DJPH - Health Policy 2023 by Delaware Academy of Medicine and the Delaware Public Health Association

Delaware Journal of

Volume 9 | Issue 5

December 2023

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

www.delamed.org | www.delawarepha.org

Delaware Academy of Medicine OFFICERS Lynn Jones, L.F.A.C.H.E. President Stephen C. Eppes, M.D. President Elect Ann Painter, M.S.N., R.N. Secretary

Delaware Journal of

December 2023

Public Health Volume 9 | Issue 5

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

Jeffrey M. Cole, D.D.S., M.B.A. Treasurer S. John Swanson, M.D. Immediate Past President Timothy E. Gibbs, M.P.H. Executive Director, ex officio

DIRECTORS David M. Bercaw, M.D. Saundra DeLauder, Ph.D. Eric T. Johnson, M.D. Erin M. Kavanaugh, M.D. Joseph Kelly, D.D.S. Omar A. Khan, M.D., M.H.S. Brian W. Little, M.D., Ph.D. Daniel J. Meara, M.D., D.M.D. John P. Piper, D.O. Megan L. Werner, M.D., M.P.H. Charmaine Wright, M.D., M.S.H.P.

EMERITUS Barry S. Kayne, D.D.S. Joseph F. Kestner, Jr., M.D.

Delaware Public Health Association ADVISORY COUNCIL Omar Khan, M.D., M.H.S. Chair Timothy E. Gibbs, M.P.H. Executive Director

COUNCIL MEMBERS Alfred Bacon, III, M.D. Louis E. Bartoshesky, M.D., M.P.H. Gerard Gallucci, M.D., M.S.H. Allison Karpyn, Ph.D. Erin K. Knight, Ph.D., M.P.H. Laura Lessard, Ph.D., M.P.H. Melissa K. Melby, Ph.D. Mia A. Papas, Ph.D. Karyl T. Rattay, M.D., M.S. William Swiatek, MA, A.I.C.P.

Delaware Journal of Public Health Timothy E. Gibbs, M.P.H. Publisher Omar Khan, M.D., M.H.S. Editor-in-Chief Timothy E. Gibbs, M.P.H. Guest Editor Kate Smith, M.D., M.P.H. Copy Editor Suzanne Fields Image Director

ISSN 2639-6378

3 | I n This Issue

26 | Drought: Ten to Do Ten

4 | Th e DJPH Experience

34 | Global Health Matters Newsletter November - December 2023

6|A (Brief) History of Health Policy in the United States

46 | Delaware Healthcare Workforce Update

12 | Health Literacy As A Pathway To Wellbeing: A Celebration Of Health Literacy Month

70 | Opportunities to Improve Outcomes for Families with Children through the Community Choice Demonstration

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

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

Greg O’Neill, M.S.N., A.P.R.N., A.G.C.N.S.-B.C. Peggy Geisler

14 | Unraveling Healthcare Shortages in Delaware and Charting a Course for Equity and Resilience Nicole Sabine, B.S. Timothy E. Gibbs, M.P.H.

Bridget Knitowski

Fogarty International Center Timothy E. Gibbs, M.P.H. Matt McNeill, B.S.

U.S. Department of Housing and Urban Development

72 | Index of Advertisers 74 | Delaware Journal of Public Health Submission Guidelines

20 | Family Medicine Training in the US and Delaware: Opportunities and Growth in Primary Care Workforce Omar A. Khan, M.D., M.H.S., F.A.A.F.P. Erin M. Kavanaugh, M.D., F.A.A.F.P. Robert A. Monteleone, M.D. Brintha Vasagar, M.D., M.P.H., F.A.A.F.P. Joyce F. Robert, M.D., F.A.A.F.P.

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). Submissions: Contributions of original unpublished research, social science analysis, scholarly essays, critical commentaries, departments, and letters to the editor are welcome. Questions? Contact managingeditor@djph.org. Advertising: Please contact tgibbs@delamed.org for other advertising opportunities. Ask about special exhibit packages and sponsorships. Acceptance of advertising by the Journal does not imply endorsement of products. Copyright © 2023 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 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. Any report, article, or paper prepared by employees of the U.S. government as part of their official duties is, under Copyright Act, a “work of United States Government” for which copyright protection under Title 17 of the U.S. Code is not available. However, the journal format is copyrighted and pages June not be photocopied, except in limited quantities, or posted online, without permission of the Academy/DPHA.Copying done for other than personal or internal reference use-such as copying for general distribution, for advertising or promotional purposes, for creating new collective works, or for resale- without the expressed permission of the Academy/DPHA is prohibited. Requests for special permission should be sent to managingeditor@djph.org.

IN T H IS ISSU E Health Policy Our last issue on health policy was in December 2019 (Health Policy: The Road to Value-Based Care) – just before the COVID-19 pandemic, which disrupted so much of our world and challenged the policies and interventions that had been in place for decades. For those of us who have lived through a few pandemics (think H1N1, SARS, and HIV/AIDS), it started off feeling like a rehash of the past – but proved to be far more challenging with the addition of politics – quite a strange bedfellow. This issue, four-plus years later, introduces new thinking and progress to the mix. Health policy and public health improvement are intricately connected, as policies set the guidelines and priorities that shape the health of a population. Policies determine resource allocation, and influence the funding and support for public health programs and interventions. Effective health policies establish regulations and standards, ensuring the quality of healthcare services and providing a framework for disease prevention. Additionally, policies can address social determinants of health, influencing factors like education and employment that impact overall well-being. By creating an environment conducive to public health goals, policies play a pivotal role in driving improvements, promoting health equity, and fostering a healthier society. In essence, the relationship between health policy and public health improvement lies in the ability of policies to shape and direct efforts towards a healthier and more resilient population. Topics in this issue include health literacy, workforce development, primary care, and a historic reflection on health policy in the US. With special permission, we are also including a reprint on Community Choice Demonstration from the U.S. Department of Health and Urban Development. We also are leveraging this issue to publish updated information from the Delaware Health Force Initiative about our healthcare workforce, and some of the policy recommendations forthcoming from that body of work. Policies are intended to serve the population, and thus should reflect health and wellbeing in their entirety, not just in policies relating to health. Policies also must be guided by ethics and social justice, and seek to make meaningful change in the lives of everyone, and when necessary, redress wrongs which also happen in an evolving society. We remain committed to the health of our local and global population, and we hope in some small way the Journal and all its theme issues are a meaningful contribution towards that goal.

Omar A. Khan, M.D., M.H.S. Editor-in-Chief, Delaware Journal of Public Health

Doi: 10.32481/djph.2023.12.001

Timothy E. Gibbs, M.P.H Publisher, Delaware Journal of Public Health

The DJPH Experience Timothy E. Gibbs, M.P.H. Publisher, Delaware Journal of Public Health

This is the final issue of the Delaware Journal of Public Health that I will be honored to publish. My colleague, Kate Smith, M.D., M.P.H., N.P.Mc., steps into the role of executive director on January 1st, 2024, and she will assume the role of publisher going forward. As such, I reflect for a moment on the “DJPH Experience.” In 2015, I recommended to the Board of Directors of the Delaware Academy of Medicine/Delaware Public Health Association that we undertake to publish a peer-reviewed journal focusing on public health issues in Delaware. With strong support from Dr. Omar Khan, then a board member, and the full board of directors, we published the first issue in September of 2015. I distinctly remember worrying about whether there would be enough content to support a new publication, and nine years later my worries have proved baseless. On a couple of occasions, we have had so much content that we added a sixth issue just to maintain a manageable publication size – a good problem to have. The purpose of the Journal remains the same today as at its founding:

The aim of the journal is to stimulate debate and dissemination of knowledge in the public health ﬁeld in order to improve efficacy, effectiveness and efficiency of public health interventions to improve health outcomes of populations. Published ﬁve times a year, the Delaware Journal of Public Health considers submissions in all aspects of public health with a geographic focus on Delaware and surrounding states. From time to time, articles of a national and international nature are included as well at the discretion of the editorial board. The Journal really hit its stride when we became an accepted PubMed listed publication – an enormous but gratifying effort, especially as we were initially not approved (we were “too small”). Dr. Khan and I mounted a vigorous defense, and pointed out that some cities smaller than Delaware had PubMed indexed journals, so, why not us? In the end, they agreed and reversed their decision. Why did I think this was a good pursuit? It was simple: 1. Delaware has stories to tell that can be of value to others aiming to replicate and build upon work. 2. Delaware is an ideal mix of rural, urban, and suburban areas – a laboratory of sorts for policy work, intervention, and research. 3. Delaware practitioners of public health and medicine deserve to be published just as much as academics from major cities and research centers. 4. The professional and general public deserve to be informed of what is happening in their state, especially at a time when traditional media focuses elsewhere. I look forward to seeing where the Journal goes in the future under Dr. Smith’s leadership, and wish all readers good health and wellness.

Timothy E. Gibbs, M.P.H Publisher, Delaware Journal of Public Health

4 Delaware Journal of Public Health - December 2023

Doi: 10.32481/djph.2023.12.002

HIGHLIGHTS FROM

The

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

December 2023 - January 2024 The Nation’s Health headlines Online-only news from The Nation’s Health newspaper Stories of note include: US life expectancy inches up, but nation not on par with peers Mark Barna PrEP use rising, but uptake lags among women, people of color Kim Krisberg Creative recruitment can boost college admission diversity Melanie Padgett Powers Public health works for environmental justice in vulnerable US communities Mark Barna Many college students with food insecurity have sleep problems Melanie Padgett Powers New York state health association honored as APHA Affiliate of year Kim Krisberg For a healthy pregnancy, be wise and immunize Teddi Nicolaus APHA 2023 inspires public health workforce in Atlanta Mark Barna Submissions for APHA 2024 in Minneapolis due by March 29 Michele Late APHA-Kaiser fellows improving public health Mark Barna National Public Health Week 2024 to spotlight connections Mark Barna 5

A (Brief) History of Health Policy in the United States Katherine Smith, M.D., M.P.H. Program Manager, Delaware Academy of Medicine/Delaware Public Health Association

INTRODUCTION Trying to summarize the history of health policy in the United States is a massive undertaking. What should be included? What should be ignored? How should events be separated? Fortunately, the Kaiser Family Foundation has already done an excellent job of breaking down one thousand years of US health care (see figure 1).1

1900-1929 Health Policy and Reform in the United States began in 1912, when Teddy Roosevelt and the Progressive Party endorsed social insurance as part of their platform. This included health insurance. Not to be outdone, in that same year, the National Convention of Insurance Commissioners developed its first model of state law to regulate health insurance. A few years later, in 1915, the American Association for Labor Legislation drafted a bill to require health insurance. The United States entered World War I soon after, and the bill was not enacted. In 1921, the Sheppard-Towner Act was passed, providing matching funds to states for prenatal and child health centers.2 This Act would expire in 1929 without being reauthorized.

In 1927, the Committee on the Costs of Medical Care was formed to study the economics of medical care. The group included physicians, public health specialists, and others. The recommendation report was published in 1932, and the majority endorsed the ideas of medical group practice and voluntary health insurance.3 By 1929, Baylor Hospital had introduced a pre-paid hospital insurance plan – considered the forerunner of future Blue Cross Plans.

1930-1939 In 1930, the United States was in the midst of the Great Depression (1929-1939), and social policies to secure employment, retirement, and medical care were needed. President Franklin D. Roosevelt appointed the Committee on Economic Security to address these issues, but a national health reform did not advance. The Social Security Act was passed in 1935, which included grants for Maternal and Child Health, which restored many of the programs established under the Sheppard-Towner Act.4 It also expanded the role of the Children’s Bureau to include child welfare services.

Figure 1. Timeline of Major U.S. Health Policy Accomplishments

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Doi: 10.32481/djph.2023.12.003

In 1935-1936, the National Health Survey was conducted by the U.S. Public Health Service to assess the Nation’s health, including the underlying social and economic factors that affect health. This survey would go on to become the National Health Interview Survey. In 1938, the National Health Conference was convened in Washington, D.C. Recommendations from that conference were incorporated into the National Health Bill, which died in committee in 1939. In that same year, the first Blue Shield plans were organized to cover the costs of physician care.

1940-1949 In 1943, legislation was introduced to operate health insurance as a part of social security. The Wagner-Murray-Dingell bill included provisions for universal comprehensive health insurance and changes to social security to move it toward a life-long social insurance. It did not pass. In 1944, President Roosevelt included the right to adequate medical care and the opportunity to achieve and enjoy good health in his Economic Bill of Rights State of the Union Address. Also in 1944, the Social Security Board called for required national health insurance as a part of the social security system. President Harry S. Truman revived the idea of a national health program just after the end of World War II. The Wagner-MurrayDingell bill was reintroduced to Congress, along with the new Taft-Smith-Ball bill authorizing grants to states for medical care of the poor. Neither bill is passed, and both would be reintroduced in 1947. In 1946, the Hill-Burton Act was passed. This bill funded the construction of hospitals, and prohibited discrimination of medical services on the basis of race, religion, or national origin. It required hospitals to provide a “reasonable volume” of charitable care, and allowed for “separate but equal” facilities.5 In 1948, the National Health Assembly was convened by the Federal Security Agency. The final report called for voluntary health insurance, but also stated the need for universal coverage. That same year, the American Medical Association would launch a national campaign against national health insurance.

1950-1959 In 1951, the Joint Commission on the Accreditation of Hospitals (JCAH) formed to improve the quality of hospital care. In 1952, the Federal Security Agency proposed the enactment of health insurance for those receiving Social Security benefits. In 1956, a military program was enacted that provided government health insurance for dependents of those serving in the Armed Forces. The Forand Bill was introduced in the house in 1956 to provide health insurance for social security beneficiaries. It was reintroduced in 1959. In 1957, the AMA continued to oppose national health insurance, and the National Health Interview Survey was first conducted (it has been continuously conducted ever since).

1960-1969 As employer-based health coverage grew (and were found to be excluded from an employee’s taxable income), private plans began to set premiums based on their experiences with various health costs. Those individuals who were retired or who were living with a disability found it harder to get affordable coverage.

In 1960, the Federal Employees Health Benefit Plan was begun to provide health insurance to federal workers. The Kerr-Mills Act was passed, which used federal funds to support state programs providing medical care to the poor and elderly (a precursor to Medicaid).6 In 1961, the White House Conference on Aging was held, in which the task force recommended health insurance for the elderly under Social Security. The King-Anderson bill, introduced to create a government health insurance program for the aged, drew support from organized labor and intense opposition from the AMA and commercial health insurance carriers. President Kennedy addressed the nation in 1962 on the topic of Medicare, and President Johnson would continue to advocate for Medicare when he succeeded President Kennedy. In 1965, a year after the passing of the Civil Rights Act, the Medicare and Medicaid programs were incorporated into the Social Security Act and signed into law by President Johnson.7 The bill had massive public approval, the support of the hospital and insurance industries, and no government cost controls or physician fee schedules within it. Also in 1965, the Office on Economic Opportunity established Neighborhood Health Centers (precursors to Federally Qualified Health Centers (FQHCs)) to provide health and social services to poor and medically underserved communities.

1970-1979 By the early 1970s, inflation and health care costs were both growing. President Nixon put forth the Comprehensive Health Insurance Plan (CHIP), and other congressmen put forth others, splitting support for any one reform. In 1972, the Supplemental Security Income (SSI) program began providing cash assistance to the elderly and disabled. Social Security amendments allowed people under the age of 65 with long-term disabilities and/or end stage renal disease to qualify for Medicare coverage.1 In 1974, The Hawaii Prepaid Health Care Act required employers to provide insurance for any employee working more than 20 hours per week, while the Employee Retirement Income Security Act (ERISA) exempted self-insured employers from state health insurance regulations. The enactment of the Health Planning Resources Development Act in that same year required states to develop health planning programs to prevent the duplication of services – this resulted in the widespread use of Certificate of Need programs. In 1977, the Health Care Financing Administration was established within the Department of Health, Education, and Welfare (renamed the Department of Health and Human Services in 1980). The National Medical Care Expenditure Survey (NMCES) of that year provided detailed data on how much individuals were spending on health care.

1980-1989 In 1981, a federal budget reconciliation required states to make additional Medicaid payments to hospitals serving a disproportionate share of Medicaid and low-income patients. It also repealed the requirement that Medicaid programs pay hospital rates equal to those paid by Medicare, and required states to pay nursing homes at “reasonable and adequate” rates. Two types of Meidcaid wavers were also established, allowing 7

states to mandate managed care enrollment of certain groups to cover home and community based long-term care. In 1982, states allowed a Medicaid expansion to children who require institutional care but could be cared for at home.1 In 1983, Medicare introduced Diagnostic Related Groups, as a potential payment system for hospital payment. The Emergency Medical Treatment and Active Labor Act (EMTALA) was passed in 1986, requiring any hospital participating in Medicare to screen and stabilize all individuals presenting to emergency departments, regardless of their ability to pay. Also in 1986, the federal budget reconciliation gave the option for Medicaid to cover infants, young children, and pregnant women up to 100% of the poverty level regardless of receipt of public assistance. 1987: 31 million (13%) of the population are uninsured

1990-1999 The 1990s were a decade of change for health policy in the United States. In 1990, OBRA 90 required Medicaid coverage of children aged 6-18 who were living under the poverty level. President Bill Clinton, upon assuming office in 1993, convened a White House Task Force on Health Reform, appointing First Lady Hillary Clinton as the chair. The Health Security Act was introduced to both houses of Congress in November, but gained little support, and saw push back from the Health Insurance Association of America. Other national health reform proposals were introduced to the legislature (McDermott/Wellstone single payer, Cooper’s proposal for managed competition), The Administration began approving Medicaid waivers, allowing statewide expansion, and many states moved toward managed care for service delivery. They also used the cost savings to expand coverage for those previously uninsured. The Vaccines for Children Program was established to provide federally purchased vaccines to states, allowing those parents who were previously unable to afford vaccines due to financial constraints to obtain them for their children. The Health Insurance Portability and Accountability Act (HIPAA) was passed in 1996, restricting the use of pre-existing conditions in health insurance coverage determinations, setting standards for the privacy of medical records, and favorably taxed long-term care insurance.8 In that same year, the Personal Responsibility and Work Opportunity Act removed the link between Medicaid and cash assistance eligibility, and allowed states to cover parents and children at higher rates. It also banned Medicaid coverage of legal immigrants in their first five years of living in the country, with an exemption for emergency care. The Mental Health Parity Act of 1996 prohibited group health plans from having lower yearly or lifetime limits for mental health benefits than medical or surgical benefits.9 1997: Approximately 42.4 million (15.7%) are uninsured In 1997, the Balanced Budget Act was passed, and included • Changes in provider payments to slow Medicare spending and to establish the Medicare + Choice (renamed Medicare Advantage in 2003); 8 Delaware Journal of Public Health - December 2023

• The enactment of the State Children’s Health Insurance Program (S-CHIP) to provide block grants to states allowing for health insurance coverage of children who are low-income but whose household is not eligible for Medicaid; • Supplying health insurance for employed individuals with a disability and an income of up to 250% of poverty; • Permission for mandatory Medicaid enrollment in managed care. In 1999, the Ticket to Work Incentives Improvement Act extended states’ ability to cover working disabled to individuals with incomes above 25% of poverty and gave states the ability impose income-related premiums.

2000-2009 In 2000, the Breast and Cervical Cancer Treatment and Prevention Act allowed states to provide Medicaid coverage to uninsured women for treatment of breast or cervical cancer, provided they are diagnosed through a CDC screening program, regardless of income. In 2002, President Bush expanded the number of community health centers serving underserved populations with the Health Center Growth Initiative. The next year, the Medicare Drug, Improvement, and Modernization Act (MMA) was passed, and created a (voluntary) subsidized prescription drug benefit under Medicare. Medicare legislation also created Health Savings Accounts, allowing users to set aside pre-tax dollars to for current and future medical expenses. In 2005, the Deficit Reduction Act made changes to Medicaidrelated premiums, cost sharing, benefits, and asset transfers. Medicare Part D (drug benefits) went into effect in January of 2006, followed by the State of Massachusetts implementing legislation to provide health care coverage for nearly all state residents. One month later, Vermont also passed health care reform aiming for near-universal coverage. The City of San Francisco provided universal access to health services within the city for its residents in that same year. 2007: Approximately 45.6 million (15.3%) are uninsured10 In 2007, Senators Wyden and Bennet introduced the Healthy Americans Act, which would require individuals to obtain private health insurance through a state pool, thus eliminating employersponsored insurance programs. The legislation gained bipartisan support, but did not pass. President Bush announced a similar health reform plan replacing employer-sponsored insurance with a standard health care deduction. Congress would not upon it. Congress passed two versions of a bill to reauthorize S-CHIP with bipartisan support, but President Bush vetoes both bills, and Congress can not override the veto. A temporary extension of the program is passed in December. California fails to pass a health reform plan with an individual mandate and shared financing responsibility. In 2008, the Mental Health Parity Act was amended to include substance use disorders. Insurance companies must now treat SUD on an equal basis with physical conditions when health policies cover both.9 That same year, the presidential campaign began with a focus on national health reform. Later, this would

be overshadowed by a housing crisis and an economic downturn. Both major party candidates announced comprehensive health reform proposals. Senator Baucus (Chairman of the Senate Finance Committee) released a White Paper outlining a national plan based on the Massachusetts model. In 2009, President Obama established the Office of Health Reform to coordinate administrative efforts on a national health reform. The Children’s Health Insurance Program (CHIP) is reauthorized, and provides states with additional funding, tools, and fiscal incentives to heap reach an estimated 4.1 million children who would be otherwise uninsured by Medicaid and CHIP. President Obama’s fiscal year budget for 2010 includes out principles for health reform and proposes $634 billion to be placed in a health reform reserve fund.

2010-2019 On February 22, 2010, the White House released President Obama’s proposal for health care reform. This reform bill includes elements of House and Senate bills passed in the last months of 2009. On March 21, the House of Representatives passes the Patient Protection and Affordable Care Act, sending it to President Obama for his signature. The Health Care and Education Reconciliation Act of 2010 was also passed, reflecting amendments and including a reform of the national student loan system. On March 23, 2010, President Obama signed the Patient Protection and Affordable Care Act into law.11 This historic reform required that all individuals have health insurance by 2014. The poorest individuals will be covered under a Medicaid expansion, and people with incomes in the low to mid-range who do not have access to health insurance through their jobs will be able to purchase with the help of federal subsidies through insurance exchanges. Large businesses who do not provide their employees with health insurance or subsidies will face penalties, and no insurance plan will be allowed to deny coverage for any reason, nor will they be able to charge more due to health status or gender. Young adults will be able to stay on their parents’ health plans until age 26.

accelerate development, and mitigate vaccine manufacturing challenges like cost, manufacturing, and distribution.13,14 The Biden Administration took action to lower the cost of healthcare, and increase enrollment using the healthcare marketplace.15 August 2023: Approximately 7.7% of the US population is uninsured.16 In the most recent ACA Open Enrollment period, an estimated 16 million people enrolled in health insurance coverage through HealthCare.gov or state websites. Approximately 6.3 million people have gained coverage since 2020. The American Rescue Plan Act (ARPA) enhanced the Affordable Care Act subsidies, and the Inflation Reduction Act extended them, allowing for increased enrollment, a continuous enrollment condition in Medicaid, state Medicaid expansions, and increased outreach by the Biden-Harris administration. Uninsured rates have declined among adults 1864 (from 14.5% in late 2020 to 11.0% in early 2023) and children aged 0-17 (from 6.4% in 2020 to 4.2% in early 2023), but were largest for individuals with incomes below 100% of the Federal Poverty Level and between 200-400% of the FPL.

Uninsured

Despite these gains, millions of Americans remain uninsured (see figure 2). Some are eligible for subsidized coverage via Medicaid or the Marketplaces but have yet to enroll, or have lost coverage. The Marketplaces offer challenges (i.e. a perceived lack of affordable options).17 Despite subsidies, affordability remains a barrier for some, especially those at the higher end of income ranges eligible for subsidies. Others are not eligible for subsidies at all, due to having an affordable offer of employer insurance, or being part of the “family glitch:” if an employer-sponsored plan satisfied the affordability threshold for that year, the entire family becomes ineligible for subsidies, even if a family plan through the employer would cost more than the affordability threshold. Figure 2. The US Uninsured Population, by Subgroup, 201817

In 2016, President Trump eliminated the individual mandate section of the Affordable Care Act, removing monetary penalties for not having health insurance. During his presidency, President Trump added pooled health plans, short-term/limited-duration plans, and new Medicare Advantage plans to the marketplace; lowered Medicare Advantage premiums; and improved access to health savings accounts (HSAs).12 He also took action to end surprise medical billing and increase price transparency.

2020-NOW The COVID-19 pandemic required legislators and policy makers to take a hard look at health care access and utilization. Access to telemedicine and telehealth, which had significant effects on rural and underserved communities was expanded.12 In order to speed up development of COVID-19 vaccines, a partnership between the national Department of Health and Human Services and the Department of Defense was formed: Operation Warp Speed (OWS).13 OWS played a key part in selecting vaccine candidates for further study, studying the safety and efficacy of overlapping clinical trial phases to

High premiums and premium increases for those paying full price for Marketplace plans, plans exiting the Marketplace, and eligibility confusion.17 Mistrust in the system, navigator and assistance programs also help to lower enrollment rates. 9

Low enrollment and high dropout rates in Medicaid were present before the ACA, and state approaches to Medicaid (high cost sharing, HSAs, and work requirements) have all been linked to confusion and loss of coverage. Additionally, the “Medicaid Gap” affects people living in states that did not expand Medicaid and have incomes too low to qualify for Marketplace subsidies. They are stuck, with incomes above Medicaid eligibility thresholds, and (potentially) a high burden of chronic conditions. There are also uninsured immigrants, who are not eligible for any subsidized coverage due to their undocumented status.

Under Insured

7. National Archives. (2022). Medicare and Medicaid Act. https://www.archives.gov/milestone-documents/medicare-andmedicaid-act 8. US Department of Health and Human Services. (n.d.). Summary of the HIPAA privacy rule. https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/ index.html 9. Centers for Medicare & Medicaid Services. (n.d.). The mental health parity and addiction equity act. https://www.cms.gov/marketplace/private-health-insurance/mentalhealth-parity-addiction-equity

Even among those with insurance, barriers to care remain. High deductibles and cost sharing plans have lead patients to cut back on necessary and unnecessary care, especially among low-income adults with chronic conditions.18 Decreasing subsidies, changes in the executive oversight of the ACA, shorter enrollment periods, less advertising outreach, lower-cost and less comprehensive plans are likely to have had an effect on the number of uninsured.17

10. Garfield, R., Orgera, K., & Damico, A. (2019). The uninsured and the ACA: A primer – Key facts about health insurance and the uninsured admidst changes to the Affordable Care Act. KFF. https://www.kff.org/report-section/the-uninsured-and-the-aca-a-primerkey-facts-about-health-insurance-and-the-uninsured-amidst-changesto-the-affordable-care-act-how-many-people-are-uninsured/

CONCLUSION

11. US Department of Health and Human Services. (n.d.). About the affordable care act. https://www.hhs.gov/healthcare/about-the-aca/index.html

Whatever the reason, health policy reform has been rife with political and medical backing and arguments since the country started considering a national health insurance program, with no likely end in sight. Health policy is necessary, to codify, equalize, and ensure that everyone has an equal right to good health and wellbeing, regardless of their employment or health state, and each administration pursues their own view of how best to accomplish these efforts. Dr. Smith may be contacted at ksmith@delamed.org

REFERENCES 1. Kaiser Family Foundation. (2011). Timeline: History of health reform in the US. https://www.kff.org/wp-content/uploads/2011/03/5-02-13-history-ofhealth-reform.pdf 2. United States Government. (1921). H.R. 12634, A bill to encourage instruction in the hygiene of maternity and infancy, July 1, 1918. Visitthecapitol.gov. https://www.visitthecapitol.gov/artifact/hr-12634-bill-encourageinstruction-hygiene-maternity-and-infancy-july-1-1918 3. Ross, J. S. (2002). The committee on the costs of medical care and the history of health insurance in the United States. The Einstein Quarterly Journal of Biology and Medicine, 19, 129–134. Retrieved from: https://einsteinmed.edu/uploadedFiles/EJBM/19Ross129.pdf 4. Social Security Administration. (n.d.). Historical background and development of social security. https://www.ssa.gov/history/briefhistory3.html 5. Harvard University. (2020). Hill-Burton Act. https://perspectivesofchange.hms.harvard.edu/node/23 6. Medicaid and CHIP Payment and Access Commission. (n.d.). Putting the program in context. https://www.macpac.gov/putting-the-program-in-context/

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12. Trump Whitehouse Archives. (n.d.). Healthcare. https://trumpwhitehouse.archives.gov/issues/healthcare/ 13. US Government Accountability Office. (2021, Feb). Operation warp speed. https://www.gao.gov/products/gao-21-319 14. National Indian Health Board. (2020). Explaining operation warp speed. https://www.nihb.org/covid-19/wp-content/uploads/2020/08/Fact-sheetoperation-warp-speed.pdf 15. The White House. (2023). The Biden-Harris Record. https://www.whitehouse.gov/therecord/ 16. US Department of Health and Human Services. (2023, Aug 3). National uninsured rate reaches and all-time low in early 2023. Office of the Assistant Secretary for Planning and Evaluation. https://aspe.hhs.gov/reports/national-uninsured-rate-reaches-all-timelow-early-2023 17. Sommers, B. D. (2020, March). Health insurance coverage: What comes after the ACA? Health Affairs (Project Hope), 39(3), 502–508. https://doi.org/10.1377/hlthaff.2019.01416 18. Brot-Goldberg, Z. C., Chandra, A., Handel, B. R., & Kolstad, J. T. (2017). What does a deductible do? The impact of cost-sharing on health care prices, quantities, and spending dynamics. The Quarterly Journal of Economics, 132(3), 1261–1318. https://doi.org/10.1093/qje/qjx013

REQUESTING SUPPORT FOR DCPAP RESEARCH INTERVIEWS

The Delaware Child Psychiatry Access Program (DCPAP) is a statewide program that provides pediatric primary care professionals with free

DCPAP is embarking on an important initiative to better understand the

child psychiatry consultation and behavioral health training.

perspectives of Delaware providers who may be seeking support for their pediatric patients with

In partnership with Aloysius Butler & Clark (AB&C), DCPAP is hoping to conduct 30-minute phone interviews with Delaware pediatric providers to gain insight into your perceptions of DCPAP services. As a thank-you, participating providers will receive a $30 Amazon gift card after completing the interview. AB&C and DCPAP want to assure you that your feedback and personal information will remain confidential during this interview process.

behavioral health disorders.

If you are interested in participating, please email David Brond dbrond@abccreative.com Please note your availability to schedule the interview.

Additionally, if you have time to fill out a brief survey about the resources and services DCPAP provides primary care providers for the behavioral health needs of patients ages birth to 21, DCPAP would greatly appreciate your input.

Health Literacy as a Pathway to Wellbeing: A Celebration of Health Literacy Month Greg O’Neill, M.S.N., A.P.R.N., A.G.C.N.S.-B.C. Director, Patient & Family Health Education, ChristianaCare Peggy Geisler Owner and Senior Consultant, PMG Consulting LLC

In an age where health information is abundant, and misinformation is equally (if not more) prevalent, the importance of health literacy cannot be overstated. The Health Literacy Council of Delaware is bringing this concept to the attention of Delawareans, statewide. Health Literacy is the ability to obtain, understand, and apply health information to make informed decisions about one’s health and well-being. It serves as the foundation upon which individuals can build a healthier and more fulfilling life. It is multi-faceted, encompassing skills such as reading, listening, analytical thinking, decision-making, and in many cases, knowledge and understanding of digital platforms. Far too often, medical terminology and healthcare materials are difficult to understand, especially for those with limited education, or individuals unfamiliar with the English language. Patients and their loved ones are frequently inundated with information from medical professionals or from their own research, resulting in overload, confusion, and frustration. The National Assessment of Adult Literacy – a large, nationally representative sample of health literacy in the United States – suggests that 36% of U.S. adults have substantial limitations in their ability to understand and use health information necessary to prevent and manage disease and chronic conditions and effectively seek and obtain healthcare.1 Contrary to popular belief, health literacy is not exclusively the responsibility of the individual receiving healthcare. Medical providers, policymakers, and educators each play crucial roles in ensuring that health information is accessible and comprehensible to all communities. By ensuring all participants in a loved one’s healthcare have a solid foundation of health literacy, we as a state stand to gain: 1. Improved Health Outcomes: Individuals with higher health literacy are more likely to engage in preventive behaviors, manage chronic conditions effectively, and adhere to treatment plans. This leads to better health outcomes and reduced healthcare costs. 2. Enhanced Patient-Provider Communication: Effective communication between healthcare providers and patients is vital for accurate diagnosis and treatment. Health-literate patients can ask questions, understand instructions, and actively participate in their care. 12 Delaware Journal of Public Health - December 2023

3. Increased Health Equity: Research shows that a person’s level of health literacy is closely linked to socioeconomic status and education level. Improving health literacy can help reduce health disparities by giving everyone, regardless of their background, the tools to take control of their health. 4. Increased Autonomy: A health-literate individual not only possesses the knowledge needed to make informed decisions about their health, but they are confident in their choices, promoting a sense of autonomy and self-efficacy. The Health Literacy Council of Delaware was founded to initiate these gains for the First State. Under the auspices of the Delaware Literacy Alliance, the Council brings together key leaders and stakeholders from anchor healthcare, education, and state institutions to chart a path forward for health literacy integration across the age and culture spectrum. The Council has already made significant strides, such as standard development for the statewide Community Health Worker Apprenticeship program, which has successfully graduated 27 newly certified Community Health Workers. The fourth cohort is well underway. We are also in the early stages of integrating health literacy into high school and post-secondary curricula, as well as building a dedicated workforce pipeline from our state colleges into in-demand healthcare careers in Delaware. These and many other endeavors culminate into one dedicated visionachieving more equity through health literacy. Health literacy is an essential skill that inspires individuals to take control of their health. It is a key fixture in achieving positive health outcomes, reduced healthcare costs, and increased health equity. As we ramp up for the new year and what 2024 may bring, join the Health Literacy Council of Delaware as we highlight this imperative aspect of healthcare. Ultimately, health literacy is not just a concept; it is a path to empowerment, better health, and a brighter future for all. To learn more about the Delaware Health Literacy Council, or to join, please contact Greg O’Neill at GONeill@Christianacare.org, Megan McNamara Williams at megan@deha.org, or Adara Scholl at ascholl@pmgconsulting.net

REFERENCES 1. Kutner, M., Greenberg, E., Jin, Y., & Paulsen, C. (2006). The Health Literacy of America’s Adults: Results From the 2003 National Assessment of Adult Literacy (NCES 2006–483). U.S. Department of Education. Washington, DC: National Center for Education Statistics. Doi: 10.32481/djph.2023.12.004

Adverse Childhood Experiences (ACEs) webinar series JOIN US for a webinar series geared toward public health and clinical practitioners, community health center staff, and social services personnel.

February 8, 2024 ACEs: What Public Health Practitioners and Health Care Providers Should Know

February 15, 2024 Disrupting ACEs with Trauma-informed Health Care

February 22, 2024 Mending ACEs with Traumainformed Communication

Thursdays in February 2024 10–11 a.m. Eastern For more information and to register, visit: www.marphtc.pitt.edu 13

Unraveling Healthcare Shortages in Delaware and Charting a Course for Equity and Resilience Nicole Sabine, B.S. Research Associate, Delaware Academy of Medicine/Delaware Public Health Association Timothy E. Gibbs, M.P.H. Executive Director, Delaware Academy of Medicine/Delaware Public Health Association

INTRODUCTION A workforce shortage occurs when there is an insufficient number of individuals with the necessary skills in the appropriate locations and times to deliver required services to the intended recipients.1 The term “healthcare shortage” typically refers to a situation where the demand for healthcare services, including medical professionals, exceeds the available supply. This imbalance can manifest in various forms, such as a shortage of healthcare workers, medical facilities, or specific medical resources.2 Healthcare shortages can occur on both a global and local scale, affecting different components of the healthcare system. The consequences of these shortages include reduced access to care, longer wait times, and increased strain on healthcare professionals, potentially contributing to health disparities.2 It is important to note that, in Delaware, talking about shortages on a statewide basis can be misleading. In Delaware, until recently the population was substantially located in New Castle County, while Kent and Sussex Counties were less populated rural areas. Therefore, a significant percent of healthcare practitioners were located in New Castle County, which enjoyed numerical advantages over Kent and Sussex in gross numbers, and in provider to population ratios. These phenomena speaks to a “maldistribution” of providers.3 This phenomena is global and well as regional and local, as noted by the World Health Organization.4 In the United States, the COVID-19 pandemic has intensified stress within the healthcare workforce, leading to acute shortages and heightened burnout, exhaustion, and trauma among healthcare professionals.5 Importantly, these challenges unfold against a backdrop of persistent workforce shortages and maldistribution, amplifying pre-existing issues of burnout, stress, and mental health problems. In this context, our exploration shifts to the specific challenges faced by the State of Delaware. Examining Delaware’s healthcare system allows us to pinpoint where these challenges are particularly pronounced, offering opportunities for targeted interventions and strategies.

DEFINING SHORTAGE The U.S. Bureau of Labor Statistics projects a need for more than 275,000 additional nurses from 2020 to 2030, with nursing employment opportunities growing at nine percent, faster than all other occupations from 2016 through 2026.6 Health Workforce Shortage Areas data from the Health Resources & Services Administration (HRSA) indicates the need for more than 17,600 additional primary care practitioners, 13,000 dental health practitioners, and 8,400 mental health practitioners in the United States.7 14 Delaware Journal of Public Health - December 2023

In Delaware, HRSA recognizes 37 Health Professional Shortage Areas (HPSA) among the primary care, dental and mental health disciplines. Of these areas, 22 are facilities and 15 are population groups (i.e., low-income, homeless, migrant farmworker, and Medicaid eligible). Each designation is given a score between 0-26, the higher the number the greater the need.7 New Castle County has 15 facilities and six population groups recognized by HPSA. The highest scoring, and therefore those with the greatest need, are the facilities of Southbridge Medical and Westside Family Healthcare, across all disciplines. Primary care is needed especially in the low-income population groups of Southwest Wilmington (score of 14) and Newark/Wilmington (18). Dental health is needed in Wilmington/New Castle (16) and Newark/ Wilmington (17). Mental health is needed in Newark/Stanton (16) and the City of Wilmington (18). In Kent County, there is one HPSA facility and four population groups, all with relatively high scores. Delaware Guidance Services in Dover is the one facility with a score of 17, however it is proposed for withdrawal from HPSA status. The four population groups are all low income and span across all disciplines, with scores ranging from 15-17. Sussex County has six facilities and five population groups. Across all disciplines, La Red Health Center shows the greatest need, with scores ranging from 21-25. Of the five population groups, two are low income under dental and mental health (16 and 17) and three are Medicaid eligible (14-16) one in each discipline. The American Association of Colleges of Nursing (AACN) projects a need for more than 200,000 new nurses annually until 2026 to fill new positions or replace retiring nurses.8 The American Association of Medical Colleges (AAMC) predicts a shortage of 37,800 to 124,000 physicians by 2034, driven primarily by demographics, including population growth and aging.9 During this time, the U.S. population is projected to grow by 10.6%, from about 328 million to 363 million, with a projected 42.4% increase in those aged 65 and above. Therefore, demand for physician specialties that predominantly care for older Americans will continue to increase. More than two of every five active physicians in the U.S. will be 65 or older within the next decade.9 Their retirement decisions will dramatically affect the magnitude of national workforce shortages. Additionally, according to the AAMC’s 2019 National Sample Survey of Physicians, 40% of the country’s practicing physicians felt burned out at least once a week before the COVID-19 crisis began—and the issue of increased clinician burnout could cause doctors and other health professionals to reduce their hours or retire sooner.10 If individuals from marginalized minority populations, residents in rural communities, and those without health insurance were to access healthcare at rates comparable to populations facing fewer barriers, the demand for physicians would require an Doi: 10.32481/djph.2023.12.005

additional 180,400 practitioners.9 The COVID-19 pandemic has brought attention to the existing disparities in health and access to care among underserved populations. This analysis emphasizes the systematic variations in healthcare services experienced by insured and uninsured individuals, those residing in urban and rural areas, and individuals of diverse races and ethnicities. Separate from the projections for shortages, these estimates serve to highlight the significant barriers to care, offering an additional reference point for evaluating the adequacy of the physician workforce supply.

PERCEPTIONS OF SHORTAGES By the end of 2022, a staggering 145,213 healthcare providers exited the profession, with nurse practitioners witnessing a departure of 34,834 practitioners nationwide. Notably, fields such as internal medicine, family practice, and clinical psychology bore the brunt of staffing shortages from 2021 through 2022.11 Professionals in these specialties, often at the frontline during the pandemic, faced elevated risks of coronavirus exposure and the heightened pressures and stressors outlined earlier. This is supported by data from HHS and Becker’s Hospital Review, reported in July and September 2023, pinpointed the top states grappling with critical staffing shortages in hospitals and primary care—one of which was Delaware.12,13 A survey conducted by the Medical Protection Society (MPS), encompassing 5495 doctors with an 861-response rate (15%), revealed profound concerns within the medical community. A staggering 95% (818) of responding doctors identified staff shortages as a major threat to patient safety, with nearly half (49%, 422) contemplating their career trajectory due to this concern. Over half (54%) expressed that the impact of staff shortages on patient safety was affecting their mental wellbeing, with 79% indicating a moderate to significant effect.14 Notably, 38% of doctors acknowledged that the fear of medicolegal issues stemming from staff shortages was detrimental to their current mental wellbeing. Anonymous comments from survey participants vividly portrayed the challenges, with one doctor expressing, “It is demoralizing to be continuously unable to provide the standard of care you know patients deserve due to inadequate staffing.” Another noted, “Watching patients get suboptimal care is exhausting, and watching colleagues stretched beyond belief is upsetting. People get sick waiting for care as an inpatient and outpatient.”14 Even before the COVID-19 pandemic, physician shortages were acutely felt across the nation. In 2019, the U.S. Health Resources & Services Administration estimated an additional need for 13,758 primary care physicians and 6,100 psychiatrists to address HPSA designations for areas facing shortages in primary care and mental health.15 Findings from the 2019 AAMC Public Opinion Research revealed a consistent belief among registered voters, with 65% feeling that the United States lacked sufficient doctors to meet healthcare needs. Notably, 75% of rural area residents shared this sentiment. The survey also highlighted a concerning trend—25% in 2015 to 35% in 2019—indicating an increasing number of people struggling to find a doctor in the past two or three years.16 Additionally, a majority of voters perceived shortages in both primary care doctors (61%) and specialty physicians (53%)—the highest numbers since the question’s inception in 2006. Despite a lack of understanding of

the term “social determinants of health” by 51% of the public, majorities believed that factors like homelessness, insufficient food, residing in an unsafe neighborhood, or experiencing poverty could adversely impact a person’s health. Impressively, 93% of respondents agreed with the overarching goal of health equity, with seven in ten considering it a top priority for the United States, and 44% attributing the responsibility for achieving health equity to the federal government.16 Patient perception of missed care is also a significant driver of a continuing dialog between policy makers and resource distributors and there is always the factor of healthcare quality to consider.17 It is not enough to simply have all slots occupied by staff, those staff should also have good health outcomes for their patients.1

IMPACT ON HEALTH EQUITY Healthy People 2030 defines health equity as “the attainment of the highest level of health for all people” and notes that “it requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and health and health care disparities.”18 Beyond mere access to healthcare, health equity extends to the broader social determinants of health, aiming to ensure a just opportunity for everyone to lead a healthy life. In essence, health equity seeks to eliminate systematic disparities in health and healthcare driven by social, economic, and environmental factors. Pertinently, within the context of shortages, health equity emphasizes the equitable distribution of healthcare resources and services to mitigate disparities among diverse populations. Shortages, be they in workforce, facilities, or resources, have the potential to worsen existing inequalities, impeding the realization of health equity. In 2022, researchers at ECRI, the nation’s largest nonprofit patient safety organization, highlighted that “inadequate staffing is actively jeopardizing patient safety. Due to staffing shortages, many patients are waiting longer for care, even in life-threatening emergencies, or simply being turned away.”19 The COVID-19 pandemic underscored the inequities experienced by health workers and those at high risk and in need of care. Challenges with limited personal protective equipment (PPE) disproportionately affected certain workers, such as home health care workers, often earning at or below minimum wage.20,21 For low-wage health care workers, predominantly women and people of color, challenges extend beyond the workplace to housing instability, food insecurity, childcare issues, lack of health and dental insurance, and, in some cases, racism. Evidence also suggests that Black and other minority health workers faced higher risks of COVID-19 infection.22

IMPACT ON VULNERABLE POPULATIONS Health equity is intricately tied to the distribution of healthcare resources, and maldistribution plays a pivotal role in shaping disparities across diverse communities. Maldistribution refers to the uneven allocation of healthcare resources—professionals, facilities, and services—across geographic areas or population groups. In the context of shortages, healthcare maldistribution can exacerbate challenges associated with achieving health equity. Uneven distribution of healthcare professionals can lead to greater shortages in certain regions or populations, resulting in disparities in access and quality of care. Maldistribution compounds the impact of shortages, particularly affecting vulnerable or underserved communities. 15

Maldistribution also poses challenges for rural communities. When certain providers, especially specialists, are lacking in rural areas, patients may have to travel longer distances or forego care if telehealth services are not available. Understaffing contributes to increased workloads, longer shifts, and less flexibility in scheduling, leading to healthcare provider burnout and difficulties in recruitment and retention. Nationally, health professionals per 10,000 population are significantly lower in rural areas than in urban areas, with the most pronounced differences observed in registered nurses (63.9 vs. 95.3) and MD physicians (10.9 vs. 31.7).23 At the end of September 2023, over 65% of HPSA medical designations were rural across the US, serving over 13.5 million people, and over 5,200 practitioners were needed to address the shortages in these areas. In Delaware, to serve the over 250,000 individuals (approximately 25% of the population) with unmet needs, 75 practitioners are needed to move into these areas.24 According to HPSA, all rural facilities in Delaware are in Sussex County (i.e., La Red Health Center and Sussex Correctional Institution). All population groups in both Kent and Sussex County are considered partially rural. There are no rural designations in New Castle County.7 Nationwide, some racial and ethnic minority groups experience higher rates of various health conditions compared to their White counterparts.25 In the US, the Black community constitutes 13% of the population, yet only 5.7% of physicians are Black.26 In 2018, a comprehensive study assessed the economic impact of health inequities among racial and ethnic minority populations, including American Indian and Alaska Native, Asian, Black, Latino, and Native Hawaiian and Other Pacific Islander communities. The findings revealed an economic burden ranging between $421 billion and $451 billion. Notably, the economic impact of health inequities for individuals without a 4-year college degree was even more pronounced, totaling between $940 billion and $978 billion.27 The study underscored that the majority of this economic burden stemmed from the poor health outcomes experienced by the Black population. However, it brought to light a concerning pattern where the burden disproportionately affected American Indian or Alaska Native and Native Hawaiian or Other Pacific Islander populations, surpassing their share of the overall population. Despite constituting only 9% of the population, these groups bore a disproportionate 26% of the economic costs.27 The State of Delaware faces a notable deficiency in the representation of minority physicians, a challenge shared with many other states across the nation. To illustrate, while non-Hispanic Black individuals constitute 23% of Delaware’s population, they are significantly underrepresented among primary care physicians, comprising only 6.6% of this professional group. This disparity highlights a pronounced maldistribution of healthcare professionals within the State.28 Further accentuating the issue, Delaware witnesses a similar pattern among its Asian population, constituting less than 6% of the total population but making up more than 22% of primary care physicians. This disparity underscores the need for targeted initiatives to address the uneven distribution of healthcare professionals across diverse demographic groups. In addition to Health Professional Shortage Area (HPSA) designations, the Health Resources & Services Administration (HRSA) acknowledges Medically Underserved Areas and Medically Underserved Populations (MUA/P). Within 16 Delaware Journal of Public Health - December 2023

Delaware, there are eight MUA/P designations, with both Kent and Sussex County being recognized as medically underserved areas in their entirety. In New Castle County, the distribution is more clustered, with areas such as Claymont/Edgemoor, Middletown/Odessa, and New Castle identified as either Medically Underserved Population (MUP) low income or MUA.

STRATEGIES AND INTERVENTIONS Mitigating shortages in Delaware’s healthcare system requires a comprehensive approach, blending workforce development initiatives and policy recommendations to create a resilient and equitable environment. On the workforce development front, a key focus should be on enhancing training opportunities for aspiring healthcare professionals within the state. Collaborative efforts between educational institutions and healthcare facilities can ensure a steady influx of skilled professionals, while retention programs must address burnout and foster supportive work environments. Drawing inspiration from successful programs in other regions is crucial. Examining initiatives that have effectively increased the number of healthcare professionals, improved skillsets, and enhanced job satisfaction can provide valuable insights. Examples such as mentorship programs, tuition reimbursement, and innovative training modalities should be explored for adaptation to Delaware’s context. In terms of policy recommendations, addressing regulatory barriers is paramount. Proposals should streamline licensing and accreditation processes, making it easier for qualified healthcare professionals to practice in Delaware. Additionally, financial incentives, such as student loan forgiveness programs or tax incentives for those committing to working in underserved areas, can be introduced. Learning from successful models in other states, these financial incentives have proven effective in attracting and retaining healthcare talent. Expanding telehealth services is another critical policy consideration. Advocating for policy changes that support telehealth expansion can increase access to healthcare in remote or underserved areas. Referencing successful telehealth policies implemented in similar contexts can inform Delaware’s approach. Encouraging collaboration between government bodies, healthcare institutions, and educational entities is essential for comprehensive policy initiatives. Policies that incentivize partnerships between urban and rural healthcare facilities can efficiently distribute resources. By strategically combining these workforce development initiatives and policy recommendations, Delaware can pave the way for a more resilient and equitable healthcare system, ultimately mitigating shortages and fostering a thriving healthcare environment for both professionals and patients.

CONCLUSION Delaware faces multifaceted challenges in its healthcare system, with shortages posing significant threats to the well-being of both healthcare professionals and the communities they serve. The definition of a workforce shortage extends beyond numerical inadequacies, encompassing issues of skill distribution, geographic disparities, and systemic barriers that hinder the delivery of quality healthcare. The adverse impacts of shortages are exacerbated by the pre-existing conditions of burnout, stress, and mental health challenges, a scenario intensified by the COVID-19 pandemic.

The examination of Delaware’s healthcare landscape reveals distinct shortages in primary care, dental, and mental health disciplines, with Health Professional Shortage Areas (HPSA) designations highlighting areas of critical need. The shortage of healthcare professionals, compounded by maldistribution, poses a significant hurdle in achieving health equity. Vulnerable populations, including minorities and those residing in rural areas, bear a disproportionate burden of these shortages, further widening existing health disparities. Perceptions of shortages, evidenced by workforce departures and critical staffing gaps, underscore the urgent need for intervention. The strain on healthcare professionals’ mental well-being and the potential threat to patient safety necessitate a reevaluation of strategies to address shortages comprehensively. Public opinion reflects a growing awareness of healthcare inadequacies, emphasizing the need for innovative solutions to bridge the widening gap between supply and demand. Delaware’s path forward involves exploring potential strategies and interventions to mitigate shortages. Workforce development initiatives, including training programs and retention strategies, can fortify the healthcare workforce. Drawing inspiration from successful programs elsewhere provides a roadmap for adaptation, ensuring these initiatives align with Delaware’s unique context. Policy recommendations emerge as a pivotal aspect of the mitigation efforts. Addressing regulatory barriers, introducing financial incentives, expanding telehealth services, and fostering collaborative policy initiatives are essential steps. Learning from successful policies implemented in analogous contexts equips Delaware with valuable insights to tailor interventions effectively. In navigating these challenges, the overarching goal is to achieve health equity — the highest level of health for all. The maldistribution of healthcare resources, exacerbated by shortages, underscores the imperative to create a fair and just healthcare system. Delaware’s journey towards mitigating shortages involves a strategic blend of workforce development and targeted policy changes, aiming not only to alleviate immediate pressures but also to lay the foundation for a resilient and equitable healthcare future. As the state charts its course, the experiences and lessons shared by others provide guidance, offering hope for a healthcare landscape characterized by accessibility, quality, and equity. Ms. Sabine may be contacted at nsabine@delamed.org

REFERENCES

4. Crisp, N., & Chen, L. (2014, March 6). Global supply of health professionals. The New England Journal of Medicine, 370(10), 950–957. https://doi.org/10.1056/NEJMra1111610 5. Turrini, G. (2023, May 3). Impact of the COVID-19 pandemic on the hospital and outpatient clinician workforce: Challenges and policy responses. Office of The Assistant Secretary for Planning and Evaluation (ASPE). https://aspe.hhs.gov/reports/covid-19-health-care-workforce 6. U.S. Department of Labor. (2022, Oct 3). US Department of Labor announces $80M funding opportunity to help train, expand, diversify nursing workforce; address shortage of nurses. U.S. Department of Labor. https://www.dol.gov/newsroom/releases/eta/eta20221003 7. Health Resources & Services Administration. (2023, Nov 30). Health Workforce Shortage Areas. https://data.hrsa.gov/topics/health-workforce/shortageareas?hmpgdshbrd=1 8. Rosseter, R. (2022, Oct). Nursing shortage fact sheet. American Association of Colleges of Nursing. https://www.aacnnursing.org/news-data/fact-sheets/nursing-shortage 9. Association of American Medical Colleges. (2019, Apr 23). New findings confirm predictions on physician shortage. https://www.aamc.org/news/press-releases/new-findings-confirmpredictions-physician-shortage 10. Association of American Medical Colleges. (2020). AAMC National Sample Survey of Physicians. https://www.aamc.org/about-us/mission-areas/health-care/workforcestudies/datasets 11. Popowitz, E. (2023, Sep). Addressing the healthcare staffing shortage. Definitive Healthcare. https://www.definitivehc.com/resources/research/healthcare-staffingshortage 12. Talaga, R. (2023, Jul 25). 10 states struggling most with primary care provider shortage. Becker’s ASC Review. https://www.beckersasc.com/news-and-analysis/10-states-strugglingmost-with-primary-care-provider-shortage-2.html 13. Becker’s Healthcare Staff. (2023, Aug 22). September 2023 issue of Becker’s Hospital Review. Becker’s Hospital Review. https://www.beckershospitalreview.com/uncategorized/september2023-issue-of-beckers-hospital-review.html

1. Džakula, A., Relić, D., & Michelutti, P. (2022, April 30). Health workforce shortage - doing the right things or doing things right? Croatian Medical Journal, 63(2), 107–109. https://doi.org/10.3325/cmj.2022.63.107

14. Rimmer, A. (2023, May 17). Staff shortages are affecting doctors’ mental health, survey finds. BMJ (Clinical Research Ed.), 381, 1121. https://doi.org/10.1136/bmj.p1121

2. Tamata, A. T., & Mohammadnezhad, M. (2023, March). A systematic review study on the factors affecting shortage of nursing workforce in the hospitals. Nursing Open, 10(3), 1247–1257. https://doi.org/10.1002/nop2.1434

15. Association of American Medical Colleges. (2021, Jun 11). AAMC report reinforces mounting physician shortage. https://www.aamc.org/news/press-releases/aamc-report-reinforcesmounting-physician-shortage

3. Rosenblatt, R. A., & Hart, L. G. (2000, November). Physicians and rural America. The Western Journal of Medicine, 173(5), 348–351. https://doi.org/10.1136/ewjm.173.5.348

16. Redford, G. (Ed.). (2020, Apr 27). What makes a good doctor - and other findings from the 2019 AAMC Public Opinion Research. Association of American Medical Colleges. https://www.aamc.org/news/what-makes-good-doctor-and-otherfindings-2019-aamc-public-opinion-research 17

17. Gustafsson, N., Leino-Kilpi, H., Prga, I., Suhonen, R., & Stolt, M., & the RANCARE consortium COST Action – CA15208. (2020, February 25). Missed care from the patient’s perspective – A scoping review. Patient Preference and Adherence, 14, 383–400. https://doi.org/10.2147/PPA.S238024 18. Office of Disease Prevention and Health Promotion, & U.S. Department of Health and Human Services. (n.d.). Health equity in healthy people 2030. Health Equity in Healthy People 2030 - Healthy People 2030. https://health.gov/healthypeople/priority-areas/health-equity-healthypeople-2030 19. Menyo, L. (2022, Mar 14). ECRI reports staffing shortages and clinician mental health are top threats to patient safety. ECRI. https://www.ecri.org/press/ecri-reports-staffing-shortages-and-clinicianmental-health-are-top-threats 20. Sterling, M. R., Tseng, E., Poon, A., Cho, J., Avgar, A. C., Kern, L. M., . . . Dell, N. (2020, November 1). Experiences of home health care workers in New York City during the coronavirus disease 2019 pandemic. JAMA Internal Medicine, 180(11), 1453–1459. https://doi.org/10.1001/jamainternmed.2020.3930 21. U.S. Bureau of Labor Statistics. (2023, Apr 25). Home health and personal care aides. https://www.bls.gov/oes/current/oes311120.htm 22. Nguyen, L. H., Drew, D. A., Graham, M. S., Joshi, A. D., Guo, C.-G., Ma, W., . . . Chan, A. T., & the Coronavirus Pandemic Epidemiology Consortium. (2020, September). Risk of COVID-19 among front-line health-care workers and the general community: A prospective cohort study. The Lancet. Public Health, 5(9), e475–e483. https://doi.org/10.1016/S2468-2667(20)30164-X

18 Delaware Journal of Public Health - December 2023

23. Rural Health Information Hub. (2023, Feb 24). Rural Healthcare Workforce Overview - Rural Health Information Hub. https://www.ruralhealthinfo.org/topics/health-care-workforce 24. Bureau of Health Workforce. (2023, Sep 30). Designated health professional shortage areas statistics. Health Resources and Services Administration (HRSA). https://data.hrsa.gov/Default/GenerateHPSAQuarterlyReport 25. Office of Health Equity. (2022, Jul 1). What is health equity? Centers for Disease Control and Prevention. https://www.cdc.gov/healthequity/whatis/index.html 26. Boyle, P. (2023, Jan 12). What’s your specialty? New data show the choices of America’s doctors by gender, race, and age. Association of American Medical Colleges. https://www.aamc.org/news/what-s-your-specialty-new-data-showchoices-america-s-doctors-gender-race-and-age 27. LaVeist, T. A., Pérez-Stable, E. J., Richard, P., Anderson, A., Isaac, L. A., Santiago, R., . . . Gaskin, D. J. (2023, May 16). The economic burden of racial, ethnic, and educational health inequities in the US. JAMA, 329(19), 1682–1692. https://doi.org/10.1001/jama.2023.5965 28. Mitchell, K., Iheanacho, F., Washington, J., & Lee, M. (2022, December 31). Addressing health disparities in Delaware by diversifying the next generation of Delaware’s physicians. Delaware Journal of Public Health, 8(5), 168–171. https://doi.org/10.32481/djph.2022.12.039

Family Medicine Training in the US and Delaware: Opportunities and Growth in Primary Care Workforce Omar A. Khan, M.D., M.H.S., F.A.A.F.P. President & CEO, Delaware Health Sciences Alliance Erin M. Kavanaugh, M.D., F.A.A.F.P. Chair, Department of Family & Community Medicine & Physician Executive, Complex and Community Care, ChristianaCare Robert A. Monteleone, M.D. Program Director, Family Medicine Residency, Saint Francis Hospital Brintha Vasagar, M.D., M.P.H., F.A.A.F.P. Program Director, Family Medicine Residency, Bayhealth Joyce F. Robert, M.D., F.A.A.F.P. Founding Program Director, Family Medicine Residency, Beebe Healthcare

INTRODUCTION

DELAWARE DEMOGRAPHICS

In 2023, 5288 Post-Graduate Year 1 (PGY-1) slots in Family Medicine were offered in the US, including the District of Columbia (DC) & Puerto Rico. With a fill rate of around 90%, the demand for family medicine training remains high, commensurate with the primary care needs of the United States.

Delaware’s approximately 1 million population is mostly in the northernmost county (New Castle). The state capital of Dover is located in the middle county, Kent; while the southernmost county (Sussex) is both the largest by area and has shown the most influx of late. Between 2010 and 2020, Sussex County had a growth of 20.4% compared to New Castle County (6%) and Kent County (12%). More recent data shows a population percent change of 7.8% from April 1, 2020 to July 1, 2022 in Sussex County compared to the state as a whole at 2.9%, Kent at 2.8% and New Castle at 0.8%.6

For the purposes of this commentary, a primary care field is defined the way most Americans seeking care and the National Academy of Medicine define it: “From this perspective, it seems clear that those trained in family medicine, general internal medicine, general pediatrics, many nurse practitioners, and physician assistants are trained in and are generally most likely to practice primary care.”1 The field of family medicine continues to supply the most primary care physicians per resident in the United States. Other specialties offering primary care as an option (internal medicine and pediatrics) are seeing increasing numbers of their residents choosing to specialize via a fellowship pathway or to choose a non-primary care career such as hospital medicine.2 Similar to most of the United States, physician shortages in Delaware are both present and anticipated. The presence of a well-trained primary care workforce is thus essential. This pipeline is established through robust pre-medical education, medical school (undergraduate medical education, or UME), and residency training (graduate medical education, or GME). A more complete analysis of Delaware’s healthcare workforce is beyond the scope of this paper but is available online.3 While Delaware is ostensibly among four states in the country without an in-state medical school, it enjoys a robust partnership with two Philadelphia medical schools through the Delaware Institute for Medical Education and Research (DIMER) program. DIMER is described more fully elsewhere, providing medical school slots to qualified Delawareans.4 The two medical schools have also established branch campuses in Delaware, in partnership with the state’s hospital systems, to train third- and fourth-year medical students entirely within the state of Delaware.4,5 20 Delaware Journal of Public Health - December 2023

The statewide census also shows a growth of 40% in between the 2010 and 2020 census in the number of Delawareans who identified as Hispanic or Latino. That population growth was very evident in Sussex County which saw a 58% increase of Delawareans identifying as Hispanic or Latino. Thus, an increasing number of entering FM residents are bilingual; 50% of this year’s entering classes at Beebe (Sussex County) and 33% of current residents at Saint Francis (New Castle County) are bilingual in English and Spanish. The ’silver tsunami’ (i.e., growth in the geriatric population in the state) continues to rise as well, reflecting a nationwide trend. As of July 1, 2022, nearly a third (29.8%) of Sussex County residents were over 65 years of age, compared with Kent County at 17.9% and New Castle at 6.6%.

FAMILY MEDICINE TRAINING IN DELAWARE For the first time in several decades, the last three years have seen growth in PGY-1 Family Medicine training slots in Delaware. The first family medicine residency program in Delaware was established in 1971 at The Medical Center of Delaware which became Christiana Care in 1985. The program has a current complement of nine categorical FM residents and three emergency medicine/family medicine (EM/FM) residents in each PGY year, making their way to a complement of 42 residents. Saint Francis Hospital started training family medicine residents in 1979 and has 18 residents (six in each post-graduate year). Bayhealth started FM training in 2021 with 8 PGY-1 slots, and Beebe Healthcare initiated its first class of PGY-1 FM residents in 2023 with 4 residency slots. Doi: 10.32481/djph.2023.12.006

It is noteworthy that Delaware now has Family Medicine residency programs in each of its three counties. Nearly every other program is in the singular (e.g. one Pediatrics program, one Ob/Gyn program, with Internal Medicine being offered at two sites). Family Medicine is currently the highest represented training program with four available institutions, and the only specialty with a residency site in each of Delaware’s three counties. This is appropriate given that the broadest base and diversity of the population pyramid is generally served by this specialty.

THE FOUR GME SITES FOR FAMILY MEDICINE IN DELAWARE ChristianaCare's Family Medicine Residency Program, located in New Castle County, was the first in Delaware, and has a particular focus on ambulatory training and community medicine. Meeting the needs of the community is a key goal and long-term aspiration. Recently enhanced areas of curriculum include substance use disorder and Hepatitis C in primary care, comprehensive contraception access, including medication abortions, and gender wellness. Existing areas of focus include training for academic and community roles, global health, and quality improvement training. The program has retained close to 50% of their graduating classes in the community and health system, many of whom are DIMER grads. This year, four of the seven of the graduating class of 2023 are staying within the state, and six of seven are staying within the community. One of the two combined Emergency Medicine-Family Medicine (EM-FM) graduates are staying in the state/system/community as well. The ChristianaCare program matched three DIMER students to be members of the Family Medicine residency class of 2026, indicating a commitment to the Delaware community and longitudinal pipeline of physicians. The Saint Francis Family Medicine Residency Program was established in 1979 in Wilmington, Delaware (New Castle County) with the objective to train outstanding physicians to care for patients in this community. Saint Francis Hospital, founded by the Sisters of Saint Francis of Philadelphia in 1924, heeds a particular call to serve those in need. Over 100 of the approximately 250 past graduates still practice in the Delaware region. Two of six graduates from the 2023 class will be practicing outpatient family medicine with Trinity Health Mid-Atlantic here in Delaware and five of six will be practicing in the region. The training at Saint Francis has historically been strong in preparing residents for full spectrum family medicine, including obstetrics and newborn care. Many current residents are bilingual, with a third being fluent in Spanish. The residency prides itself on attracting residents to best serve the diverse patient population of Delaware. The Bayhealth Family Medicine Residency Program was the first residency program in Kent and Sussex counties. Given that both counties are health professional shortage areas, defined as less that one physician for every 2,000 people, the residency program was an intentional strategy by the health system to create a pipeline for bringing new physicians to Delaware. The program focuses on physician leadership and advocacy, with a particular interest in health equity and service to the underserved. Residents spend three years building social capital by partnering with groups already working to improve the health

of the community. Improving access to care, the new ambulatory practice adds over 30,000 visits to the community each year. Here, residents work in interdisciplinary teams to improve the biggest healthcare needs in the state of Delaware: mental health. addiction, and obesity.7 Beebe Healthcare’s Family Medicine Residency program recently joined the ranks of the three established FM programs in the state of Delaware. It holds the distinction of being the first program in the first town (Lewes) of the first state. The program received initial accreditation from the ACGME in November 2022, subsequently matching four inaugural Family Medicine interns. The program’s focus is a strong the strong commitment to the Sussex county community (the quickest growing county in the state); collaboration with Beebe’s population health department including a new mobile unit for outreach; and an innovative leadership curriculum. Beebe is also a Core Clinical Campus with the Philadelphia College of Osteopathic Medicine (PCOM) since July 2022 with 50% of the inaugural residency class from that school. One of those PCOM students is also a DIMER student from Delaware.

RESULTS FROM FAMILY MEDICINE RESIDENCY WORKFORCE Several factors make it essential to grow and sustain effective primary care in the United States, and those factors are mirrored in Delaware. Each of the three counties has its distinct character and needs. They share in common a need for well-trained family physicians to treat, diagnose, refer; and also take an increasing role in population health, prevention, and health care reform. This need is most acute in areas already underserved, which makes it more challenging to recruit and retain physicians.8 We analyzed data for all PGY-1 Family Medicine slots offered across the United States, and compared it with the population of each state (Table 1). The median statistic of population served was 63,301 people per Family Medicine PGY-1 resident (lower numbers indicate improved access). The recent (last 3 years) expansion in family medicine GME slots in Delaware has effectively doubled the number of FM residencies in the state. Thus, Delaware’s statistic is now 36,664 people per FM resident, which means it ranks third from the top in the United States for lowest population per FM PGY-1 resident. This indicates a likely improvement in patient access to family medicine in the coming years. This measure, along with county-wide representation of Family Medicine residencies, indicates that Delaware’s GME program in primary care is robust and is poised to lead in providing access to trained family physicians for the state (table 2). In the next two years, all four FM programs in the state will have graduated a full class of FM residents into attending physicians. The retention of several of these physicians in Delaware will be an important factor in alleviating workforce shortages and access shortfalls in the state. Programs like the federal Student Loan Repayment Program (SLRP) have recently been supplemented by the DIMER group’s efforts to create a Delaware-specific Health Care Professional Loan Repayment Program (HCPLRP).12,13 This program aims to attract DIMER graduates and even nonDelawareans back to the state to serve for a number of years, while repaying their medical student loans essentially in full. 21

Table 2. Delaware Residency Programs

Table 1. Family Medicine Residencies in the United States9–11 PGY-1 FM Residents

State Population

Population per resident

Pennsylvania

543

13,002,700

23946.04052

North Dakota

779,094

27824.78571

Delaware

989,948

32998.26667

Arkansas

3,011,524

33093.67033

South Carolina

136

5,118,425

37635.47794

Wyoming

576,851

38456.73333

Idaho

1,839,106

39129.91489

Michigan

252

10,077,331

39989.40873

Maine

1,362,359

40069.38235

State

West Virginia

1,793,716

43749.17073

Washington

170

7,705,281

45325.18235

Oklahoma

3,959,353

45509.8046

Alabama

107

5,024,279

46955.8785

Wisconsin

119

5,893,718

49527.04202

South Dakota

886,667

52156.88235

Nebraska

1,961,504

53013.62162

Ohio

222

11,799,448

53150.66667

Illinois

237

12,812,508

54061.21519

Montana

1,084,225

54211.25

Iowa

3,190,369

55006.36207

Mississippi

2,961,279

56947.67308

Indiana

116

6,785,528

58495.93103

712,816

59401.33333

New Mexico

2,117,522

60500.62857

Alaska

733,391

61115.91667

All US

2518

106,178,942

42167.96743

Kansas

2,937,880

66770

New Jersey

133

9,288,994

69842.06015

Colorado

5,773,714

70411.14634

Louisiana

4,657,757

70572.07576

California

560

39,538,223

70603.96964

Minnesota

5,706,494

71331.175

Missouri

6,154,913

71568.75581

Oregon

4,237,256

73056.13793

Virginia

118

8,631,393

73147.39831

Rhode Island

1,097,379

73158.6

New York

274

20,201,249

73727.18613

North Carolina

136

10,439,388

76760.20588

Nevada

3,104,614

81700.36842

Arizona

7,151,502

82201.17241

Tennessee

6,910,840

83263.13253

Kentucky

4,505,836

83441.40741

Texas

341

29,145,505

85470.68915

New Hampshire

1,377,529

86095.5625

Georgia

116

10,711,908

92344.03448

Florida

221

21,538,187

97457.85973

Vermont

643,077

107179.5

Hawaii

1,455,271

111943.9231

Utah

3,271,616

112814.3448

Massachusetts

7,029,917

132639.9434

Connecticut

3,605,944

144237.76

Maryland

6,177,224

199265.2903

Puerto Rico

3,264,000

408000

22 Delaware Journal of Public Health - December 2023

Residency Program

Number of PGY-1 (1st year) Slots

Health System Characteristics

Geographic Location

Bayhealth

8 Categorical PGY1

2 Community Hospitals with ambulatory sites

Kent and Sussex County

Beebe

4 Categorical PGY1

1 Community Hospital with ambulatory sites

Sussex County

2 hospitals in DE, 1 community hospital in MD, ambulatory sites statewide in DE, and in PA, NJ, MD.

New Castle County

1 Community Hospital with ambulatory sites

New Castle County

ChristianaCare

Saint Francis

9 Categorical PGY-1 3 EM-FM PGY-1

6 Categorical PGY1

CONCLUSION Challenges for the future include the long-term retention of these trained residents as practicing physicians within the state. There are also increasing areas of need within certain populations in Delaware, such as geriatrics, gynecological care, and pediatric care. These areas are part of the scope of general family medicine and can also represent (in the case of geriatrics and women’s health) areas of FM specialization. There also exists a growing need to serve rural communities in the state, for which an emphasis on retention in the more rural counties will be essential. The growth of primary care training opportunities in Delaware is an encouraging trend. Collaboration among the programs, including the four programs in Family Medicine, as well as those in other primary care-providing specialties, will be essential to create and sustain a stable pipeline of well-qualified physicians caring for the residents of the state of Delaware.

ACKNOWLEDGMENTS The support of the Board of the Delaware Health Sciences Alliance (DHSA, www.dhsa.org), DIMER, and the State of Delaware Health Care Commission, for medical education and workforce in the region is gratefully appreciated. The State of Delaware Healthcare Workforce report referenced herein is available in full-text here: https://djph.org/focus-ondelawares-workforce/ . The analytical work of Mr. Timothy Gibbs, MPH, and Dr. Kate Smith of the Delaware Academy of Medicine/Delaware Public Health Association is gratefully acknowledged. The authors may be contacted at okhan@dhsa.org (Dr. Khan), ekavanaugh@christianacare.org (Dr. Kavanaugh), Robert.monteleone@ che-east.org (Dr. Monteleone), brintha_vasagar@bayhealth.org (Dr. Vasagar), and jrobert@beebehealthcare.org (Dr. Robert).

REFERENCES 1. Institute of Medicine (US) Committee on the Future of Primary Care. Donaldson, M. S., Yordy, K. D., Lohr, K. N., & Vanselow, N. A. (Eds.). (1996). Primary care: America’s health in a new era. National Academies Press (US). 2. Deutchman, M., Macaluso, F., Chao, J., Duffrin, C., & Hanna, K. Avery, D.M., …, James, K.A. (2020). Contributions of US medical schools to primary care (20032014): determining and predicting who really goes into primary care. Fam Med, 52(7), 483-490. https://journals.stfm.org/familymedicine/2020/july-august/ deutchman-2020-0065/ 3. Khan, O. A., & Gibbs, T. (2022). Focus on Delaware’s healthcare workforce. Delaware Journal of Public Health, 8(5), 3. Retrieved from: https://djph.org/focus-on-delawares-workforce/ https://doi.org/10.32481/djph.2022.12.001 4. Townsend, S. L., & Khan, O. (2020, April 17). DIMER at 50: Delaware’s best value for medical education. Delaware Journal of Public Health, 6(1), 62–63. https://doi.org/10.32481/djph.2020.04.014 5. Delaware Institute for Medical Education and Research. (2019). DIMER Anniversary Report. Retrieved from: https://dhss.delaware.gov/dhcc/files/dimer50annrpt_2020.pdf 6. U.S. Census Bureau. (n.d.). QuickFacts: Kent County, Delaware; New Castle City, Delaware; New Castle County, Delaware; Sussex County, Delaware; Delaware. Retrieved from: https://www.census.gov/quickfacts/fact/table/

The DPH Bulletin

From the Delaware Division of Public Health

DPH announces public hearings on lead poisoning prevention regulations

December 2023

Heed safety advice for winter weather

The Delaware Division of Public Health (DPH) seeks public comment on proposed revisions to two lead poisoning prevention regulations.

When severe winter weather occurs, it poses serious risks to health and safety.

DPH proposes revising 16 Delaware Administrative Code Regulation 4459, Lead-Based Paint Hazards, to:

According to the Federal Emergency Management Agency at Ready.gov, “Winter storms create a higher risk of car accidents, hypothermia, frostbite, carbon monoxide poisoning, and heart attacks from overexertion. Winter storms including blizzards can bring extreme cold, freezing rain, snow, ice, and high winds.”

• Add electronic payments for accreditation of training programs. • Remove the requirement for the Secretary to maintain a list of parities whose accreditation has changed. • Add the ability for an abatement worker to apply for a one-year provisional certification. A public hearing in hybrid format is scheduled for Dec. 21, 2023 at 2:30 p.m. at the Delaware Department of Natural Resources and Environmental Control’s Richardson & Robbins Building. It will be held in the auditorium, located at 89 Kings Highway, Dover, Delaware 19901. Teleconferencing is available via Zoom meeting: https://us06web.zoom.us/j/81003211489?pwd=uJZrt 6jnrhnaEVQt4Iaj3P7HI1y6od.1. The Meeting ID is: 810 0321 1489 and the Passcode is 523652. Dial: 1-301-715-8592. On Dec. 21 at 3:00 p.m. at the above location, DPH is holding a second public hearing in hybrid format. DPH proposes revising 16 Delaware Administrative Code Regulation 4459A, Regulations Governing the Childhood Lead Poisoning Prevention Act, to: • Add DPH investigation and reporting obligations. • Make technical and renumbering revisions. Teleconferencing is available via Zoom meeting: https://us06web.zoom.us/j/84423347909?pwd=WrM ablaEIMmig0OFuYkXaUKvgGbOg6.1. The Meeting ID is: 844 2334 7909 and the Passcode is: 028501. Dial: 1-301-715-8592. Those wishing to offer verbal comments during the public hearing must pre-register no later than noon on Dec. 21. Public comments will be accepted through Jan. 8, 2024 in written form via email to DHSS_DPH_regulations@delaware.gov, or by U.S. mail to: Vicki Schultes, Hearing Officer, Division of Public Health, 417 Federal Street, Dover, DE 19901. The proposed revisions are available online in the December 1, 2023 Delaware Register of Regulations or by calling DPH at 302-744-4700. 24 Delaware Journal of Public Health - December 2023

Follow these safety recommendations from the Delaware Emergency Management Agency and the Centers for Disease Control and Prevention to prepare for winter: • Make a plan, build an emergency kit, and expand your support network; visit https://preparede.org/make-a-plan/ and https://dhss.delaware.gov/dhss/dph/php/prepare dnessbuddy.html. • Register to receive Delaware emergency alerts at https://dema.delaware.gov/onlineServices. • Weatherproof your home. • Listen to weather forecasts and comply with official Delaware driving level restrictions. • Bring your pets indoors. • Get your car ready. During and after winter storms: • Be prepared for power loss. • Heat and light your home safely. • Follow space heater and generator guidelines. • Conserve heat. • Make sure infants and older adults stay warm. • Keep a water supply. • Eat well-balanced meals and avoid alcoholic and caffeinated drinks. Stay safe outdoors: • Try to stay indoors. Make trips outside brief. • Wear several layers of cold-weather clothing. • Cover up; do not leave any skin exposed. • Stay dry. Do not ignore shivering. Know the signs of frostbite and hypothermia. • Stay off the ice and treat walkways to avoid falls. • Breathing cold, dry air can trigger an asthma attack.

State Council for Persons with Disabilities creates Brain Injury Toolkit Brain injury survivors, their families, and caregivers can now access a Brain Injury Toolkit on the newly improved State Council for Persons with Disabilities website. The Council’s Brain Injury Committee (BIC), Public Outreach Data Development Subcommittee created the toolkit.

Brain injuries can occur from accidents, falls, sports injuries, and assaults. The Brain Injury Toolkit provides information about brain injuries and how to access rehabilitation, testing, therapy, and treatments. Users can access brain injury resources such as support groups, crisis hotlines and interventions, and traumatic brain injury (TBI) financial assistance. Links to state financial and legal resources and survivor stories are meant to assist and inspire. So that survivors and their families can better prevent and identify concussions, the Council included information on Delaware’s Concussion Protection in Youth Athletic Activity Act. Signed by Governor Jack Markell on September 6, 2016, the legislation is to protect minors participating in athletic activities who manifest symptoms of concussion, increase recognition of the symptoms of concussion through training and education, and establish standards for return to play.

Published in 2023

DPH’s Health Promotion and Disease Prevention Section published the following documents in 2023: 1. Advancing Healthy Lifestyles Initiative: Triple Play Summary, May 2023 2. The Impact of Diabetes in Delaware, 2023 3. Lung Cancer Incidence and Mortality in Delaware, 2015-2019 4. Delaware Cancer Incidence and Mortality in Delaware, 2016-2020 5. Census Tract-Level Cancer Incidence and Mortality in Delaware, 2016-2020 DPH’s Office of Medical Marijuana published the Delaware Medical Marijuana Program Annual Report, Fiscal Year 2023.

The brain heals slowly and differently than any other organ. TBI patients need ongoing rehabilitation to relearn processes over months to years, according to the Centers for Disease Control and Prevention (CDC). In 2010, the U.S. economic burden of TBI exceeded $76 billion. In the U.S., the cost of TBI care per person varies from around $100,000 to millions of dollars, depending on the severity and the potential for rehabilitation and recovery. As of August 2020, 66,599 Delawareans live with a TBI, according to BIC researchers trying to determine gaps in TBI care. The BIC also found that 34,870 Delawareans were treated at an emergency department for a new TBI between 2013 and 2020. That number does not include the number of Delawareans with mild to moderate TBIs treated in urgent care centers and medical provider offices.

The DPH Bulletin – December 2023

This and more resources are available at http://covidmaterialsde.com.

Page 2 of 2 25

STUDENT SPOTLIGHT Interns at the Delaware Academy of Medicine/Delaware Public Health Association research a ‘gap’ in public health, and create a program to close that gap. They choose a public health theory or model to inform their program, and create a logic model to describe it. The Student Internship Program is open to any high school, undergrad, or graduate student, in Delaware and beyond. If you or someone you know would like to apply, please check out our webpage: https://delamed.org/programs/student-internship/

Drought: Ten to Do Ten Bridget Knitowski Intern, Delaware Academy of Medicine/Delaware Public Health Association

INTRODUCTION To have a drought, there has to be “an extended period of dry weather” (p. 405).1 Additionally, a drought can cover a range of areas, from a single county to an entire region. A drought can also last up to several years or decades.1 According to the National Integrated Drought Information System, there are six categories to quantify a drought.2 The D0 category is for when the area is abnormally dry, but it is not in a drought. The D1 category is moderate drought. The D2 category is severe drought. The D3 category is extreme drought. The D4 category is exceptional drought. The final category is the total area in drought, and it consists of the sum of D1 through D4. To detect for a drought, several physical indicators are tracked. These include temperature, precipitation, water supply, and soil moisture. Lastly, scientists can assess quantitative data from looking at the historical trend from years when a drought occurred.2 I chose to do my internship with the Delaware Academy of Medicine/Delaware Public Health Association on how drought is connected to public health issues. I am interested in the topic of drought, and this was an area that I identified as lacking existing research. To increase awareness about the issue, I wanted to use the existing literature to show the important association that drought has with public health issues. I also wanted to look at information pertaining to Delaware because this is where I am from, and I wanted to know how the topic is currently forecasted to impact the area or what actions could occur to decrease the potentially severity of the relevant issues.

BACKGROUND The droughts of 1953 to 1957, 1961 to 1971, 1979 to 1983, 1984 to 1988, 1995, and 1999 were among the most prominent drought periods that Delaware has faced within the last century. The drought of 1953 to 1957 affected the entire state, with more prolonged effects impacting northern Delaware.1 According to Paulson et al., this drought significantly decreased the water supply in Delaware.1 Less total water means that there is a reduced amount even for essential activities, such as drinking water. An inadequate amount of drinking water is one primary cause of dehydration. The U.S. Department of Veterans Affairs notes that dehydration can have a particularly fast onset for older adults, and it can spur more severe health problems.3 It is also admitted that 26 Delaware Journal of Public Health - December 2023

older adults might not be fully aware of the need to drink water or that the recommended amount of water for adults to have per day is nine to thirteen cups.3 Statistics from the Administration for Community Living also highlight the increasing older population in Delaware.4 The state’s population of individuals 60 and older is growing at a faster rate than the 0 to 19, 20 to 39, and 40 to 59 age ranges. It is also projected that the 2030 population of individuals 60 and older will be 28.4 percent, and this translates to an increase of 41 percent than compared to 2012.4 The cumulation of these data points reinforces the potential problems that drought conditions could have in the future. The drought of 1961 to 1971 was the longest drought that Delaware has had in the last century. Kent County endured drought conditions all the way until 1971. New Castle County dealt with the drought until 1970, and Sussex County faced it until 1967. This was also the most severe and longest drought affecting the northeastern United States. To meet demands for water in these communities during the drought, many areas tried to build additional water-supply facilities.1 However, Delaware still relies on a limited number of sources for water. The Brandywine Creek is the only resource for drinking water for Wilmington city. To the same end, the watershed demand from 2013 to 2020 was projected to increase by 10.4 million gallons per day (mgd) because of increased industrial use and population. This means that even without a drought, Wilmington’s source for drinking water was already strained because of increasing demand.5 An improved drinking water resource is a source that includes tube wells or boreholes, protected springs, public taps or standpipes, protected dug wells, and rainwater collection. With Delaware’s example of limited water resources, people could be forced to use unsafe water in the case of a drought. These types of water sources lead to about 1.2 million deaths per year, which is 2.2% of deaths worldwide. Additionally, unsafe water is stated to be one of the most significant health and environmental issues across the globe.6 During the drought of 1979 to 1983, conditions first impacted northern Delaware, then went on to hurt central Delaware followed by southern Delaware. One of the responses to the decreased water supply was a water-rationing program. However, this was only implemented at certain times of the drought, so it was partially unsuccessful at conserving water. The rationing of Doi: 10.32481/djph.2023.12.007

water could potentially have had a more effective impact if it was implemented for the entire time of the drought.1 Although more consistent water rationing could help alleviate some demands for water during a drought, it could cause people to resort to using other water resources that are unsafe. In addition to death, unsafe water sources can make malnutrition worse and increase an individual’s risk for infectious diseases, including typhoid, cholera, dysentery, polio, and hepatitis A.6 As with the previous droughts, the drought of 1984 to 1988 negatively impacted agricultural yields from decreased soil moisture, streamflow, and rainfall. As northern Delaware’s water supplies became increasingly lower in 1988, there was a more direct attempt to limit nonessential water usage. This meant that certain water-based activities were restricted, such as lawn watering and vehicle washing.1 The U.S. Department of Veterans Affairs created information to inform older adults about how to prevent dehydration.3 The information mentions that dehydration can cause dark colored urine, frequent urination with limited output, dry mouth or coated tongue, constipation, dry skin, frequent urinary tract infections, headache, confusion, lightheadedness after standing up, increased heart rate, and dry eyes. These dehydration symptoms could become exacerbated and turn into even worse health problems as, according to the information, older adults might not even feel thirsty when they are dehydrated.3 During a drought, older adults could be similarly susceptible to overlooking the use of unsafe water resources as they focus more on just having water to use, in general. The droughts of 1995 and 1999 were the starts of multi-year droughts.7 During these periods, Delaware agriculture particularly suffered. From 1995 to 2001, land usage decreased as a result of the drought conditions. This had consequences for pastures, cropland, and other areas of agricultural operations. In turn, decreased agricultural product due to drought could have critical economic impacts.5 Those of the middle and upper classes might be able to handle some period with lower income or lack of access to agricultural products, but people living in poverty might not be able to adapt as easily. Agricultural workers already living in poverty could be laid off and have to find other work in order to have an income. If those workers have to perform different manual labor outdoors during a drought, they might not be accustomed to the higher-than-normal temperatures associated with drought.2 Furthermore, this could increase the likelihood of dehydration as the workers either drink too little of water, lose too much fluid from sweating while they work, or a combination of these factors. Dehydration can cause a range of symptoms, and some of these, like headache or confusion, could inhibit workers or even prevent them from performing their jobs.3 This could ultimately result in the workers being fired, which would mean the loss of income and insurance. Those individuals could then have a much more difficult time seeking affordable healthcare, so pertinent health issues could go undiagnosed or untreated as those individuals become financially barred from medical care. The droughts of 1995 and 1999 were the precursor to an even more extreme dry period. According to the Institute for Public Administration, “[t] he drought of 2002 was the 100-year-drought” (p. 4).7 This assessment was made after looking at streamflow and precipitation data from the Brandywine Creek over the

past century. Additional findings suggested that the watermanagement plans at the time were insufficient to meet the predicted demand in 2020. As of 2002, the Delaware Water Supply Coordinating Council had been trying to increase the Delaware water supply by more than one billion gallons. This additional water was coming from the Hoopes Reservoir Deep Storage Project, Aquifer Storage and Recovery Project, Newark Reservoir, Artesian Water Company new wells project, and Newark South Wellfield Treatment Plant. The identified gap between the projected water supply levels versus the projected water supply demand resulted in a Delaware Policy Forum meeting on October 9, 2002.7 This allowed for a debate and panel discussion to propose a plan for moving forward. The proceedings centered on one main question, “What should be done to ensure the delivery of clean and plentiful drinking water to Delaware residents and businesses?” (para. 2).7 Some proffered ideas were supply-side approaches, like constructing desalination plants or enlarging reservoir capacities. Other ideas were demand-side approaches, like altering prices to promote water conservation. After discussion, the ideas for a water policy ranged from highest to lowest, respectively, included to expand Hoopes Reservoir, recycle wastewater, store water in underground reservoirs, and not make any changes.7

CASE STUDIES There have been a few Delaware case studies related to drought. One case report focused on Wilmington, Delaware. It looked at how food, water, and energy systems are handled in three cities near water in the United States. It also notes that after the drought of 2002, certain actions were taken in 2003 to prevent a future drought from being as impactful. These included constructing a 300-million-gallon capacity reservoir on the White Clay Creek and putting in an iron removal plant for treating ground water.5 However, the study fails to mention projected demand, allocations, and availability of water resources. These would be important factors for state-wide planning regarding water supply. Another case study was carried out in northern New Castle County, Delaware. The research presents a model for drought demand rates to lessen the impact of urban drought. Drought demand rates are a method for water conservation that increases water rates to prompt consumers to use less water. The article concludes that the drought demand rates fostered favorable outcomes, with increased efficiency, neutral revenue, equitable distribution, and guaranteed conservation of water. Additionally, the research supported the idea that long-term outreach efforts are essential to increase awareness about water conservation and truly change consumer demand.8 An additional field study was partly conducted in New Castle County, Delaware. The research focuses on whether people would utilize recycled water or only stick to conventional sources for water usage. To do the study, the researchers utilized a questionnaire to gather data from participants. The results from all three cities in the study showed that people tend to be more opposed to using recycled water for purposes where they are near the water, such as drinking. To illustrate this, differences were observed between participant responses to using recycled water for lawn irrigation, food irrigation, and drinking water. In addition, the results indicated that a region’s water abundance is not necessarily linked to preference for or 27

against using recycled water.9 These examples of Delawarebased research are crucial when weighing options for how to handle drought. They offer particularly relevant insight into solutions that could be most effective. Initiatives have also been tested in a state where drought is currently more of a pressing issue: California. Quin and Horvath looked at different water sources to use for irrigation, and it serves as a point of reference for a more emergent situation that Delaware could face if there is a failure to act.10 One of the primary catalysts for this research is drought. The other motivating factors include unreliable water supplies and increased demand for water usage, both of which drought is closely linked. The information appears to be very objective as it focuses on quantitative statistics to assess recycled water, desalinated brackish water and seawater, and stormwater. Findings indicate that, economically, stormwater and recycled water are more advantageous for irrigation over desalinated brackish water and seawater. Importantly, stormwater and recycled water have already been used for irrigation purposes. According to Qin and Horvath, these types of irrigation-water sources have also been used in several places within the state.10 The National Integrated Drought Information System does not currently forecast a drought in its monthly or seasonal outlooks.2 However, drought preparation is still vital for mitigating potential public health issues over the next several decades. With the Institute for Public Administration classifying the drought of 2002 as the once-in-a-century drought, this insinuates the recurrence of a severe drought.7 Historical trends of drought in Delaware are relevant to consider for preparations today. The National Drought Mitigation Center contains data about drought impacts in Delaware over time, and it filters these results based on the National Integrated Drought Information System’s drought severity categories, D0 to D4. Over the past ten years, drought impacts under the D0 category include corn yields suffering as a result of insufficient rainfall. The statistics also reflect Delaware being in a D1 category drought for five weeks during the summer of 2022 and two weeks during the fall of 2019. Observed effects included lower corn yields from less rain and increased difficulty with planting because of hard and dry soil.11 These issues could deteriorate over time. Information about trends in extreme weather support the idea that climate change is an imminent problem. Additionally, predictions for the 21st century include more rapid and frequent occurrences of extreme weather compared to that of the 20th century, which was already recordbreaking for its time.12

TRANSTHEORETICAL MODEL The transtheoretical model is a theory to promote behavior change using a series of steps to recruit the population. The model was first developed by James Prochaska and Carlo DiClemente, and they applied it to their 1983 paper about a plan for promoting smoking cessation.13 This model uses the temporal dimension as the foundation for five progressing steps to foster change: precontemplation, contemplation, preparation, action, and maintenance. The time before action occurs is the temporal distance of behavior, and the time afterward is the duration of behavior. Additionally, unlike other behavioral theories that focus on one measurable outcome, the transtheoretical model emphasizes intermediate outcomes throughout its stages. The 28 Delaware Journal of Public Health - December 2023

decisional balance involves an assessment of the pros and cons to making change. Typical trends show that before the change is instituted, the cons increase at a faster rate than the pros, but the pros then become more equal to the cons and the pros even surpass the cons after the change is instituted. Another intermediate measure is for temptations. The temptations measure notes the level of urges to engage in the adverse behavior, and the urges have typically been observed to decline with progression through each stage. The transtheoretical model also includes ten independent measures to assist in stage progression, the processes of change. The ten independent measures include consciousness raising, dramatic relief, environmental reevaluation, social liberation, self-reevaluation, stimulus control, helping relationship, counterconditioning, reinforcement management, and self-liberation. Consciousness raising is about increasing people’s awareness of the issue and ideas for change. Dramatic relief has to do with recognizing how discussions related to the topic of change impact people emotionally. Environmental reevaluation occurs when considerations are made regarding the behavior’s negative impact on the environment and others. Social liberation emphasizes finding the opportunities that make it easier to change the negative behavior. Self-reevaluation notes the personal detriment of continuing the behavior in question. Stimulus control deals with removing potential triggers. Helping relationship is about forming support to aid in carrying out the behavior change. Counter-conditioning is when a healthier behavior is substituted for the old, more negative action. Reinforcement management centers on the reward for engaging in the healthier behavior. Lastly, self-liberation is about committing to moving forward and not regressing. The transtheoretical model provides a thorough outline for creating a program of behavioral change in society. The stages involved in the transtheoretical model directly apply to Drought: Ten to Do Ten (DTDT). The program utilizes the transtheoretical model’s ten process of change steps to address the public health implications of drought in Delaware over ten years. DTDT will have a timeline that is in accordance with the model’s precontemplation, contemplation, preparation, action, and maintenance steps for change. DTDT will also include the intermediate, dependent measures related to decisional balance and temptations. Keeping track of these measures will help improve the program’s potential for success throughout its stages, and it will allow the program to consider the individual challenges that the Delaware population could face when instituting change. DTDT will start Delaware off at the transtheoretical model’s precontemplation stage. The first step of the program will try to increase awareness about the numerous ways in which drought is connected to public health. The program will achieve this with methods of mass communication. The second step of the program will involve in-person informative sessions about the topic to reach the audience on a more personal level. Ideally, this would bolster initial thoughts about the program to aid Delaware’s progression within it. DTDT will then advance Delaware to the contemplation stage. The third step of the program seeks to expose Delawareans to the current state of the drought issue. It will consist of video to show the actual areas that drought has impacted. The purpose would be to prompt consideration about the need for change.

The program will further move Delaware to the determination/ preparation stage. DTDT will have the greatest focus on this stage of change to provide the most solid foundation possible for the program to succeed long term. The program’s fourth step will take a societal view to establish how support for the program is more than an effort from individuals alone. The fifth step of the program will illustrate the state’s position in this preparation stage because this step involves directly providing informative material about drought to Delawareans in order to increase overall readiness for change. The sixth step of the program will provide an external motivating factor to prevent Delawareans from regressing or ending their progress on understanding more about drought and personal changes to prevent the issue from becoming a more prevalent public health concern. Additionally, the seventh step of the program will provide reinforcement for the importance of the program’s original intention and current actions. This involves fostering a relationship with medical providers to ensure further progression through the transtheoretical model’s stages of change and promoting the long-term success of the program. After establishing determination, DTDT will move Delaware to the action stage. The eighth step of the program involves the true action of change because new drought-mitigating actions will have to replace previously adverse behaviors. This will take time and tremendous effort, but the program’s ninth step will initiate additional fortifying factors. This step will utilize a type of incentive for engaging in behavior that works to improve or mitigate drought conditions. In other words, the step will increase the likelihood of Delawareans engaging in the program’s actions. The final goal of DTDT is to keep Delaware in the maintenance stage and prevent termination of the program’s progress. The tenth step of DTDT will assess program status at intervals over time, and it will seek out feedback from the Delaware population to consider adjustments if appropriate. As a result of following the procedural-like steps of this theory, DTDT intends to establish a firm foundation for addressing the impact of drought and, in turn, aid the conditions of public health in Delaware.

DROUGHT: TEN TO DO TEN Drought: Ten to Do Ten (DTDT) is intended to address the public health implications of drought in Delaware. Over the next ten years, DTDT will progress through each step of the transtheoretical model to allow for a greater percentage of Delawareans to be informed about drought and how it is related to public health. The program aims to build on this foundation to maintain its awareness-based, model-based, and action-based efforts for reducing the public health implications of drought. The first goal of DTDT, definition and structure, is one of the most important program goals (Table 1). DTDT will form relationships with local environmental agencies or clubs interested in a topic pertaining to drought and public health. Health-related research about drought will be emphasized with these organizations, and the focus of the partnership will be on ultimately promoting public health. DTDT will work with the Delaware Academy of Medicine/Delaware Public Health Association, the Delaware Division of Public Health, and other stakeholders to educate about the public health

impacts of drought in Delaware. DTDT will also coordinate with water companies in Delaware to allow monetary rebates for customer water usage that complies with standards DTDT helps establish to limit water consumption without limiting usage for activities essential to public health promotion. Increased awareness is another main goal of DTDT. The program will use mass communication of information to convey that drought is connected to public health issues. DTDT will attempt to do that through presenting research to electronic and print news sources to try to gain assistance in mass dissemination of material to their viewers. To be cost effective, DTDT will initially try to work with types of organizations that offer opportunities for free newsletter submissions that, if published, are sent to the organization’s entire subscriber base. This will also assist in establishing the authority of drought as an important topic, particularly as it pertains to the connection to public health repercussions. Additionally, the DTDT aims to use in-person presentations to connect directly with Delawareans of all ages and backgrounds. This approach allows the audience to have an interactive experience that is unavailable with other types of information consumption. The presentation audience will have the opportunity to ask questions about drought and public health that might pertain to them on a more individualized level. DTDT intends to use this approach to increase Delawareans’ inclination to want to further understand the program and the topic of issue. Another method for DTDT to increase awareness will come from working closely with professionals in the healthcare industry to have flyers in doctors’ offices that are about drought and can bolster an initial conversation. Additionally, the physician will be there, as an informed professional, to answer questions about the flyer’s information regarding health issues connected to drought. After increasing awareness, DTDT will try to show how drought is directly impacting the local area to see that drought, itself, is already a present issue. This educational view serves to indicate the idea that Delaware could see resulting repercussions from drought, not only in the physical environment, but also within the public health sphere. DTDT will also prioritize independent, informed decision-making while providing Delawareans with a typed list of information about drought-mitigating behavioral changes (Appendix A). DTDT expects this to increase determination to address the public health issues associated with drought because Delawareans use the provided information to come to their own motivating conclusions. Direct instruction will also be an educating method because casual-style livestreams will allow DTDT to promote healthier alternatives from an everyday view. These ideas about how to address drought and its public health issues are intended to be straightforward to show that it does not have to be an overwhelming task. Individuals each make a difference through their choices, and like DTDT being a long-term plan, counteracting adverse behavior will become increasingly important as more Delawareans act over time. Another main intention of DTDT is to change public policy. DTDT will try to impact legislative decisions around drought-related issues. Restrictions created to address drought conditions, such as water-usage limits or bans, will provide 29

Table 1. Drought: Ten to Do Ten Logic Model Goal

Step

Implementation Activities/Objectives

Short Term Deliverables

Work with current environmental and public health organizations in Delaware to initiate partnership

Work with Delaware water companies to design incentives for water conservation or non-traditional methods promoting sustainability

Utilize mass communication to inform Delawareans about drought and its ties to public health

Provide in-person presentation to Delawareans about the issue to convey information using a more personal level

Mid Term Deliverables

Long Term Outcomes

2023 Year End Reached out to 10 organizations

10/2024 Formulated partnership with 1 environmental agency and 1 public health organization

Create new partnerships yearly until all companies in Delaware are in partnership

2023 Year End Created list of 10 potential incentives to present to companies

10/2025 Presented incentives list to over half of major Delaware water companies and have plans for at least 1 partnered incentive

2033 Implemented incentive plan for customers at waterresource company with 10000 individual or commercial customers

2023 Year End Compiled research on topic into 1 formal paper

10/2028 Published research in e-newsletters with combined viewer base of at least 10000

Submitted ongoing research to print/ electronic news sources at yearly intervals for update

2023 Year End 1 presentation created to be used at each event

10/2029 Presentation given to combined total audience of at least 10000

2033 Agreement formulated to allow yearly presentations at 10 local schools in addition to increasing current presentation agreement obligations by 10% per year

Create ﬂyers about drought for use in Delaware physician offices

2023 Year End Flyers created and 10000 produced

10/2026 All initially created ﬂyers distributed to and put up in physician offices

Flyers distributed throughout Delaware until all primary care offices contain them

Create video to show Delawareans actual drought-stricken locations and caution about excessive at-home water usage

2023 Year End 1 video ﬁlmed to be used until updated over time

10/2028 Video updated to account for increased/ decreased drought effects

2033 Video updated within the past year and distributed to viewing audience of at least 10000

Distribute typed list of issues not commonly thought to contribute to drought and related health risks

2023 Year End List created with 10 most important issues

10/2028 Physical copies sent to homes in 10000 residencies throughout Delaware

Physical and electronic copies sent to personal residencies each year until all population in all major Delaware towns have been covered

Livestream alternative everyday activities to promote actual ideas for water conservation

2023 Year End Created livestream account with at least 1 site

10/2029 Created consistent schedule of posting videos with 10% increase in amount produced per year

2033 Accumulated 10000 total views

Advocate for legislative restrictions on water usage

2023 Year End Formal letter sent to 1 state Congressmen

10/2025 Organized at least 1 protest in Delaware

2033 Organized annual protests with at least 10000 attendees

Gather feedback from initial outreach populations about behavioral changes related to water conservation and potentially observed health beneﬁts

2023 Year End Finalized list of total initial outreach populations

10/2024 Sent feedback inquiry to entire list via physical and/or electronic communication

Continue to reach out to recipient list yearly until at least 10000 responses received

Deﬁnition and Structure

Increased Awareness

Education

Public Policy

Evaluation

30 Delaware Journal of Public Health - December 2023

foundational support for improving the human factors that make drought conditions worse. In other words, people will be less likely to engage in adverse behaviors, like using excessive amounts of unnecessary water, if these actions have additional repercussions, like monetary fines. With the drought issue itself addressed, DTDT will decrease the potential for resulting public health issues. The final goal of the program is to assess the implementation over time. Important factors to consider will involve reaching out to the populations that had been exposed to DTDT. One main point will include gathering qualitative data and quantitative information about the presence of and/or type of drought-mitigating changes made over time. Assessing correlating health information will also be important to observe. This type of approach to program assessment will provide additional opportunity for Delawareans to voice their opinions about improvements to DTDT. The program will be adjusted thereafter to increase the potential for continued effectiveness.

DISCUSSION This topic applies to overarching public health topics, which include epidemiology, health inequity, health in all policies, and population health. Epidemiology is the study of diseases and their methods of transmission to prevent negative health outcomes among the population.14 This connects to drought as drought is associated with a lack of water, and that could lead people to use other, unsafe water sources. In either or both cases, drought can cause dehydration, disease, and even death.6 The Centers for Disease Control and Prevention notes that typhoid, polio, and cholera can especially be transmitted via contaminated water.15 This is also particularly relevant to Delaware because even fifty years after the federal Clean Water Act was passed to improve water quality across the country, 70.5% of reservoir and lake acres and 100% of harbor, estuary, and bay square acres are impaired.16 This indicates that drought could cause severe epidemiological consequences for the state. Health inequity is the concept that people have variable health outcomes and access to resources because of social determinants.17 There is an inherent lack of water supply when there is a drought. From an economic standpoint, this tends to increase the cost to access water when demand remains at least the same. To that end, low-income areas are more likely to face health inequities from a drought, compared to higher-income areas, because people in the lower-income areas would be less likely to afford the increased pricing of water. As a result, this population would be more susceptible to using unclean water resources or not using water for activities vital to individuals’ health. In Delaware, 10.6 to 13.3% percent of the population lives below the poverty line, and the county with the highest percentage of poverty is Kent County.18 This suggests that individuals in Kent County could be particularly vulnerable to health inequities from drought. The idea of health in all policies is to approach policymaking with consideration for population health and equity, and it can involve public health liaisons within organizations or the government.14 This has to do with drought because as policies

are made regarding water resources, a ‘health in all policies’ approach would include high regard for factors such as the way the policy could impact access to clean, usable water. Population health is the focus on individuals’ overall wellbeing.17 In addition to drought having impacts on physical health, it can also affect people mentally and emotionally. During a three-phase research study, the psychological effects of drought were assessed to impact mental health. The reason for this stems from drought being a time of potentially severe environmental challenges. The study suggested that the direct results of a drought could then increase psychological distress and psychiatric disorders from the persistence of the drought issues.19 The plan for handling a drought has to be comprehensive in order to mitigate public health issues.

CONCLUSION The internship experience I had allowed me to increase my understanding of the impact of drought. The information I had previously focused on with drought was primarily about the environment. However, this internship pushed me to think about how else drought affects the world. I initially tried to find sources that directly linked drought to public health issues, but I was unable to find adequate information. The internship allowed me to figure out how to synthesize information to form conclusions. This is a foundational skill that I can implement in future academic studies to investigate ideas while also being able to back up the information using credible sources. During the process, I was also able to increase my understanding of public health issues. This included finding out about the various areas within public health, overall, and the specific applications that those areas had to my topic. The internship showed me just how comprehensive public health is as I was able to center on a topic that, at first, appeared unrelated. Overcoming issues faced during the internship increased my ability to be more informed about a variety of important topics. Ms. Knitowski may be contacted at bridget.knitowski@icloud.com.

REFERENCES 1. Paulson, R. W., Moody, D. W., Roberts, R. S., & Chase, E. B. (1991). National water summary 1988-89-hydrologic events and floods and droughts. U.S. Government Printing Office. 2. National Integrated Drought Information System. (2023, Apr 25). Delaware. https://www.drought.gov/states/delaware 3. U.S. Department of Veterans Affairs. (2018). Preventing dehydration in older adults. https://www.nutrition.va.gov/docs/UpdatedPatientEd/ PreventingDehydrationinOlderAdults2018.pdf 4. Administration for Community Living. (2012, Oct). Policy academy state profile. https://acl.gov/sites/default/files/programs/2016-11/Delaware%20 Epi%20Profile%20Final.pdf 5. Pierce, A. L., Sharma, S., & Tye, M. R. (2021). Case report for Wilmington, Delaware, USA. https://doi.org/10.31219/osf.io/y78dh 31

6. Ritchie, H., & Roser, M. (2021). Clean water. Our World in Data. https://ourworldindata.org/water-access 7. Institute for Public Administration. (2002). In Drought. 02: A debate and panel discussion concerning water supply policy in Delaware. Newark. http://www.wrc.udel.edu/wp-content/uploads/2016/07/ wpfproceedings2002.pdf 8. Smith, W. J., & Wang, Y.-D. (2008). Conservation rates: The best ‘new’ source of urban water during drought. Water and Environment Journal : the Journal / the Chartered Institution of Water and Environmental Management, 22(2), 100–116. https://doi.org/10.1111/j.1747-6593.2007.00085.x 9. Li, T., & Roy, D. (2021). “Choosing not to choose”: Preferences for various uses of recycled water. Ecological Economics, 184(3), 106992. https://doi.org/10.1016/j.ecolecon.2021.106992 10. Qin, Y., & Horvath, A. (2020). Use of alternative water sources in irrigation: Potential Scales, costs, and environmental impacts in California. Environmental Research Communications, 2(5). https://doi.org/10.1088/2515-7620/ab915e 11. National Drought Mitigation Center. (2023). State impacts. U.S. Drought Monitor. Retrieved May 1, 2023, from https://droughtmonitor.unl.edu/DmData/StateImpacts.aspx?10 12. Ebi, K. L., & Schmier, J. K. (2005). A stitch in time: Improving public health early warning systems for extreme weather events. Epidemiologic Reviews, 27(1), 115–121. https://doi.org/10.1093/epirev/mxi006 13. Velicer, W. F., Redding, C. A., Norman, G. J., Fava, J. L., & Prochaska, J. O. (1998). Detailed overview of the transtheoretical model. Lungenordination. https://www.lungenordination.at/TTM.pdf 14. Rivier University. (2023). Public health fields and specialties. Program Resources. https://www.rivier.edu/academics/online/resources/programresources/public-health-fields-and-specialties/ 15. Centers for Disease Control and Prevention. (2022, Oct 18). Disease impact of unsafe water. Household Water Treatment. https://www.cdc.gov/healthywater/global/disease-impact-of-unsafewater.html 16. Environmental Integrity Project. (2022, March 17). The clean water act at 50. Reports. https://environmentalintegrity.org/reports/the-clean-water-act-at-50/ 17. McCartney, G., Popham, F., McMaster, R., & Cumbers, A. (2019, July). Defining health and health inequalities. Public Health, 172, 22–30. https://doi.org/10.1016/j.puhe.2019.03.023 18. U.S. Department of Health and Human Services. (2023). Poverty (Persons below poverty) for Delaware by County. National Institute of Minority Health and Health Disparities. https://hdpulse.nimhd.nih.gov 32 Delaware Journal of Public Health - December 2023

19. Abunyewah, M., Byrne, M. K., Keane, C. A., & Bressington, D. (2023, February 16). Developing psychological resilience to the impact of a drought. International Journal of Environmental Research and Public Health, 20(4), 3465. https://doi.org/10.3390/ijerph20043465 20. American Rivers. (2023). 10 ways to save water at home comments. https://www.americanrivers.org/rivers/discover-your-river/top-10ways-for-you-to-save-water-at-home/ Conservation. 21. Environmental Protection Agency. (n.d.). Ways to save water. https://www.epa.gov/watersense/how-we-use-water 22. Lawrence KS Utilities Assets. (n.d.). How we use water. https://assets.lawrenceks.org/utilities/files/Conservation.pdf 23. Volusia County Government Online. (n.d.). 25 was to save water. https://www.volusia.org/services/growth-and-resourcemanagement/environmental-management/natural-resources/waterconservation/25-ways-to-save-water.stml

APPENDIX A. OVERLOOKED ISSUES CONTRIBUTING TO DROUGHT20–23 1. Leaking toilet: Can waste over 100 gallons of water per day. Test if toilet is leaking by putting food coloring in the tank. The evidence of a leak would be if the color seeps into the bowl without the toilet being flushed. 2. Leaking outdoor pipe, faucet, or hose: Wastes water 24 hours per day. 3. Overwatering lawn: Wastes water when there are colder temperatures or rain. The lawn should be watered less frequently but for a longer period to get the most out of the process if lawn watering is necessary. 4. Using toilet to be like a trashcan: Each toilet flush uses 5 to 7 gallons of water. 5. Not having aerators on home faucets: The aerator creates small air pockets in the water to prevent splashing and conserve water flow. 6. Flushing toilet excessively: Toilet flushing accounts for most in-house water usage for average family of four at 40% of total usage. 7. Overlooking usage of water bill: Use water bill to identify how much of the resource is being used. Consumers can ask the local government to do home water audit. 8. Not conserving water using toilet tank: Put plastic bottle filled with one inch of weigh-down material into tank to conserve water while maintaining toilet operation. 9. Not collecting outdoor water runoff: Use a barrel to catch stormwater runoff from hard surfaces. 10. Not having flow restrictors: These items can be purchased at inexpensive prices. They can reduce water usage to 3 gallons per minute instead of up to 10 gallons per minute.

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GLOBAL GLOBAL GLOBAL HEALTH HEALTH HEALTH M AT TERS M AT TERS M AT TERS

Inside this issue Inside this equity issue Creating health Inside this issue Inside this equity issue through communityCreating health Creating health equity based participatory through communityCreating health equity through communityresearch . . . p. 5 based participatory through communitybased participatory research . . . p. 5 based participatory

NOV/DEC 2023 NOV/DEC 2023 FOGARTY INTERNATIONAL CENTER • NATIONAL INSTITUTES OF HEALTH • DEPARTMENT OF .HEALTH research . . p. 5 AND HUMAN SERVICES NOV/DEC research . . . p. 37 5 NOV/DEC 2023 2023 FOGARTY INTERNATIONAL CENTER • NATIONAL INSTITUTES OF HEALTH • DEPARTMENT OF HEALTH AND HUMAN SERVICES

Fogarty’s “Global Brain” program enters its third decade Fogarty’s “Global Brain” program enters its third decade Fogarty’s Fogarty’s “Global “Global Brain” Brain” program program enters enters its its third third decade decade FOGARTY INTERNATIONAL CENTER • NATIONAL INSTITUTES OF HEALTH • DEPARTMENT OF HEALTH AND HUMAN SERVICES FOGARTY INTERNATIONAL CENTER • NATIONAL INSTITUTES OF HEALTH • DEPARTMENT OF HEALTH AND HUMAN SERVICES

FOCUS FOCUS FOCUS FOCUS 34 Delaware Journal of Public Health - December 2023

Research roundup Research roundup • Examining impact of COVID-19 on mortality in the U.S. • Studying COVID-19 South Africa Research roundup • Examining impact of in COVID-19 on mortality in the U.S. Research roundup

• modelling and phylogenetic studies Studying COVID-19 South Africa • COVID-19 Examining impact of in COVID-19 on mortality in the U.S. • Examining impact of COVID-19 on mortality in the U.S. • Notable studies on flu, clean cooking, and other topics • COVID-19 modelling and phylogenetic studies Studying COVID-19 in South Africa • Studying COVID-19 in South Africa more on pages 39-41 6–9 More Notable studies on flu,and clean cooking, and otherRead topics • COVID-19 modelling phylogenetic studies • COVID-19 modelling and phylogenetic studies more on pages 6 – 9 • Notable studies on flu, clean cooking, and otherRead topics • Notable studies on flu, clean cooking, and other topics Read more on pages 6 – 9 Read more on pages 6 – 9

Photo Photo courtesy Photo courtesy Photo of National courtesy courtesy of National of Institute ofNational National Institute on Drug Institute Institute on Abuse Drug onon Abuse Drug DrugAbuse Abuse

Fogarty’s Global Brain and Nervous System Disorders Reat Serbia's Vinca Institute while developing a strong crosssearch across the Lifespan program is all grown up now: th e cultural program in basic and translational in Fogarty’s Global Brain and Nervous System Disorders Reat Serbia's Vinca Institute while developing aresearch strong crossinitiative celebrates its 20th anniversary this year. Global partnership with a Northwestern University laboratory. search across theBrain Lifespan is all grown up now: cultural program in basic and translational in Fogarty’s Global and program Nervous System Disorders Re-the at Serbia's Vinca Institute while developing aresearch strong crossFogarty’s Globalgrants Brainto and Nervous Systembuild Disorders Reat Serbia's Vinca Institute while developing strong crossBrain provides help investigators research This collaboration accelerated the discoveryaof therapeutic, initiative celebrates its 20th anniversary year. partnership with ain Northwestern University laboratory. search across the Lifespan program is allthis grown upGlobal now: the cultural program basic and translational research in search across the Lifespan program countries is all grown up now: the cultural program in basic and translational capacity in lowand middle-income (LMICs) while diagnostic, and prognostic targets for PTSD.research Her mostin Brain provides grants helpanniversary investigators build research This collaboration accelerated the discovery of therapeutic, initiative celebrates itsto 20th this year. Global partnership with a Northwestern University laboratory. initiative celebrates its anniversary this year. partnership with a paper Northwestern University laboratory. conducting research on20th health issues related to theGlobal brain recently published explored thePTSD. molecular and cellular capacity in lowand middle-income countries (LMICs) while diagnostic, and prognostic targets for Her most Brain provides grants to help investigators build research This collaboration accelerated the discovery of therapeutic, Brain providesnervous grants to help investigators buildliving research This collaboration accelerated the discovery of therapeutic, and extended system that affect people there. mechanisms of howpaper memories of stressful eventsand contribute conducting research on health issues related to the brain recently published explored thePTSD. molecular capacity in lowand middle-income countries (LMICs) while diagnostic, and prognostic targets for Her mostcellular capacity in low-long-term and middle-income countries while diagnostic, and prognostic targets for PTSD. Her most The program's goal is to sustain the(LMICs) advancement to depression-like behavior. and extended nervous system that affect people living there. mechanisms of how memories of stressful events contribute conducting research on health issues related to the brain recently published paper explored the molecular and cellular conducting research onin health issues tosystem the brain recently published paper explored the molecular and cellular of research capabilities the is areas of related nervous The program's long-term goal to sustain the advancement to depression-like behavior. and extended nervous system that affect people living there. mechanisms of how memories of stressful events contribute and extended nervoussystem systemimpairment that affect people living there. mechanisms memories of stressful eventsproject, contribute function and nervous across the globe. Another case of in how point: the NeuroGAP-Psychosis led of research capabilities ingoal the is areas of nervous system The program's long-term to sustain the advancement to depression-like behavior. The program's long-term goal is to sustain the advancement to depression-like behavior. by Dr. Karestan Koenen, is a collaboration of Addis Ababa function and nervous system across the globe. Another case in point: the NeuroGAP-Psychosis project, led of research capabilities in the impairment areas of nervous system of research capabilities in the areas of nervous system “Since the program’s inception in 2002, University Ethiopia, Makerere University by Dr. Karestan Koenen, aincollaboration of Addis Ababa function and nervous system impairment across the globe. Another case in point: theisNeuroGAP-Psychosis project, led function andconferred nervous system impairment across the globe. Another case in point: the NeuroGAP-Psychosis project, led n Fogarty has 314 total awards in Uganda, and the University of Cape Tow “Since the program’s inception in 2002, University in Ethiopia, Makerere University by Dr. Karestan Koenen, is a collaboration of Addis Ababa by Dr. Karestan Koenen, isAfrica a collaboration of Addis Ababa to support research in 66 lowand in South in partnership with the Fogarty has conferredinception 314 totalin awards in Uganda,in and the University of University Cape Town “Since the program’s 2002, University Ethiopia, Makerere “Since the program’s inception in University in Ethiopia, Makerere University middle-income countries,” saidand Dr.2002, Harvard T.H. Chan School of Public Health. to support research in 66 lowin South Africa in partnership with the Fogarty has conferred 314 total awards Uganda, and the University of Cape Town Fogarty has conferred total the awards in Uganda, and the University of Cape Town Kathleen Michels, who314 founded The ongoing project aims to build and middle-income countries,” said Dr. Harvard T.H. Chan School of Public Health. to support research in 66 low- and in South Africa in partnership with the to support research in 66 lowand in South Africa in partnership with the program and has since retired. the expand the capacity of African scientists Kathleen Michels, who founded The ongoing aims toofbuild and middle-income countries,” said Dr. Harvard T.H.project Chan School Public Health. middle-income countries,” said Dr. Harvard T.H. Chan School of Public Health. to conduct large-scale genetic studies of program and has since retired. the expand the capacity of African scientists Kathleen Michels, who founded The ongoing project aims to build and Kathleen Michels, who founded the The ongoing project aims to build and The need for this program is clear. s schizophrenia and other psychotic disorder to conduct of program and has since retired. expand the large-scale capacity of genetic Africanstudies scientists program and hasGlobal since retired. expand the capacity of African scientists According to the Burden of by enabling the local generation, analysis The need for this program is clear. s schizophrenia and other psychotic disorder to conduct large-scale genetic studies of to conduct large-scale genetic studies of Disease survey, disorders and interpretation of generation, data. Scientists According to this theneurological Global Burden of by enabling the local analysis The need for program is clear. schizophrenia and other psychotic disorders The the need for this program is clear.and schizophrenia and other disorder are leading cause of disability work to validate tools for psychotic diagnosing and s Disease survey, disorders A functional MRI (fMRI) image of preteen brain and interpretation of generation, data. Scientists According to theneurological Global Burden of by enabling the local analysis According to the Global Burden of by enabling the local generation, analysis the second leading cause of death while child performs a wor king memory task. The screening schizophrenia psychosis, are the leading of disability and work to validate tools for and diagnosing Disease survey,cause neurological disorders and interpretation of data. Scientistsand A functional MRI (fMRI) image of preteen brain are the most active. regions in yellow and red Disease survey, neurological disorders and interpretation of data. Scientists worldwide. Over time, death and characterize the clinical phenomenology the second leading cause of death while child performs a wor king memory task. The screening schizophrenia and psychosis, are the leading cause of disability and work to validate tools for diagnosing and A functional MRI (fMRI) image of preteen brain are the leading of disability and work toschizophrenia validate toolsand for diagnosing and disability due tocause neurological diseases regions in yellow and red areofthe most active. patients with psychotic A functional MRI (fMRI) image of13,000 preteen brain worldwide. Over time, death and characterize the clinical phenomenology the second leading cause of death while child performs a working memory task. The screening schizophrenia and psychosis, the second leading cause of death while child performs a wor king memory task. The screening schizophrenia and psychosis, have risendue substantially, particularly and perform largest gene-discovery study of regionsIn in fact, yellowaand red aredisorders, the most active. disability to neurological diseasesin LMICs. 13,000 patients with the schizophrenia andphenomenology psychotic worldwide. Over time, death and characterize the clinical regions in yellow and red areofthe most active. worldwide. Over time, deathpositive and characterize the clinical phenomenology concerning paradox exists: trends in LMICs—such as schizophrenia in Africa to date. have risendue substantially, particularly disorders, and perform largest gene-discovery study of disability to neurological diseasesin LMICs. In fact, a of 13,000 patients with the schizophrenia and psychotic disability due to diseases 13,000 patients with schizophrenia and psychotic improvements inneurological health care and increasing expectancy— of concerning paradox exists: positive trends inlife LMICs—such schizophrenia in Africa to date. have risen substantially, particularly in LMICs. In fact, a as disorders, and perform the largest gene-discovery study of haveto risen substantially, particularly in LMICs. In fact, a disorders, andprojects performinclude the largest gene-discovery ofthe lead more children surviving past age 5 into adulthood notable a planning grant tostudy reduce improvements in health care and increasing expectancy— concerning paradox exists: positive trends inlife LMICs—such as Other in Africa to date. concerning paradoxage) exists: positive trends in LMICs—such as schizophrenia schizophrenia in Africa to date. (and into advanced with their brain health impaired due burden of chronic psychotic disorders in Tanzania; a psycholead to more children surviving past age 5 into improvements in health care and increasing lifeadulthood expectancy— Other notable projects include a planning grant to reduce the improvements in health care and increasing life expectancy— biological study of early psychosis in China; an exploration to early illnesses, malnutrition, and adverse environmental (and into advanced age) with their brain health impaired burden of chronic psychotic disorders in Tanzania; a psycholead to more children surviving past age 5 into adulthooddue Other notable projects include a planning grant to reduce the lead to more children surviving past age 5 into adulthood Other notable projects include a planning grant toinvestireduce the impacts and experiences. of the family consequences of Zika in Brazil; an to early illnesses, malnutrition, and adverse environmental biological study of early psychosis in China; an exploration (and into advanced age) with their brain health impaired due burden of chronic psychotic disorders in Tanzania; a psycho(and into advanced age) with their brain health impaired due burden chronic psychotic disordersand in Tanzania; a psychogation ofofmaternal traumatic child development impacts and experiences. of the family consequences of stress Zika in in China; Brazil; investito early illnesses, malnutrition, and adverse environmental biological study of early psychosis an exploration to early illnesses, malnutrition, and adverse environmental biological study of early psychosis in China; an exploration In the past, Global Brain program investigators have in South a study of internet-based treatment for gation of Africa; maternal traumatic child development impacts and experiences. of the family consequences of stress Zika inand Brazil; an investiimpacts and experiences. of the family consequences ofLatin Zika in Brazil; an an exploration investiaddressed a range of diseases and disorders. For exampl e, common mental disorders in America; In the past, Global Brain program investigators have in South a study of internet-based treatment for gation of Africa; maternal traumatic stress and child development gation of maternal traumaticinstress and child on development Dr. Jelena Radulovic of Northwestern University received of the genetics ofdisorders psychosis Africa; a study dementia addressed range of diseases and investigators disorders. Forhave example, common mental in Latin America; an exploration In the past,aGlobal Brain program in South Africa; a study of internet-based treatment for In the past, Global Brain program stress investigators have in South Africa; a study of internet-based for an study post-traumatic disorder (PTSD) and related health and social challenges intreatment Lebanon; and Dr. award Jelenato Radulovic Northwestern University of the genetics of psychosis in Africa; a study on dementia addressed a range of of diseases and disorders. Forreceived example, common mental disorders in Latin America; an exploration addressed a range of diseases and disorders. For example, common mental disorders in Latin America; an exploration in Serbia. Radulovic’s team enhanced research capacity schizophrenia research capacity building in Macedonia. an study post-traumatic stress disorderreceived (PTSD) and related health and social in Lebanon; and Dr. award Jelenato Radulovic of Northwestern University of the genetics of psychosis inchallenges Africa; a study on dementia Dr. Jelena Radulovic of Northwestern University received of the genetics of psychosis in Africa; a study on dementia in Serbia. Radulovic’s team enhanced research capacity schizophrenia research capacity building in Macedonia. an award to study post-traumatic stress disorder (PTSD) and related health and social challenges in Lebanon; and an award to study post-traumatic stress disorder (PTSD) and related health and social challenges in Lebanon; and in Serbia. Radulovic’s team enhanced research capacity schizophrenia research capacity building in Macedonia. in Serbia. Radulovic’s team enhanced research capacity schizophrenia research capacity building in Macedonia.

NOVEMBER/DECEMBER 2023

NIMH marks 75 years of mental health research By Judy Coan- Stevens

Since its founding in 1949, the National Institute of Mental Health (NIMH) has transformed the understanding and treatment of mental illnesses through basic and clinical research, bringing hope to millions of people. In recent decades, global health researchers have placed new emphasis on mental health against the backdrop of natural disasters, armed conflict, forced displacement, and major disease outbreaks. Mental disorders and diseases are an enormous burden in low- and middleincome countries (LMICs) which lack the financial and human resources to deal with them. According to the WHO World mental health report published in June 2022, mental disorders are the leading cause of years lived with disability (YLDs), accounting for one in every six YLDs globally. This report also indicates that worldwide one in eight individuals live with a mental health condition. However, these mental health conditions remain undertreated and health services continue to be underfunded. NIMH’s vision statement envisions a world in which mental illnesses are prevented and cured. Global mental health research is one of the institute’s priority research areas. As Leonardo Cubillos and Collene Lawhorn of the Center for Global Mental Health Research within NIMH wrote in a recent blog post, “Mental illnesses are not confined by geography; our research should not be either.” The center coordinates efforts to generate knowledge that will improve the lives of people living with or at risk for mental illnesses in LMICs. Two of its flagship initiatives are the biannual Global Mental Health Conference, which gathered for its 12th meeting earlier this year, and the Global Mental Health Research Webinar Series. The center

currently prioritizes supporting implementation science and health services research applied to key global mental health challenges, such as integration of mental health care in primary care, suicide prevention, mobile populations, and social determinants of mental health. For several decades, NIMH has been an important partner to Fogarty International Center on programs such as Emerging Global Leader, International Research Scientist Development Award (IRSDA), Global Brain Disorders Research, Global Health Fellows and Scholars/ LAUNCH, and Chronic, Noncommunicable Diseases and Disorders Research Training (NCD-Lifespan). NIMH also provides support to Fogarty trainees as they progress in their careers. With this support, Fogarty trainees and grant recipients have measured the prevalence of mental disorders in western Kenya, where no baseline for these conditions had been established; studied the benefits of including fathers when providing mental health services to displaced Syrian families living in Turkey; researched how mental health care can be normalized in wartime Ukraine; and measured the impact of apartheid-based prenatal stress and COVID-19 in South Africa. Including diverse populations, communities, contexts, geographical regions, researchers, and technologies across the globe can accelerate and enrich scientific advancements while helping to address challenges both globally and domestically. NIMH is celebrating 75 years of research, discovery, and hope with special events, videos, podcasts, and feature stories that highlight the Institute’s research and its impact on mental health. Check out their website: nimh.nih.gov.

Image courtesy of National Institute of Mental Health

Map of countries participating in the NIMH-supported Research Partnerships for Scaling Up Mental Health Interventions in Low- and Middle-Income Countries (Scale-Up Hubs).

NOVEMBER/DECEMBER 2023

Two APTI fellows focus on neglected tropical diseases

and research, and to find out their goals for the future. Fogarty International Center

Dr. Chinwe Chukwudi

Dr. Chinwe Chukwudi is currently studying protozoan parasites at the National Institute of Allergy and Infectious Diseases.

Originally from the southeastern region of Nigeria, Dr. Chinwe Chukwudi began her research journey at the Royal Veterinary College, University of London, where she obtained her PhD in molecular biology and microbial genetics and completed postdoctoral studies under the sponsorship of the Commonwealth Scholarship Commission in the UK.

Now, with support from the University of Nigeria Nsukka, Chukwudi is working on two research projects at NIH as part of her APTI fellowship. Both focus on neglected tropical diseases (NTDs). The first aims to develop a broad-spectrum topical treatment for cutaneous leishmaniasis by repurposing two existing antimicrobial agents. Leishmaniasis is a parasitic disease found in parts of the tropics, subtropics, and southern Europe. It is caused by infection with Leishmania parasites, which are spread by the bite of phlebotomine sand flies. In her second APTI project, she is investigating the population genomics of African trypanosomes, parasites that infest the blood of various vertebrates, circulating in humans and animals in Nigeria. This project has uncovered new, previously overlooked areas where infections are occurring in Nigeria. Through the APTI fellowship she has, “learned that a successful science or research career requires more than laboratory or research skills. Soft skills such as grantsmanship, research management, and knowing how to present and publish your research are equally, if not more, important.” With these skills and the laboratory training she has received during her fellowship, Chukwudi feels better prepared for success. Her career goal moving forward is to help train the next generation of African scientists and build a team of

36 Delaware Journal of Public Health - December 2023

researchers in molecular biology and genetics that will develop effective interventions for the infectious diseases endemic to Nigeria and Africa. Photo courtesy Ajakaye Oluwaremilekun Grace

The African Postdoctoral Training Initiative (APTI), established in 2019, prepares future generations of African researchers through four-year fellowships—two years spent in an NIH lab and an additional two years at their home institutions in Africa. Fogarty caught up with two fellows from APTI’s second cohort, now in their second year, to learn how the program has impacted their careers

Dr. Ajakaye Oluwaremilekun Grace Dr. Ajakaye Oluwaremilekun Grace, another member of the second APTI cohort originally from Nigeria, has focused her research on neglected parasites, particularly those prevalent in Africa. Her research aims to uncover the genetic diversity of these parasites, as variations within parasite populations Dr. Ajakaye Oluwaremilekun Grace is currently studying procan influence virulence, tozoan parasites at the National transmission, and drug Institute of Allergy and Infectious resistance. Genotyping these Diseases. neglected parasites is the key to understanding their complex biology. The challenge, however, lies in resource-constrained environments where conventional genotyping methods are often impractical. Because of this, Grace’s primary goal for her APTI fellowship has been to develop cost-effective and adaptable genotyping technologies specifically designed for these settings, which she has already accomplished. With a year still left in her fellowship, she’s created a lowcost, versatile, technique for genotyping these parasites. With this method, she has successfully characterized parasite samples (i.e., compared different types of parasites to determine how they are related and how they have evolved) from Nigeria and the Democratic Republic of the Congo. As a result, she discovered a hybrid schistosome species in both countries, thus shedding light on the intricate interactions and genetic diversity within these parasites.

“ I believe that training African scientists to lead research

and break new ground will have a ripple effect across Africa in the coming years.

”

— AJAKAYE OL UWAREMILEKUN GRACE Grace says that her APTI fellowship has been “the springboard for her career” and believes its impact will extend well beyond these short four years. She hopes ultimately that this experience will allow her to influence the trajectory of parasitology research in Nigeria, the continent of Africa, and the world.

PP RR OO FF II LL EE PROFILE Expanding medical Expanding medical Expanding medical literature access in Peru literature access in Peru literature access in Peru

4 4 4

Roxanna Garcia, MD, MPH Roxanna Garcia, MD, MPH Fogarty Fellow: 2019-2020 Roxanna Garcia, MD, MPH Fogarty Fellow: 2019-2020 U.S. institution: Fogarty Fellow: U.S. institution: Foreign institution: U.S. institution: Foreign institution: Research topic: Foreign institution: Research topic: Current affiliation: Research topic: Current affiliation: Current affiliation:

Northwestern University 2019-2020 Northwestern University Universidad Peruana Cayetano Heredia Northwestern University Universidad Peruana Cayetano Heredia Neurosurgery Universidad Peruana Cayetano Heredia Neurosurgery Feinberg School of Medicine, Northwestern University Neurosurgery Feinberg School of Medicine, Northwestern University Feinberg School of Medicine, Northwestern University

patients. Many hospitals her team studied, even in very patients. hertools, teamworkforce, studied, even very populatedMany cities,hospitals lacked the andin institupatients. Many hospitals her teamaworkforce, studied, even very populated cities, lacked tools, andininstitutional support needed tothe perform basic craniotomy, a populated cities, lacked tools,for workforce, and institutional support needed tothe perform a basic craniotomy, afrom potentially life-saving procedure patients suffering tional support needed procedure to perform a basic craniotomy, afrom potentially life-saving for patients suffering subdural hematomas. This condition, when blood collects potentially life-saving procedure patients suffering from subdural hematomas. This when collects between the covering of the condition, brainfor (dura) andblood the surface of subdural hematomas. This condition, when blood collects between covering of to the brain (dura) and the surface of the brain,the occurs in up 25% of patients suffering a brain between the covering of to theif brain (dura) and the surface of the brain, occurs up 25% patients suffering a brain injury, and can beindeadly notof treated quickly. the brain, up to 25% patients suffering a brain injury, andoccurs can beindeadly if notoftreated quickly. injury, and can be deadly if not treated quickly. Ultimately, her team recommended expanding access to Ultimately, her recommended to the literature onteam neurosurgery. Thisexpanding would helpaccess to explain Ultimately, heron team recommended access to the literature neurosurgery. Thisexpanding wouldcare helpin tolower explain disparities in access to neurosurgical the literature on This wouldcare help explain the disparities inneurosurgery. access neurosurgical intolower resource settings and to to prevent publication bias—selective the disparities in access to neurosurgical care in lower resource settings and tostudies preventbased publication bias—selective publication of research on results, where resource settings andoutcomes tostudies preventare publication bias—selective publication ofpositive research based on results, where studies with favored over those with publication ofpositive research studies based on results, where studies outcomes are favored over those with negativewith outcomes. studies positive outcomes are favored over those with negativewith outcomes. negative outcomes. Today, Garcia serves as an assistant professor of neuroToday, Garcia serves as an assistant professor of neurological surgery at Northwestern University’s Feinberg Today, Garcia serves as an assistant professor of neurological at Northwestern University’s School surgery of Medicine with about six more yearsFeinberg before logical surgery at Northwestern University’s Feinberg School ofbecoming Medicine about six more years beforeShe officially awith board-certified neurosurgeon. School of Medicine with about six more years beforeShe officially becoming a board-certified neurosurgeon. sits on several international neurosurgical committees, officially becoming a Federation board-certified neurosurgeon. She sits on several international neurosurgical committees, including the World for Neurosurgical sits on several international neurosurgical committees, including Worldin Federation Neurosurgical Societies. the Founded 1955, it isfor one of the oldest and including the World in Federation Neurosurgical Societies. Founded 1955, it isfor one of the oldest As anda largest international neurosurgery organizations. Societies. Founded inneurosurgery 1955, one of10 theneurosurgeons oldest and largest international organizations. As a part of this global group, sheitisisone of largest neurosurgery organizations. As a part of international thistoglobal group, she isfor one of 10 neurosurgeons who work strategize targets improving neurosurgical part of this global group, she is one of 10 neurosurgeons who to strategize targets improving neurosurgical care work in collaboration with WHOfor partners. who to strategizewith targets forpartners. improving neurosurgical care work in collaboration WHO care in collaboration with WHO partners. She advises future trainees, especially those interested She advises future those in interested in neurosurgery, totrainees, “embraceespecially the challenges your She advises especially those interested in neurosurgery, totrainees, “embrace the challenges in but yourif you personal andfuture academic life. No one is immune, in neurosurgery, to “embrace the challenges in your personal andand academic life.toNo one is immune, but with if you stay positive continue network and connect personal and academic life. No one is immune, but with if you stay positive and continue to network and connect mentors, it can change your life.” stay positive andchange continue to life.” network and connect with mentors, it can your mentors, it can change your life.” 37

Photo courtesy Northwestern Medical Group Photo courtesy Northwestern Medical Group Photo courtesy Northwestern Medical Group

Dr. Roxanna Garcia didn’t have in her mind a clear path Dr. GarciaAs didn’t have in her mind a clear path intoRoxanna neurosurgery. a first-generation medical school Dr. Roxanna Garcia didn’t have in her mind a clear path into neurosurgery. first-generation medical school applicant, she says,As “I awas skeptical that I would even be into neurosurgery. first-generation medical applicant, shemedical says,As“I aschool, was skeptical that I would even be accepted into let alone become aschool surgeon, applicant, she medical says, “I school, was skeptical that I would even be accepted into let alone become a surgeon, and especially a neurosurgeon.” accepted into medical school, let alone become a surgeon, and especially a neurosurgeon.” and especially a neurosurgeon.” For those unfamiliar with how long it takes to become a For those unfamiliar with how long it takes to become neurosurgeon in the United States, is a 15-year tracka at For those unfamiliar with how long it takes to become a at neurosurgeon in the United it why is a there 15-year a minimum. This is likely theStates, reason aretrack only neurosurgeon in the United States, it is a 15-year track at a minimum. This is likely the reason why there are only 4,000 or so practicing neurosurgeons in the country today. a4,000 minimum. This is likely the reason why there are only so entering practicing neurosurgeons in the country today. Garciaor was her sixth year of training when she 4,000 orwas sothe practicing neurosurgeons in the country today. Garcia entering her sixth year of training when she applied to Fogarty Fellows and Scholars program, now Garcia entering her sixth year trainingprogram, when she applied to LAUNCH. the Fogarty Fellows and of Scholars now known was as applied to the Fogarty Fellows and Scholars program, now known as LAUNCH. known asfor LAUNCH. Her love public health drove her initial interest in Her love school for public drove her initial interest medical andhealth she originally planned to work in Her love school fordisease public health drove her initial interest in medical andor she originally planned to work in infectious as an epidemiologist. Her ideas medical school and she originally planned to work in infectious disease or as an epidemiologist. Her ideas changed after her undergraduate and preclinical years infectious disease as degrees an epidemiologist. Her ideas changed her or undergraduate preclinical years and afterafter she obtained in and public health and changed after her undergraduate and preclinical years and after through she obtained degrees inofpublic healthBerkeleyand medicine the University California, and after she obtained degrees inof public healthBerkeleyand medicine through the University California, University of California, San Francisco Medical Program. medicine through the University of California, BerkeleyUniversity of California, Francisco Medical Program. Along the way, she’d alsoSan spent some time in Mexico University of California, Francisco Medical Program. Along the way, she’d alsoSan spent some to time in Mexico doing infectious disease work related Chagas disease. Along spentrelated some time in duties Mexico doing infectious work to Chagas disease. “It hit the me way, whileshe’d Idisease wasalso performing my clinical that doing infectious work related towas Chagas disease. “It me whileinfectious Idisease was performing my clinical duties that thehit day-to-day disease work not for me. “It hit me while I was performing clinical duties that the day-to-day infectious disease my work for me. While it was interesting intellectually, I was was not also drawn the day-to-day infectious disease work Iwas me. While itawas interesting intellectually, wasnot alsofor drawn toward different medical discipline—neurosurgery: While it was interesting intellectually, I was also drawn toward a different medical discipline—neurosurgery: there was something very intense and unique about it.” toward a different medical discipline—neurosurgery: there was something verytransitioned intense andtounique about Understanding this, she a career thatit.” there was something very intense andto unique about Understanding this, she transitioned a career that merges her interests in public health and surgery. “Iit.” feel Understanding this, she transitioned to a career that merges herfortunate intereststo inhave public health and surgery. “I feel incredibly found this path.” merges herfortunate interests to in have public health and surgery. “I feel incredibly found this path.” incredibly fortunate to have found this path.” Garcia’s Fogarty project aimed to describe the current Garcia’s Fogarty project aimed the current to health care system in Peru andto itsdescribe level of preparedness Garcia’s Fogarty project aimed toitsdescribe current health system in primary Peru andneurosurgical level of the preparedness to providecare essential and care. She and health care system in Peru and its level of preparedness to provide and primary care. She and her teamessential also identified target neurosurgical areas for further research provide essential and primary care. She and her team alsointerventions identified target areas further research projects and thatneurosurgical wouldfor strengthen the her team also identified target areas for further research projects interventions that would strengthen the surgical and ecosystem within Peru. projects interventions that would strengthen the surgical and ecosystem within Peru. surgical ecosystem withinthat Peru. Her research team found there were often delays in Her research foundbasic that and there were often delays in accessing the team country’s essential primary care, Her research found that and there were often delays in accessing theteam country’s basic primary care, let alone higher-level services and essential surgical care. Everyone accessing the country’s basic and primary care, let alone higher-level services and surgical care. Everyone in the Peruvian system receives anessential identification number, let alone higher-level services and surgical care. Everyone in the Peruvian system receives an identification similar to a Social Security number in the Unitednumber, States. in the Peruvian receives anconnected identification number, similar to not a Social Security number in the United States. However, allsystem the hospitals are digitally similar to not a Social Security number in the United States. However, all the hospitals connected digitally which causes discrepancies inare tracking and follow-up with However, not all the hospitalsinare connected digitally with which causes discrepancies tracking and follow-up which causes discrepancies in tracking and follow-up with

Q&A

PURNIMA MADHIVAN AN, MBBS, PHD, MPH

Dr. Purnima Madhivanan, associate professor at the Mel & Enid College of Public Health at University of Arizona, trained as a physician at Government Medical College in Mysore, India. Afterwards, she earned an MPH and a PhD in epidemiology from the University of California, Berkeley. While writing her dissertation, she established the Public Health Research Institute of India (PHRII); PHRII’s Mysorebased reproductive health clinic has delivered services to more than 24,000 low-income women living in the district since 2005. She is principal investigator on the Global Health Equity Scholars Training Program, a collaboration of Yale, Stanford, University of Arizona, and University of California, Berkeley. Her research includes working with Hispanic populations in Arizona.

The most important feature of CBPR is its fundamental focus on creating health equity in communities that may be affected by social, structural and environmental racism. There is a tendency for people to define CBPR as just another research method to be used in every situation, but I disagree. In my way of interpreting CBPR, it is a community-building approach, a methodology that recognizes community as a unit with its own identity, strengths and resources already in place. CBPR is assetfocused. It begins with an idea that is positive, instead of “Oh, this community does not have this, so let's bring that to them.” CBPR identifies a community’s strengths and then builds on those strengths.

You see the individuality of communities, do you also see commonalities? There are many commonalities! For instance, there are people here in Arizona who are exposed to high rates of pesticides in their drinking water. All the mining here means we have a lot of toxic metals in our soil and in our environment. They also have a higher risk of developing Alzheimer’s, Parkinson’s, and multiple sclerosis. This community is distinct, yet it shares some basic characteristics with other communities with similar problems, like poverty, low levels of health literacy, discrimination, systemic racism, and a lack of medical care. Such commonalities are important but each time we approach a new community, we must prioritize the things that are important to that community. They might share similar issues as others, but how they prioritize them might be different. So even if you think you know what should be done and the order of steps to be taken, it’s more about empowering an individual community to voice and solve its own problems.

38 Delaware Journal of Public Health - December 2023

You work at the intersection of infectious and chronic diseases: please explain.

Photo courtesy of University of Arizona Cancer Center

What is community-based participatory research (CBPR)?

Cervical cancer is the fourth most common cancer among women globally with about 600,000 new cases and about 300,000 deaths each year. In India alone, we have about 100,000 new cervical cancer cases and 72,000 deaths annually. It is a persistent infection with a virus called human papillomavirus (HPV)—the high-risk HPV strain— that leads to cancer. HPV is an infection, cervical cancer is a chronic disease, so the intersection between the two is significant. We’re seeing more and more examples of viruses causing cancer, including Epstein-Barr, hepatitis B, hepatitis C and human herpes virus 8 (also known as Kaposi’s sarcoma herpesvirus). A lot of my work has been about identifying infection so that we can prevent cancer by vaccinations (primary prevention) or screening (secondary prevention). Now that we have a vaccine for hepatitis B, let’s make sure everybody’s vaccinated; there’s a vaccine for HPV, let’s get that into every 9-year-old—that’s my focus.

How has implementation science influenced you? The field of implementation research understands that use of research knowledge, not just production of knowledge, is a primary concern and so implementation scientists ask a unique set of questions: Are we working with the communities to formally define an implementation process? Who is the primary audience? How do we plan to reach them? Over time, practices in the field have become more formalized with researchers using evidence-based interventions to change health behaviors across communities. In many ways, I’ve been doing implementation science all along. Now, though, I plan to formalize implementation research methodology in my work and I’m going to be more intentional about these methods as I move forward with my research.

Division Divisionof ofInternational International Division of International Epidemiology Epidemiology and and Epidemiology and Population PopulationStudies Studies Population Studies Research ResearchRoundup Roundup Research Roundup

Image adapted from Figure 2 of the publication, courtesy Wha-Eum Lee, et al. Image adapted Image adapted from Figure from2Figure of the2publication, of the publication, courtesycourtesy Wha-Eum Wha-Eum Lee, et al. Lee, et al.

FFO OCCUUSS FOCUS

TheThe authors authors estimate estimate there there were were 102,800 102,800 excess excess deaths deaths from from external external causes causes from from March March 1, 1, 2020, 2020, to January to January 1, 1, 2022 2022 The authors estimate there were 102,800 excess deaths from external causes from March 1, 2020, to January 1, 2022

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etween etween January January and and November November 2023, 2023, Fogarty’s Fogarty’s Di-Division vision ofof International International Epidemiology Epidemiology and and Population Population etween January and November 2023, Fogarty’s DiStudies Studies (DEIPS) (DEIPS) has has published published 25 25 studies studies inin peerpeervision of International Epidemiology and Population reviewed reviewed journals. journals. The The following following pages pages summarize summarize the the Studies (DEIPS) has published 25 studies in peerteam’s team’s significant significant contribution contribution toto scientific scientific research research onon aa reviewed journals. Theto following pages summarize the range range ofof topics topics related related to both both domestic domestic and and global global health. health. team’s significant contribution to scientific research on a range of topicsimpact related toof both domestic and global health. Examining Examining impact ofCOVID-19 COVID-19 on on mortality mortality

ininthe theU.S. U.S. Examining impact of COVID-19 on mortality Senior author Cécile Cécile Viboud Viboud and and her her colleagues colleagues examined examined inSenior theauthor U.S.

the the impacts impacts ofof the the COVID-19 COVID-19 pandemic pandemic onon U.S. U.S. mortality mortality Senior author Cécile and her colleagues examined inin this this eLife eLife study. study. AtViboud At the the end end ofof January January 2023, 2023, Johns Johns the impacts of the COVID-19 pandemic ontotal U.S. mortality Hopkins Hopkins University University reported reported 1,056,000 1,056,000 total U.S. U.S. deaths deaths in this eLife study.yet Atyet the end of January 2023, Johns due due toto COVID-19, COVID-19, some some scientists scientists suggest suggest this this figure figure is is Hopkins University reported 1,056,000 total U.S. deaths not not high high enough. enough. Excess Excess mortality mortality methodologies, methodologies, which which due to COVID-19, yet some scientists this figure is measure measure increases increases inin mortality mortality over over a suggest historical a historical baseline, baseline, not high enough. Excess mortality methodologies, which have have been been used used forfor more more than than a century a century toto capture capture the the full full measure increases indisease mortality over awell historical baseline, scope scope ofof infectious infectious disease events events asas well asas ofof heatwaves heatwaves have been used forHere, more than a and century toco-authors capture the full and and earthquakes. earthquakes. Here, Viboud Viboud and her her co-authors aimed aimed scope of infectious disease events as well as of heatwaves toto disentangle disentangle direct direct and and indirect indirect mortality mortality impacts impacts ofof and earthquakes. Here, Viboud andregression her co-authors aimed the the pandemic pandemic inin the the U.S. U.S. byby using using regression models models and and to disentangle analyses. direct and indirect mortality impacts of synchronicity synchronicity analyses. the pandemic in the U.S. by using regression models and synchronicity analyses. “Direct “Direct effects” effects” ofof COVID-19, COVID-19, the the authors authors explain, explain, are are

pollution. pollution. Indirect Indirect pandemic pandemic impacts impacts onon mental mental health, health, violence, violence, and and addiction addiction remain remain debated, debated, especially especially since since pollution. Indirectlarge pandemic impacts on mental health, these these potentially potentially large effects effects onon mortality mortality may may or or may may not not violence, and addiction remain debated, especially since coincide coincide (timewise) (timewise) with with COVID-19 COVID-19 waves. waves. these potentially large effects on mortality may or may not coincide (timewise) with COVID-19 waves.ofof InIn the the U.S., U.S., the the trajectory trajectory and and experience experience the the COVID-19 COVID-19 pandemic pandemic varied varied greatly greatly depending depending onon the the region region and and time time In the U.S., the trajectory and experience of the COVID-19 period. period. There There were were also also inconsistencies inconsistencies inin the the interventions interventions pandemic varied greatly depending ondifferences the region and time implemented implemented inin each each region. region. These These differences provide provide period. There were also inconsistencies in the interventions anan opportunity opportunity toto separate separate the the contributions contributions ofof viral viral implemented inother each region. differences provide infection infection from from other drivers drivers ofThese of mortality. mortality. ToTo separate separate an opportunity to separate the contributions of direct direct consequences consequences ofof SARS-CoV-2 SARS-CoV-2 infection infection onviral on ageageinfection from other drivers of mortality. To separate specific, specific, state-specific state-specific and and cause-specific cause-specific mortality mortality from from direct consequences of associated SARS-CoV-2 infection onstrain ageindirect indirect consequences consequences associated with with hospital hospital strain and and specific, state-specific and applied cause-specific mortality from interventions, interventions, the the authors authors applied time time series series analytic analytic indirect consequences associated with hospital strain and1,1, approaches approaches toto four four large large waves waves ofof COVID-19 COVID-19 from from March March interventions, the authors applied time series analytic 2020, 2020, toto January January 1,1, 2022. 2022. approaches to four large waves of COVID-19 from March 1, 2020, to January 1, 2022. The The pandemic’s pandemic’s direct direct and and indirect indirect effects effects varied varied substansubstan-

those those deaths deaths that that result result from from SARS-CoV-2 SARS-CoV-2 infection infection and and tially tially byby chronic chronic condition condition and and age age group, group, the the authors authors “Direct effects” of as COVID-19, the authors explain, are itsits complications complications as well well asas those those deaths deaths sparked sparked by by viral viral The pandemic’s direct and indirect effects varied substanestimated. estimated. Somewhere Somewhere in in the the range range of of 65% 65% to to 94% 94% ofof the the those deaths that resultafrom SARS-CoV-2 infection and infection. infection. For For instance, instance, rise a rise in in diabetes diabetes mortality mortality would would tially by chronic condition and age group, the authors rise rise in in all-cause all-cause mortality mortality could could be be statistically statistically linked linked to to its complications as wellwith as those deaths sparkedcases by viral bebe expected expected toto coincide coincide with a rise a rise inin COVID-19 COVID-19 cases estimated. Somewhere in the range of 65% and toand 94% of the SARS-CoV-2 SARS-CoV-2 activity. activity. Mortality Mortality in in children children young young adults adults infection. For instance, a patients rise in would diabetes mortality would because because some some diabetic diabetic patients would have have died died due due rise in all-cause mortality could be statistically linked to and and mortality mortality from from accidents, accidents, injuries, injuries, drug drug overdoses, overdoses, be expected to coincide with a rise in COVID-19 cases toto anan undetected undetected SARS-CoV-2 SARS-CoV-2 infection infection triggering triggering their their SARS-CoV-2 activity. Mortality in children and young adults assaults, assaults, and and homicides, homicides, showed showed a marked a marked relationship relationship with with because some diabetic patients wouldfrom have died due condition—just condition—just asas every every year year deaths deaths from chronic chronic conditions conditions and mortality from accidents, injuries, drug overdoses, COVID-19 COVID-19 interventions, interventions, supporting supporting the the idea idea that that indirect indirect to analongside undetected SARS-CoV-2 infection triggering their rise rise alongside seasonal seasonal fluflu deaths. deaths. “Indirect “Indirect effects,” effects,” onon assaults, and homicides, showed aactual marked relationship with pandemic pandemic effects effects (unrelated (unrelated toto anan actual SARS-CoV-2 SARS-CoV-2 condition—just as every year deaths from chronic conditions the the other other hand, hand, are are both both the the positive positive and and negative negative changes changes COVID-19 interventions, supporting the idea that indirect infection) infection) increased increased death death rates. rates. The The authors’ authors’ most most striking striking rise alongside seasonal flu deaths. “Indirect effects,” on inin mortality mortality that that are are not not linked linked toto an an actual actual SARS-CoV-2 SARS-CoV-2 pandemic effects (unrelated to anexcess actual SARS-CoV-2 finding finding is is an an estimated estimated 112,200 112,200 excess deaths deaths in in individuals individuals the other during hand, are both the positive and negative changes infection infection during the the pandemic pandemic period. period. Possible Possible reasons reasons forfor infection) increased rates. The authors’ most striking 2525 toto 4444 years years old old bydeath by January January 1,1, 2022—of 2022—of these these not not even even aa in mortality that are not linked to an actual SARS-CoV-2 these these changes changes include include avoidance avoidance ofof health health care care systems, systems, finding is an estimated 112,200 excess deaths in individuals third third are are ascribed ascribed to to COVID-19 COVID-19 in in the the official official statistics. statistics. infection during the pandemic period. Possible reasons stressed stressed health health care care systems, systems, mental mental health health issues issues ininfor 25 to 44 years old by January 1, 2022—of these not even a these changes include avoidance of health care systems, families families ofof severely severely affected affected COVID-19 COVID-19 patients, patients, societal societal Article Article title: title: Direct Direct and indirect indirect mortality mortality impacts impacts ofof the the third are ascribed toand COVID-19 in the official statistics. stressed health care systems, mental health issues in disruptions, disruptions, decreased decreased social social interaction interaction that that suppresses suppresses COVID-19 COVID-19 pandemic pandemic inin the the United United States, States, March March 1,1, 2020 2020 families of severely affected COVID-19 patients, societal Article title: 1, Direct and indirect mortality impacts of the circulation circulation ofof endemic endemic pathogens, pathogens, and and decreased decreased airair toto January January 1, 2022 2022 disruptions, decreased social interaction that suppresses COVID-19 pandemic in the United States, March 1, 2020 circulation of endemic pathogens, and decreased air to January 1, 2022

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Studying COVID-19 in South Africa sheds light on how immunity contributes to variant success First author Dr. Kaiyuan Sun was joined by Dr. Cécile Viboud and colleagues from the CDC, Johns Hopkins University, and South African academies and institutions for this Nature Communications study.

For data, the authors turned to a prospective study of roughly 200 randomly selected South African households, half of which live in a rural community in Mpumalanga Province, the other half in an urban community in North West Province. Participants in the PHIRST-C study—the Prospective Household study of SARS-CoV-2, Influenza, and Respiratory Syncytial virus community burden, Transmission dynamics and viral interaction in South Africa study—were visited twice-weekly for collection of nasal swabs and information on symptoms, and every two months for blood draws. PHIRST -C seeks to answer various questions, including: Who is most at risk for severe illness? Can asymptomatic individuals transmit the virus? How is SARS-CoV-2 influenced by other respiratory viruses, including flu? How do age and HIV-infection affect transmission and symptoms? Sun and his co-authors quantified changes in immunologic exposure to SARS-CoV-2 across the population and over time and compared Omicron’s epidemiology to that of prior variants. The team found the Omicron wave infected 58% and 65% of the population in the study’s urban and rural cohorts, respectively. Re-infections and vaccine breakthrough infections accounted for more than half of the Omicron infections, the researchers noted. After adjusting for prior immunity and other factors, they estimated that people were more than twice as likely to get infected during Omicron than Delta; and relaxing

40 Delaware Journal of Public Health - December 2023

Colorized scanning electron micrograph of a cell (red) infected with the Omicron strain of SARS-CoV-2 virus particles (yellow), isolated from a patient sample.

nonpharmaceutical interventions likely contributed to this higher risk. Overall, the Omicron wave had a significantly higher attack rate in South Africa compared to previously circulating strains. Dr. David Spiro, director of Fogarty's Division of International Epidemiology and Population Studies, commented: “This study showcases some of the cutting-edge research recognized as typical of our team by others in the field.” Article title: Rapidly shifting immunologic landscape and severity of SARS-CoV-2 in the Omicron era in South Africa

Other articles of note Understanding the diversity and relatedness of early Omicron strains in Pakistan Drs. David Spiro, Nídia Trovão and Zeba Rasmussen contributed to this BMC Genomics study that sought to understand the diversity and phylogenetic relatedness of SARS-CoV-2 strains in various regions of Pakistan. The team analyzed data on 276,525 COVID-19 cases and 1,031 genomes sequenced from December 2021 to August 2022. They found the highest case numbers and deaths recorded in Sindh and Punjab, Pakistan’s most populous provinces. Omicron variants comprised 93% of all genomes, with subvariants BA.2 (32.6%) and BA.5 (38.4%) predominating. Analysis identified Sindh as a hotspot for viral dissemination. Article title: Sequential viral introductions and spread of BA.1 across Pakistan provinces during the Omicron wave

Image courtesy of NIAID

SARS-CoV-2’s rapid evolution throughout the pandemic has been one of the virus’s most prominent features. Every few months new variants have emerged to become dominant globally. To date, the World Health Organization has classified five SARS-CoV-2 lineages as variants of concern (VOCs), including Alpha, Beta, Gamma, Delta and Omicron. The selective advantage of each new variant (and its subvariants) is shaped in part by host population immunity. As of August 1, 2022, South Africa had experienced five SARS-CoV-2 epidemic waves. Scientists suggest the Beta VOC and Omicron subvariants BA.1, BA.4 and BA.5 are likely to have emerged in the region. For this reason, detailed studies of South Africa’s immunologic landscape could provide a unique perspective on how immunity contributes to variant success.

FOCUS ON DIVISION OF INTERNATIONAL EPIDEMIOLOGY AND POPULATION STUDIES RESEARCH ROUNDUP FOCUS ON DIVISION OF INTERNATIONAL EPIDEMIOLOGY AND POPULATION STUDIES RESEARCH ROUNDUP FOCUS ON DIVISION OF INTERNATIONAL EPIDEMIOLOGY AND POPULATION STUDIES RESEARCH ROUNDUP

Exploring intercontinental movement of Exploring intercontinental of influenza among migrating movement aquatic birds influenza among migrating aquatic birds Exploring intercontinental movement of

Dr. Nídia Trovão co-authored this paper exploring influenza among migrating aquatic birds Dr. Nídia Trovão movement co-authored this paper exploring intercontinental and reassortment of influenza iDr. ntercontinental movementamong and ofthat influenza Nídia Trovão co-authored this reassortment paper exploring A viruses (IAV) circulating aquatic birds intercontinental movement reassortment of influenza A virusesto(IAV) circulating among aquatic birds that m igrate breeding zones and in the Arctic and sub-Arctic. A igrate viruses (IAV) circulating among birdssub-Arctic. that m breeding zones in theaquatic Arctic B etweento May 2010 and February 2018,and the team obtained m igrate to breeding zones in the Arctic and sub-Arctic. etweenfrom May various 2010 and February 2018, the team obtaine iBsolates species of seabirds, shorebirds and d etween from May 2010 andspecies February 2018, the shorebirds team obtained iB solates various of seabirds, w aterfowl plus samplings of avian fecal material fromand isolates from various species seabirds, shorebirds and aterfowl plus samplings ofof avian fecal material lwocations throughout Iceland, which connects thefrom east w aterfowl plus samplings of avian fecal material from locations throughout Iceland, whichand connects the east a nd north Atlantic flyways. Trovão her co-authors locations throughout Iceland, which connects the east atated nd north Atlantic flyways. Trovão and her co-authors s in Molecular Ecology, “Gulls play outsized role and north Atlantic flyways. Trovão and heran co-authors stated in of Molecular Ecology, “Gulls play anavian outsized role a s sinks influenza A viruses from other hosts stated in Molecular Ecology, “Gulls play an outsized role asrior sinks of influenza A viruses from other avian hosts p to onward migration.” as sinks of influenza A viruses from other avian hosts p rior to onward migration.” prior to onward migration.”

A map showing migratory ranges for types of birds that are hosts for various

A map showing migratory foroftypes birds for various influenza Amigratory viruses. A map showing rangesranges for types birds of that are that hostsare for hosts various influenza A viruses. influenza A viruses.

Image adapted from Figure 3 of the publication, courtesy Jonathon D. Gass Jr., et al.

Exploring hotspots of mutation in bacterial Exploring hotspotsofofmutation mutation bacterial Exploring hotspots inin bacterial genomes genomes genomes

Image Image adapted adapted fromfrom Figure Figure 3 of3the of the publication, publication, courtesy courtesy Jonathon Jonathon D. Gass D. Gass Jr., et Jr.,al. et al.

Article title: Global dissemination of influenza A virus is A rticle title: Global dissemination influenza A virus Ariven rticle title: Global ofof influenza virus is is d by wild birddissemination migration through arctic Aand subarctic d riven by wild wildbird birdmigration migrationthrough through arctic and subarctic dones riven by arctic and subarctic z zzones ones

In Salmonella, a G run of length three increases the a G by run length three increases the In Salmonella, aG run of of length three increases mutation rate a of factor (approximately) 26, athe run of Dr. Joshua Cherry published this exploration of bacterial In Salmonella, mutation rate rate by a by factor of (approximately) 26, a run Dr. Joshua Joshua Cherry published this exploration of bacterial mutation a factor of (approximately) 26, of a run 100, of Dr. Cherry published this exploration of bacterial length four increases it by a factor of (approximately) mutation in Genome Biology and Evolution. The rate of length fourfour increases it by it a factor of (approximately) 100, 100, mutation in Genome Biology and Evolution. The rate of of length increases by a factor of (approximately) mutation in Genome Biology and Evolution. The rate while runs of five or more increase it by a factor of more mutation is known to vary across genome position, yet while runsruns of five more increase it by a factor of moreof more mutation is totovary across genome position, yetyet while of or five or more increase by a factor mutation is known known vary genome than 400 (on average). This effect isitmuch stronger when local sequence context can across affect this rate,position, he notes. than 400 (on average). This effect is much stronger when when local sequence context can affect this rate, he notes. than 400 (on average). This effect isthe much stronger local sequence context can affectGthis rate, he notes. the T is on the leading rather than lagging strand of Preceding runs of three or more residues greatly the T is on the leading rather than the lagging strand of Preceding runs of three or more G residues greatly the T replication. is on the leading rather than the lagging strand of Preceding runs ofof three or more G residues greatly of this DNA increase the rate T to G mutation. The strength DNA replication. increase the rate of T to G mutation. The strength of this DNA replication. increase the ratewith of Tthe to G mutation. The strength of this effect increases length the run, a phenomenon effect increases with the length ofof the run, a phenomenon effect increases with the length of the run, a phenomenon Article T Residues Preceded by of Runs of Hotspots G Are Hotspots observed in all allbacteria bacteriaanalyzed analyzed yet strongest Article title:title: T Residues Preceded by Runs G Are observed in yet strongest in in Article title: T Residues Preceded by Runs of G Are Hotspots observed in (and all bacteria analyzed yetE. strongest in G Mutation in Bacteria Salmonella nearlyasas strong coli). of ToftoTGto Mutation in Bacteria Salmonella (and nearly strong inin E. coli). of T to G Mutation in Bacteria Salmonella (and nearly as strong in E. coli).

Air Pollution Intervention Network (HAPIN) trial trial Three studies studiesfrom fromthe theHousehold Household Air Pollution Intervention Network (HAPIN) Three studies from the Household Air Pollution Intervention Network (HAPIN) trial

Photo Photo courtesy courtesy Peace Peace Corps Corps

Photo courtesy Peace Corps

households, traditional stovesstoves were used median Reducing household requires nearly excluhouseholds, traditional were aused a median Reducing householdair airpollution pollution requires nearly exclu- tiontion tion households, traditional werepost-birth used a median Reducing air fuels. pollution requires nearly exclu- of 0.4% of allofmonitored days;days; pre-stoves and data sive use clean trial participants— of 0.4% all monitored pre-post-birth and data sive use of ofhousehold cleancooking cooking fuels.HAPIN HAPIN trial participants— of 0.4% of all monitored days; preand post-birth data showed no significant differences in adherence. Fogarty’s sive use of clean in cooking fuels.India, HAPIN trial participants— pregnant women Peru, and showed no significant differences in adherence. Fogarty’s pregnant women inGuatemala, Guatemala, India, Peru, and Dr. Joshua Rosenthal co-authored this study published showed no significant differences in adherence. Fogarty’s Rwanda—either a aliquefied petroleum (LPG) pregnant womenreceived in Guatemala, India, Peru, gas and Dr. Joshua Rosenthal co-authored this study published Rwanda—either received liquefied petroleum gas (LPG) stove interventionreceived or continued cooking Dr. Joshua International. Rosenthal co-authored this study published Rwanda—either awomen) liquefied gas (LPG) in Environment in Environment International. stove intervention(1,590 (1,590women) or petroleum continued cooking with traditional stoves (1,605). The intervention included in Environment International. stove intervention (1,590 women) orintervention continued cooking with traditional stoves (1,605). The included Article title: Fidelity and adherence to a liquefied petroleum a free stove, unlimited of LPG delivered to the Article title: Fidelity and adherence to a liquefied petroleum with stovessupply (1,605). intervention a freetraditional stove, unlimited supply ofThe LPG delivered toincluded the gas Article stove and fuel intervention: The multi-country title: Fidelity and adherence a liquefied petroleum home, repairs, and behavioral messaging. In intervengas stove and fuel intervention: Theto multi-country a free stove, unlimited supply of LPG delivered to the home, repairs, and behavioral messaging. In intervenHousehold gas stove and fuel intervention: The multi-country Household home, repairs, and behavioral messaging. In intervenTwo large black pots used for cooking over a wood fire in Eswatini. Household Dr. Rosenthal also co-authored two additional HAPIN Two large black pots used for cooking over a wood fire in Eswatini. Dr.articles. Rosenthal also co-authored two additional HAPIN study Two large black pots used for cooking over a wood fire in Eswatini. Dr. Rosenthal study articles. also co-authored two additional HAPIN Article title:articles. Effects of a LPG stove and fuel intervention on study Article title: Effects of a A LPG stove and randomized fuel intervention on adverse maternal outcomes: multi-country Article title: Effectsoutcomes: ofby a LPG stove andAir fuel intervention adverse maternal A multi-country randomizedon controlled trial conducted the Household Pollution adverse maternal outcomes: A multi-country randomized Intervention Network (HAPIN) by the Household Air controlled trial conducted Pollution controlled trial conducted by the Household Air Pollution Publication: Environment Intervention NetworkInternational (HAPIN) Intervention Network (HAPIN) Publication: Environment International Article title: Exposure-response relationships for personal Publication: Environment International exposure to fine particulate matter (PM2·5), carbon monArticle title: Exposure-response relationships for personal Article title: Exposure-response relationships for personal oxide, and black carbon and birthweight: an observational exposure to fine particulate matter (PM2·5), carbon monanalysis of the multicountry Household Air Pollution Inter-monexposure to fine particulate matter (PM2·5), carbon oxide, and black carbon and birthweight: an observational vention Network (HAPIN) trial.and birthweight: an observational oxide, and carbon analysis of black the multicountry Household Air Pollution InterPublication: The Lancet—Planetary Health analysis of the multicountry Household Air Pollution Intervention Network (HAPIN) trial. 8 vention Network (HAPIN) trial. Publication: The Lancet—Planetary Health Publication: The Lancet—Planetary Health 8

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Additional Additional Publications Publications Transmission Dynamics and Transmission Dynamics and Epidemiological Characteristics Epidemiological Characteristics of the SARS-CoV-2 Delta Variant – of the SARS-CoV-2 Delta Variant – Hunan Province, China, 2021 Hunan Province, China, 2021 • Fogarty author: Kaiyuan Sun • Fogarty author: Kaiyuan Sun • Publication: China CDC Weekly • Publication: China CDC Weekly Accelerating Bayesian inference of Accelerating Bayesian inference of dependency between mixed-type dependency between mixed-type biological traits biological traits • Fogarty authors: Nídia Trovão, • Fogarty authors: Nídia Trovão, Joshua Cherry Joshua Cherry • Publication: PLoS Computational • Publication: PLoS Computational Biology Biology Restriction Endonuclease-Based Restriction Endonuclease-Based Modification-Dependent Enrichment Modification-Dependent Enrichment (REMoDE) of DNA for Metagenomic (REMoDE) of DNA for Metagenomic Sequencing Sequencing • Fogarty author: Joshua Cherry • Fogarty author: Joshua Cherry • Publication: Applied and • Publication: Applied and Environmental Microbiology Environmental Microbiology Context-dependent representation Context-dependent representation of within- and between-model of within- and between-model uncertainty: aggregating uncertainty: aggregating probabilistic predictions in infectious probabilistic predictions in infectious disease epidemiology disease epidemiology • Fogarty author: Cécile Viboud • Fogarty author: Cécile Viboud • Publication: The Journal of the • Publication: The Journal of the Royal Society Interface Royal Society Interface Estimating the time-varying Estimating the time-varying reproduction number for COVID-19 reproduction number for COVID-19 in South Africa during the first four in South Africa during the first four waves using multiple measures of waves using multiple measures of incidence for public and private incidence for public and private sectors across four waves sectors across four waves • Fogarty author: Cécile Viboud • Fogarty author: Cécile Viboud • Publication: PloS One • Publication: PloS One Application of Phylodynamic Tools to Application of Phylodynamic Tools to Inform the Public Health Response to Inform the Public Health Response to COVID-19: Qualitative Analysis of COVID-19: Qualitative Analysis of Expert Opinions Expert Opinions • Fogarty author: Nídia Trovão • Fogarty author: Nídia Trovão • Publication: MIR Formative • Publication: MIR Formative Research Research 42 Delaware Journal of Public Health - December 2023

Core mitochondrial genes are Core mitochondrial genes are down-regulated during SARS-CoV-2 down-regulated during SARS-CoV-2 infection of rodent and human hosts infection of rodent and human hosts • Fogarty author: Nídia Trovão • Fogarty author: Nídia Trovão • Publication: Science • Publication: Science Translational Medicine Translational Medicine Host heterogeneity and epistasis Host heterogeneity and epistasis explain punctuated evolution of explain punctuated evolution of SARS-CoV-2 SARS-CoV-2 • Fogarty author: Cécile Viboud • Fogarty author: Cécile Viboud • Publication: PloS • Publication: PloS Computational Biology Computational Biology Multiple models for outbreak Multiple models for outbreak decision support in the face of decision support in the face of uncertainty uncertainty • Fogarty author: Cécile Viboud • Fogarty author: Cécile Viboud • Publication: PNAS • Publication: PNAS Leveraging Serosurveillance Leveraging Serosurveillance and Postmortem Surveillance to and Postmortem Surveillance to Quantify the Impact of Coronavirus Quantify the Impact of Coronavirus Disease 2019 in Africa Disease 2019 in Africa • Fogarty authors: Cécile Viboud • Fogarty authors: Cécile Viboud • Publication: Clinical Infectious • Publication: Clinical Infectious Diseases Diseases Impact of SARS-CoV-2 vaccination Impact of SARS-CoV-2 vaccination of children ages 5–11 years on of children ages 5–11 years on COVID-19 disease burden and COVID-19 disease burden and resilience to new variants in the resilience to new variants in the United States, November 2021– United States, November 2021– March 2022: a multi-model study March 2022: a multi-model study • Fogarty author: Cécile Viboud • Fogarty author: Cécile Viboud • Publication: The Lancet • Publication: The Lancet Regional Health—Americas Regional Health—Americas Behavioral factors and SARS-CoV-2 Behavioral factors and SARS-CoV-2 transmission heterogeneity within a transmission heterogeneity within a household cohort in Costa Rica household cohort in Costa Rica • Fogarty authors: Kaiyuan Sun, • Fogarty authors: Kaiyuan Sun, Cécile Viboud Cécile Viboud • Publication: Communications • Publication: Communications Medicine Medicine

Inferring the differences in Inferring the differences in incubation-period and generationincubation-period and generationinterval distributions of the Delta interval distributions of the Delta and Omicron variants of SARSand Omicron variants of SARSCoV-2 CoV-2 • Fogarty authors: Kaiyuan Sun, • Fogarty authors: Kaiyuan Sun, Cécile Viboud Cécile Viboud • Publication: PNAS • Publication: PNAS A Retrospective Modeling Study of A Retrospective Modeling Study of the Targeted Non-Pharmaceutical the Targeted Non-Pharmaceutical Interventions During the Xinfadi Interventions During the Xinfadi Outbreak in the Early Stage of the Outbreak in the Early Stage of the COVID-19 Pandemic — Beijing, COVID-19 Pandemic — Beijing, China, 2020 China, 2020 • Fogarty author: Kaiyuan Sun • Fogarty author: Kaiyuan Sun • Publication: China CDC • Publication: China CDC Weekly study Weekly study Evolutionary and spatiotemporal Evolutionary and spatiotemporal analyses reveal multiple analyses reveal multiple introductions and cryptic introductions and cryptic transmission of SARS-CoV-2 VOC/ transmission of SARS-CoV-2 VOC/ VOI in Malta VOI in Malta • Fogarty author: Nídia Trovão • Fogarty author: Nídia Trovão • Publication: Microbiology • Publication: Microbiology Spectrum Spectrum Predictors of severity of influenzaPredictors of severity of influenzarelated hospitalizations: Results related hospitalizations: Results from the Global Influenza Hospital from the Global Influenza Hospital Surveillance Network (GIHSN) Surveillance Network (GIHSN) • Fogarty author: Cécile Viboud • Fogarty author: Cécile Viboud • Publication: The Journal of • Publication: The Journal of Infectious Diseases Infectious Diseases Global and national influenzaGlobal and national influenzaassociated hospitalization rates: associated hospitalization rates: Estimates for 40 countries and Estimates for 40 countries and administrative regions administrative regions • Fogarty author: Cécile Viboud • Fogarty author: Cécile Viboud • Publication: Journal of Global • Publication: Journal of Global Health Health

9 9

DIRECTOR’S COLUMN By Dr. Peter Kilmarx, Acting Director, Fogarty International Center

In Memoriam: Robert B. Eiss –1954-2023 It is with a heavy heart that I remember and celebrate our dear colleague and friend, Rob Eiss, who passed away in late October. Rob was a dedicated, long-time member of our team and a quietly wise, remarkably knowledgeable, and profoundly effective advocate for global health research partnerships.

Whenever I felt stymied with some seemingly intractable problem of global health science, diplomacy, or advocacy, I would walk up to Rob’s door. He always made time for me, and always had clear insights on the central issues, the historical context, the multiple viewpoints to be considered, and the best way forward.

Rob’s contributions were not limited to Fogarty. He also served as a member of the NIH global health research Rob Eiss, a long-term team and as an advisor to former NIH Director Dr. member of the Fogarty Francis Collins. As a representative at the National Rob served Fogarty in a variety of team, passed away in late October. Science and Technology Council Subcommittee on capacities beginning in 1993, startInternational Science & Technology Coordination, he ing as a program officer in the Division ensured that global health was prominently featured of International Relations, then serving as director of the in the biennial report on international cooperation. As Office of International Science Policy and Analysis. From a lead writer for the National Science and Technology 2000 to 2003 he took on the role of associate director Council, he authored reports on U.S. government for planning and budget at the White House Office of science and technology relations with Russia as well National Drug Control Policy, and from 2005 to 2007 as on European economic integration and science he served as the CEO of the Center for Management and technology cooperation. of Intellectual Property in Health Rob also advised the WHO Research, a non-profit based in Science Council and worked Oxford, UK, that partnered with the on an initiative to engage the Medical Research Council of South public and private sector in Africa. Rob returned to Fogarty in strengthening the genomic 2007, serving as senior advisor to research workforce in Africa, Fogarty Director Dr. Roger Glass which has since expanded and, following Roger’s retirement in significantly. He also was the January, Rob became my advisor. NIH lead on issues related to the EU General Data Protection Rob was a leader, a negotiator, an Regulation, a long-term organizer, a representative, and a challenge for international visionary, who understood Fogarty research collaboration requiring and recognized the vital potential for very high-level diplomacy that global health research partnerships. Rob handled with remarkable His early, significant contribution Rob Eiss (left) and Peter Kilmarx (right) in an undated photo. skill and persistence. was leading the creation of Fogarty’s first strategic plan for 2000-2003, which reoriented our Throughout his admirable career, Rob demonstrated an programs and our focus toward the persistent burdens of unwavering commitment to advancing collaborations communicable and emerging chronic diseases in low- and in pursuit of global health equity. His contributions middle-income countries. This plan provided the analytic were not only significant in their impact but also framework for NIH investments in Africa that ultimately characterized by a humility and quiet determination led to the Multilateral Initiative on Malaria. Rob had a that left a lasting impression on all who had the rare ability to quickly synthesize information, apply his privilege of working with him. In the last month I have unique perspective, and then discover fresh opportunities heard from colleagues from all over NIH, other U.S. for the advancement of NIH’s global mission. agencies, academia, and around the world about Rob’s important contributions, his admirable qualities, and Before the COVID-19 pandemic, Rob and I shared their sadness at his loss. adjacent offices in the Fogarty Director’s office suite.

PEOPLE PEOPLE PEOPLE Monica Bertagnolli confirmed as NIH Director Monica Bertagnolli Bertagnolli confirmed confirmed asasNIH NIH Director Dr.Monica Monica Bertagnolli has been confirmed asDirector the 17th director

Dr. Monica Monica Bertagnolli Bertagnolli has has been been confirmed confirmed asas the the 17th 17th director director of Dr. NIH. Bertagnolli is the first surgeon and the second woman to of of NIH. NIH. Bertagnolli Bertagnolli is is the the first first surgeon surgeon and and the the second second woman woman to to hold this prestigious position. A physician-scientist, Bertagnolli hold hold this this prestigious prestigious position. position. A physician-scientist, A physician-scientist, Bertagnolli Bertagnolli was most recently director of the National Cancer Institute. She was was most most recently recently director director of of the National National Cancer Cancer Institute. Institute. She She was chief of surgical oncology atthe the Dana-Farber Brigham was was chief chief of of surgical surgical oncology oncology at at the the Dana-Farber Dana-Farber Brigham Brigham Cancer Center before joining NIH. Cancer Cancer Center Center before before joining joining NIH. NIH.

Fogarty mentor Rose Leke receives Virchow Prize Fogarty Fogarty mentor mentor Rose Leke Leke receives receives Virchow Virchow Prize Prize Dr. Rose Leke, whoRose has served as a mentor for Fogarty trainees for

Dr. Dr. Rose Rose Leke, Leke, who who has has served served as as a 2023 mentor a mentor forfor Fogarty Fogarty forfor many years, has been awarded the Virchow Prize trainees fortrainees Global many many years, years, has has been been awarded awarded the the 2023 2023 Virchow Virchow Prize Prize forfor Global Global Health. She was awarded for her exceptional lifetime achievements Health. Health. She She was was awarded awarded forfor her her exceptional exceptional lifetime lifetime achievements achievements in strengthening global health and pioneering infectious disease in in strengthening strengthening health health and and pioneering pioneering infectious disease disease research towardsglobal a global malaria-free world and for infectious her relentless research research towards towards a malaria-free a malaria-free world world and and forfor her her relentless relentless dedication to advancing gender equality. dedication dedication to to advancing advancing gender gender equality. equality.

Wright named NIH Climate Scholar for Fogarty

Wright Wrightnamed named NIHClimate ClimateScholar Scholarat forfor Fogarty Fogarty Caradee Wright, aNIH chief specialist scientist the South African Caradee Caradee Wright, Wright, a chief a chief specialist specialist scientist scientist at at the the South South African African Medical Research Council and adjunct professor at the University Medical Medical Research Research Council Council and and adjunct adjunct professor professor at at the the University University of Pretoria and the University of Johannesburg, has been named of Pretoria Pretoria and and the the University University of of Johannesburg, Johannesburg, has has been been named anof NIH Climate Scholar for Fogarty. Her research focuses onnamed an an NIH NIH Climate Climate Scholar Scholar for for Fogarty. Fogarty. Her Her research research focuses focuses onon environmental health epidemiology, with an emphasis on climate environmental environmental health health epidemiology, epidemiology, with with an an emphasis emphasis on on climate climate change and air pollution risk factors in Africa. change change and and airair pollution pollution risk risk factors factors in in Africa. Africa. Alfred Mteta, AFREHealth vice president, passes away Alfred AlfredMteta, Mteta, AFREHealth vicepresident, president, passes passes away away AFREHealth viceAFREHealth president and vice Fogarty grant recipient, Alfred A AFREHealth vice vice president president and Fogarty Fogarty grant grant recipient, recipient, Alfred Alfred MFREHealth teta, has passed away. Anand accomplished consultant surgeon M teta, M teta, has has passed passed away. away. An An accomplished accomplished consultant consultant surgeon surgeon with over 30 years of experience in health care and medical w ith with over over 30 30 years years of of experience in health health care care and medical medical education, Mteta was a experience principalin investigator onand Fogarty’s MEPI e ducation, e ducation, Mteta Mteta was was a principal a principal investigator investigator on on Fogarty’s Fogarty’s MEPI MEPI program and served as the CEO of Bugando Medical Centre. program program and and served served asas the the CEO CEO of of Bugando Bugando Medical Medical Centre. Centre.

Global Virus Network names new president

Global Global Virus VirusNetwork Network namesnew newpresident president Dr. Sten Vermund, longtimenames Fogarty grantee and former dean of Dr. Dr. Sten Sten Vermund, Vermund, longtime longtime Fogarty Fogarty grantee grantee and and former former dean dean of the Yale School of Public Health, has been named president of of the the the Yale Yale School School of of Public Public Health, Health, has has been been named named president president of of the Global Virus Network (GVN). Vermund brings years of experiencethe Global Virus Virus Network Network (GVN). (GVN). Vermund Vermund brings brings years years ofand of experience experience in Global researching health care access, adolescent sexual in in researching researching health health care care access, access, adolescent adolescent sexual sexual and and reproductive health, HIV transmission prevention, and reproductive reproductive health, HIV HIV transmission transmission prevention, prevention, and and health policy.health, health health policy. policy.

44 Delaware Journal of Public Health - December 2023

Global Global Global HEALTH HEALTH HEALTHBriefs Briefs Briefs GPMB reports on pandemic preparedness GPMB reports reports onon pandemic pandemic preparedness preparedness TheGPMB Global Preparedness Monitoring Board’s report,

The The Global Global Preparedness Preparedness Monitoring Monitoring Board’s Board’s report, report, “A Fragile State of Preparedness,” reveals global “A Fragile “A Fragile State State of Preparedness,” of Preparedness,” reveals reveals global global pandemic preparedness inadequacies despite postpandemic pandemic preparedness preparedness inadequacies inadequacies despite despite postpostCOVID progress. The report emphasizes the need COVID COVID progress. progress. The The report report emphasizes emphasizes the the need need for political commitment and increased resources for for political political commitment commitment and and increased increased resources resources to bolster global readiness. The board recommends to bolster to bolster global global readiness. readiness. The The board board recommends recommends improvements in monitoring, financing, and supply improvements improvements in monitoring, in monitoring, financing, financing, andand supply supply chains. chains. chains.

Lancet calls for health-centered climate Lancet Lancet calls calls forfor health-centered health-centered climate climate action action action The 2023 Lancet Countdown report underscores the

The The 2023 2023 Lancet Lancet Countdown Countdown report report underscores underscores thethe escalating health risks of climate change, revealing escalating escalating health health risks risks of climate of climate change, change, revealing revealing the impacts of global temperature increases on the the impacts impacts ofinequities global of global temperature temperature increases increases on rising health and economic losses,on and rising rising health health inequities inequities and and economic economic losses, losses, and and projects dire consequences of further inaction. The projects projects dire dire consequences consequences of further of further inaction. inaction. The report urges policymakers to take a health-focusedThe report report urges urges policymakers policymakers tothe take afuture. health-focused a health-focused approach to climate action to fortake approach approach to climate to climate action action forfor thethe future. future.

Clean cooking alliance launches digital Clean Clean cooking cooking alliance alliance launches launches digital digital magazine magazine Themagazine Clean Cooking Alliance (CCA) launched a new

The The Clean Clean Cooking Cooking Alliance Alliance (CCA) (CCA) launched launched a new a new digital magazine, Vantage Point: Perspectives on digital digital magazine, magazine, Vantage Vantage Point: Point: Perspectives Perspectives on on Clean Cooking. This interactive publication aims to Clean Clean Cooking. Cooking. This This interactive interactive publication publication aims aims to shed light on women’s crucial role in shaping the to shed shed light light on on women’s women’s crucial crucial rolerole in shaping in shaping the the clean cooking landscape and explore financial and clean clean cooking cooking landscape landscape and and explore explore financial financial and policy solutions needed to increase access to cleanand policy policy solutions solutions needed needed to increase to increase access access to clean to clean cooking around the world. cooking cooking around around thethe world. world.

TDR unveils 2024-2029 strategy TDR unveils unveils 2024-2029 2024-2029 strategy strategy TheTDR WHO’s Special Programme for Research

The WHO’s WHO’s Special Programme Programme for Research Research andThe Training inSpecial Tropical Diseasesfor(TDR) released and and Training Training in Tropical in Tropical Diseases Diseases (TDR) (TDR) released its 2024-2029 strategy emphasizing thereleased role its its 2024-2029 2024-2029 strategy strategy emphasizing emphasizing the the role of implementation research in public healthrole of implementation of implementation research research in public inresilience. public health health emergencies and overall system TDR emergencies emergencies and and overall overall system system resilience. resilience. TDRTDR will also focus on supporting country-led research, will will also also focus focus on on supporting supporting country-led country-led research, research, improving access to health interventions, and improving improving access access to health to health interventions, interventions, and and strengthening health systems. strengthening strengthening health health systems. systems.

USAID expands Feed the Future program

USAID USAID expands Feed thethe Future program program USAID isexpands investing $79Feed million toFuture expand the USAID USAID is investing is investing $79 $79 million million to expand to expand the Feed the Future Innovation Labs network. the These Feed Feed the the Future Future Innovation Innovation Labs Labs network. network. These efforts aim to empower small-scale farmers, These efforts efforts aimaim to empower to to empower small-scale small-scale farmers, farmers, foster resilience climate change, and enhance foster foster resilience resilience to climate to climate change, change, and and enhance enhance agricultural productivity in vulnerable regions agricultural agricultural productivity productivity in vulnerable in vulnerable regions regions promoting One Health strategies for livestock and promoting promoting One One Health Health strategies strategies forfor livestock livestock andand human well-being. human human well-being. well-being.

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Global Health Matters November/December 2023

NIH revises grant review process to reduce bias

Volume 22, No. 6 ISSN: 1938-5935 Fogarty International Center National Institutes of Health Department of Health and Human Services Communications director: Andrey Kuzmichev Andrey.Kuzmichev@nih.gov Managing editor: Judy Coan-Stevens Judith.Coan-Stevens@nih.gov Writer/editor: Mariah Felipe Mariah.Felipe@nih.gov Writer/editor: Susan Scutti Susan.Scutti@nih.gov Digital analyst: Merrijoy Vicente Merrijoy.Vicente@nih.gov Designer: Carla Conway

In rare cases when a correction is needed after an issue’s printed version has been finalized, the change will be made and explained in the online version of the article.

All text produced in Global Health Matters is in the public domain and may be reprinted. Please credit Fogarty International Center. Images must be cleared for use with the individual source, as indicated.

SCAN AND READ THIS ISSUE ONLINE

The National Institutes of Health (NIH) has revamped its grant review process to create an environment where the most promising and innovative research projects receive the support they deserve. The new process focuses on scientific merit and reflects NIH’s commitment to reducing reputational bias in its evaluation of grant proposals. The new framework will be implemented for grant applications received on or after Jan. 25, 2025. In the current system, five criteria are scored individually using a common scale. The new, simplified review framework reorganizes these criteria into three factors. The first two factors—the importance of research and rigor and feasibility— are scored using a common scale. The third and final factor– expertise and resources–is evaluated for sufficiency only and not given a numeric score. The intent is to reduce the weight of an institution's or investigator’s reputation and elevate the merit of the proposed research, ideally creating a fair and equitable system that provides equal opportunities for all researchers. Learn more about the upcoming changes to the NIH grant review process on grants.nih. gov.

Delaware Healthcare Workforce Update Timothy E. Gibbs, M.P.H. Executive Director, Delaware Academy of Medicine/Delaware Public Health Association Matt McNeill, B.S. Research Associate, Delaware Academy of Medicine/Delaware Public Health Association

ABSTRACT Working from data provided by the Delaware Division of Professional Regulation from May 2022 to September 2023, this 16-month update supports a general rebound in active licensing numbers across the Delaware Healthcare industry in professions licensed through the Division of Professional Regulation’s DelPros system. This report articulates the types of data analysis currently available through the data and research initiative of Delaware Health Force, provides a high-level overview of the data, and offers preliminary recommendations based on the data. Overall, the healthcare workforce in Delaware shows a steady rebound, with many license types appearing to reach new highs. There are some areas in which continued loss of active licenses is of concern.

INTRODUCTION Delaware Health Force (DHF) is a public-private partnership between the State of Delaware and the Delaware Academy of Medicine / Delaware Public Health Association (Academy/ DPHA). DHF is the outgrowth of work started by the Academy/ DPHA and the Delaware Health Sciences Alliance (DHSA) in 2019. At inception, DHF was funded, in part, by the Delaware Health Care Commission (DHCC), the DHSA, and Delaware INBRE. In 2022, DHF received funding from the State of Delaware as a distribution from the American Rescue Plan Act (ARPA). That funding supported four initiatives, of which the Core Data and Research component of DHF is one. The other three initiatives include Delaware Mini Medical School, a graduate medical education expansion initiative, and an interest-free student loan program.

METHODS This report examines changes in the healthcare workforce over the 16-month period from May 2022 to September of 2023 based on data from the State of Delaware’s Division of Professional Regulation’s (DPR) licensing system called DelPros (Delaware Professional Regulation Online Service). DelPros data exchange is authorized under a Data Use Authorization (DUA) between DPR and the Academy/DPHA. Core to the DUA is that no individual record information is shared under any circumstances with any other party without the express permission of DPR. That said, most of the information is searchable by the general public at https://DelPros.delaware.gov/OH_HomePage. The DelPros system is seated within the Salesforce cloud-based CRM (Customer Relationship Management) architecture. This robust, highly secure architecture is used by the State to maintain licensing records on many types of healthcare providers licensed to practice in Delaware. It is not a charge of the Division of Professional Regulation to aggregate additional information for each licensee, or to analyze the data based on co-variables 46 Delaware Journal of Public Health - December 2023

including geolocation, population needs, chronic disease expression, and other factors. Those tasks are performed by the DHF core data and research team in collaboration with Agile Cloud Consulting, the Delaware Health Information Network, Deloitte Digital, and Tech Impact’s Data Innovation Lab. License data from the DelPros system comes with a variety of fields as show in Table 1. This data is then supplemented with a variety of other fields as shown in Table 2. It should be noted that note all fields shown are relevant to all license types. Data is exported from DelPros to DHF where it is imported into Salesforce.org. This is accomplished by SFTP, and in the future will be handled by a Salesforce Connector which provides seamless integration of data across system boundaries. For geographic analysis we use Geopointe and ArcGIS.

Current Data Analytic Capabilities

Three types of data analysis can be undertaken with the data to varying degrees based on the completeness of data records: descriptive analysis, comparative analysis, and predictive analysis. Descriptive Analysis • Number of licensed providers of a particular type • Age (and therefore retirement likelihood) • Gender • Degree • Specialization (if applicable) • Location by zip code • School attended (for physicians – partial complete) • Undergrad school attended (for physicians – partial complete) • DIMER – yes/no • Rural designation Comparative Analysis • Providers to population ratios • Specialists to chronic disease ratios • Change in provider numbers by license type • Degree advancement – for instance, resident to fully time practice physician, or stacking of nursing degrees • Providers and provider type against most publicly available census data Predictive Analysis • We need a minimum of three data points over time with which to work. In the first quarter of 2024 we will have collected enough data over time to begin predictive analytics. • We will be prepared to start showing trends (and therefore be predictive) after we have the fourth data point (monolithic data upload) in January 2024. • We CAN perform simple linear regression analysis, and therefore identify outlier datapoints from a statistical standpoint using the sorting method, data visualization method, z scores, or interquartile range method. Doi: 10.32481/djph.2023.12.008

Table 1. License Data from the DelPros System Account

Account ID

License

License ID

Account Name

MUSW* APPLICANT

Created Date

MUSW PRIMARY LICENSEE

Last Modiﬁed Date

LICENSEE NAME FACILITY NAME

Contact

Contact ID

BOARD

Account ID

NAME

MUSW TYPE

Phone

LICENSED BY

Gender

MUSW STATUS

Deceased

NON DISCIPLINARY ACTION – Field not used

Birth Year

MUSW EXPIRATION DATE

Deployment Start Date

MUSW RENEWAL DATE

Deployment End Date

EFFECTIVE DATE

STILL SERVING IN MILITARY?

MUSW ISSUE DATE

Created Date

MED SPECIALTY

Last Modiﬁed Date

IMLC SPL

First Name

Created Date

Last Name

Last Modiﬁed Date

License Parcel

Record ID

* MUSW is a prefix from Clariti software which has no meaning in this context and can be ignored. Specialty

Record ID

MUSW LICENSE2

LICENSE

PARCEL CITY

SPECIALTY

PARCEL STATE

ARE YOU BOARD CERTIFIED

PARCEL ZIP CODE

ARE YOU BOARD ELIGIBLE

PHYSICAL ADDRESS

LICENSE R.BOARD

MAILING

Created Date

PRACTICE LOCATION

Last Modiﬁed Date

OTHER BOARD MUSW LICENSE2 R.BOARD Created Date Last Modiﬁed Date

There are limitations and key basic assumptions regarding any analysis run by DHF. First, we accept data from the DelPros system as our source of truth and do not double check it for accuracy which would be out of scope for this work. Next, the licensing cycle of boards is not consistent across the healthcare workforce and can result in cyclic trends that would otherwise appear to represent shortages and surpluses from time period to time period. Except in nursing, active license status does not imply that a

practitioner is seeing patients. To maintain an active nursing license in Delaware, nurses must complete 30 hours of continuing education (CE) every two years. This includes three hours of CE related to substance abuse. Nurses must also show that they have practiced at least 1,000 hours in the last five years or 400 hours in the last two years.1 Most other license types renew on a biennial basis, but only require continuing education, not practice hours. In many categories of licensed healthcare practitioners, this leads to much higher numbers of active licenses than is reflective of actual “practicing” clinicians and healthcare professionals. 47

Table 2. Supplemental Data Gathered by DHF Core Data and Research Team* Specialization

Education

AAMC Specialty

Undergraduate School

ACGME Medical Specialty

Undergraduate State Year Graduated

National Provider Index

Medical School

NPI Number

Medical School State

NPI Taxonomy

Year Graduated

NPI Number Enumeration Date

Residency Location

NPI Last Update Date

Residency Type Residency State

CMS Medicare related PECOS ID

Additional Education/Degrees

Accepts Medicare/Medicaid

Additional Degree(S)

Accepts Other Insurance

Additional Degree School

Is A Concierge Provider

Additional Degree State

Other Demographics

Located in Health Professional Shortage Area?

Race/Ethnicity

Primary Care

Language(s) Spoken

Dental Health

Country of Birth

Mental Health

*At the time of writing this report, there is still much data gathering and verification to be done in Table 2 fields. In addition, not all of these fields are relevant to all degree types. For instance, AAMC Specialty (American Association of Medical Colleges) and ACGME Medical Specialty (American College of Graduate Medical Education) information is only relevant to physicians (both D.O. and M.D.).

Concierge physicians (also called membership medicine, cashonly practice, and direct care) are those practitioners who are paid directly by patients, not by third parties. We are making every effort to determine, on an ongoing basis, which providers are concierge practitioners. At this time, we do not have an effective grasp on which insurance coverages are accepted by which practitioners, however we do have current information from CMS regarding practices who are signed up to receive Medicaid/Medicare. Users of the DelPros system do not consistently note their practice location versus the address they use for their license. This creates bias in the resulting maps, showing provider clustering by zip code around medical facilities. We are working to address this.

RESULTS From a high-level view, “rebound” in healthcare practitioners licensing is substantiated by the data. In other words, after a period of time where active licenses in healthcare decreased, active licenses are returning to, and in some cases exceeding, prepandemic levels. Interstate Compacts are a legally binding agreement between two or more states. They carry the force of statutory law and allow states to perform a certain action, observe a certain standard, 48 Delaware Journal of Public Health - December 2023

or cooperate in a critical policy area. In the healthcare field, this is the vehicle by which healthcare providers licensed in another state can legally practice in Delaware. For instance, the Nurse License Compact (NLC) works by requiring state nursing boards to participate in a national database, Coordinated Licensure Information System (CLIS), or a Nurses License Verification database. This allows states (like Delaware), to share information for verification of nurse licensure, discipline, and practice privileges.2 These compacts allow practitioners to hold one multistate license with the privilege to practice in other compact states. The following pages are comprised of data, diagrams, mapping, and other relevant data. Beneath the data content is a discussion of the data. DelPros encompasses twenty boards of practice, and one overarching advisory committee. These 21 elements are listed in alphabetic order with additional relevant data interwoven throughout (Table 3). Several boards encompass more types of licenses than can be portrayed in one data content component, notably the Board of Medical Licensure and the Board of Nursing. All data, graphs, and maps are based on data from May 2022 to August 2023, a period of 14 months. The combination of net loss over the reporting period plus the retirement eligible number is reflected in the red flag at the top right of the graphic, indicating opportunity for improvement/renewal.

Table 3. Boards of Practice Figure

Board or Related Data Element

Board of Chiropractic

Board of Dentistry and Dental Hygiene

Board of Dietetics and Nutrition

Board of Funeral Services

Board of Massage and Bodywork

Board of Medical Practice, Physician MD Distribution by Zip Code

Geographic Distribution of Physician DOs and Physician Assistants

Physician Specialty by AAMC Taxonomy

Geographic Distribution of Pediatric Physicians and Family Medicine Physicians

Geographic Distribution of Psychiatry Physicians and Internal Medicine Physicians

Board of Medical Practice: Paramedics, Genetic Counselors, and Respiratory Practitioners

Geographic Distribution of Genetic Counselors and Paramedics

Board of Mental Health

Board of Mental Health and Chemical Dependency Professionals

Board of Nursing

Registered Nurses and Licensed Practical Nurses

Certified Nursing Specialists

Board of Nursing Home Administrators

Board of Occupational Therapy Practice

Board of Examiners in Optometry

Board of Pharmacy

Board of Physical Therapists and Athletic Trainers

Board of Podiatry

Board of Examiners of Psychologists

Board of Speech Pathologists, Audiologists, and Hearing Aid Dispensers

26 27

Geographic Distribution of Audiologists and Speech/Language Pathologists Board of Social Work Examiners

Geographic Distribution of Bachelor of Social Work and Master of Social Work Practitioners

Geographic Distribution of Licensed Clinical Social Workers

Board of Veterinary Medicine

Controlled Substance Advisory Committee 49

Board of Chiropractic

As shown in Figure 1, there are a total of 383 licensed chiropractors in Delaware, of which 247 are men and 103 are women. Currently, gender selection is not a required field. The recommendation is to make this field required, with contemporary updates to gender selection. Based on Social Security Administration age data, 37 of them are full retirement age eligible. At this time, the Board of Chiropractic does not distinguish between licensed and seeing patients versus maintaining a license but not seeing patients. As a result, the number 383 may not represent the actual number of chiropractors seeing patients in Delaware. For this board and all other boards with the exception of the Board of Nursing, the recommendation has been made to request practice status at the time of license renewal to address this data deficiency. Another recommendation common to all boards is to ask practitioners to specify practice location(s) separately from the postal address they use when obtaining or renewing their license. Based on November 2023 data from CMS we see that many providers who accept Medicare operate from multiple sites. This aids in distinguishing between license address versus practice address, and while the CMS data is enlightening, is only covers a portion of the total healthcare workforce. During the period reviewed, there was a net loss of 13 active licenses (-3.3943%). Chiropractor licenses renew in June of even years. As shown on the map, there is a high concentration of chiropractors in New Castle County than there are in Kent and Sussex where there are some zip codes with few or no practitioners.

Figure 1. Board of Chiropractic

50 Delaware Journal of Public Health - December 2023

Board of Dentistry and Dental Hygiene

Practitioners licensed under the Board of Dentistry and Dental Hygiene cover a variety of degree types including DDS, DMD, and dental hygienists. Focusing on dentists, there are a total of 565 licensed dentists in Delaware, of which 353 are men and 219 are women (Figure 2). Based on Social Security Administration age data, 109 of them are full retirement age eligible. During the period reviewed, there were 856 dental hygienists of which 833 are women, and 17 are men. Based on Society Security Administration age data, 33 of them are retirement eligible. At this time, the Board of Dentistry and Dental Hygiene does not distinguish between licensed direct patient care, versus maintaining a license but not seeing patients. As a result, the number 539 may not represent the actual number of dentists seeing patients in Delaware, and the number 856 dental hygienists may be high as well. For dentists during the period reviewed, there was a net addition of 26 active licenses (+4.824%). However, there was a net loss of 20 dental hygienists (-2.336%). All Board of Dentistry and Dental Hygiene licenses renew in May of even years. As shown on the map, there is a higher concentration of dentists in New Castle County than there are in Kent and Sussex where there are some zip codes with few or no practitioners. In particular, western Sussex County appears to have a continuing shortage of dental providers.

Figure 2. Board of Dentistry and Dental Hygiene

Board of Dietetics and Nutrition

Focusing on dieticians and nutritionists, there are a total of 532 licensed practitioners in Delaware, of which 22 are men and 477 are women (Figure 3). Based on Social Security Administration age data, 23 of them are full retirement age eligible. At this time, the Board of Dietetics and Nutrition does not distinguish between licensed direct patient care, versus maintaining a license but not seeing patients. As a result, the number 532 may not represent the actual number of dieticians/nutritionists seeing patients in Delaware. During the period reviewed there was a net addition of 48 active licenses (+9.465%). Dieticians/Nutritionists renew in May of odd years. As shown on the map, there is a higher concentration of dieticians/nutritionists in New Castle County than there are in Kent and Sussex where there are some zip codes with few or no practitioners.

Figure 2. Board of Dentistry and Dental Hygiene

52 Delaware Journal of Public Health - December 2023

Board of Funeral Services

The Board of Funeral Services licenses both individuals and facilities. There is a total of 185 licensed funeral directors in Delaware, of which 158 are men and 65 are women (Figure 4). Based on Social Security Administration age data, 48 of them are full retirement age eligible. At this time, the Board of Funeral Services does not distinguish between licensed and practicing, versus maintaining a license but not practicing. As a result, the number 185 may not represent the actual number of funeral directors in Delaware. During the period reviewed, there was a net loss of seven active funeral director licenses (-3.784%). However, there was an increase of three additional funeral resident interns. Funeral director and establishment licenses are renewed in August of even years. As shown on the map, there is a population appropriate distribution of funeral directors throughout the State, and the number of licensed Funeral Establishments increased by 8 (+3.784%).

Figure 4. Board of Funeral Services

Board of Massage and Body Work

The Board of Massage and Body Work licenses both establishments and individuals. There is a total of 630 licensed massage therapists and 507 massage technicians in Delaware, of which 154 are men and 917 are women (Figure 5). Based on Social Security Administration age data, 42 of them are full retirement age eligible. At this time, the Board of Massage and Body Work does not distinguish between licensed and practicing, versus maintaining a license but not practicing. As a result, the numbers shown may not represent the actual number of massage therapists and technicians in Delaware. Licenses renew in August of even years. For Massage therapists during the period reviewed, there was a net loss of 33 active licenses (-5.238%). However, there was an increase of 54 addition massage technicians equaling an increase of 11.921%. The loss of over 10% of the workforce is concerning. Massage practitioners and establishment licenses are renewed in August of even years. As shown on the map, there is a population appropriate distribution throughout the State.

Figure 5. Board of Massage and Body Work

54 Delaware Journal of Public Health - December 2023

Board of Medical Licensure and Discipline

The Board of Medical Licensure and Discipline is the second largest board in the Division of Professional Regulation having to do with healthcare (the largest is the Board of Nursing). Due to the large number of license types administered by this board, licensing occurs in both odd and even years for different license types. At this time, the Board of Medical Licensure and Discipline does not distinguish between licensed and practicing, versus maintaining a license but not practicing. As a result, the numbers shown may not represent the actual number of licenses of any given type in Delaware. That fact notwithstanding, there was a significant increase in MDs and DOs during the reporting period, which was joined by most other license types issued by this board. The reporting period ended with 1,145 physician DO licenses, an increase of 154 licenses (+15.657%). Physician MD licenses increased to 6,181, an increase of 681 licenses (+12.382%). There is a total of 1,145 licensed physician DOs and 6,181 physician MDs in Delaware, of which 4,350 are men and 2,779 are women (Figure 6). Based on Social Security Administration age data, 874 of them are full retirement age eligible. As shown on the map, there is a population appropriate distribution throughout the State, although the reader should remember that this is all physicians without respect to their specialty. Areas of Kent and Sussex Counties remain primary care shortage areas, as well as other select designated areas including correctional facilities. Figure 6 shows overall numbers and a map specific to physician MD distribution by zip code. Figure 6. Board of Medical Practice, Physician MD Distribution by Zip Code

Figure 7 shows the geographic distribution of physician DO and physician assistants by zip code. Figure 7. Geographic Distribution of Physician DOs (left) and Physician Assistants (roght)

One of the greatest challenges with the data collection method of the current licensing system is in determining what specialty a physician is practicing in Delaware. A recommendation has been made to amend the method of data collection to provide a picklist of AAMC taxonomy-based specialties to address this data deficiency going forward. This is essential information for understanding ratios of specialists to population needs. As a result, DHF researchers have been individually reviewing each of the over 7,300 physician license records and doing deep research to determine specialty type. At the writing of this report there were still close to 1,600 records to be researched (Figure 8). Internal medicine specialists are followed by family medicine, diagnostic radiology, pediatrics, emergency medicine, and psychiatry in order of license numbers. A 2024 undertaking of DHF and its partner organizations will be to create license benchmarks which directly relate to current and expected population numbers and healthcare needs. Figure 9 shows the geographic distribution of pediatric physicians and family medicine physicians, and Figure 10 shows psychiatry physicians, and internal medicine physicians. Based on this visual data, it appears that significant portions of Kent and Sussex Counties need additional pediatricians and psychiatry physicians to obtain better coverage and maintain a healthy ratio of providers to population. There was a loss of 18 paramedics (-5.373%, Figure 11). Similarly, the number of genetic counselors decreased by 10 licenses (-2.762%). On the other hand, there was a 20 license increase in respiratory practitioners (+3.299% increase). Zip code mapping (Figure 12) shows the distribution of genetic counselors, with the major concentration in northern New Castle County. Paramedics, on the other hand, are more evenly distributed in relation to the population density. Figure 8. Physician Specialty by AAMC Taxonomy

Figure 9. Geographic Distribution of Pediatric Physicians (left) and Family Medicine Physicians (right)

56 Delaware Journal of Public Health - December 2023

Figure 10. Geographic Distribution of Psychiatry Physicians (left) and Internal Medicine Physicians (right)

Figure 11. Board of Medical Practice: Paramedics, Genetic Counselors, and Respiratory Practitioners

Figure 12. Geographic Distribution of Genetic Counselors (left) and Paramedics (right)

Board of Mental Health

The Board of Mental Health oversees eight license types (Figure 13). Highlights include the addition of 210 professional counselors of mental health (+25.455%). The number of chemical dependency professionals also increased by 3 (+3.445%, Figure 14). Please note the addition of Mental Health Interstate Telehealth Registration. Interstate telehealth registration requires a health care provider to be licensed in a state other than Delaware and to have a healthcare provider-patient relationship established. The provider must also be currently licensed in good standing in all states where they are licensed.

Figure 13. Board of Mental Health

Figure 14. Board of Mental Health and Chemical Dependency

58 Delaware Journal of Public Health - December 2023

Board of Nursing

The Board of Nursing represents the single largest component of Delaware’s healthcare workforce with 28,749 practitioners licensed across 30 license types. Of that total, 25,797 are women and 2,952 are men, with 1,031 nurses being at Social Security Administration full retirement age (Figure 15). Figure 15. Board of Nursing

In the reporting period, there was an addition of 485 family nurse practitioner licenses, or a very significant 34.643% increase. Similarly, the number of adult/gerontology nurse practitioners increased by 144 licenses (+41.379%). These two increases represent two of the highest workforce improvements during the reporting period. As with the Board of Medicine Licensure, various types of nursing licenses are renewed in both even and odd years. It is important to note that to be licensed as a nurse in Delaware, there are minimum patient contact hour requirements.3 As a result, the numbers shown below are accurate counts of nurses seeing patients in Delaware.

As seen in Figure 16, registered nurses (RN) and licensed practical nurses (LPN) both enjoyed significant increases as well. RNs licenses increased by 2,068 (+10.34%). LPN license numbers increased by 397 (+14.704% increase). Figure 16. Registered Nurses and Licensed Practical Nurses

Figure 17 focuses on all types of certified nursing specialists (CNS). The numbers of Nurse CNS licenses are relatively small across all types, with psych/mental health CNS and adult gerontology CNS having the largest numbers of licenses. Figure 17. Certified Nursing Specialists

60 Delaware Journal of Public Health - December 2023

Board of Nursing Home Administrators

The Board of Nursing Home Administrators represents one of the numerically smaller license types in Delaware. As such, small decreases or increases results in large percentage differences (Figure 18). During the reporting period there was a loss of 11 licenses or 6.627%. As previously reported, nursing homes were severely impacted by the pandemic at a time when the population needs them more than ever as we age into the type of care those facilities provide. Figure 18. Board of Nursing Home Administrators

Board of Occupational Therapy Practice

The Board of Occupational Therapy Practice (Figure 19) experienced losses in both license types they administer. Thirty-one occupational therapy licenses were lost during the reporting period equaling a 3.969% decrease. Sixteen occupational therapy assistant licenses were lost (-4.52%). Of the 781 active licenses, 10 are Social Security Administration full retirement age. OT licenses renew in July of even years, and it will be informative to see what happens at that renewal window. Figure 19. Board of Occupational Therapy Practice

Board of Examiners in Optometry

The Board of Examiners in Optometry licenses for types of eyecare practitioners (Figure 20). Changes in the number of licenses were minimal, with the exception of the addition of Optometry Interstate Telehealth Registrations, new for the first time last year. Of the 212 licenses, 116 are women and 89 are men. Twenty-two individuals are at Social Security Administration full retirement age. As shown on the map, it appears that western Sussex and Kent counties may represent shortage areas for eyecare practitioners. Figure 20. Board of Examiners in Optometry

Board of Pharmacy

The Board of Pharmacy renews in September of even years. As shown in Figure 21, 52 licenses were lost during the reporting period, representing 2.596% of the workforce. As shown on the zip code map, pharmacists appear to be evenly distributed relative to population needs. Of the 2,388 active licenses, 90 are Social Security Administration full retirement eligible. Pharmacy licenses renew in September of even years. Figure 21. Board of Pharmacy

62 Delaware Journal of Public Health - December 2023

Board of Physical Therapists and Athletic Trainers

The Board of Physical Therapists and Athletic Trainers renews in January of odd years. As shown in Figure 22, with all licenses added together there are 2,451 physical therapy practitioners, of which 1,551 are women, and 771 are men. Sixty-eight active licenses are Social Security Administration full retirement eligible. Losses were experienced during the reporting period across the board: There were 282 licensed athletic trainers, representing a 31 person decrease (-10.993%). A decrease to 1,618 licensed physical therapists (-82 individuals, or -5.068%). There were 546 physical therapy assistants, representing a 38 person decrease (-6.96%). The zip code map appears to show a fairly even distribution of licenses throughout the State, however we suspect the high concentration in southern New Castle County may not accurately represent the true distribution of practice locations. Figure 22. Board of Physical Therapists and Athletic Trainers

Board of Podiatry The Board of Podiatry, shown in Figure 23, is one of the smallest boards in terms of number of licenses. During the reporting period it was also one of the most stable with little change. Only four individuals are Social Security Administration full retirement eligible. Podiatry licenses renew in June of even years. Figure 23. Board of Podiatry

Board of Examiners of Psychologists

The Board of Examiners of Psychologists licenses both psychologists and psychologist assistants. New this year, they are also including Psychologist Interstate Telehealth Registration. There is a total of 635 licensed psychologists in Delaware, of which 179 are men and 464 are women (Figure 24). Based on Social Security Administration age data, 116 of them are Social Security Administration full retirement age eligible. At this time, the Board of Psychologists does not distinguish between licensed and practicing, versus maintaining a license but not practicing. As a result, the number 635 may not represent the actual number of psychologists in Delaware who are seeing patients. During the period reviewed, there was a net add of 22 active psychologist licenses (+3.589%). Board of Psychology licenses are renewed in July of odd years. As shown on the map, the distribution of psychologists strongly favors New Castle County, with sizable portions of Kent and Sussex counties showing no or little coverage. Figure 24. Board of Examiners of Psychologists

64 Delaware Journal of Public Health - December 2023

Board of Speech Pathologists, Audiologists, and Hearing Aid Dispensers

Across license types, the Board of Speech Pathologists, Audiologists, and Hearing Aid Dispensers experienced active license losses during the reporting period. Licenses from this board renew in July of odd years. Combined, there are 1,004 active licenses within this Board (Figure 25). Of them, 917 are women and 69 are men with 44 individuals are Social Security Administration full retirement eligible. Audiologists lost three licenses (-2.752%); speech/language pathologists lost 18 licenses (-2.098%); and temporary speech/ language pathologists lost 20 active licenses (-54.054%). On the other hand, hearing aid dispenser active licenses retained all licenses. Figure 25. Board of Speech Pathologists, Audiologists, and Hearing Aid Dispensers

The maps in Figure 26 show the distribution of audiologists and speech/language pathologists throughout Delaware. It appears and audiologists cluster around more densely populated areas while speech/language pathologists are more evening distributed statewide. Figure 12. Geographic Distribution of Genetic Counselors (left) and Paramedics (right)

Board of Social Work Examiners

The Board of Social Work Examiners covers four license types, one of which is the new Social Work Examiners Interstate Telehealth Registration. Figure 27 represents a combined total of 2,833 active licenses: 2,289 women, and 366 men. There are 182 Social Security Administration full retirement eligible individuals. Bachelors of social work active licenses decreased by 97 (-29.45%). Similarly, masters of social work licenses decreased by 57 (-5.465%). However, Clinical Social Work active license numbers increased by 153 (+12.24%). Figure 27. Board of Social Work Examiners

Figure 28 contains two zip code maps showing the distribution of bachelor of social work and master of social work practitioners. Figure 28. Geographic Distribution of Bachelor of Social Work (left) and Master of Social Work (right) Practitioners

Figure 29 shows the distribution of licensed clinical social workers. For all three license types the vdistribution appears to be relatively population consistent. Figure 29. Geographic Distribution of Licensed Clinical Social Workers

66 Delaware Journal of Public Health - December 2023

Board of Veterinary Medicine

The Board of Veterinary Medicine is always included as a part of the healthcare workforce due to the increasingly obvious connections between animal and human health and wellness. Licenses under this board renew in July of even years. As shown in Figure 30, there were a total of 1,040 active licenses at the end of the study period. Of them, 787 are women and 221 are men, with 71 individuals Social Security Administration full retirement eligible. Veterinary technicians enjoyed a small gain of two licenses (+0.548%). Unfortunately, there was a 34 active license decrease (-5.052%) in the Veterinarian workforce. Figure 30. Board of Veterinary Medicine

Controlled Substance Advisory Committee

Finally, the Controlled Substance Advisory Committee provides secondary licensing across a variety of individuals and facility/ institutions licensed by other boards. “The Committee issues registrations to practitioners and facilities that prescribe, dispense, manufacture or distribute controlled substances. Practitioners include physicians, physician assistants, advanced practice registered nurses, podiatrists, dentists, optometrists, and veterinarians. Facilities include pharmacies, distributors, manufacturers, hospitals, clinics, researchers, laboratories and provider pharmacies.”4 As shown in Figure 31, a total of 8,017 individuals and facilities have been granted CSR licensure. Of those licenses, 3,888 are women and 3,092 are men. The high number of null (no gender selection) is partially due to facility/institutional licenses. For this study, we highlight increases in advanced practice nurse CSR licenses, adding 150 active licenses (+10%), and the addition of 59 physician CSR licenses (+1.595%).

Figure 31. Controlled Substance Advisory Committee

68 Delaware Journal of Public Health - December 2023

DISCUSSION

ACKNOWLEDGEMENTS

With some notable exceptions, the healthcare workforce has added active licenses during the study period. As we move forward to the benchmarking phase of the project, we will establish reality-based numbers against which to compare changes in the workforce.

The authors want to thank and acknowledge the Delaware Division of Professional Regulation, Delaware Health Information Network, Delaware Health Care Commission, the Delaware Office of Healthcare Provider Resources and the Primary Care Office, the Medical Society of Delaware, the Delaware Nurses Association, Agile Cloud Consulting, Tech Impact’s Data Innovation Lab, the Delaware Departments of Information Technology and Department of Labor, and the Delaware Health Sciences Alliance.

As we collect longitudinal data, we can start making projections more broadly. At this time, we only project the number of active licenses who are eligible to retire with full Social Security Benefits, and we do not assume that all types of healthcare professionals will approach retirement in the same manner, therefore, we cannot generalize at this time. With additional data over time, we may be able to determine trends and make more relevant predictions.

POLICY RECOMMENDATIONS Throughout this study, we have identified important changes that are recommended to enhance the quality and accuracy of the data – and therefore the conclusions which can be drawn from it. Collectively those policy recommendations include the following: • Make gender selection required, with contemporary updates to gender selection options. • In order to distinguish between active licenses who are and are not seeing patients, request practice status at the time of license renewal (as is already done for nursing). • To provide more accurate and granular information on coverage throughout the State, ask practitioners to specify practice location(s) separately from the postal address used when obtaining or renewing a license. • Amend the method of data collection to provide a mandatory picklist of AAMC taxonomy-based specialties (specific to MD and DO physician licenses). • Collect race and ethnicity information from individual practitioners to support racial concordance. This can improve provider/patient trust and communication, improve adherence to medical advice, and improve patient perceptions of care.

We also acknowledge the support of the Governor’s office and the many individuals with whom we continue to work as an ARPA fund recipient receiving State and Local Fiscal Recovery Funds through the Department of Treasury and State of Delaware [SLFRP0139]. With special additional thanks to the Delaware Health Care Commission Chair, Nancy Fan, MD; Delaware Secretary of Finance, Rick Geisenberger; and Professor Kathleen S. Matt, PhD for their unwavering encouragement and support.

REFERENCES 1. Delaware Division of Professional Regulation. (n.d.). Board of nursing, license renewal. https://dpr.delaware.gov/boards/nursing/renewal/ 2. Nursing World. (n.d.). Interstate nurse licensure compact. https://www.nursingworld.org/practice-policy/advocacy/state/interstatenurse-compact2/ 3. Fast, C. E. U. (n.d.). Delaware continuing education requirements. https://ceufast.com/staterequirements/delaware 4. Delaware Division of Professional Regulation. (n.d.). Controlled substances. https://dpr.delaware.gov/boards/controlledsubstances/ 5. Guillaume, G., Robles, J., & Rodríguez, J. E. (2022, October). Racial concordance, rather than cultural competency training, can change outcomes. Family Medicine, 54(9), 745–746. https://doi.org/10.22454/FamMed.2022.633693

“Provider-patient race concordance can achieve broader, systemic goals of improving cross-cultural care delivery and improved patient outcomes. For instance, racial concordance is more clearly associated with better communication between patients and providers in one systematic review that involved Black patients.”5

Opportunities to Improve Outcomes for Families with Children through the Community Choice Demonstration U.S. Department of Housing and Urban Development

The Demonstration aims to identify the services or combination of services that are most influential and cost effective for helping HCV families with children move to areas of opportunity. The Office of Policy Development and Research’s (PD&R’s) demonstration projects1 and associated research, such as program evaluations, help build the evidence base for effective HUD policy. PD&R recently released the “Research Design, Data Collection, and Analysis Plan (RDDCAP): Evaluation of the Community Choice Demonstration,” which outlines how the office will evaluate the impacts and effectiveness of the Community Choice Demonstration (Demonstration) with a randomized control trial that is expected to enroll more than 15,000 families with children in HUD’s Housing Choice Voucher (HCV) program.2 HUD selected 8 sites that include 10 public housing agencies (PHAs) to participate in the Demonstration and provide mobility-related services to more than 9,000 families with children to expand residential choices and access to lowerpoverty areas, designated as “opportunity areas.” For the purposes of this Demonstration, researchers identified opportunity areas based on factors such as poverty rate, proportion of HUD-assisted rental units that include children, school test scores, and other opportunity indices. HUD is interested in families moving to areas of opportunity because research has shown that children who grow up in these areas experience improved life outcomes. Families participating in the HCV program, however, are unlikely to use vouchers to rent housing in areas of opportunity without deliberate supports and coaching to facilitate such moves. The Demonstration aims to identify the services or combination of services that are most influential and cost effective for helping HCV families with children move to areas of opportunity. Researchers will evaluate the two main interventions of the Demonstration: Comprehensive Mobility-Related Services (CMRS) and Selected Mobility-Related Services (SMRS). CMRS aims to help participants overcome the financial barriers, knowledge and skill gaps, family hesitancy, and landlord hesitancy that often impede moves to low-poverty and high-opportunity areas. The suite of CMRS includes pre-move coaching for families; assistance in searching for housing in areas of opportunity; financial assistance for application fees, security deposits, and transportation costs for families; holding fees to cover unfinished leases, leaseup bonuses, and damage mitigation funds for landlords; 70 Delaware Journal of Public Health - December 2023

and post-move check-ins and support. CMRS also includes post-move supports to help families that move to opportunity areas stay there or help them with second moves to another opportunity area. The SMRS intervention will take a subset of the services CMRS offers to determine whether a more limited and less costly intervention can effectively assist moves to areas of opportunity. The eight sites for the Demonstration are Cleveland, Ohio; Los Angeles, California; Minneapolis, Minnesota; Nashville, Tennessee; New Orleans, Louisiana; New York City, New York; Pittsburgh, Pennsylvania; and Rochester, New York. The Demonstration will proceed in two phases. The first phase started in late 2022 and will assess the primary impacts of CMRS, including the percentage of families receiving services who move to areas of opportunity and their length of stay, and secondary outcomes such as the percentage of families who use vouchers to find a new unit and move to any location. Researchers will also assess the relative effectiveness of different services and the household- and site-level characteristics associated with moves to areas of opportunity. The sites began with a 6- to 9-month pilot period and most are now in full implementation ending in September 2024. To rigorously test the effectiveness of the intervention, the researchers will use the gold standard in experimental research design — random assignment — with families randomly placed in either the CMRS group or a control group that offers the PHA’s typical services. The second phase will begin in October 2024 and is expected to end by April 2028. During this phase, researchers will randomly assign some families to a third option, SMRS, whereas others will continue to be assigned to the CMRS group or the control group. The specific bundle of services that SMRS will include will be based on early analysis of the most effective CMRS services from Phase 1. The researchers will have the option of testing up to three distinct combinations of services, testing each of them at two to four sites. Quantitative data collection will be supplemented by qualitative interviews, as well as a process evaluation and a cost analysis. The evaluation results will be completed at four junctures: • Phase 1 implementation and early findings, in 2024. • Phase 1 process, impact, and cost evaluation, in 2026. • Phase 2 Interim Impact Evaluation, in 2028. • Phase 1 and 2 Comprehensive Impact Evaluation, in 2031. Doi: 10.32481/djph.2023.12.009

The Community Choice Demonstration will initially enable HUD to assess the effectiveness of different services to facilitate HCV families’ access to low-poverty, high-opportunity neighborhoods. At the same time, the Demonstration will deepen stakeholders’ understanding of the relationship between moves to opportunity areas and health, education, and economic outcomes, building on the existing literature from HUD’s Moves to Opportunity Demonstration3 and Opportunity Insights’ Creating Moves to Opportunity,4 and other housing mobility randomized controlled trials. In the tradition of PD&R demonstration projects, the findings will shape evidence-based HUD policy to achieve better outcomes for HUD-assisted families with children. This article was originally published on December 19, 2023, in PD&R Edge.

REFERENCES 1. McCabe, B. J. (2023, May). The importance of demonstration projects to the mission of PD&R. PD&R Edge. https://www.huduser.gov/portal/pdredge/pdr-edge-pdrat50-053023.html 2. Abt Associates. (2023, Jan). Research design, data collection, and analysis plan (RDDCAP): Evaluation of the community choice demonstration. US Department of Housing and Urban Development. https://www.huduser.gov/portal/portal/sites/default/files/pdf/ResearchDesign-Data-Collection-and-Analysis-Plan.pdf 3. Office of Policy Development and Research. (n.d.). Moving to opportunity. US Department of Housing and Urban Development. https://www.huduser.gov/portal/mto.html 4. Chetty, R., Hendren, N., Bergman, P., DeLuca, S., Katz, L., & Palmer, C. (2023, Jun). Creating moves to opportunity: Experimental evidence on barriers to neighborhood choice. Opportunity Insights. https://opportunityinsights.org/paper/cmto/

DON’T LET THE FLU STOP YOU. Get your flu vaccine. Everyone 6 months and older is eligible.

To find locations, scan the QR code or visit flu.delaware.gov. 71

Index of Advertisers The Nation's Health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 American Public Health Association DCPAP Survey. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 The Delaware Child Psychiatry Access Program Adverse Childhood Experiences Webinar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Mid-Atlantic Regional 2023 Fact Sheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Dover YouthCommittee The DPH Bulletin - December 2023. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Delaware Division of Public Health Delaware Mini Medical School. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Delaware Health Force Submission Guidelines. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 Delaware Journal of Public Health

72 Delaware Journal of Public Health - December 2023

“I’m asking to be around for him.”

Prostate cancer is the second-leading cause of cancer death for Black men. Ask about a prostate screening, and you’re asking for so much more. If you are 40 or older, or have a family history of prostate cancer, ask your health care provider about a screening. Screenings can detect cancer early, when it’s most treatable. Don’t have insurance? You could be eligible for a free screening. Visit HealthyDelaware.org/Prostate or call 2-1-1 to learn more.

Delaware Journal of

Public Health

Submission Guidelines

updated August, 2023

About the Journal Established in 2015, The Delaware Journal of Public Health is a peer-reviewed electronic publication created by the Delaware Academy of Medicine/Delaware Public Health Association. The publication acts as a repository of news for the medical, dental, and public health communities, and is comprised of upcoming event announcements, past conference synopses, local resources, peer-reviewed content ranging from manuscripts and research papers to opinion editorials and personal interest pieces, relating to the public health sector. Each issue is largely devoted to an overarching theme or current issue in public health. The content in the DJPH is informed by the interest of our readers and contributors. If you have an event coming up, would like to contribute an Op-Ed, would like to share a job posting, or have a topic in public health you would like to see covered in an upcoming issue, please let us know. If you are interested in submitting an article to the Delaware Journal of Public Health, or have any additional inquiries regarding the publication, please contact the managing editor at managingeditor@djph.org, or the publisher at tgibbs@delamed.org.

Information for Authors Submission Requirements The DJPH accepts a wide variety of submission formats, including brief essays, opinion editorials pieces, research articles and findings, analytic essays, news pieces, historical pieces, images, advertisements pertaining to relevant, upcoming public health events, and presentation reviews. Additional types of submission not previously mentioned may be eligible, please contact a staff member for more information. The initial submission should be clean and complete, without edits or markups, and contain both the title and author(s) full name(s). Submissions should be 1.5 or double spaced with a font size of 12. Once completed, articles should be submitted via the submission page at https://djph.org/submissions/submit-an-article/ Graphics, images, info-graphics, tables, and charts are welcome and encouraged to be included in articles. Please ensure that all pieces 74 Delaware Journal of Public Health - December 2023

are in their final format, and all edits and track changes have been implemented prior to submission. To view additional information for online submission requirements, please refer to the DJPH website: https://djph.org/submissions/submit-an-article/ Trial registration information is required for all clinical trials and must be included in the final article and/or abstract.

Abstracts Authors must submit a structured or unstructured abstract along with their article. Abstracts will have a maximum of 200 words, including headings. Structured abstracts should employ 4-5 headings, and may include Objectives, Methods, Results, and Conclusions. A fifth heading, Policy Implications, may be used if relevant to the article. All abstracts should provide the date(s) and location(s) of the study if applicable, as well as any trial registration information.

Submission Length

Conflicts of Interest

While there is no prescribed word length, full articles will generally be in the 2,500-4,000word range, and editorials or brief reports will be in the 1,500-2,500-word range. If there are any questions regarding the length of a submission or APA guidelines, please contact a staff member.

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 will be published alongside articles in the final publication.

Copyright The journal and its content is copyrighted by the Delaware Academy of Medicine / Delaware Public Health Association (Academy/DPHA). The contents are licensed under Creative Commons License – CC BY-NC-ND (https://creativecommons.org/licenses/by-nc-nd/4.0/). Images are NOT covered under the Creative Commons license and are the property of the original photographer or company who supplied the image.

Nondiscriminatory Language Use of nondiscriminatory language is required in all DJPH submissions. The DJPH reserves the right to reject any submission found to be using sexist, racist, or heterosexist language, as well as unethical or defamatory statements.

Opinions expressed by authors of articles summarized, quoted, or published in full within the DJPH represent only the opinions of those authors and do not necessarily reflect the official policy of the Academy/DPHA, the DJPH, or the institution with which the authors are affiliated.

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The Delaware Academy of Medicine is a private, nonprofit organization founded in 1930. Our mission is to enhance the well being of our community through medical education and the promotion ofpublic health. Our educational initiatives span the spectrum from consumer health education tocontinuing medical education conferences and symposia. The Delaware Public Health Association was officially reborn at the 141 st Annual Meeting of the American Public Health Association (AHPA) held in Boston, MA in November, 2013. At this meeting, affiliation of the DPHA was transferred to the Delaware Academy of Medicine officially on November 5, 2013 by action of the APHA Governing Council. The Delaware Academy of Medicine, who’s mission statement is “to promote the well-being of our community through education and the promotion of public health,” is honored to take on this responsibility in the First State.

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