings
All5/31/23K-12DE schools have updated safety plans and protocols in place
Educate on the correlation of mental health and school shootings
Public Policy
PlanCommunication
Have12/31/22aplan set by Legislaturesthe to get gun laws passed in Delaware advocacyOngoing for federal and local gun regulations
Speak10/22 to increasinglegislatorsDelawareabouttheaccess to mental health resources especially in schools
Create10/31/22posters on the topic and create a curriculum to be taught in schools
4.
50%2/28/23ofDE K-12 schools protocolsplansupdatedhavesafetyand
10/31/22- 25% of K-12 schools in DE have updated safety plans and protocols in place
availablecurriculumPosters12/31/22andto ½ DE K-12 schools
Goal Activities/ImplementationObjectives
Posters2/28/23and curriculum available to all Delaware K-12 schools
Short DeliverablesTerm MidtermOutputs
ambassadorInitiate9/30/22schoolprogram
1. Create an Instagram, Tik Tok and Twitter createdAccounts9/1/22 ambassadorssocialbyareAccounts10/23updatedstudentmedia
3. Sandy Hook Promise. (n.d.) 16 facts about gun violence and school shootings. Retrieved from https://sandyhookpromise.org/blog/gunviolence/16-facts-about-gun-violence-and-school-shootings/
12. McLeroy, K. R., Bibeau, D., Steckler, A., & Glanz, K. (1988, Winter). An ecological perspective on health promotion programs. Health Education Quarterly, 15(4), 351 377. https://doi.org/10.1177/109019818801500401
REFERENCES
4. Everytown. (2021, Jan 25). Keeping our schools safe. Everytown. Retrieved from https://everytownresearch.org/report/preventing-gunviolence-in-american-schools/
14 Centers for Disease Control and Prevention. (2016, Jun 9). Health in All Policies. Retrieved from: https://www.cdc.gov/policy/hiap/index.html
APPENDIX B: EXAMPLE POSTER 106 Delaware Journal of Public Health - August 2022
13. Artiga, S., & Hinton, E. (2018, May 10). Beyond health care: the role of social determinants in promoting health and health equity. KFF. Retrieved from https://www.kff.org/rac https://www.kff.org/racial-equity-and-health-policy/issue-brief/ beyond-health-care-the-role-of-social-determinants-in-promotinghealth-and-health-equity/
1. Children’s Hospital of Philadelphia. (2020). Preventing school shootings. Children’s Hospital of Philadelphia Center for Violence Prevention. Retrieved from https://violence.chop.edu/types-violence-involving-youth/schoolshootings/preventing-School-shootings
9 Brucato, G., Appelbaum, P. S., Hesson, H., Shea, E. A., Dishy, G., Lee, K., . . . Girgis, R. R. (2021, February 17). Psychotic symptoms in mass shootings v. mass murders not involving firearms: Findings from the Columbia mass murder database. Psychological Medicine, 1 9. https://doi.org/10.1017/S0033291721000076
5 Roth, J. A., & Koper, C. S. (1999, Mar). Impacts of the 1994 Assault Weapons Ban: 1994-96. National Institute of Justice. Retrieved from https://www.ojp.gov/pdffiles1/173405.pdf
11 Associated Press. (2022, 25 May). From Columbine to Robb, 169 dead in US mass school shootings. AP News. Retrieved from https://abcnews.go.com/US/wireStory/deadliest-us-schoolshootings-84949424
7 Masters, J. (2022, May 26). How does the U.S gun policy compare with the rest of the world? PBS WHYY. https://www.pbs.org/newshour/nation/how-does-u-s-gun-policycompare-with-the-rest-of-the-world
10 Columbia University Department of Psychiatry. (6 July, 2022). Is There a Link Between Mental Health and Mass Shootings. Retrieved from https://www.columbiapsychiatry.org/news/mass-shootings-andmental-illness-5
6. Elving, R. (2019, Aug 13). The U.S. once had a ban on assault weapons- why did it expire? NPR. Retrieved from https://www.npr. org/2019/08/13/750656174/the-u-s-once-had-a-ban-on-assaultweapons-why-did-it-expire
2. Bonanno, C. M., & Levenson, R. L. (2014). School shooters: History, current theoretical and empirical findings, and strategies for prevention. SAGE Open https://doi.org/10.1177/2158244014525425
8 Glick, I. D., Cerfolio, N. E., Kamis, D., & Laurence, M. (2021, JulyAugust 01). Ju-Aug). Domestic mass shooters: The association with unmedicated and untreated psychiatric illness. Journal of Clinical Psychopharmacology, 41(4), 366 369. https://doi.org/10.1097/ JCP.0000000000001417
We’ll meet you where you are. Get personal support for those who have a disability. We provide information on how the vaccine works, how to get it, and how to separate the myths from the facts. I want to be sure that the COVID-19 vaccine is safe for me. Emmanuel, Sussex County, DE VaccineAccessDE.com1-833-643-1715 107
Rui Li, Ph.D.
INTRODUCTION
DOI: 10.32481/djph.2022.08.018
are inductions of labor and cesarean deliveries that occur without indication in maternal or fetal medical conditions (e.g., preeclampsia, eclampsia, diabetes, congenital malformations, fetal distress, etcetera).11–14 The American Congress of Obstetricians and Gynecologists (ACOG) have consistently advised against NMETD.11–14 Although ACOG has provided labor and delivery guidance for hospital disaster preparedness including pandemics,15,16 there is limited information on whether perinatal quality indicators (i.e., a measure of quality of care) vary during pandemics. Our primary goal was to assess statewide changes in NTSV and, NMETD rates comparing before and during the COVID-19 pandemic in Delaware.
The findings and conclusions in this study are those of the authors and do not necessarily represent the official position of the U.S. Department of Health and Human Services, the Centers for Disease Control and Prevention, the Health Resources and Services Administration, the Delaware Department of Health Social Services, Division of Public Health, or ChristianaCare.
Delaware Department of Health and Social Services, Division of Public Health Mathew K. Hoffman, M.D., M.P.H., F.A.C.O.G.
STUDY DESIGN AND METHODS
Pre and Post-Lockdown Cesarean Deliveries and Perinatal Quality Indicators During the COVID-19 Pandemic
Delaware Department of Health and Social Services, Division of Public Health Maridelle Dizon, B.S.
Jennifer Miles, B.S.
Marie E. Pinizzotto, M.D., Endowed Chair, Department of Obstetrics & Gynecology, Director, Center for Women & Children’s Health Research, ChristianaCare
The World Health Organization declared COVID-19 a public health emergency of international concern on January 30, 2020 and subsequently a global pandemic on March 11, 2020 leading to global lockdowns.1 The COVID-19 pandemic has affected healthcare access, delivery, and utilization in the U.S.,2 and pregnant women may face unique challenges,3 which may manifest in perinatal quality indicators related to timing and mode of delivery.
Khaleel S. Hussaini, Ph.D.
We used birth certificate data from January 2019 through December 2021 comprising 36 time points from Delaware for a total of 30,972 births; 2021 data were provisional. Provisional estimates of birth rates track closely with estimates based on final data.17 We calculated monthly NTSV rates with NTSV births as the numerator (i.e., singleton, 37 weeks or greater gestation, with cephalic presentation to nulliparous women, with cesarean mode of delivery) and all hospital singleton term births to nulliparous women with cephalic presentation as the denominator. We calculated monthly NMETD rates with NMETD as the numerator
108 Delaware Journal of Public Health - August 2022
US Department of Health and Human Services, Centers for Disease Control and Prevention, Division of Reproductive Health, Field Support Branch, Atlanta, GA; Delaware Department of Health and Social Services, Division of Public Health
U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau, Office of Epidemiology and Research, Division of Research
ABSTRACT
One in three deliveries in the U.S. are by a cesarean delivery (CD),4 and cesarean deliveries increase the risk of maternal morbidity when not clinically indicated.5 Nulliparous term singleton vertex (NTSV) cesarean birth or “low-risk cesarean” is an endorsed perinatal quality indicator by the Joint Commission (TJC) and the National Quality Forum (NQF) and focuses on first-time, uncomplicated pregnancy and assesses the outcome of labor management.6–8 In 2020, the U.S. NTSV rate of 25.9% was above the Healthy People 2030 benchmark rate of 23.6%,4,9 One recent study found that there is considerable variation in NTSV rates among U.S. hospitals, suggesting differences in local policies, culture, and provider attitudes.10 A second perinatal quality health indicator is non-medically indicated early term deliveries (NMETD) prior to 39 weeks gestation. NMETD
We examined statewide perinatal quality indicators: nulliparous singleton term vertex cesarean births (NTSV) or low risk cesarean births, and non-medically indicated early term delivery (NMETD) rates during COVID-19 pandemic pre-lockdown (1/1/2019 to 3/23/2020) and post-lockdown (after 3/23/2020). Interrupted time-series analyses were used to examine the effects of the COVID-19 pandemic on these indicators. We observed a statistically significant increase in NTSV cesarean rates, 4.4% (95%CI: 1.3,7.4) immediately after lockdown, and a decrease in NMETD rate, 1.6% (95%CI: -2.5,-0.7). We observed an increase (0.3%; 95%CI: 0.0,0.6) in the slope (i.e., trend change) of NTSV rates post-lockdown and a decrease (-0.2%; 95%CI: -0.3,-0.1) in the slope of NMETD rates. Results suggest that the COVID-19 pandemic had an immediate effect on perinatal quality indicators in Delaware, with gradual return to pre-pandemic rates as the pandemic continued. In addition to emergency preparedness planning, hospital monitoring of perinatal quality indicators might improve obstetrical care during public health emergencies.
(i.e., singleton, 370/7 and 386/7 weeks of gestation with cephalic presentation to nulliparous women) and excluded the following maternal conditions11–14 available on Delaware’s birth certificate: preeclampsia, eclampsia, chorioamnionitis, premature rupture of membranes, prolonged labor, pre-pregnancy diabetes, gestational diabetes, congenital anomalies, fetal distress, and history previous poor outcomes. All early term (370/7 and 386/7 weeks of gestation) singleton hospital births formed the denominator.
The ITS is a quasi-experimental design to determine the influence of events at clearly defined time-points such as policies, interventions, or natural disasters.18–23 Segmented regression models have two parameters of interest: 1) the intercept (i.e. level change); and 2) slope (trend change and/or month-to-month variation) and is expressed as follows:
Figure 1. Nulliparous Term Singleton Vertex Cesareans and Non-Medically Indicated Early Term Deliveries Before and During the COVID-19 Pandemic in Delaware, January 2019-December 2021
Notes: Delaware Department of Health and Social Services, Delaware Health Statistics Center, Monthly Vital Statistics data. The calendar year 2020 and 2021 data are provisional. COVID-19 Stay-At-Home Order began March 24, 2020 at 8:00 a.m. and Stay-At-Home ended on May 31, 2020 in Delaware.
Yt = β0 + β1*time + β2*lockdown due to COVID19 + β3*time + ε t ----> (1)
Interrupted time-series (ITS) analyses were used to examine the effects of the COVID-19 pandemic on NTSV and NMETD rates using Delaware’s Executive Order on Stay-At-Home (lockdown) as the point of interruption indicating the pre-lockdown (1/1/2019 to 3/23/2020; n = 13,034) and postlockdown (after 3/23/2020 onward; n = 17,938) periods.
In this model, Yt is the NTSV or NMETD monthly rate, β1*time is the slope or overall secular trend for NTSV or NMETD expressed as a continuous variable beginning 1 in January of 2019 to 36 in December of 2021; β2*lockdown due to COVID-19 is a dichotomous variable (0 = pre-lockdown or 1 = post-lockdown) and provides an immediate effect on the level of the outcome (i.e.,
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*NTSV cesareans are singleton births, 37 weeks or greater gestation, with cephalic presentation to nulliparous women, with cesarean mode of delivery and all hospital singleton term births (>37 weeks or greater gestation) to nulliparous women with cephalic presentation serve as the †NMETDdenominator.issingleton births at 37 and 38 weeks of gestation with cephalic presentation to nulliparous women that exclude preterm births and conditions such as preeclampsia, eclampsia, chorioamnionitis, premature rupture of membranes, prolonged labor, pre-pregnancy diabetes, gestational diabetes, congenital anomalies, fetal distress, and history previous poor outcomes and all early term (37 and 38 weeks of gestation) singleton hospital births serve as the denominator.
Figure 1 displays the time-series and Table 1 provides the ITS regression results. During pre-lockdown, baseline NTSV rates decreased by 0.3% (95%CI: -0.5, 0.0), and NMETD rates increased by 0.2% (95%CI: 0.0,0.3). Immediately after lockdown due to COVID-19 (i.e., level change) we observed a significant increase in NTSV rate of 4.4% (95%CI: 1.3,7.4), and a decrease in NMETD rate, of 1.6% (95%CI: -2.5,-0.7) respectively. A small increase (0.3%; 95%CI: 0.0,0.6) in the slope of NTSV rates and a small decrease (-0.2%; 95%CI: -0.3,-0.1) in the slope of NMETD rates (i.e., trend change) was observed post-lockdown. To test for potential bias from study population change, we tested for differences in the total number of deliveries pre-lockdown and post-lockdown and found no change.
Notes: Delaware Department of Health and Social Services, Delaware Health Statistics Center, Monthly Vital Statistics data. The calendar year 2021 data are provisional. COVID-19 Stay-At-Home Order began March 24, 2020 at 8:00 a.m. and Stay-At-Home ended on May 31, 2020 in Delaware. The model of interruption was beginning of Stay-At-Home order on March 24, 2020. Denominator comprises of monthly hospital births. Stationarity was assessed using Augmented Dickey-Fuller test and Durbin-Watson statistic was used for autocorrelation. All parameters were modeled using autoregressive errors, as seasonality produces an autocorrelation at the seasonal lag. We used backward stepwise elimination specifying a lag of 13 for our monthly data, plotted our residuals and checked for normality using Anderson-Darling test. We estimated robust standard errors using Newey-West correction for any heteroscedasticity and autocorrelation.
Table 1. Interrupted Time-Series Regression Results for Cesarean Deliveries, Non-Medically Indicated Deliveries, Non-Medically Indicated Inductions, Non-Medically Indicated Cesareans, Before and During The COVID-19 Pandemic in Delaware, January 2019-March 2021
an intercept or a level change); β3*time is time after transition or the continuing effect of the lockdown due to COVID-19 (i.e., slope change) in successive time periods after a one month lag beginning 1 in May of 2020 to 20 in December of 2021 postlockdown. The pre-lockdown months January of 2019 to March of 2020 are coded as 0 and finally ε t is the random error term for each month.18–23 We used augmented Dickey-Fuller unit root test to assess seasonal fluctuations (stationarity) and Durbin-Watson statistic and test for autocorrelation. All parameters were modeled using autoregressive errors, as seasonality produces an autocorrelation at the seasonal lag. We used backward stepwise elimination specifying a lag of 13 for our monthly data, plotted our residuals and checked for normality using Anderson-Darling test. We estimated robust standard errors using Newey-West correction for any heteroscedasticity and autocorrelation. We conducted all analysis using SAS 9.4 and the significance level was set at alpha 0.05. Because we utilized aggregate data involving no human subjects, the study was exempt from review by Delaware Department of Health and Social Services review board.
DISCUSSION
†NTSV cesareans are singleton births, 37 weeks or greater gestation, with cephalic presentation to nulliparous women, with cesarean mode of delivery and all hospital singleton term births (>37 weeks or greater gestation) to nulliparous women with cephalic presentation serve as the ‡NMETDdenominator.issingleton births at 37 and 38 weeks of gestation with cephalic presentation to nulliparous women that exclude preterm births and conditions such as preeclampsia, eclampsia, chorioamnionitis, premature rupture of membranes, prolonged labor, pre-pregnancy diabetes, gestational diabetes, congenital anomalies, fetal distress, and history previous poor outcomes and all early term (37 and 38 weeks of gestation) singleton hospital births serve as the denominator.
110 Delaware Journal of Public Health - August 2022
RESULTS
Although differences were small, NTSV rates decreased and NMETD rates increased during pre-lockdown period. When lockdown was announced in Delaware, the downward trend
Outcomes Mean (SD) Parameters Final Model b (SE) 95% CI Percent nulliparous term singleton vertex cesareans† 27.3 (+/-3.1) Intercept 28.0 (1.0)*** 26.1, 30.0 Baseline trend -0.3 (0.1)** -0.5, 0.0 Level change 4.4 (1.5)** 1.3, 7.4 Trend change 0.3 (0.1)** 0.0, 0.6 Percent indicatednon-medicallyearlytermdeliveries‡ 8.1(+/-1.1) Intercept 6.4 (0.4)*** 5.6, 7.3 Baseline trend 0.2 (0.1)** 0.1, 0.3 Level change -1.6 (0.4)** -2.5, -0.7 Trend change -0.2 (0.0)** -0.3, -0.1 p-value ***<0.01 **<0.05
REFERENCES
STRENGTHS AND LIMITATIONS
CONCLUSION
2. Czeisler, M. É., Marynak, K., Clarke, K. E. N., Salah, Z., Shakya, I., Thierry, J. M., . . . Howard, M. E. (2020, September 11). Delay or avoidance of medical care because of COVID19-related concerns - United States, June 2020. MMWR. Morbidity and Mortality Weekly Report, 69(36), 1250–1257. https://doi.org/10.15585/mmwr.mm6936a4
5. Keag, O. E., Norman, J. E., & Stock, S. J. (2018, January 23). Long-term risks and benefits associated with cesarean delivery for mother, baby, and subsequent pregnancies: Systematic review and meta-analysis. PLoS Medicine, 15(1), e1002494 https://doi.org/10.1371/journal.pmed.1002494
6 Main, E. K., Moore, D., Farrell, B., Schimmel, L. D., Altman, R. J., Abrahams, C., Sterling, J. (2006, June). Is there a useful cesarean birth measure? Assessment of the nulliparous term singleton vertex cesarean birth rate as a tool for obstetric quality improvement. American Journal of Obstetrics and Gynecology, 194(6), 1644 1651 https://doi.org/10.1016/j.ajog.2006.03.013
8. National Quality Forum. (2016). Perinatal and Reproductive Health 2015-2016. Final Report 2016. Available at: https://www.qualityforum.org/Perinatal_Project_2015-2016.aspx
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10. Rosenstein, M. G., Chang, S. C., Sakowski, C., Markow, C., Teleki, S., Lang, L., . . . Main, E. K. (2021, April 27). Hospital quality improvement interventions, statewide policy initiatives, and rates of cesarean delivery for nulliparous, term, singleton, vertex births in California. Journal of the American Medical Association, 325(16), 1631 1639 https://doi.org/10.1001/jama.2021.3816
Strengths of this analysis include use of current statewide data available from birth certificates to assess two important perinatal quality indicators using a robust quasi-experiment design. As of this writing, we have identified two studies28,29 specific to how these indicators are influenced during a pandemic. These studies were single hospital-based studies that compared data for a specific month as pre and post COVID-19 and found decreases in NTSV rates. However, such comparisons may not account for seasonal variations.30 Our ITS study accounts for this potential issue using a large time-series that includes 36 months. Despite its strengths, the study is limited by the fact that birth certificate data are administrative data and the accuracy of certain conditions for medical indications may lack sensitivity and may be overestimated.31 The aggregate nature of data also limited us from stratification of NTSV and NMETD rates by maternal age, race and ethnicity, and by hospitals that influence these indicators.6,7
9. Healthy People 2030. (n.d.) Reduce cesarean births among low-risk women with no prior births – MICH-06. Available at: https://health.gov/healthypeople/objectives-and-data/browse-objectives/ pregnancy-and-childbirth/reduce-cesarean-births-among-low-risk-women-noprior-births-mich-06
Reasons for the abrupt increase in NTSV and decrease in NMETD are unclear based on these data but may be due to delay or avoidance of care, limited resources, changes in labor and delivery unit practices or management.2,10,15,16,24,25 These perinatal quality indicators are reported to the Joint Commission26 and may be available to hospitals in their hospital electronic medical records in near real-time or monthly or quarterly basis. Further, perinatal quality collaboratives26 can play an important role in monitoring these indicators4,10,11,27 and may provide guidance in quality initiatives to improve triage, labor and delivery staffing during public health emergencies.
7 Coonrod, D. V., Drachman, D., Hobson, P., & Manriquez, M. (2008, June). Nulliparous term singleton vertex cesarean delivery rates: Institutional and individual level predictors. American Journal of Obstetrics and Gynecology, 198(6), 694. e1 694.e11. https://doi.org/10.1016/j.ajog.2008.03.026
in NTSV rate was briefly interrupted with a four percentagepoint increase while NMETD rates decreased by more than one percentage-point. During the post-lockdown period, NTSV rates continued to increase, while NMETD rates continued in a downward trend. These results suggest that the COVID-19 pandemic was associated with an immediate change in perinatal care in Delaware but appeared to gradually return to previous trends as the pandemic continued.
1. World Health Organization. (n.d.). COVID-19 Public Health Emergency of International Concern (PHEIC) Global research and innovation forum. Available at https://www.who.int/publications/m/item/covid-19-public-healthemergency-of-international-concern-(pheic)-global-research-andinnovation-forum
Our study assessed statewide changes in NTSV, NMETD rates comparing before and during the COVID-19 pandemic lockdown in Delaware and found that there was an abrupt increase NTSV rates and decrease in NMETD rates postlockdown impacting perinatal care. Future studies might explore occurrence of and reasons for changes in obstetrical care using multi-state or national initiatives such as the National Network of Perinatal Quality Collaboratives (NNPQC), Alliance for Innovation in Maternal Health (AIM) data, regional perinatal quality collaboratives chart-abstracted data and/or hospital network data that would provide more observations for further stratification. In addition to emergency preparedness planning, hospital monitoring and reporting of perinatal quality indicators to increase provider awareness of NTSV rates, reallocating and prioritizing clinical resources through surge capacity staffing in labor and delivery units might improve obstetrical care as measured by perinatal quality indicators during public health Dr.emergencies.Hussaini may be contacted at khaleel.hussaini@delaware.gov
4. Martin, J. A., Hamilton, B. E., & Osterman, M. (2021, September). Births in the United States, 2020. NCHS Data Brief, N0(418), 1 8. Retrieved from https://www.cdc.gov/nchs/data/databriefs/db418.pdf
3 Basu, A., Kim, H. H., Basaldua, R., Choi, K. W., Charron, L., Kelsall, N., Koenen, K. C. (2021, April 21). A crossnational study of factors associated with women’s perinatal mental health and wellbeing during the COVID-19 pandemic. PLoS One, 16(4), e0249780. https://doi.org/10.1371/journal.pone.0249780
17 National Center for Health Statistics. (2021). Quarterly provisional estimates – technical notes, natality, quarter 3, 2021. Accessed March 9, 2021. https://www.cdc.gov/nchs/nvss/vsrr/natality-technical-notes.htm
13. American College of Obstetricians and Gynecologists. (2019, February). ACOG Committee Opinion No. 764: Medically indicated late-preterm and early-term deliveries. Obstetrics and Gynecology, 133(2), e151 e155. https://doi.org/10.1097/AOG.0000000000003083
24. Ekperi, L. I., Thomas, E., LeBlanc, T. T., Adams, E. E., Wilt, G. E., Molinari, N.-A., & Carbone, E. G. (2018, September 13). The impact of Hurricane Sandy on HIV testing rates: An interrupted time series analysis, January 1, 2011‒December 31, 2013. PLoS Currents, 10, ecurrents.dis. ea09f9573dc292951b7eb0cf9f395003
25 Plough, A. C., Galvin, G., Li, Z., Lipsitz, S. R., Alidina, S., Henrich, N. J., . . . Shah, N. T. (2017, August). Relationship between labor and delivery unit management practices and maternal outcomes. Obstetrics and Gynecology, 130(2), 358 365. https://doi.org/10.1097/AOG.0000000000002128
26. Harkness, M., Yuill, C., Cheyne, H., Stock, S. J., & McCourt, C., & the CHOICE Study Consortia. (2021, April 19). Induction of labour during the COVID-19 pandemic: A national survey of impact on practice in the UK. BMC Pregnancy and Childbirth, 21(1), 310. https://doi.org/10.1186/s12884-021-03781-x
28 Sinnott, C. M., Freret, T. S., Clapp, M. A., Reiff, E., & Little, S. E. (2021, October). Investigating decreased rates of nulliparous Cesarean deliveries during the COVID-19 pandemic. American Journal of Perinatology, 38(12), 1231 1235 https://doi.org/10.1055/s-0041-1732449
29 Boehler-Tatman, M., Howard, E., & Russo, M. L. (2022, February 1). Examining outcomes for nulliparous, at term, singleton and vertex deliveries during the first wave of the COVID-19 pandemic in Rhode Island. R I Med J (2014), 105(1), 37 41
30 Currie, J., & Schwandt, H. (2013, July 23). Within-mother analysis of seasonal patterns in health at birth. Proceedings of the National Academy of Sciences of the United States of America, 110(30), 12265 12270 https://doi.org/10.1073/pnas.1307582110
31 Bailit, J. L., & the Ohio Perinatal Quality Collaborative (2010, September). Rates of labor induction without medical indication are overestimated when derived from birth certificate data. American Journal of Obstetrics and Gynecology, 203(3), 269.e1 269.e3 https://doi.org/10.1016/j.ajog.2010.07.004
12 Kacica, M. A., Glantz, J. C., Xiong, K., Shields, E. P., & Cherouny, P. H. (2017, April). A statewide quality improvement initiative to reduce non-medically indicated scheduled deliveries. Maternal and Child Health Journal, 21(4), 932 941. https://doi.org/10.1007/s10995-016-2196-5
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14. American College of Obstetricians and Gynecologists. (2021). ACOG Committee Opinion No. 831: Medically indicated latepreterm and early-term deliveries. Obstetrics and Gynecology, 138(1), e35 e39 https://doi.org/10.1097/AOG.0000000000004447
22 Lieberman, D. A., Polinski, J. M., Choudhry, N. K., Avorn, J., & Fischer, M. A. (2016, January 15). Medicaid prescription limits: Policy trends and comparative impact on utilization. BMC Health Services Research, 16, 15. https://doi.org/10.1186/s12913-016-1258-0
15. Committee Opinion No. (2017, December). Committee Opinion No. 726: Hospital Disaster Preparedness for Obstetricians and Facilities Providing Maternity Care. Obstetrics and Gynecology, 130(6), e291 e297 https://doi.org/10.1097/AOG.0000000000002413
18 Shadish, W., Cook, T., & Camplbell, D. (2001). Experimental and Quasi-Experimental Designs for Generalized Causal Inference. Boston, MA: Houghton Mifflin.
19 Wagner, A. K., Soumerai, S. B., Zhang, F., & Ross-Degnan, D. (2002, August). Segmented regression analysis of interrupted time series studies in medication use research. Journal of Clinical Pharmacy and Therapeutics, 27(4), 299 309 https://doi.org/10.1046/j.1365-2710.2002.00430.x
21 Bernal, J. L., Cummins, S., & Gasparrini, A. (2017, February 1). Interrupted time series regression for the evaluation of public health interventions: A tutorial. International Journal of Epidemiology, 46(1), 348 355. https://doi.org/10.1093/ije/dyw098
27. Henderson, Z. T., Ernst, K., Simpson, K. R., Berns, S. D., Suchdev, D. B., Main, E., Olson, C. K. (2018, February). The national network of state perinatal quality collaboratives: A growing movement to improve maternal and infant health. J Womens Health, 27(2), 123 127 https://doi.org/10.1089/jwh.2017.6844
16 Boelig, R. C., Manuck, T., Oliver, E. A., Di Mascio, D., Saccone, G., Bellussi, F., & Berghella, V. (2020, May). Labor and delivery guidance for COVID-19. American Journal of Obstetrics & Gynecology MFM, 2(2), 100110 https://doi.org/10.1016/j.ajogmf.2020.100110
23 Leopold, C., Zhang, F., Mantel-Teeuwisse, A. K., Vogler, S., Valkova, S., Ross-Degnan, D., & Wagner, A. K. (2014, July 25). Impact of pharmaceutical policy interventions on utilization of antipsychotic medicines in Finland and Portugal in times of economic recession: Interrupted time series analyses. International Journal for Equity in Health, 13, 53. https://doi.org/10.1186/1475-9276-13-53
https://doi.org/10.1371/currents.dis. ea09f9573dc292951b7eb0cf9f395003
11 Womack, L. S., Sappenfield, W. M., Clark, C. L., Hill, W. C., Yelverton, R. W., Curran, J. S., Bettegowda, V. R. (2014, October). Maternal and hospital characteristics of nonmedically indicated deliveries prior to 39 weeks. Maternal and Child Health Journal, 18(8), 1893 1904. https://doi.org/10.1007/s10995-014-1433-z
20 Penfold, R. B., & Zhang, F. (2013, November-December). Use of interrupted time series analysis in evaluating health care quality improvements. Academic Pediatrics, 13(6, Suppl), S38 S44 https://doi.org/10.1016/j.acap.2013.08.002
QuitSupport.com BYTRAPPEDTOBACCO?WEHAVEAWAYOUT. 113
Call the Delaware Quitline and free yourself from tobacco. Free counseling, cessation aids, and medications are available to help you get on the path to living tobacco-free. Stop getting pulled back in. Let us help you quit for good.
A multiple-comparison correction used when several dependent or independent statistical tests are being performed simultaneously.
LEXICON
Chi Squared Test
Continuous Variables
Dichotomous Variable
Data Source Triangulation
A variable that can take on one of a limited, usually fixed, number of possible values (i.e. race/ethnicity).
A variable that has only two values, 0 or 1, for the absence/presence of an attribute.
114 Delaware Journal of Public Health - August 2022
PLACE MATTERS-GEOGRAPHY
Relating to the time immediately before and after birth.
A statistical test used to examine the differences between categorical variables from a random sample in order to judge goodness of fit between expected and observed results.
STATISTICS DEFINITIONS
Errors based on a preceding error.
Categorical Variables
A potentially dangerous pregnancy complication characterized by high blood pressure.
LEXICON AND STATISTICS DEFINITIONS
Oliguria
The use of a variety of data sources, including time, space, and persons, in a study. Using multiple datasets, methods, and/or theories to address a research question. This increases the validity and reliability of results.
Nulliparous
ANOVA
Chorioamnionitis
Eclampsia
A child bearing individual who has not borne any offspring.
Autoregressive Errors
Analysis of Variance; a statistical method in which the variation in a set of observation is divided into distinct components, systematic factors and random factors.
Perinatal
Cephalic
A complication of preeclampsia, a condition in which high blood pressure results in seizures during pregnancy.
An infection with inflammation of the amniotic fluid, placenta, fetus, fetal membranes and/or the mucous membrane lining the uterus.
Low urine output (between 80-400 mL/day).
A variable that can be measured or counted (i.e. age).
Singleton
Autocorrelation
The similarity between observations as a function of the time lag between them.
Preeclampsia
Bonferroni Post Hoc Correction
A child born singly, rather than one of a multiple birth.
Of or relating to the head.
Incidence Rate Ratio
Logistic Regression
Interrater Reliability
Stigma
False negative; a researcher does not reject the null hypothesis (the outcome was not due to chance, but the researcher thought it was).
In social work, directly supporting people experiencing a variety of challenges from individual to socioeconomic, familial, or cultural hardships.
Used to test for associations between variables on a count outcome variable.
Type 2 Error
Micro Level
The degree of agreement among independent observers who rate, code, or assess the same thing.
Macro Level
Not relating to quantities; data from first-hand observation, interviews, questionnaires, etc. The data are generally nonnumerical.
In social work, working closely with individuals, families, and small groups to counsel and provide one-on-one support.
Mezzo Level
P-Values
Qualitative
Largely applied to qualitative (value-based) research, it involves studying a particular phenomenon or process and discovering new theories that are based on the collection and analysis of real world data.
A statistical method used to predict the probability of one event (out of two alternatives) taking place.
PLACE MATTERS-GEOGRAPHY LEXICON AND STATISTICS DEFINITIONS
Ratio comparing the incidence rates of events occurring at a given point in time.
False positive; a researcher thinks an outcome is significant when the outcome was due to chance; the mistaken rejection of a true null hypothesis.
Dispersion Parameters
Negative Binomial Logarithmic Count Regression Models
Large in scale or scope; taking a broad view of the systemic causes of injustice at the community, state, national, and international levels.
The ratio of the risks for an event for the exposure group to the risks for the non-exposure group. It does not provide absolute risk, but rather a higher or lower likelihood of the event in the exposure versus the non-exposure group.
Grounded Theory Approach to Analysis
Models used to establish relationships between an outcome of interest and more than one independent variables.
A statistical value indicating the probability of obtaining results that are not due to chance (a true null hypothesis). A smaller p-value means there is a strong indication that the results are not due to chance.
Relative Risk
A mark of disgrace associated with a particular quality.
Multivariable Count Regression Models
Type 1 Error
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A measure of how much a sample fluctuates around a mean (average) value.
In 1793, Dr. Edward Miller, a young Sussex County physician, prepared a paper defending the theory of the domestic origin of yellow fever (Figure 2). Upon reading the work, Dr. Rush declared its author “second to no physician in the United States.”1
Regardless, the debate and the disease thrived beyond the Delaware River valley. In 1795, Noah Webster (of dictionary fame) placed a circular in American newspapers soliciting physicians to share their observations regarding the origins of yellow fever. Though not a doctor himself, Webster believed that physicians would not find the source of the disease until they examined all available evidence. Webster received nine responses. He compiled the letters into a volume titled A Collection of Papers on the Subject of Bilious fevers, Prevalent in the United States for a Few Years Past, and, using his own money, published the book in 1796. Even though Webster created what has been called the “world’s first scientific survey,” he did not continue his inquiry into the disease.2,3 His efforts were not in vain because others were inspired to pick up where he left off.
Figure 1. Dr. Nicholas Way
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Sharon Folkenroth Hess, M.A. Collections Manager and Archivist, Delaware Academy of Medicine/Delaware Public Health Association
In 1793, a brutal yellow fever epidemic hit Philadelphia, killing thousands. Doctors in the city viciously argued in the newspapers over the cause and cure of the disease. In the meantime, twenty thousand people fled the city to seek asylum in the surrounding areas. Refugees crowded the roads and waterways to Wilmington. With the cause still unknown, city officials initially refused them entry. Dr. Nicholas Way, a founding member of the Medical Society of Delaware, and others convinced the city to accept them (Figure 1). Despite the risk, New Castle County escaped the 1793 outbreak unscathed.
Interestingly, those studying the disease fell into two camps: one believed that a miasma created by domestic filth and overcrowded conditions was the cause, and the other declared that international trade imported the contagion from more tropical locations. Dr. Benjamin Rush of Philadelphia became the leader of the first camp. Now that the disease was no longer obscure in the area, Delaware’s doctors again sought to weigh in on the matter.
After attempting to discover the “origin and nature of the noxious power which especially prevails in hot and moist climates during summer and autumn and produces intermittent and remittent fevers, and certain other disease, and by what means may this insalubrity of climate be corrected and the diseases thence arising be most successfully prevented and treated,” (p. 472-473)
the Society agreed they had failed. The awarding committee determined that the research assumed too many facts without evidence. A lack of experimental inquiry resulted in “the defect of all original discovery.” Even though Philadelphia saw an outbreak in 1762, yellow fever was just too obscure in Delaware to provide physicians with enough data to work with.1
e Healing Arts in History: Location, location, location!
During the first annual meeting of the Medical Society of Delaware in Dover in 1790, members decided they needed to support original research on subjects of “general medicine or hygienic interest.” They chose a topic for study, with doctors presenting their findings at the following annual meeting. Over the decades, the Society awarded prizes for groundbreaking work on diverse topics, including ophthalmia, influenza, cholera infantum, smallpox, and the “Epidemic of Bilious Colic in Dover.” In the first year, however, they did not award a prize.
The First State has more to offer residents than tax-free shopping. In addition to world-class museums, quiet neighborhoods, and many acres of park and farm land, Delaware is a convenient central location within the Mid-Atlantic region. Its largest city is half an hour from Philadelphia, an hour from the beaches, and two hours from New York City. For those working in the nation’s capital, a quick train ride makes living in New Castle County an attractive alternative. While modern Delawareans may enjoy proximity to larger cities, epidemics often made this less appealing to our eighteenth-century predecessors. Regarding yellow fever, Wilmington’s location mattered in surprising ways.
Yellow fever again devastated cities during the summers of 1796 and 1797. Both times, the disease spared Delaware, although the
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The origin of the pestilence continued to evade physicians. In a letter from Dr. James Tilton to William Currie on November 13, 1798, he breaks from the domestic vs. foreign origin argument. He notes that neither thoroughly explains the unusual patterns of the disease:
state’s luck soon ran out. In late spring 1798, heavy rains flooded the region, and the land remained soggy and damp even with that summer’s oppressive heat. The bilious fever attacked again in June; for a third time, Philadelphians fled for safety en masse. Now a deadlier strain of the disease followed them to Delaware.
On August 7th, Wilmington saw its first cases of yellow fever. By the epidemic’s end, more than 240 people had died in the city alone (Figure 3 & 4).
Figure 2. Dr. Edward Miller
Figure 3. The Wilmington Mercury
e fever became epidemic between the 15th and 20th.—It commenced with persons immediately from Philadelphia, as well inhabitants of the borough, as of the city. Shallop-men and others, who passed from one place to the other by water, were the rst victims. From there it extended rapidly to the inhabitants of xed residence. A ship manned chie y by French royalists that entered our port after the sickness had commenced was also suspected of contributing to the evil; but of this, I have no evidence. From all the information that came to my knowledge, every physician of this place and all others of correct observation agree that the disease was imported to us from Philadelphia by infected goods and furniture, as well as infected persons. We suppose the disease to be propagated by contagion, from infected persons, clothing, vessels, houses, &c. It is remarkable, however, that stronger exhalations arise from persons a ected by this fever than in other febrile diseases, and we have reason to believe that many were a ected by the contagion at a distance from the sick, reaching quite across our streets. No instance of those who ed to the country communicating it to others has come to my knowledge within the vicinity of Wilmington (p. 138-139).4
Tilton’s letter was later published in William Curries’ epidemiological study of the outbreak. The study included data on weather conditions, statistics on the sick and dead, and the proceedings of the Board of Health and Guardians of the Poor.
REFERENCES
In other words, it is a condition of the atmosphere and not the e uvia from the sick, which is to be dreaded. us, in 1797, the fugitives and sick from Philadelphia did not spread the fever in Wilmington - in 1798, they did. at is, in 1797, the atmosphere of Wilmington would not generate and nurse the disease - in 1798, it would (p. 336).5
In A Brief History of Disease and Pestilence, Webster, citing evidence gathered by Tilton and Currie, theorizes why Wilmington avoided an outbreak until 1798:
e distemper has an atmosphere in which it is readily contracted. Beyond that atmosphere, it is not infectious.
2. Skinner, D. (2021, Spring). Noah Webster, chronicler of disease. Humanities (Washington), 42(2). Retrieved from https://www.neh.gov/article/noah-webster-chronicler-disease
4. Currie, W. (1798). Memoirs of the yellow fever, which prevailed in Philadelphia, and other parts of the United States of America, in the summer and autumn of the present year, 1798. Philadelphia: Thomas Dobson.
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3. Pak, C. (2021). Noah Webster, yellow fever, and the first U.S. medical journal. Medical Humanities. https://blogs.bmj.com/medical-humanities/2021/03/26/noah-websteryellow-fever-and-the-first-u-s-medical-journal/
Figure 4. The Wilmington Mercury, October 23 & 24, 1798.
1. Scharf, J. T. (1888). History of Delaware: 1609-1888. Philadelphia, L.J. Richards & Co.
5. Webster, N. (1799). A brief history of epidemic and pestilential diseases, with the principal phenomena of the physical world, which precede and accompany them, and observations deduced from the facts stated. Hartford: Hudson & Godwin.
Even though physicians isolated the conditions in which the disease thrived and eliminated the possibility of direct patient-topatient transmission, the third piece to the puzzle— mosquitoes— remained elusive until 1901. Regardless, the investigations into the 1790s yellow fever epidemics stand out as the earliest examples of interdisciplinary medical geography. Delaware’s proximity to Philadelphia, the ease of travel between the two cities, and the international ports provided the ideal conditions for testing hypotheses on the origin and nature of the disease’s spread. Location really does matter.
Delaware Division of Public Health
American Public Health Association
Delaware Division of Public Health
The DPH Bulletin - June 2022
Submission Guidelines
Delaware Journal of Public Health
The Nation's Health
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e 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.
e 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.
Submission Requirements
Established in 2015, e Delaware Journal of Public Health is a bi-monthly, peer-reviewed electronic publication, created by the Delaware Academy of Medicine/Delaware Public Health Association. e 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.
Information for Authors
Cover Letters must address the following four article requirements:
3. One sentence summarizing the main message(s) of the paper, which may be used to disseminate the paper on social media.
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 e Delaware Academy of Medicine and Delaware Public Health Association, Timothy Gibbs, at Publictgibbs@delamed.orgHealthDelawareJournalof
Submission Guidelines
e initial submission should be clean and complete, without edits or markups, and contain both the title and author(s) fulls name(s). Submissions should be 1.5 or double spaced with a font size of 12. Initial submissions must also contain a cover letter with concise text (maximum 150 words). Once completed, articles should be submitted via email to Elizabeth Healy at 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.
All manuscripts must be submitted via email to Elizabeth Healy at ehealy@delamed.org.
1. A description of what the paper adds to current knowledge, in particular with respect to material previously published in DJPH, and if systematic reviews exist on the topic.
About the Journal
120 Delaware Journal of Public Health - August 2022
2. e public health importance of the paper.
updated April, 2020
4. For individual or group randomized trials, provide the date of trial registration and the NCT number from www.Clinicaltrials.gov or other approved registry. In the cover letter only, not in the paper. Do NOT include the trial registration or NCT number in the abstract or the body of the manuscript during the initial submission.
Use of nondiscriminatory language is required in all DJPH submissions. e DJPH reserves the right to reject any submission found to be using sexist, racist, or heterosexist language, as well as unethical or defamatory statements.
Structured abstracts should employ 4-5 headings: Objectives (begins with “To…”)
Please Note: All authors and contributors are asked to submit a brief personal biography (3 sentences maximum) and a headshot along submissions. ese will be published alongside final submissions in the final electronic publication. For pieces with multiple authors, these additional documents are requested for all contributors.
Note: ere is no Background heading.
Trial Registration information is required for clinical trials and must be included in the final version abstract
AConclusionsResultsMethodsfifthheading,
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.
Copyright
All abstracts should provide the dates(s) and location(s) of the study is applicable.
e word limit is 200 words, including headings. A title page should be submitted with this abstract as well.
Nondiscriminatory Language
Submission Length
121
Authors must submit a structured or unstructured abstract along with their article.
Policy Implications, may be used if relevant to the article.
Additional Documents and Information for Authors
Abstracts
To view additional information for online submission requirements, please refer to the website for the Delaware Journal of Public https://djph.org/sample-page/submit-an-article/Health:
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.
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.
Con icts of Interest
The Delaware Academy of Medicine is a private, nonprofit organiz ation foun de d in 1930 Our mission is to enhance the well bein g of our community through medical education an d the promotio n of public health. Our edu cational initiative s span the spectr um fr om consumer health education tocontinuing medical education conferences an d symposia
ISSN 2639-6378
The Delaware Public Health Association wa s of ficially reborn at the 141st Annual Meetin g of the American Public Health Association (A HPA) held in Boston , MA in November, 2013 At this meeting, af filiation of the DPHA wa s transferred to the Delaware Academy of Medicine of ficially on November 5, 2013 by action of the APHA Governing Council. The Delaware Academy of Medicine, who’ s mission statemen t is “t o pr omot e the well-being of our communit y through education an d the promotio n of public health,” is honore d to take on this respon sibility in the First State.
Delawa re Academy of Medici ne / DPHA 4765 Og letown-Sta nton Road Su ite L10
Ne wa rk, DE 19713 www.dela med.org | www.djph.org
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