UCLA Public Health Magazine - November 2009

NOVEMBER 2009

UCLA

PUBLIC HEALTH

HAND in HAND UCLA

The school partners with the community in pursuit of health equity.

School of

Public Health

What do kids eat at school? What do they learn about nutrition?

The answers, SPH faculty such as William McCarthy say, may affect child obesity rates.

Many cancers can now be prevented or detected at an early, treatable stage, but not all are benefiting.

Roshan Bastani is doing something about that.

Robin Jeffries was the first in her family to attend college.

But that wasn’t enough, and she is now on her way to a Dr.P.H. in biostatistics.

UCLA

PUBLIC HEALTH

Gene Block, Ph.D. Chancellor

Linda Rosenstock, M.D., M.P.H. Dean, UCLA School of Public Health

Sarah Anderson Assistant Dean for Communications

John Sonego Assistant Dean for Development and Alumni Relations

features

Dan Gordon Editor and Writer

Martha Widmann Art Director

E D I TO R I A L B OA R D Richard Ambrose, Ph.D. Professor, Environmental Health Sciences

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Roshan Bastani, Ph.D. Professor, Health Services Associate Dean for Research

Thomas R. Belin, Ph.D. Professor, Biostatistics

Pamina Gorbach, Dr.P.H. Associate Professor, Epidemiology

F. A. Hagigi, Dr.P.H., M.B.A. Professor, Health Services

William Hinds, Ph.D. Professor, Environmental Health Sciences

Moira Inkelas, Ph.D. Associate Professor, Health Services

Michael Prelip, D.P.A. Associate Professor, Community Health Sciences

Julia Caldwell and Goleen Samari Co-Presidents, Public Health Student Association

Christopher Mardesich, J.D., M.P.H. ’98

UCLA

President, Alumni Association

School of

Public Health

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HAND in HAND: The School Partners with the ROSHAN BASTANI: Community in Pursuit Bringing Cancer of Health Equity Advances to When SPH faculty and students work in tandem Communities with agencies on the ground to address public health concerns, everyone wins.

The school’s associate dean for research goes to the low-income, ethnic minority and immigrant populations disproportionately affected by the disease, working with them to test and implement strategies designed to save lives.

STRENGTH IN NUMBERS: Biostatistics Faculty Are in Great Demand in the SPH and Beyond

FOOD for THOUGHT: Working Toward Healthier School Nutrition Environments

in every issue 23 RESEARCH Conversation and language development…crossing the border for care…tobacco sales near schools…high uninsurance for Latinos of Mexican ancestry…wellwater consumption and Parkinson’s…protein predicting type 2 diabetes.

14 Even within a field as interdisciplinary as public health, the experts in making sense of complex data stand out for their linkages throughout the school and the UCLA campus.

28 STUDENTS

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30 FACULTY

California led the way in raising the standards for what can be sold on K-12 campuses, but the work is far from over. SPH faculty continue to play an important role.

32 NEWS BRIEFS

ON THE COVER The common goal of addressing disparities in health status and healthcare has led to deeper partnerships between the school and the community. iStockphoto © 2009

PHOTOGRAPHY Reed Hutchinson / TOC: Community, Bastani, Biostatistics; p. 5; p. 8: HEAC; p. 12: Bastani; p. 17: Weiss/Gorbach; pp. 28-29; p. 32: Wynn

ASUCLA / pp. 14-16; p. 30: Telesca Courtesy of UCLA School of Public Health / TOC: Nutrition; p. 2; p. 4:Yancey; pp. 6-10; p. 15: Sugar; p. 17: Kitchen; p. 18: Wang; pp. 19-20; p. 22: Prelip; p. 30: Rodriguez; p. 32: Bastani,Yancey

Courtesy of Harold Goldstein / p. 21 Punchstock © 2009 / p. 18: Nutrition illustration Veer © 2009 / p. 21: Vending machines iStockphoto © 2009 / Cover; p. 4: Hands; p. 22: Girl with peas; p. 23; pp. 25-26; p. 33

School of Public Health Home Page: www.ph.ucla.edu E-mail for Application Requests: info@ph.ucla.edu UCLA Public Health Magazine is published by the UCLA School of Public Health for the alumni, faculty, students, staff and friends of the school. Copyright 2009 by The Regents of the University of California.

Permission to reprint any portion must be obtained from the editor. Contact Editor, UCLA Public Health Magazine, Box 951772, Los Angeles, CA 90095-1772. Phone: (310) 825-6381.

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dean’s message COMMUNITY, BY DEFINITION, IS A SOCIAL GROUP of any size whose members reside in a specific locality and often have a common cultural and historical heritage. The UCLA School of Public Health faculty, students and alumni play an important role in many communities locally and globally by developing culturally relevant health approaches based on research.

Over the past several decades, our understanding of what it takes to promote health has evolved. We now know that a healthy community is a key to keeping individuals healthy. Indeed, the latest research shows that what takes place in a doctor’s office is far less important to an individual’s health than what takes place in his or her community.

To that end, our school’s researchers collaborate with community groups to develop practical tools but also, and critically, they study how best to address the obstacles (e.g., cultural beliefs, language, poverty) that keep many from taking the steps necessary to promote good health. The cover story of this issue (page 4) highlights some of our efforts in the greater Los Angeles community and illustrates the ways in which a university can help improve health quality.

One of our school’s lead centers in providing community support recently received a generous endowment from another partner in our community, Kaiser Permanente. We are excited to announce the UCLA Kaiser Permanente Center for Health Equity. A $5.2 million endowment will provide core support to ensure that the previously named Center to Eliminate Health Disparities will continue its important work of promoting healthy communities. Communities differ, and so do approaches to them. The Center for Health Equity has a proven track record of understanding these challenges and developing programs that have been replicated in cities and states across the country. The Kaiser endowment will enable us to do more.

News of the endowment, the school’s largest to date, is particularly welcome as we face mounting budget cuts. The continued reduction in state funding for the University of California has resulted in a cut of $1.2 million to the school’s operating budget for the year – about 12 percent. In addition, faculty and staff have received pay cuts ranging from 4 to 10 percent, offset in part by furlough days to be taken in the next year. We are doing more with less, and I am thankful for the first-rate faculty and staff who, despite a difficult financial climate, remain dedicated to making the school’s mission and the UCLAPUBLIC HEALTH

education of our students their top priority.

3 2009-10 DEAN’S A DV I S O RY B OA R D

School of Public Health supporters to consider doing more. Your generosity

Ira R. Alpert * Lester Breslow Sanford R. Climan Edward A. Dauer Michele DiLorenzo (Chair) Robert J. Drabkin Gerald Factor (Vice Chair) Jonathan E. Fielding Dean Hansell Cindy Harrell Horn Stephen W. Kahane * Carolyn Katzin * Carolbeth Korn * Jacqueline B. Kosecoff Kenneth E. Lee * Edward J. O’Neill * Monica Salinas Fred W. Wasserman * Pamela K. Wasserman * Cynthia Sikes Yorkin

is critical to sustaining the school’s excellence during this economic hardship.

*SPH Alumni

That’s one of the best things about working with students: Their energy and enthusiasm is contagious. Our students are among the best and brightest in the country, and this year’s incoming class is one of the most competitive we’ve admitted. With applications up 18 percent, our program continues to be much sought after, resulting in outstanding-quality students. In addition to a top-tier education, we offer these students an opportunity to learn about public health in a wide array of settings – thanks to our heavy involvement in the community.

In the pages ahead you will read about UCLA’s work in the community and learn about the hands-on community-based training our students are afforded by studying public health in one of the most diverse cities in the country.

As we do more with less, I would like to ask our community of UCLA

Our students, who face escalating fees, need your assistance now more than ever. If you’ve made a donation this year, please consider giving more. If you have not made a contribution this year, I hope you will consider a gift to the school to help our faculty and students continue to better our communities – both locally and globally.

Linda Rosenstock, M.D., M.P.H. Dean

TOTAL EXPENDITURE S Grants and Contracts State-Generated Funds Gifts and Other Fiscal Year 08-09 $59.2 million

UCLAPUBLIC HEALTH

4 W HEN SPH FACULTY AND STUDENTS WORK IN TANDEM WITH AGENCIES ON THE GROUND TO ADDRESS PUBLIC HEALTH CONCERNS , EVERYONE WINS .

HAND in HAND:

The School Partners with the Community in Pursuit of Health Equity

UCLAPUBLIC HEALTH

Dr. Marjorie Kagawa-Singer has a simple answer “These organizations provide cultural proficiency and help to broaden a student’s horizon.

They give students who don’t come from disadvantaged backgrounds the perspective of what it’s like to be on the ground floor working with populations that have the greatest level of need.”

—Dr. Antronette Yancey

to why she and her students spend so much of their time outside of Westwood, where Kagawa-Singer is a professor in the School of Public Health and UCLA’s Department of Asian American Studies.

“Because that’s where the answers are to the problems we’re trying to address,” she says.

Public health academics and professionals alike face diverse challenges as they seek to fulfill their research and practice missions, but a single theme cuts across many, if not most of them: the wide disparities in how different populations are affected by health issues, driven by socioeconomic factors such as poverty, lack of health insurance, race/ethnicity, immigration status, and unhealthy home and work environments. For Kagawa-Singer and many of her colleagues at the school, successfully addressing these issues requires leaving the university and teaming with community-based organizations, whether the purpose is research to determine the best approach to problems or implementing solutions.

5 endow the school’s Center for Health Equity. The center, co-directed by Bastani and Dr. Antronette Yancey, is dedicated to improving the health of underserved populations through research, community collaboration and leadership development. The UCLA Kaiser Permanente Center for Health Equity will support partnerships with community-based organizations to further that mission (see page 32).

“The very health of our communities is now in the spotlight, but the issue of health equity has persisted under the radar for far too long,” said Dr. Benjamin Chu, president of Kaiser Permanente Southern California, in announcing the gift. “We must challenge assumptions and open our minds to the possibilities of what focused research and collaboration can mean to the lives of thousands of families who are struggling to preserve their health. This center has the potential to inspire positive change, and we will be there with them every step of the way.”

In the center and beyond, UCLA School of Public Health faculty and students are working deeply in the community to address health equity issues, taking advantage of long-standing collaborations with community-based organizations (CBOs)

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“Academic research is fundamentally about closing the gap between what we know and what we don’t know,” says Dr. Neal Halfon, professor and director of the school’s Center for Healthier Children, Families and Communities. “But there is also a gap – in many areas equally large – between what we know and what we do. For example, it’s very clear what should be done to prevent obesity or optimize the development of young children, yet that knowledge isn’t always translated into changes in clinical practice, community programs or public policy. That’s something we need to do through partnerships with the community.”

To Dr. Roshan Bastani, professor and associate dean for research at the school, it’s a no-brainer: “You can’t be a school of public health and not engage in the community,” she says. “If we want to make a difference in the health of populations, we have an obligation to be out there among them, not sitting in the ivory tower of the university.” The collaborations with community agencies bring a multitude of benefits to both the university and the partner organizations, Bastani adds – but above all, to the populations both are trying to serve. (For more on Bastani’s work, see the profile on page 12.)

The vital importance of the school’s partnerships in the community was recognized last month with a $5.2 million gift from Kaiser Permanente to

partners

Maternal and Child Health Access

UCLAPUBLIC HEALTH

Lynn Kersey (M.A./M.P.H. ’85) (inset), who graduated from the school’s joint M.P.H. and M.A. in Latin American Studies program, went on to found Maternal and Child Health Access, a community-based organization in Downtown Los Angeles. Kersey serves as executive director of the organization, which is dedicated to ensuring meaningful access to health and social services for low-income women and their families through direct services, such as support and education programs and assisting with health insurance coverage; technical assistance to other organizations; and advocacy.

Kersey continues to work closely with both faculty and students at the school. “UCLA has provided exceptional graduate student interns who have conducted projects with county, statewide and even national impact,” she says. “Former professors are now sources for technical assistance and professional exchange for our programs, and our agency serves as a community reality check for some of the work they do.” Kersey helped to launch a child advocacy fellowship program at the school, and has taught a child health advocacy course as well as guest-lecturing annually in several classes.

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“The huge demographic shifts in this country make it mandatory that we pay attention to what’s going on in the communities that are most affected by health disparities.”

—Dr. Marjorie Kagawa-Singer

while continuing to develop new ones. The relationships are manifest in many ways, with research serving as only part of the equation. A number of community practitioners bring their on-the-ground experiences to the school by providing guest lectures or teaching courses themselves, including Drs. Jonathan Fielding, director of the Los Angeles County Department of Public Health; and Diana Bonta (M.P.H. ’75 Dr.P.H. ’92), vice president of public affairs for Kaiser Permanente Southern California and former director of the California Department of Health Services. The school’s Center for Public Health and Disasters regularly provides training to community organizations on disaster preparedness matters, while the Center for Health Policy Research teaches community-based groups how to utilize research data for advocacy and program development. The UCLA Kaiser Permanente Center for Health Equity trains its many community-based collaborators in how to select, adapt, implement and evaluate evidence-based initiatives.

When done right, faculty members say, partnerships between the school and CBOs represent an ideal melding of two entities that bring complementary strengths to a common mission. CBOs are closer to the populations they serve and have expertise in the practicalities of implementing programs and strategies.

They enable the school’s faculty to tackle important problems and offer its students invaluable field experiences. At the same time, members of the school’s faculty bring expertise in areas such as science and program evaluation, knowledge of best practices, and a level of credibility that is often helpful in opening doors, delivering messages and advocating for policies.

At a time when many community agencies are grappling with reductions in budgets that were small to begin with, academics can also boost CBOs’ capacity both by providing students for internships and through funding that comes from research grants. Bastani, for example, ensures that CBOs collaborating on her group’s cancer-control intervention studies receive funding as part of the grant, and routinely includes agency members as investigators. Sometimes it goes further. By assisting with the grant proposal and signing on as a subcontractor to conduct the evaluation, Bastani was able to help one of her long-time community partners, the Northeast Valley Health Corporation, obtain $2 million in federal funding for a cancer patient “navigator” program for its low-income, mostly Latino population in San Fernando, Calif.

Similarly, a recent collaboration between a research team headed by Dr. Pamina Gorbach, associate professor of epidemiology, and the communitybased agencies Friends Research Institute and AIDS Project Los Angeles provided lasting benefits for the organizations. Because part of the study involved testing individuals at high risk for sexually transmitted diseases, the collaborating sites received equipment, training and logistical support that enabled them to conduct STD testing – a service they will be able to continue following the study. Gorbach also works closely with the Los Angeles Gay and Lesbian Center, and has provided that organization with both financial and staff support for HIV testing services through her research grants. The assistance was particularly welcomed coming on the heels of state cuts in funding for HIV testing and counseling services.

For her part, Gorbach – whose studies focus on the sexual behaviors of individuals living with or at high risk for HIV – benefits from the collaborations

connections

UCLAPUBLIC HEALTH

Vicente Lara, M.P.H. student AND The Violence Prevention Coalition of Greater Los Angeles The Violence Prevention Coalition of Greater Los Angeles (VPC) – a broad-based group of community service providers promoting safe, nonviolent communities through advocacy and education – has a long relationship with UCLA and the School of Public Health. Founded in 1991

by Billie Weiss, who currently serves as associate director of the school’s Southern California Injury Prevention Research Center (SCIPRC), VPC has partnered with the SCIPRC to provide training to its members in program evaluation and related topics. Since the trainings began in 2007, 115 VPC representatives from 58 different organizations have participated.

Last summer, Lara worked with the VPC to conduct an evaluation of its Youth Challenge Grants project. Lara provided a summary of youthdriven violence prevention activities and identified barriers organizations faced during the implementation of their projects, as well as alternative youth-member roles in future VPC activities. “His work will be a significant factor in the project’s ongoing effectiveness,” says Bill Martinez, VPC’s director. Says Lara of the experience: “In the classroom I obtained an overall skill set for working in public health, which was invaluable. But things come up in the real world that you can’t learn from a textbook or a lecture. It was a great experience to see how organizations function on a dayto-day basis.”

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Alison Herrmann, Ph.D. student AND

Los Angeles Korean Community Groups Herrmann works closely with the Los Angeles Korean community in her position as project director of a randomized intervention trial (headed by Dr. Roshan Bastani, co-director of the UCLA Kaiser Permanente Center for Health Equity) designed to reduce the disproportionate burden of hepatitis B and liver cancer among Korean Americans. Capitalizing on the large proportion of Koreans who regularly attend church, the project is conducted at Korean churches and tests an intervention to increase receipt of hepatitis B screening.

“As a student interested in chronic disease prevention and control among diverse population groups, I have been afforded an invaluable opportunity to gain experience conducting communitybased research while connecting with the Los Angeles Korean community, the largest outside of Korea,” Herrmann says. Her active involvement in the community has led to the development of relationships with church leaders and community members alike as Herrmann seeks to gain a more comprehensive understanding of Koreans’ health-related attitudes, beliefs and behaviors.

Events such as this “Street Poets Open Mic” are part of the youth-driven activities of the Violence Prevention Coalition of Greater Los Angeles.

partners

March of Dimes In the last two years, the March of Dimes has been assisted through internships by four UCLA School of Public Health students – Janet Beyan, Vanessa Novoa, Bogdana Kovshilovskaya and Kavita Ramakrishnan.

These students have conducted a variety of evaluation projects and have opened doors in the community for the expanded implementation of March of Dimes programs supporting outreach to increasingly diverse communities.

Projects have included working with clinic systems, Head Start and faith-based communities to reach families of childbearing age with preconception information while evaluating self-reported information and intent to make lifestyle changes. The students have also conducted research on issues and provided valuable input to county collaborative projects. March of Dimes has also called on faculty members at the school, including Dr. Michael Prelip, to advise and assist with evaluation of grantfunded community outreach projects.

“Interns have completed evaluation projects that have led to significant improvements in subsequent program development,” says Victoria Lombardo, March of Dimes’ associate state director of program services.

“With the assistance and creativity of the students during their internship, the March of Dimes has been able to rapidly expand services to the community.”

UCLAPUBLIC HEALTH

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connections

Yelena Nedelko, M.P.H. student AND

Westside Infant-Family Network

UCLAPUBLIC HEALTH

Nedelko was inspired to conduct her field studies internship at Westside Infant-Family Network (WIN) after hearing Anna Henderson, WIN’s executive director, give a guest lecture in an early-childhood interventions graduate seminar co-taught by Dr. Neal Halfon, director of the school’s Center for Healthier Children, Families and Communities.

WIN serves the West Los Angeles community by providing free mental healthcare, social services and access to general healthcare for families with children from the prenatal period through age 3.

As WIN’s first public health intern, Nedelko played a leadership role in building the organization’s service and systems capacity by assisting in conducting and analyzing WIN’s bi-annual outcomes evaluation and developing a Web-based community resource database.

“Some of my richest learning experiences occurred during casual conversations with WIN’s directors,” Nedelko says.

“The executive director often invited me into her office or for brisk walks around the neighborhood where she took time to talk to me about WIN’s funding sources, the challenges and rewards of leading a community-based, nonprofit organization, and the logic behind WIN’s system and service goals.”

For a study aiming to increase informed decision-making by Latino men about prostate cancer screening, a group headed

by Dr. Roshan Bastani recruited some 1,400 low-income, uninsured Latino men in churches and on the streets.

partners

Healthy Eating Active Communities Healthy Eating Active Communities (HEAC), a program sponsored

by The California Endowment, aims to fight the state’s childhood obesity epidemic through policy and advocacy efforts. UCLA School of Public Health student and former HEAC intern Rachel Yu was integral in developing and implementing one of HEAC’s key initiatives, a menu-labeling project called Smart Menu. As a result of public policy efforts to address the obesity epidemic, state law now requires chain restaurants of 20 or more to disclose nutrition information at the point of purchase. HEAC, in collaboration with the Los Angeles County Department of Public Health, has supported small independent restaurants that, though not covered by the mandate, have joined the movement to offer calorie counts and other nutrition information for all of their standard menu items.Yu’s involvement in Smart Menu included everything from research design and implementation to training of survey takers, development of the brochures containing nutrition information and promotion of the program.

HEAC now has another UCLA School of Public Health intern, Jessica Lowe (above, inset), who has been involved in the program’s teen nutrition education and advocacy classes – teen-focused sessions that help participants gain an awareness of their food environment and question why their communities lack the fresh food resources (grocery stores, farmers markets) that many affluent communities have. HEAC is piloting the program at a community clinic in South Los Angeles, St. John’s Well Child & Family Health Center. After Yu conducted preliminary research, Lowe completed the curriculum and developed evaluation instruments to measure the program’s effectiveness. She also teaches the class, in partnership with a community health promoter from Esperanza Community Housing Corporation.

For the school’s faculty members who strive to expose their students to the everyday practice of community public health, partnerships with CBOs are critical. Says Yancey: “These organizations provide cultural proficiency and help to broaden a student’s horizon. They give students who don’t come from disadvantaged backgrounds the perspective of what it’s like to be on the ground floor working with populations that have the greatest level of need.”

Indeed, the ongoing partnerships with CBOs provide vital links between the school and the community for students seeking their first experience with public health practice, says Dr. Michael Prelip, associate professor in the school’s Department of Community Health Sciences, who also oversees students’ summer internships as the department’s field program supervisor.

Among the many CBO partners where Prelip has recently placed students is Healthy Eating Active Communities (HEAC), a six-year, multi-million dollar program sponsored by The California Endowment that aims to fight the growing childhood obesity epidemic in California and develop state policy changes that will reduce the risk factors for diabetes and obesity. “Our collaborations with our UCLA School of Public Health interns have greatly enhanced our capacity to develop and evaluate our programs,” says Pri de Silva, HEAC’s project coordinator. “In turn, we are able to offer a work and learning experience ideal for individuals who are interested in nutrition, physi-

9 cal activity and diabetes, and want to learn innovative approaches to addressing health disparities. Our interns are invaluable members of the HEAC team.”

Prelip notes that the school’s partnerships with CBOs give students access to more meaningful opportunities for fieldwork. Through these experiences, students often find mentors who provide career guidance and networking benefits, leading to post-graduation jobs – often at the place where the student first interned. For example, because of his ongoing relationship with MotherNet L.A., a family resource center in Compton, Calif., Prelip has gotten students involved in countless research projects and internships. Two of MotherNet’s executive directors have been UCLA School of Public Health graduates.

The opportunity for alumni to stay connected with the school represents yet another benefit of these collaborations – and when students end up working for the organization where they did their internship, it strengthens the connection and perpetuates the cycle with new students.

Students in other departments benefit as well.

Gorbach has placed a number of her epidemiology students at community sites through her collaborations. Many students in the Department of Health Services also seek experiences at CBOs, says Dr. Diana Hilberman, professor and student internship supervisor for the department. “Our students are going into management and policy settings, and many of these organizations provide important skills in understanding how policy winds up being implemented at the community level,” says Hilberman.

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by gaining a level of access to the populations she studies that would be nearly impossible without the partnerships. “My research involves a lot of people who are drug users, many of whom are homeless, and are thus hard to find and hard to follow,” Gorbach says. “Community agencies with a solid recruitment and retention infrastructure have both the know-how and the trust from these individuals that universities, for all of their other strengths, often lack.”

“These experiences have broadened my definition of community health, which recognizes that people are healthy not because of access to health services alone but also because of neighborhood vitality, affordable housing, livingwage employment, safety, adequate recreational facilities, and many other factors.”

—Jeremiah Garza, M.P.H. student

One of Prelip’s former students, Nancy WongvipatKalev (M.P.H. ’98), serves as director of health education for Health Net of California, one of the largest health plans in the state; nearly half of her

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Kshama Shah, Allen Suh and Jacqueline Newton, M.P.H. students AND KHEIR and PolicyLink UCLAPUBLIC HEALTH

Using their UCLA School of Public Health education, Shah, Suh and Newton volunteered at KHEIR, a community-based health services center located in the heart of Koreatown. They created a questionnaire to facilitate the clinic’s evaluation of the usefulness of its services and developed a presentation for parents discussing sexual health resources for their children. “Volunteering these services allowed us the opportunity to apply the theories and strategies we learn in the classroom to an organization that deserves support for its service to the community,” says Shah.

Shah also did an internship at PolicyLink, a national nonprofit organization working on issues of social and economic justice through a policy lens. “Truly inspiring about the organization is its ability to connect issues around transportation, housing and fresh food financing, among other things, to health,” Shah says. “PolicyLink is looking at how the places in which we live affect how we live.”

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“I wanted to make sure the community members and public health professionals who are charged every day with trying to improve their health could apply the findings in their work.”

—Dr. Chandra Ford

staff are also UCLA School of Public Health alumni.

Two years ago she approached Prelip about a funding opportunity from the National Institutes of Health for a program dealing with health literacy – how to assist low-income populations in understanding health and utilizing health systems more efficiently. Could they work together on a proposal? For the next 18 months, Prelip and his faculty colleague Dr. Deborah Glik worked closely with the organization to define the problem and the research questions that should be studied; together they wrote the grant proposal, and recently received funding.

In the past, university researchers have been criticized for taking a different tact: defining problems and proposing solutions without community input, then using the community as a laboratory to advance the literature rather than as a partner in solving the problem. But Yancey and others at the school say the best university/community collaborations involve a more authentic partnership. “In my experience, whatever we can come up with and work on together, with both partners bringing their unique expertise and lens to the process, turns out much better than what either side could have come up with on its own,” she says. That’s the approach Yancey and colleagues have taken in working with the San Diego Padres baseball organization and The California Endowment to plan and implement FriarFit, a multi-year community-wide fitness initiative launched in 2008.

Jeremiah Garza, an M.P.H. student who has worked with several organizations in South Los Angeles in efforts to create sustainable alliances between these CBOs and the various neighborhoods,

AANCART, a multi-site initiative led in Los Angeles by Dr. Marjorie Kagawa-Singer, professor at the school, is the first cancer prevention and control research initiative targeting Asian Americans. businesses, clinics and government entities with which they interact, says the most valuable lesson he has learned is the need to work with, rather than on, the community. “Ultimately, these experiences have broadened my definition of community health, which recognizes that people are healthy not because of access to health services alone but also because of neighborhood vitality, affordable housing, living-wage employment, safety, adequate recreational facilities, and many other land use and built environment factors,” Garza says.

For faculty, a partnership with the community means that when the study is completed and published, the work isn’t necessarily over. Dr. Chandra Ford, assistant professor at the school, studies how social inequalities can contribute to or exacerbate health disparities. Earlier this year, the American

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Chris Hunt and Goleen Samari, M.P.H. students AND Community Partners; LA Health Action Hunt and Samari did joint internships with two organizations, both of which have strongly founded objectives in improving community health. Community Partners offers support, guidance and training to nonprofit and other organizations with innovative community-building ideas; LA Health Action advocates on health policy for the Los Angeles safety net population. With Community Partners, the students worked for the Building Clinic Capacity for Quality program, assisting community clinics in implementing quality improvement strategies focused on the adoption of health information technology such as electronic medical records. With LA Health Action, they provided summaries on the goings-on related to healthcare reform and provided research support for a collaborative group that is developing a model for integrated school-based health centers in the Los Angeles Unified School District.

“I felt very lucky to be entrenched in an environment where many organizations were working toward improving community health from a multitude of angles: from the policy level to the patient level,” says Samari. Adds Hunt: “I benefited from having amazing mentors guiding me during the internship, was able to see how local healthcare organizations operate at all levels, and had the opportunity to apply the skills I learned in my first year in the M.P.H. program.”

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connections

Jacqueline Newton, M.D./M.P.H. student AND

Asian Pacific AIDS Intervention Team

partners

Friends Community Center While a student in the school’s Department of Epidemiology, Galina Inzhakova (M.P.H. ’06) gained research experience working for the Los Angeles County Department of Public Health on the HIV/AIDS Care Assessment Project funded by the Ryan White Care Act. Soon after graduating, she began working as a site coordinator at Friends Community Center, a division of Friends Research Institute (FRI) – a research, treatment and grantsadministration organization dedicated to promoting community health and well-being. Inzhakova serves as coordinator of two bio-behavioral research studies at Friends Community Center’s Network for AIDS Research in Los Angeles (NARLA).

The collaborative project between community sites and UCLA has enabled FRI to, for the first time, conduct biomedical specimen collection for sexually transmitted infections and perform HIV testing and counseling.

The collaboration has proved mutually beneficial. “While UCLA brought opportunities for the new services at the study site, FRI expanded the NARLA target population and recruited hard-to-reach, highrisk gay and bisexual men and male-to-female transgenders,” Inzhakova says. During her employment, Inzhakova has supervised a UCLA School of Public Health student, Mohammad Mir, who completed his field studies in epidemiology by working at the community site on the NARLA project. The FRI site was able to take advantage of the new research talent by recruiting another recent graduate from the school, Paymon Ebrahimzadeh.

UCLAPUBLIC HEALTH

The Asian Pacific AIDS Intervention Team (APAIT), a nonprofit organization in Downtown Los Angeles, provides free, culturally and linguistically appropriate HIV prevention and treatment services tailored for, but not limited to, Asian Pacific Islanders (APIs). Newton spent last summer working in the Prevention Unit, a department that creates HIV prevention programs for at-risk populations.

Among other things, she assisted in the implementation and evaluation of the Sisterhood Program, an HIV education and empowerment program for monolingual Chinese women engaging in sex work at massage parlors; and helped with recruitment for Know Now, a program offering free and confidential rapid HIV testing and counseling for men, women and transgenders.

“My involvement with APAIT has allowed me to apply theoretical concepts from the classroom to real-life situations, strengthening skills in areas like program design and impact evaluation,” Newton says. “APAIT has inspired me to work at a community-based organization in the future, where I will provide healthcare services and create public health programs for entire communities.”

cover story

Journal of Public Health published the results of a community-based study Ford had led as a doctoral student at the University of North Carolina. Although she is now at UCLA – where Ford works closely with a Los Angeles City Council task force to improve the city’s ability to address domestic violence among lesbian, gay, bisexual and transgender populations – Ford made it a point to return to the communities in North Carolina that were involved in the study to disseminate the results. “I wanted to make sure the community members and public health professionals who are charged every day with trying to improve their health could apply the findings in their work,” she says.

Ideally, Halfon says, partnerships with the community endure beyond any single grant period, allowing mutual understanding and trust to build. “When we begin the process of working with a community organization, we set certain criteria,” he explains. “Our goals have to be aligned with the community’s goals, and it can’t be a hit-and-run operation – there is an understanding that we’re going to be there for a long time, working with the organization on these problems.”

Kagawa-Singer, whose work focuses on cancer disparities in ethnic minority populations, particularly Asian American/Pacific Islanders, was working closely with community groups to formulate appropriate research questions long before the concept began to be promoted by the National Institutes of Health and other funding agencies and foundations in recent years. She currently serves as principal investigator for the Los Angeles site of the Asian American Network for Cancer Awareness Research and Training (AANCART), the first cancer prevention and control research initiative targeting Asian Americans. To ensure that the project is grounded in community concerns, she has a steering council consisting of representatives from 17 CBOs serving the diverse Asian American communities of the Los Angeles area. “The huge demographic shifts in this country make it mandatory that we pay attention to what’s going on in the communities that are most affected by health disparities,” she says. “Working in partnership with organizations that are on the front lines of serving these communities is the way we can make a difference.”

12 T HE

SCHOOL ’ S

ASSOCIATE DEAN FOR RESEARCH GOES TO THE LOW - INCOME , ETHNIC MINORITY AND IMMIGRANT POPULATIONS DIS PROPORTIONATELY AFFECTED BY THE DISEASE , WORKING WITH THEM TO TEST AND IMPLE MENT STRATEGIES DESIGNED TO SAVE LIVES .

ROSHAN BASTANI:

Bringing Cancer Advances to Communities In the more than two decades

since Dr. Roshan Bastani embarked

on her public health career, much has been learned about how the risk of developing certain cancers can be reduced and how some of the most common tumors can be detected in their early, treatable stages. But not everyone has benefited from these discoveries. Disparities exist in who gets certain cancers and who dies from them. These gaps – reflected in rates of potentially life-saving cancer screenings and in risk factors

UCLAPUBLIC HEALTH

such as obesity and exposure to environmental carcinogens – can often be traced to socioeconomic factors.

“When an important scientific discovery is made, it doesn’t automatically translate to the population.”

Bastani says, “and it’s only when a technology is adopted at the level of entire communities that you can really have an impact on population health.”

At the UCLA School of Public Health, Bastani wears several important hats. She has been the school’s associate dean for research since 2001, a period during which the school’s external grant funding has increased by approximately four-fold. Since 1990 she has served as associate director of the UCLA Jonsson Comprehensive Cancer Center’s Division of Cancer Prevention and Control Research, and was recently named the cancer center’s director for Cancer Disparities Research. In 2004, she spearheaded the effort to establish what is now the UCLA Kaiser Permanente Center for Health Equity, which Bastani co-directs with Dr. Antronette Yancey. (For more on the recent endowment of the center, see page 32.) The center, based in the School of Public Health, brings together more than 50 UCLA faculty members and their students, along with a large number of community-based groups, to address disparities in critical health issues.

13

“Making a difference in communities requires interventions that are practical, realistic, can be integrated into existing community structures, and that the community partners are interested in adopting.”

—Dr. Roshan Bastani

UCLAPUBLIC HEALTH

her focus. “I began to see that the context in which people live influences outcomes – that it’s not always within an individual’s control,” she says. That led to her emphasis on addressing community-level disparities. In the years since, Bastani’s group has forged ties with more than 150 community-based organizations, working with them on research that seeks to have a lasting impact. “Making a difference in communities requires interventions that are practical, realistic, can be integrated into existing community structures, and that the community partners are interested in adopting,” Bastani says. “Otherwise you can have a great academic exercise, but it’s not very useful.”

Examples can be seen in Bastani’s current work.

One study tests an intervention aiming to increase informed decision-making by Latino men when it comes to prostate cancer screening. Bastani’s group recruited some 1,400 low-income, uninsured Latino men in churches and on the streets and randomized them into a control group or an intervention group in which they engage in small-group discussions on the pros and cons of prostate cancer screening.

Another current project involves a collaboration with churches in Los Angeles-area Korean neighborhoods to test an educational intervention to increase screening and prevention for hepatitis B. Koreans have among the highest rates of hepatitis B infection, which can lead to liver cancer when untreated.

Bastani is also principal investigator of the UCLA Community Research in Cancer (CORICA) Network, one of eight in the nation funded by the Centers for Disease Control and Prevention and National Cancer Institute.

In addition to conducting her own research, Bastani devotes considerable effort to mentoring junior investigators, particularly those from traditionally underrepresented minority groups and those interested in working with underserved populations.

Since 1990, she has actively supported and mentored more than 25 junior researchers who have gone on to obtain independent funding to conduct their own cancer control studies. All of Bastani’s projects are also staffed with the school’s graduate students.

Bastani is regularly reminded of the power of her group’s work – often through small but powerful gestures. When testing an intervention to improve screening for colorectal cancer, she was taken aback when many subjects returned the $25 they were paid to participate, some of them stuffing an extra $5 or $10 contribution into the envelope along with a note thanking the researchers for their work.

“These were people with very little money, but they felt the research was so important that they wanted to contribute,” Bastani says. “It was so touching.

Knowing we’re making a difference in the lives of people like that is very rewarding.”

faculty profile

But her administrative roles notwithstanding, the heart of Bastani’s work is in the community – particularly in the low-income, ethnic minority and immigrant communities that are disproportionately affected by cancer, and where working with populations to apply what is known about prevention and early detection can save countless lives.

Bastani has developed close relationships with scores of Los Angeles-area community-based organizations over the course of her career, working with them to develop strategies for increasing cancer screening and promoting cancer-preventing behaviors among diverse populations. While there is undeniably a service component to the work, the communitybased studies conducted by Bastani’s group are as rigorous as any university-based clinical trial. “It’s one thing to think you have a great idea for an intervention, but without sound research we don’t know whether what’s being proposed will make a difference,” Bastani says.

Indeed, determining the best ways of bringing important cancer discoveries into communities is its own science. “It’s not as if we can say, ‘We now have this screening method, it’s good for you,’ and then everyone goes out and gets it,” Bastani explains. So, with continuous funding as a principal investigator from the National Institutes of Health since 1988, she has conducted intervention trials to increase utilization of screening for a variety of tumors, starting with breast and cervical cancer, then colorectal and prostate cancer. Most recently, Bastani’s focus has expanded with the advent of screening and vaccines for hepatitis B, which can cause liver cancer, and the human papillomavirus (HPV), which can cause cervical cancer.

Bastani’s path to a public health career began in graduate school, where she earned her doctorate in social psychology. As part of a health psychology course, students were asked to design an intervention around a health issue. Bastani chose breast cancer for very personal reasons: Her mother had been diagnosed with the disease at a young age.

At the time mammography was relatively new, and few researchers were studying factors influencing whether women were being screened for breast cancer. Starting with her dissertation, Bastani filled that niche. She conducted studies seeking to identify barriers to mammography screening and tested interventions designed to overcome them, often including large numbers of ethnic minority populations to ensure that she could ascertain whether the strategies were working in certain groups but not others.

Drawing on her training, Bastani initially focused on psychological factors keeping women from getting mammograms. But soon after joining the UCLA School of Public Health faculty in 1990, she expanded

14

E VEN

WITHIN

A FIELD AS INTER DISCIPLINARY AS PUBLIC HEALTH , THE EXPERTS IN MAKING SENSE OF COMPLEX DATA STAND OUT FOR

STRENGTH IN NUMBERS: Biostatistics Faculty Are in Great Demand in the SPH and Beyond

THEIR LINKAGES THROUGHOUT THE SCHOOL AND THE

UCLA

CAMPUS .

UCLAPUBLIC HEALTH

Among the members of the school’s Department of Biostatistics faculty (clockwise starting from lower left): Drs. Catherine Sugar,Thomas Belin, William Cumberland, Angela Presson, Catherine Crespi, Donatello Telesca, Dorota Dabrowska and Abdelmonem A. Afifi.

“The ability to take data – to be able to understand it, to process it, to extract value from it, to visualize it, to communicate it – that’s going to be a hugely important skill in the next decade. ... Now we really do have essentially free and ubiquitous data. So the complementary scarce factor is the ability to understand that data and extract value from it.”

— Hal Varian, Chief Economist, Google

15

feature

To the layperson, the biostatistician is rarely seen or heard in the coverage of health-related studies. But those involved in the studies – and the agencies that fund them – know that having someone skilled in understanding and extracting value from data, to paraphrase Google’s chief economist, is essential. and School of Dentistry; major campus entities such as UCLA’s Jonsson Comprehensive Cancer Center, UCLA AIDS Institute and UCLA Semel Institute for Neuroscience and Human Behavior; and numerous individual faculty, departments and groups across the UCLA campus.

Biostatisticians focus on applied studies in public health and medicine, often specializing in a specific discipline. The tools they develop tend to be motivated by the collaborations. Survival analysis, the area of expertise for faculty in the department such as Drs. Gang Li and Dorota Dabrowska, has become an integral part of clinical trials for its ability to measure the time to a specific event such as death. Faculty such as Dr. Weng Kee Wong specialize in other aspects of clinical trials design. With this expertise, the Department of Biostatistics is recognized as one of the top programs in the country.

But even when they specialize, most of the department’s faculty find themselves answering calls from wide-ranging sources. Dr. Robert Weiss, a professor of biostatistics who has co-authored scholarly articles with researchers from 19 different departments, notes that it’s helpful for the biostatistician to have expertise in the topic being studied, but more important to develop the type of working relationship in which the statistician and his or her collaborators are educating each other. “It’s difficult to become expert in two subjects,” Weiss says, “so we become expert in statistics and in communicating statistical concepts and tools to colleagues, who in turn educate us about their discipline.”

In the best cases, Weiss explains, the biostatistician is brought in from the start – participating in discussions on the science and the impetus for the study, the data that need to be gathered and how to collect it, and other details of the study’s design – rather than coming in only at the time of data analysis. “Often, we’re the ones who know what kinds of questions can be answered, and by being involved at the beginning we can help scientists do a better job with their research,” Weiss says.

For more than five years, Weiss has been a key contributor to the studies of Dr. Pamina Gorbach,

“Every time I work with a new researcher or a new disease, I learn fascinating new things.

And almost all of the work we do as biostatisticians has the potential to have an immediate impact on real people.”

—Dr. Catherine Sugar

UCLAPUBLIC HEALTH

Biostatisticians are involved in planning population surveys and in optimally designing experiments.

They ensure that data are properly collected and they play a key role in making sense of it – determining what conclusions can be gleaned and the strength of those conclusions, through the use of analytic tools that they and their colleagues have developed and honed.

“It’s all too easy to draw incorrect conclusions from data if you haven’t been trained in how to interpret them properly,” says Dr. William Cumberland, professor and chair of the Department of Biostatistics in the UCLA School of Public Health. For scientists well versed in statistics, he adds, “It’s a way of understanding that even when there’s a lot of randomness in data, you can often reach conclusions about the general health of the public.”

“Biostatistics is a discipline that tries to identify the real explanations for what’s going on,” says Dr. Thomas Belin, another professor in the department.

That often means taking into account factors that could influence a statistical outcome, he explains.

For example, if a group of people receiving an experimental intervention fares better than the “control” group not receiving it, was it the intervention itself that made the difference or were other factors at play, such as disparities in education? “If you’re trying to identify the real explanation for something you have to rule out other possible explanations,” says Belin, “including that the result was due to chance.”

The department’s research falls into two categories. The first category involves biostatistics faculty working closely with non-biostatistics researchers as collaborators on their studies. In so doing, they encounter statistical problems for which there is no easy solution. These problems become the basis for the second category, biostatistics-specific research, wherein the department’s faculty develop new methodologies and improve established ones.

Even within a field as interdisciplinary as public health, the Department of Biostatistics stands out for its linkages throughout the school and beyond. All of the school’s departments and centers have long-term collaborations with one or more of the school’s biostatisticians, as do many departments within UCLA’s David Geffen School of Medicine, School of Nursing

16

“Many of the challenges we deal with relate to the number of factors that can influence an outcome. How do you handle it when there are hundreds or thousands of quantities that might matter?”

UCLAPUBLIC HEALTH

—Dr. Thomas Belin

associate professor of epidemiology. Gorbach’s research on the high-risk sexual behaviors of individuals in intimate partnerships produces complex data because it involves multiple measures: For each study participant, Gorbach’s group collects information at different points in time as a way of detecting behavioral changes; what’s more, this information often covers different behaviors with more than one partner. Data on the partners are also collected. Thus, a study of 200 people is likely to encompass some 900 partnerships over the course of a year. The statistical approach used to make sense of this type of complicated data, longitudinal analysis, is Weiss’ specialty.

Over time Weiss has taken on a growing role as Gorbach’s collaborator, providing more intensive input on the design of the studies. “Rob’s expertise has allowed me to collect more complex behavioral data,” Gorbach says. “We’ve developed a common language and it’s really strengthened our work, so that data that come out are both epidemiologically useful and statistically interesting.”

In testing new medical treatments, the randomized, placebo-controlled clinical trial is considered the gold standard for understanding whether any difference in outcomes can be attributed to the intervention. But in most biomedical studies – and virtually all public health research – such a setup isn’t possible. As a result, “Much of the challenge of being a statistician is to make correct inferences even when information is missing or you haven’t been able to collect exactly the data you want,” says Dr. Catherine Sugar, an assistant professor in the Department of Biostatistics and director of the Semel Institute Statistics Core, which provides statistical support for researchers in UCLA’s Department of Psychiatry and Semel Institute for Neuroscience and Human Behavior.

Statisticians create and extend tools that can be used to build bridges from data to conclusions.

Biostatistics faculty members train all public health students to understand and interpret p-values (the lower the p-value, the more surprising it would be for the observed finding to be explained by chance alone, and hence the more significant the observed finding). More complex tools include longitudinal designs, which follow the same people over time and thus must account for variations between people and across time points. Belin specializes in methods for dealing with missing or incomplete data: how to account for non-responses to surveys, for example, or people who drop out of studies for any of a number

of reasons. There are multivariate tools for combining different types of measurements, and models that wed these and the many other statistical models.

Non-parametrics are used to reduce assumptions that go into the analysis. “Many of the challenges we deal with relate to the number of factors that can influence an outcome,” says Belin. “How do you handle it when there are hundreds or thousands of quantities that might matter?”

Other challenges are related to the study type.

A sample survey such as the California Health Interview Survey conducted by the UCLA Center for Health Policy Research (based in the School of Public Health), for example, depends on a strict methodology and sound design to ensure that it can provide a detailed and accurate picture of the health and healthcare needs of the state’s population by racial, ethnic, geographic and other measures. For her studies, Dr. Christina Ramirez Kitchen works with both basic scientists and HIV clinicians to learn how the virus mutates in response to drugs, as well as how the immune system changes with changes in the virus. Using complicated mathematical formulas specific to statistical genetics, she is able to help the researchers draw conclusions about the interactions among the virus, HIV drugs, and immune response.

True to the collaborative nature of biostatistics, Ramirez Kitchen has been sought for her expertise and, like many of her colleagues in the department, has ended up collaborating not only with UCLA faculty but also with researchers at UC San Francisco and UC San Diego, and with the New York State Department of Health.

When he was an undergraduate student, Weiss had trouble choosing a major. “Everything was interesting,” he says. Then Weiss stumbled upon statistics, realized he had a knack for it, and ended up getting his Ph.D. “The nice thing is I still don’t have to decide what discipline I want to work in,” Weiss quips. “I get to continue learning different things from experts in different subjects.”

Sugar had a similar experience: Although she had always loved mathematics, she had such an array of other interests that she would have been happy with a classic Renaissance education. As a biostatistician she sometimes feels as if she is getting one.

“There are a lot of fields in which you have to focus narrowly on one thing, but as a biostatistician you can work on almost anything,” Sugar says. “Every time I work with a new researcher or a new disease, I learn fascinating new things. And almost all of the work we do as biostatisticians has the potential to have an immediate impact on real people.”

17

feature Dr. Robert Weiss, professor of biostatistics, has been a key contributor to the research of Dr. Pamina Gorbach, associate professor of epidemiology, for more than five years.Weiss has taken on a growing role as Gorbach’s collaborator, applying his expertise in longitudinal analysis to enable Gorbach to collect more complex behavioral data.

“We’re quite popular – to get major grants, you almost have to have one of us on the application.

We are a very collaborative group. We like to help people.”

– Dr. Christina Ramirez Kitchen

UCLAPUBLIC HEALTH

For Sugar, one of the most rewarding parts of her work is being able to teach the basic concepts of biostatistics to students and, in the process, demonstrate how relevant statistics are to their everyday lives. “We’re constantly getting data thrown at us, and knowing how to be an intelligent consumer of that information – understanding, for example, whether a conclusion being drawn from the data is reasonable – can be a very useful skill,” she says. Since joining the school’s faculty three years ago, Sugar has twice been honored for her teaching excellence with the Professor of the Year award given by the Public Health Students Association.

Those who have received advanced training in that skill from top biostatistics departments, including that of the UCLA School of Public Health, find themselves in high demand, and not just from Google. The vast majority of biostatistics graduates pursue positions in academia, government or industry – particularly biotech and pharmaceutical companies. If they are anything like their UCLA mentors, they keep busy. In addition to research and teaching responsibilities, the department’s faculty devote considerable time to reviewing the scholarly work of their peers – whether through editorial work for journals as article reviewers and editors, participation on panels that review research grant applications, or service on doctoral dissertation committees. (Dr. Abdelmonem A. Afifi, professor emeritus in the department and former dean of the school, has served on more than 130 doctoral dissertation committees and is currently on two dozen more.)

Then there’s the research. At any one time, Belin says, he is on as many as 30 or more studies, and he suspects that many of his department colleagues would report the same level of activity. Many of the faculty are kept busy in their roles heading statistical cores for clusters of like-minded investigators, often as part of research centers or programs. Through these entities, biostatistics faculty are often called upon by multiple researchers to provide consultation and support – and even one active researcher can keep a biostatistician fairly busy, Belin notes.

“We’re quite popular – to get major grants, you almost have to have one of us on the application,” says Ramirez Kitchen. She explains that at a time when competition for federal research funding is fierce, granting agencies want assurance that the protocols have a high likelihood of success and that data collection and analysis will unfold in a way that is sound. Not that members of the department’s faculty mind the attention. “We are a very collaborative group,” Ramirez Kitchen says. “We like to help people.”

18

C ALIFORNIA

LED

THE WAY IN RAISING THE STANDARDS FOR WHAT CAN BE SOLD ON

K-12

CAMPUSES ,

BUT THE WORK IS FAR FROM OVER .

SPH

FACULTY CON -

TINUE TO PLAY AN IMPORTANT ROLE .

FOOD for THOUGHT:

Working Toward Healthier School Nutrition Environments With the obesity epidemic

continuing to rank at or

near the top of any list of public health concerns, California has spearheaded a national movement to change the nutrition environment in K-12 public education. The multifaceted strategy focuses on making healthier foods more accessible

UCLAPUBLIC HEALTH

and appealing, reducing or eliminating unhealthy choices, and improving nutrition

“When we help kids eat healthier it reduces costs to society in the long term, because obesity and poor diet are associated with higher rates of chronic diseases, hospital expenditures and lost productivity.

We also know that if children aren’t eating well it affects their learning, school performance and self-esteem.”

—Dr. May Wang

education in schools – all toward the goal of reaching children before they develop the seemingly intractable eating and physical activity patterns that are contributing to the alarming overweight and obesity rates.

“When you consider that children spend the majority of the day at school, we have a huge opportunity to make a difference in their lives,” says Dr. Wendy Slusser, one of a handful of UCLA School of Public Health faculty who have spent much of the last decade engaged in research and policy work on the issue. “If we’re going to require that children be there, we have an obligation to provide them with the healthiest environment possible.”

For more than a decade, three faculty members have worked closely with the Los Angeles Unified School District as the nation’s second-largest district has sought to increase healthy eating at its schools. In recent years a central part of that effort has come through the Network for a Healthy California-LAUSD (for-

19 related to better nutrition for both parents and their children. There’s a community that develops, and the parents learn from each other.”

A five-part, 10-hour program in low-income LAUSD schools has led to changes in knowledge, skills and behaviors related to better nutrition for both parents and their children.

UCLAPUBLIC HEALTH

Neumann had a well-established research program focused on addressing malnutrition among schoolchildren in Africa when, a little more than a decade ago, she was taken aback by a series of articles in the Los Angeles Times on hungry children in UCLA’s own backyard. Neumann brought in Slusser and the pair received funding to study the diet and body mass index of children in low-income LAUSD schools. They found that 11 percent were moderately malnourished – most of them recent arrivals from war-torn nations.

But Neumann and Slusser also discovered something that at the time qualified as shocking: Nearly half of the second- through fifth-grade children they surveyed were obese or overweight. Neumann and Slusser, later joined by Prelip, received funding from the state and began working with LAUSD in the capacity of advisers and evaluators as the district began to implement programs designed to combat the problem.

At about the same time as Neumann and Slusser were conducting their survey in LAUSD, the Santa Monica-Malibu Unified School District was experiencing success with a program to bring fresh fruits and vegetables to its schools. Featuring tasty produce presented in a visually appealing way, the salad barstyle fare proved highly popular. On the basis of Santa Monica-Malibu’s success, the UCLA School of Public Health researchers collaborated with LAUSD’s food services director to install salad bars (later referred to as fruit and vegetable bars) in a small number of low-income schools, with Slusser evaluating the effects. She found that the introduction of the salad bars resulted in a significant increase in fruit and vegetable consumption at the pilot schools, as well as higher participation in the school lunch program.

Based on those results, Slusser and colleagues recently received funding from Woodland Hills, Calif.-based Anthem Blue Cross for a larger study.

The health plan’s director of clinical programs, Harvinder Sareen (Ph.D. ’04), was familiar with Slusser’s work dating to her time as a doctoral student at the school. In her current position she heads a child obesity initiative across WellPoint, Anthem’s parent company. “We’ve gone beyond the traditional role of the health benefits company and focused on communities, especially elementary schools,” Sareen explains “We know that in order to really make a difference on

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merly known as The LAUSD Nutrition Network), funded by the U.S. Department of Agriculture through the State of California to promote fruit and vegetable consumption in low-income schools. Since 2001, LAUSD has contracted with a UCLA School of Public Health faculty team, now headed by Dr. Michael Prelip and also including Slusser and Dr. Charlotte Neumann, to evaluate LAUSD’s nutrition education programs. The district was motivated to pursue the funding in part by research in the late 1990s by Neumann and Slusser showing high levels of obesity within LAUSD. “There are many kids eating the wrong foods, and in particular not eating adequate amounts of fruits and vegetables, which is associated with risk of obesity and many chronic diseases,” says Prelip. “There is a growing sense that many of the health issues that plague us as a country are tied to behaviors that kids are setting down early in their lives, and that by addressing these behaviors in schools we have the opportunity to make a difference.”

Beyond evaluating the nutrition education programs, Prelip’s group has provided technical assistance in their design and implementation. At first those programs were based almost exclusively in the classroom.

More recently, at the urging of the UCLA School of Public Health faculty advisers, the district has broadened its focus to include more programs that target teachers, parents and the school environment.

Most K-12 teachers have had little preparation for educating students in nutrition, Prelip notes. The capacity-building effort aims to equip them with know-how and skills – and in the process make them more comfortable providing nutrition education. “If teachers aren’t sure how to access available resources or incorporate nutrition messages into other subject areas, they’re less likely to do it,” Prelip says. In the past, LAUSD has offered in-person teacher training, but that limits participation because of limits on resources. This year, in an effort to reach more teachers, Prelip’s group is working with the district to provide an online course and are investigating the feasibility of other non-traditional approaches.

Expanding the district’s parent education programs has been particularly successful. Prelip’s team had conducted research with low-income parents to determine what would be most helpful. “They sent us a strong message that they already know about the food pyramid and what their kids should be eating, but they wanted help in figuring out strategies for making the necessary changes,” Prelip says. Out of that came a five-part, 10-hour parent education program. “The face-to-face training has been quite effective with these parents,” says Prelip. “We have observed changes in knowledge, skills and behaviors

20

Fruit and vegetable bars have proved popular at schools that have installed them, including Hooper Avenue Elementary, a low-income school in Los Angeles.

“The body of research tells us that if kids have increased availability, accessibility and choices, they’re going to eat more fruits and vegetables.”

UCLAPUBLIC HEALTH

—Dr. Wendy Slusser

this issue we need to reach our youngest members not just in the primary care setting, but also in an environment where they spend a significant amount of time.” The study was recently completed and the soon-to-be-published results drew the attention of policy makers in Washington, D.C. who were looking to promote fruit and vegetable bars in schools through reauthorization of the federal Child Nutrition Act. Not everyone expected children to embrace the fruit and vegetable bars. Slusser remembers one wellknown adviser to LAUSD predicting, “You’ll never get rid of the sloppy joes.” But Slusser believed otherwise. “The body of research tells us that if kids have increased availability, accessibility and choices, they’re going to eat more fruits and vegetables,” she says. Slusser is hopeful that her study will continue to provide ammunition for policy makers and public health advocates. In LAUSD, where a 2002 school board motion called for the installation of fruit and vegetable bars at every school with the infrastructure to support them, they are in place at only a small percentage of schools.

Dr. William McCarthy had an up-close view of the success of the Santa Monica-Malibu district with its salad bar initiative as a member of the district’s Advisory Committee on Health and Safety at the time the program was implemented. In the years since, he has been involved in a number of studies on issues related to nutrition and physical activity in schools. A long-term collaboration with UCLA School of Public Health faculty colleague Dr. Antronette Yancey began with a pilot study in the Culver City School District aiming to help sixthgrade girls become more physically active and make

better food choices. That was followed by Community Steps to Fitness, a program with the Los Angeles County Department of Health Services to promote physical activity at two resource-poor inner-city LAUSD schools.

McCarthy has also explored strategies to increase the number of children eating breakfast. A healthy breakfast has been associated with a lower risk of obesity and diabetes, as well as better academic outcomes.

Although federally subsidized breakfasts are offered to low-income students, McCarthy has found that many children opt out because of the perceived stigma associated with participation. This has led McCarthy and others to advocate a universal free breakfast program.

“LAUSD has universal free breakfast on days of standardized testing, because it improves scores,” McCarthy notes. “The limiting fuel in brain function is glucose, and without it, kids don’t do as well. So why wouldn’t we want to maximize how well our children’s brains function every school day? Like with anything else, it comes down to money.”

To be sure, educational and public health leaders trying to use the school environment to influence children’s nutritional attitudes and behaviors face daunting challenges, particularly in low-income neighborhoods. If children learn to embrace a nutritious diet from their teachers at school but aren’t being served healthy foods at home, progress is difficult. Thus, educating parents becomes an important part of the strategy. But even when parents turn out for such a program, providing proper nutrition for children isn’t easy in communities where fast-food chains are plentiful and supermarkets with fresh produce are few. In addition, Prelip argues, programs seeking to change behaviors are doomed to failure if they are not intensive. “You have to deliver a heavy

21

“Schools had become soda and junkfood super stores.

Nutrition was taught in the classroom and then the lunch bell would ring, the kids would go onto the school campus and what was sold was everything that the teacher had just told them not to eat.”

—Harold Goldstein, M.S.P.H. ’89, Dr.P.H. ’97

UCLAPUBLIC HEALTH

In 2002 McCarthy had been contracted through San Francisco-based WestEd, an education-focused research, development and service agency, to evaluate the sources of nutrition for students at LAUSD schools. The study was particularly concerned with so-called competitive foods: items sold on campus but outside of the school lunch program – whether in vending machines, in the student store or a la carte in the cafeteria – and thus not subject to the same nutritional quality standards. McCarthy and a WestEd colleague visited a random sample of LAUSD schools and were appalled by what they saw. “Particularly in the higher grades, we found a reliance on chips and sodas as the major source of nutrition for many students,” McCarthy recalls. Especially troubling was the high proportion of students eligible for free meals who were forgoing the cafeteria food in favor of chips-andsoda lunches – in some schools as many as one in four children. Children appeared to avoid the U.S.D.A.-approved meals because they wanted to avoid the perception that their family was dependent on public assistance, McCarthy says.

Harold Goldstein (M.S.P.H. ’89, Dr.P.H. ’97) was equally dismayed when he began to focus on the nutritional quality of school foods in 1999. “There were standards for school meals, but for everything else sold on school campuses it was a free-for-all,” says Goldstein, executive director of the nonprofit California Center for Public Health Advocacy. “Schools had become soda and junk-food super stores. Nutrition was taught in the classroom and then the lunch bell would ring, the kids would go onto the school campus and what was sold was everything the teacher had just told them not to eat.”

At the time, Goldstein says, members of the state Legislature were unaware of the burgeoning obesity epidemic. In its effort to do something about the problem, Goldstein’s organization decided that starting with children, in a venue where policy makers had responsibility, was the ideal strategy. With the California Center for Public Health Advocacy and others leading the way, the state by 2005 had passed legislation signed by the governor that eliminated the sale of soda and other sweetened beverages on school campuses and established the most rigorous minimum nutrition standards in the country for food sold outside the school meal program.

Other states have followed California’s lead. “It was the beginning of a national movement to change the food environment,” says Goldstein. “We are surrounded by unhealthy food choices. Everywhere we turn, we’re bombarded with large portions of high-fat, high-sugar and high-salt foods.”

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enough of a dose to make a difference, and a 20-minute program isn’t going to come close to doing that,” he says. At low-income schools, the pressure to raise test scores has the potential to be all-encompassing, leaving administrators and teachers to make difficult decisions about where to focus their limited time and energy.

With that in mind, Prelip successfully applied for a grant from the California Vitamin Settlement Fund to work with the Alhambra Unified School District in implementing an after-school program. “School districts are dealing with an impacted curriculum during the day, but in an after-school program there’s much more freedom,” explains Prelip. Working with Slusser, he is piloting a program at a dozen elementary schools in Alhambra, a city eight miles east of Los Angeles. The youth leaders running the school programs go through a two-day training and are provided resources to help them incorporate nutrition and physical fitness education and activities. “It’s been very exciting to see young people from the community bringing their energy to these programs,” Prelip says.

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“There is a growing sense that many of the health issues that plague us as a country are tied to behaviors that kids are setting down early in their lives, and that by addressing these behaviors in schools we have the opportunity to make a difference.”

UCLAPUBLIC HEALTH

—Dr. Michael Prelip

While the legislation was important, the problem is far from solved. The standards apply only during school hours and not after school or at activities such as athletic events and fund-raisers. Moreover, says Goldstein: “The nutrition standards were designed only to take out the worst of the worst products. There are still a lot of foods sold on California school campuses that are far from being healthy.” He sees a growing consensus in the public health community to eliminate all competitive foods so that only healthy, balanced meals are sold at schools.

Many districts are implementing strategies that go beyond the state’s mandate. Dr. May Wang, a nutritional epidemiologist who recently joined the UCLA School of Public Health faculty from UC Berkeley, was contracted to evaluate the School Lunch Initiative, a partnership between the Chez Panisse Foundation and Berkeley Unified School District that set out to change what the 9,000 Berkeley public schoolchildren eat for lunch. The initiative, launched in 2004, built on the innovative cooking and gardening program offered at The Edible Schoolyard, a Chez Panisse Foundation program at one middle school in which students participate in all aspects of growing, harvesting and preparing nutritious produce. The district’s nutrition services department was overhauled to replace processed and prepackaged foods that barely met nutritional standards with healthy meals prepared from scratch at a central kitchen using fresh ingredients.

Wang and colleagues at UC Berkeley’s Center for Weight and Health were called on to measure the impact of the program by tracking the eating habits of fourth- and fifth-graders at four schools for three years. While the researchers are still analyzing the data from the third year, after the first two years they had already found positive changes in nutrition-related knowledge and attitudes, as well as in eating behaviors – including an increase in fruit and vegetable consumption at the schools where the most intensive interventions were in place.

Wang is hopeful that the Berkeley project’s success will serve as a model for other similar-sized districts; in the meantime, she intends to continue pursuing research on how environments affect behaviors that can increase or reduce obesity risk.

Creating environments conducive to healthy behaviors is a central tenet of public health, and a critical part of the effort to combat the child obesity epidemic. “We want the default choice to be eating healthy foods and being physically active,” McCarthy says. Despite movement in the right direction, he believes it is still all too easy for children to make the wrong choices for their health. Cashstrapped schools are contracting with large companies to sell foods and drinks that are high in calories and low in nutrients. Some districts, for instance, are signing lucrative “pouring rights” deals with soft drink companies seeking to cultivate brand loyalty with the young generation. “We need to de-commercialize the schools,” says Yancey. “Particularly at the high school level, our schools are serving corporate America more than they’re serving our kids. Schools shouldn’t have to have pouring rights contracts in order to afford books and pencils.”

Wang suggests that costs associated with creating healthier food environments at schools should be weighed against the costs of not taking such action.

“When we help kids eat healthier it reduces costs to society in the long term, because we know that obesity and poor diet are associated with higher rates of chronic diseases, hospital expenditures and lost productivity,” she says. “We also know that if children aren’t eating well it affects their learning, school performance and self-esteem. Child obesity rates are higher in minority groups, and when we address child obesity it means we are taking one more step toward addressing social disparities in health. So, there are many reasons for us to try to improve the nutrition environment in schools.”

research highlights

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research

Conversing Helps Language Development More Than Reading Alone, SPH Study Finds

More conversations means more opportunities for mistakes, and therefore more chances for valuable corrections. Furthermore, conversing provides an opportunity for children to practice new vocabulary.

UCLAPUBLIC HEALTH

ADULT-CHILD CONVERSATIONS have a more significant impact on language development than exposing children to language through one-on-one reading alone, according to a UCLA School of Public Health study that appeared in the July 2009 issue of Pediatrics, the journal of the American Academy of Pediatrics.

“Pediatricians and others have encouraged parents to provide language input through reading, storytelling and simple narration of daily events,” explains the study’s lead author, Dr. Frederick J. Zimmerman, the Fred W. and Pamela K. Wasserman Chair in Health Services at the school. “Although sound advice, this form of input may not place enough emphasis on children’s role in language-based exchanges and the importance of getting children to speak as much as possible.”

The study of 275 families of children ages 04 was designed to test factors that contribute to language development of infants and toddlers.

Participants’ exposure to adult speech, child speech and television was measured using a small digital language recorder or processor known as the LENA System. This innovative technology allowed researchers to hear what was truly going on in a child’s language environment, facilitating access to valuable new insights.

The study found that back-and-forth conversation was strongly associated with future improvements in the child’s language score. Conversely, adult monologuing, such as monologic reading, was more weakly associated with language development. TV viewing had no effect.

“What's new here is the finding that the effect of adult-child conversations was roughly six times as potent at fostering good language development as adult speech input alone,” says Zimmerman.

Each day, children hear an average of approximately 13,000 words spoken to them by adults and participate in about 400 conversational turns with adults.

More conversations means more opportunities for mistakes, and therefore more chances for valuable corrections. Furthermore, conversing provides an opportunity for children to practice new vocabulary.

Parents should be encouraged not only to provide language input to their children through reading or storytelling, but also to engage their children in twosided conversations, the study concludes. “Talk is powerful, but what’s even more powerful is engaging a child in meaningful interactions – the give and take that is so important to the social, emotional and cognitive development of infants and toddlers,” says Dr. Jill Gilkerson, language research director at LENA Foundation and a study co-author.

“It is not enough to speak to children,” Zimmerman adds. “Parents should also engage them in conversation. Kids love to hear you speak, but they thrive on trying speech out for themselves. Give them a chance to say what’s on their minds, even if it’s “goo goo gah.”

Nearly 1 Million Californians Seek Medical Care in Mexico Each Year

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Number of California Adults Seeking Health Care in Mexico

by Ethnicity and Birthplace

THOUSANDS GOING TO MEXICO

600 500 400 300 200 100 0

Medical Care M

Dental Care

Recent Mexican Immigrant Long-Stay Mexican Immigrant US-Born Mexican American US-Born Non-Latino White Other [Both Native and Immigrant]

DRIVEN BY RISING HEALTHCARE COSTS at home, nearly 1 million Californians cross the border each year to seek medical care in Mexico, according a study led by Dr. Steven P. Wallace, associate director of the UCLA Center for Health Policy Research (based in the School of Public Health) and published in the journal Medical Care.

The paper is the first large-scale population-based research published on U.S. residents who travel to Mexico for health services. It is based on an analysis of 2001 data from the California Health Interview Survey (CHIS), the nation’s largest state health survey, which is conducted by the Center for Health Policy Research.

According to the study, an estimated 952,000 California adults seek medical, dental or prescription services in Mexico each year; of these, 488,000 are Mexican immigrants. “What the research shows is that many Californians, especially Mexican immigrants, go to Mexico for health services,” says Wallace. “We already know that immigrants use less healthcare overall than people born in the United States. Heading south of the border further reduces the demand on U.S. facilities.”

Cost and lack of insurance are primary reasons both Mexican and non-Mexican U.S. residents sought health services across the border. Both “longstay” Mexican immigrants (those in the United States for more than 15 years) and “short-stay” immigrants (fewer than 15 years) have high rates of uninsurance: 51.5 percent of short-stay immigrants and 29 percent of long-stay immigrants do not have medical insurance.

Both short-stay and long-stay immigrants have even higher rates of uninsurance for dental care: 77.6 percent and 51.6 percent, respectively. Not surprisingly, dental care is the most common service obtained by immigrants crossing the border. Among non-Latino whites, prescription drugs are the most common medical service obtained in Mexico.

Long-stay immigrants use Mexican health services the most, with 15 percent reporting crossing the border for health services during a year’s time. Half Prescription Drugs of these long-stay immigrants live far from the border – more than 120 miles away. Long-stay immigrants are more likely to be documented than short-stay immigrants, Wallace notes, which makes it easier for them to travel back and forth to Mexico.

Short-stay immigrants – those most likely to be undocumented – are also the least likely to need medical care in all areas, with one exception: mental health. “Undocumented immigrants tend to be younger, stronger and consequently healthier,” Wallace says. “But they are also the most stressed out, as many are struggling economically, culturally and linguistically.”

UCLAPUBLIC HEALTH

Sale of Tobacco Near Schools Increases Students’ Smoking Risk THE DENSITY OF TOBACCO RETAILERS NEAR SCHOOLS increases the risk of students experimenting with smoking, according to a study led by Dr. William McCarthy, professor of health services in the UCLA School of Public Health and lead evaluator for the State of California’s tobacco-use education and prevention

Latinos of Mexican Ancestry Have Lower Insurance Rates Than Other Latinos

Students in schools with more tobacco retailers within a mile of the campus were 11 percent more likely to initiate tobacco use for every 10 additional tobacco retailers.

UCLAPUBLIC HEALTH

U.S. LATINOS OF MEXICAN ANCESTRY have lower rates of health insurance coverage than non-Mexican U.S. Latinos even when taking into account differences in major socioeconomic and demographic factors between the populations, according to a study led by Dr. Arturo Vargas-Bustamante, assistant professor of health services in the UCLA School of Public Health. The study was published in the October issue of the Journal of General Internal Medicine.

Most previous studies of health insurance coverage among U.S.-residing Latinos have either compared differences between their coverage rates and those of other ethnic and racial groups or have focused on disparities among a few Latino groups: Mexican Americans, Cubans and Puerto Ricans. VargasBustamante’s study, which used the National Health Interview Survey database from 1999 to 2007 to analyze health insurance coverage for 33,847 Latinos, focused specifically on differences in coverage rates between U.S. Latino adults of Mexican ancestry and all other U.S. Latino adults.

Vargas-Bustamante and colleagues found that only 59 percent of U.S. Latinos of Mexican ancestry are insured, compared with 73 percent of their nonMexican Latino counterparts. In delving further, the researchers examined the contribution of key observable differences between the groups (including age, sex, income, employment status, education, citizenship status, language and

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efforts in public middle and high schools. The study, the most extensive analysis ever conducted of the association between the density of tobacco retailers around a school and the risk of tobacco use by its students, was published in the November issue of the American Journal of Public Health.

Although most states, including California, prohibit the sale of cigarettes to minors, McCarthy and other public health researchers have suspected that the sale of these products near schools could have an impact on the risk of students’ tobacco use. As the principal evaluator of the state’s tobacco-education efforts, McCarthy has found that certain community-level differences in the tobacco-use rates of students could not be explained solely by traditional socioeconomic and individual-level predictors of smoking risk.

Analyzing survey data from 19,306 students from 245 schools in the state, McCarthy’s group found that those in schools with more tobacco retailers within a mile of the campus were 11 percent more likely to initiate tobacco use for every 10 additional tobacco retailers even after taking into account the schools’ average level of parent education and whether the school was in a rural or urban area. The effect of closely situated tobacco retailers on students who were already habitual smokers was not statistically significant. Among the 19 percent of students who reported purchasing their cigarettes, the most common venue was gas stations (particularly in rural areas), followed by convenience stores (especially in urban areas). Grocery store purchases were relatively infrequent.

“We conclude that there is plausibility to the notion that the presence of tobacco retailers near a child’s school could contribute to risk of smoking initiation,” McCarthy says. “Although the effect is small, why should any student have to pay the price of a lifelong addiction for the privilege of attending that school?”

McCarthy believes communities should examine the experience of cities such as Tempe, Ariz., and La Mirada, Calif., which have passed ordinances prohibiting new tobacco retailers from locating any closer than 600 feet from a school.

health condition) to the disparity. While approximately 65 percent of the difference in coverage rates could be attributed to these socioeconomic and demographic factors, other factors accounted for 35 percent of the coverage disparity.

The research team suggested that the unobserved differences between the two groups that are contributing to the difference in coverage rates may include employment-related factors such as type of job and firm size, as well as behavioral and other factors.

“Our analysis shows that Latinos of Mexican ancestry have the worst rates of health insurance coverage among all Latino groups in the United States, and that their lower rates are not fully explained by socioeconomic, health status and geographic factors that past research has suggested are the main determinants of health insurance coverage,” Vargas-Bustamante says. “Other determinants appear to be contributing to the disparity. These determinants, which are likely related to attitudes, perception of need and preference for health insurance coverage – and may also include factors such as risk aversion and cultural familiarity with the health insurance system in the United States – need to be further investigated.”

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Consumption of Unregulated Well Water Near Pesticide Spraying Increases Parkinson’s Risk

UCLAPUBLIC HEALTH

The risk of developing Parkinson’s was 70-90 percent higher among people who were drinking from private wells near fields sprayed with the pesticides diazinon, methomyl, chlorpyrifos, propargite or dimethoate.

THE MOST EXTENSIVE AND RIGOROUS STUDY study to date on the potential link between exposure to pesticides from well water and risk of Parkinson’s disease concludes that rural residents who drink from private wells potentially contaminated with certain commonly used farm pesticides have nearly double the risk of developing the neurological disorder. The study, published in the journal Environmental Health Perspectives, builds on a growing body of evidence from a group headed by Dr. Beate Ritz, professor of epidemiology in the UCLA School of Public Health, on the association between pesticide exposure and Parkinson’s risk.

Previous studies examining the association between well water exposure and Parkinson’s disease risk have been small and have relied largely on self reports of residents’ well water consumption; in addition, none attempted to measure levels of pesticide contamination. The UCLA research team was the first to consider residents’ proximity to specific chemicals and to estimate their exposure levels. The researchers used a geographic information system that combined residential and occupational address information, land-use maps and California’s pesticide-use records for the years 1974 to 1999.to estimate exposure to pesticides among people who drank wellwater while living in the Central Valley counties of Fresno, Kern and Tulare.

They found that people residing in those areas who now have Parkinson’s were more likely to have consumed water from the private wells, and had consumed it on average 4.3 years longer than those who do not have the disease.

The risk of developing Parkinson’s was 70-90 percent higher among people who were drinking from private wells near fields sprayed with the pesticides diazinon, methomyl, chlorpyrifos, propargite or dimethoate. Private water wells, unlike municipal water supplies, are largely unregulated and not monitored for contaminants.

“The Central Valley of California produces one-fourth of the food we eat in this country and sprays about one-third of the pesticides purchased in a given

year,” says Dr. Nicole Gatto, a postdoctoral research fellow in the school’s Department of Epidemiology and lead author of the study. “We know pesticides do not stay in the areas where they are sprayed, so it is important to be aware of the far-reaching effects we can have on the environment and the effects our environment may have on our health.”

The study is the latest effort by the group headed by Ritz, who co-directs the federally funded UCLA Center for Gene-Environment Studies of Parkinson’s Disease, to learn more about the potential risks of the neurodegenerative movement disorder from pesticide exposure. It is believed that in most cases, Parkinson’s disease results from a combination of genetic and environmental factors.

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research

Protein that Regulates Sex Hormones May Be Best Predictor of Type 2 Diabetes Risk

RELATIVE RISK

Relative Risk of Type 2 Diabetes for Men as Predicted by Plasma Levels of SHBG

.62

.38

.11 MEAN PLASMA SHBG LEVELS

Highest

UCLAPUBLIC HEALTH

BLOOD LEVELS of a sex hormone-regulating protein may be the best known predictor for the risk of developing type 2 diabetes, researchers at UCLA and Harvard University reported in the online New England Journal of Medicine in August.

The research team, led by Dr. Simin Liu, professor of epidemiology in the UCLA School of Public Health and director of the UCLA Center for 1.0 Metabolic Disease Prevention, found that the lower 1.0 the plasma level of sex hormone-binding globulin (SHBG), the higher a person’s risk of going on to develop type 2 diabetes. .75 The level of SHBG, which regulates levels of testosterone and estrogen in the blood, appears to be a stronger predictor of the type 2 diabetes risk than any of the previously known risk factors, Liu .50 says, from traditional factors such as weight, smoking, blood pressure and physical activity to two wellpublicized newer markers, HbA1c and C-reactive .25 protein.

Liu and colleagues analyzed SHBG levels in 718 postmenopausal women participating in the Women’s Health Study, which began in 1993. Half of the women had been newly diagnosed with type 2 0 Lowest diabetes, while the other half were non-diabetic. The research team later confirmed the findings in a group of 340 men participating in the similarly large Physicians’ Health Study II. They found that study subjects in the lowest quartile of SHBG levels had a 10 times greater risk of developing type 2 diabetes than did those in the highest quartile. Further genetic analysis showed a relationship between two variants of the gene coding for SHBG and type 2 diabetes risk, with one increasing the risk and the other decreasing it – suggesting that more than merely being a disease marker, SHBG may play a causal role in the development of type 2 diabetes.

Nearly 24 million people in the United States have diabetes, according to the Centers for Disease Control and Prevention, and most cases are type 2. Another 57 million are believed to have pre-diabetes, a condition in which they are at significant risk for developing the disease. If the findings of the UCLA/Harvard study are confirmed in subsequent studies, routine blood screening for SBHG could help to identify high-risk patients at an earlier point, when preventive measures might be more effective. Moreover, Liu notes, SBHG’s potential role as a culprit in type 2 diabetes development may provide a new therapeutic target – specifically, measures aimed at raising SHBG levels.

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student profiles Doctoral Student Was First in Family to Attend College

“As a biostatistician, I can work with public health professionals and clinicians on a variety of different problems with real-life applications. That’s very exciting to me.”

UCLAPUBLIC HEALTH

— Robin Jeffries

AS A THIRD-YEAR STUDENT in the school’s Dr.P.H. in Biostatistics program, ROBIN JEFFRIES is reveling in the challenges of her discipline. In addition to her coursework, Jeffries has been assisting UCLA School of Public Health faculty members on two studies. For Project Connect, a multi-center study testing interventions aimed at reducing teen pregnancy and sexually transmitted diseases, Jeffries works for Drs. Abdelmonem A. Afifi and William Cumberland in the Department of Biostatistics; she also assists Dr. Pamina Gorbach, associate professor of epidemiology, in her role as an investigator on an HIV microbicide clinical trial. “It’s been an incredible experience to learn at the side of these professors,” Jeffries says.

Both studies find Jeffries working with self-report survey data in which there is the potential for “missing values” – a common problem that statisticians have developed methods to overcome. “These studies are asking sensitive questions that rely on people’s memories,” Jeffries explains. “Respondents might forget, fudge their answers, or give conflicting reports, and so the challenge is to make the data as ‘clean’ as possible.” It’s a challenge Jeffries has embraced. “Part of my nature is to want everything to be just right…to have all the ducks in a row,” she quips.

Jeffries’ enthusiasm for the academic environment has to do with the fact that she never took it for granted that she would come so far. “It was a long journey,” she says. “We didn’t have a lot when I was a kid.” Raised by her mother in Chico, in a rural part of California 90 miles north of Sacramento, Jeffries was the first in her family to attend college. She started at a community college majoring in biology but found she couldn’t stay away from the math courses. At the urging of one of her calculus professors she took a statistics class. “I instantly fell in love, because I could see that it wasn’t just theoretical – this was something I could apply in everyday life,” she says.

When she transferred to California State University, Chico, Jeffries decided to double-major in biology and statistics. There, a conversation with a chemistry professor as Jeffries was pondering which direction to take in graduate school proved fateful. “I said I didn’t know what to do – I really liked biology and I really liked statistics,” Jeffries recalls. “He suggested I look into biostatistics programs. I hadn’t even known they existed.” Jeffries ultimately chose the UCLA School of Public Health, where a Graduate Opportunity Fellowship would cover her first year of education. (As a Dr.P.H. student, Jeffries would receive more assistance as the recipient of the school’s Wayne SooHoo Memorial Scholarship.)

At first, her intention was to stay only for her master’s degree. But as the twoyear program was ending, Jeffries decided she had to continue. “I thought to myself, ‘I’m not finished – there’s still more I want to learn,’ ” she says. While she is still deciding on the course she’ll take once she obtains her Dr.P.H., Jeffries is excited about the possibilities. “As a biostatistician, I can work with public health professionals and clinicians on a variety of different problems with real-life applications,” Jeffries says.

“That’s very exciting to me.”

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students

As HIV Tester/Counselor, He Gets Up-Close Perspective of At-Risk Populations He Studies

“What I enjoy most is that by doing behavioral rather than laboratory-bench research, there is a level of human-to-human interaction that I didn’t have before.”

— Ryan Murphy (left)

UCLAPUBLIC HEALTH

RYAN MURPHY KNEW HE WOULD BE DEVELOPING analytical skills as part of his doctoral studies in the UCLA School of Public Health’s Department of Epidemiology.

But the third-year Ph.D. student didn’t necessarily plan on becoming as intimately involved in the lives of his subjects as he has.

Since he began in the program, Murphy has worked as a graduate student researcher under the direction of Dr. Pamina Gorbach, associate professor of epidemiology. In that role, Murphy has assisted on community-based studies involving largely homeless, drug-using populations at high risk for HIV. Because the studies include HIV testing, Murphy took it upon himself to become a California certified HIV tester and counselor.

“Receiving HIV test results, positive or negative, is a big moment,” Murphy explains. “For people who are taking time out of their days to participate in our studies, I wanted to make sure we were helping them in the best possible manner, and being able to provide testing, counseling and appropriate referrals was one way to ensure we could do that.”

The desire to have more direct human contact is what brought Murphy into public health in the first place. As an undergraduate at Occidental College in Los Angeles he majored in biology with an emphasis in cellular and molecular biology, and considered enrolling in a molecular biology graduate program. But in public health he saw an opportunity to become involved in research where he might be able to see a more immediate impact on populations. And in HIV epidemiology, he found what for him was the best of all worlds. “Coming from a microbiology background I was very interested in infectious disease research, and HIV is obviously a huge concern in that area,” he says.

“But what I enjoy most is that by doing behavioral rather than laboratory-bench research, there is a level of human-to-human interaction that I didn’t have before.”

For his dissertation, Murphy is exploring the role of housing status on partnership dynamics and its potential relevance to the risk of HIV transmission. Studies have indicated that people in homeless shelters are up to nine times more likely to be HIV-positive than the general population – not having a stable living environment may increase the likelihood that people will engage in riskier sexual and drug-use behaviors, Murphy notes. His study is taking a broad view of housing status to include not just people with stable homes and those living on the streets or in shelters, but also people who are “marginally housed” through friends, family members or pay-by-day motels.

As with his work on Gorbach’s studies, the dissertation will give Murphy a closeup view of the plight of the population he is studying – a vantage point he believes will be useful to his work. “From a purely research perspective, it gives you a better understanding of the data you’re generating,” Murphy explains. “If you’re only on your computer and not interacting with people, it can be harder to know what led to the data and what you might need to account for in your analysis. And on a more personal level, interacting with people who are homeless and getting to know them better serves to motivate and remind me of why I’m doing what I’m doing.”

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new faculty DR. HECTOR P. RODRIGUEZ joins the faculty as assistant professor in the Department of Health Services. Rodriguez’s research focuses on clarifying the organizational influences on medical care quality and public health system effectiveness, performance measurement, and patients’ experiences in ambulatory care.

Most recently he was assistant professor at the University of Washington, School of Public Health.

He received his M.P.H. from UC Berkeley and his Ph.D. from Harvard University in Health Policy with a concentration in Medical Sociology.

DR. DONATELLO TELESCA joins the faculty as assistant professor in the Department of Biostatistics.

Telesca comes to the school from the University of Texas M. D. Anderson Cancer Center in Houston, where he was a postdoctoral research fellow.

Telesca’s research is primarily focused on dependent data and non-parametrics. Other areas of interest include decision theory, Markov chain Monte Carlo computation and bioinformatics. He was the recipient of the Jimmy Savage Honorable Mention award for a dissertation that makes outstanding contributions and has potential to affect statistical practice from the International Society for Bayesian Analysis.

Telesca has a master’s and Ph.D. in Statistics from the University of Washington.

ALSO JOINING THE FACULTY:

CHAO CHUN Epidemiology MIA HASHIBE Epidemiology MARK MALEK Epidemiology JACK SAHL Epidemiology

UCLAPUBLIC HEALTH

CRISTINA TIRADO Community Health Sciences

contracts & grants 2008-09 DEBORAH ACKERMAN Patient-Reported Outcomes from Complementary, Alternative, & Integrative Medicine (PROCAIM) (Samueli Institute for Information Biology, $80,000 for 2 years) ROSHAN BASTANI Patient Navigator Outreach Program and Chronic Disease Prevention (DHHS/Health Resources & Services Administration & Northeast Valley Health Corporation, $76,114 for 2 years) BARBARA BERMAN Smoking Cessation in Substance Abuse Treatment Programs (UC Tobacco-Related Disease Research Program, $75,000 for 2 years) E. RICHARD BROWN The California Health Interview Survey (Blue Shield of California Research & Education Foundation, $450,000 for 3 years; The California Endowment, $3,000,000 for 2 years; Kaiser Foundation Research Institute, $500,000 for 2 years; Kaiser Foundation Research Institute, $500,000 for 2 years; National Cancer Institute, $150,000; California Department of Mental Health, $1,000,000); Medical Home & Care Coordination Module for CHIS 2009 (California Healthcare Foundation, $115,000 for 2 years); Policy Research Studies Using Data from the 2007 California Health Interview Survey (The California Endowment, $418,197 for 2 years); Study of Innovative Practices in Local Population-based Health Surveys Throughout the United States (National Cancer Institute, $99,158) ROGER DETELS UCLA Fogarty AIDS International Training and Research Program (AITRP) (NIH/Fogarty International Center, $3,734,442 for 5 years); Natural History of AIDS in Homosexual Men (National Institute of Allergy and Infectious Diseases, $19,617,878 for 5 years) JONATHAN E. FIELDING Health Forecasting: Mobilizing Communities by Providing Access to Evidence-Based Public Health (The California Endowment, $424,363 for 2 years) JOHN FROINES Proposal to the Department of Pesticide Regulation to Evaluate the Review Conducted by the Department of the Pesticide, Methyl Iodide (California EPA Pesticide Regulation, $72,164); Regional Health Impacts from Goods Movement: Raising Awareness in Four Counties (The California Endowment, $323,820 for 2 years); Sources, Composition, Variability and Toxicological Characteristics of Coarse (PM10-2.5) Particles in Southern California (U.S. Environmental Protection Agency & University of Southern California, $92,822 for 2 years)

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BETH GLENN Adapting a Breast Cancer Education Program for South Asians (California Breast Cancer Research Program, $149,999 for 2 years) DAVID GRANT Cognitive Testing of Epilepsy Questions for Use on PopulationBased Surveys Such as BRFSS and CHIS (DHHS/Centers for Disease Control, $97,000) MARTIN IGUCHI Sexual Acquisition & Treatment of HIV Cooperative Agreement Program (SATHCAP) (National Institute on Drug Abuse & Rand Corporation, $114,653) LEEKA KHEIFETS Exploring Exposure-Response for Magnetic Fields Using Data Sets (Energy Networks Association, LTD, $60,392) GERALD KOMINSKI California Healthcare-Associated Infections Prevention Initiative, Phase II (CHAIPI II) (Blue Shield of California Research and Education Foundation & UC Berkeley, $115,000 for 2 years); Supporting the California Clinical Quality Improvement (CQI) "Right Care" Initiative (Johnson & Johnson, $125,000 for 3 years); Building a Model for Consumer Health Spending and Affordability (The California Endowment, $150,000 for 2 years); California Health Benefits Review Program (UC Office of the President, $182,500) RITESH MISTRY Community and Family Context of Teen Smoking (UC TobaccoRelated Disease Research Program, $89,706 for 3 years) NINEZ PONCE Personalized Medicine for Colorectal and Breast Cancer (UC San Francisco, School of Pharmacy, $149,905 for 3 years) NADEREH POURAT Assessing Contribution of the Dental Care System to Oral Health Care Disparities (National Institute of Dental and Craniofacial Research, $124,061 for 2 years); Harris Survey Dental Snapshot & Issue Brief (California Healthcare Foundation, $60,000); HCCI Evaluation Interim Report (California Healthcare Foundation, $85,000)

ANNE PEBLEY Neighborhood and Family Effects on Disparities in Chronic Disease (National Institute of Child Health and Human Development, $442,411 for 2 years) MICHAEL PRELIP Improving Health in Children through After School Nutrition and Physical Activity Education (Vitamin Cases Consumer Settlement Fund, $316,766 for 3 years) ANNE W. RIMOIN OAR Supplement to Monkeypox Project (National Institute of Child Health and Human Development & Research Triangle Institute, $100,134)) LINDA ROSENSTOCK Public Health Workforce (The California Endowment, $215,540 for 1.5 years) STUART SCHWEITZER Developing a World-Wide Fair Drug Pricing Program for Pharmaceuticals (Eli Lilly & Company, $163,996)

This section includes new contracts and grants awarded in fiscal year 2008-09. Due to space limitations, only funds of $50,000 or more are listed, by principal investigator.

KIMBERLEY SHOAF LA County Disaster Mental Health Model-Affiliation Agreement (Addendum G) (Los Angeles Department Mental Health, $650,000 for 2 years); PsySTART Rapid Mental Health Triage — Incident Management System (County of Los Angeles, $281,604); Community Outreach for Public Health Preparedness Phase 2 (California Department of Public Health, $95,558) MICHELLE TURNER Ambient Air Toxics and Adverse Birth Outcomes (National Institute of Environmental Health Sciences, $143,958 for 2 years); Traffic-Related Air Pollution and Ultrasound Measures of Fetal Growth (National Institute of Environmental Health Sciences, $195,465 for 2 years) STEVEN WALLACE Health of Underserved Elders in California (California Wellness Foundation, $300,000 for 2 years) ROBERTA WYN Women’s Health Briefs: CHIS 2007 and Trends (California Wellness Foundation, $150,000) ANTRONETTE YANCEY Joining Forces with a Key Community to Reduce Obesity Disparities – 2 (National Center on Minority Health & Health Disparities, $3,079,956 for 5 years) UCLAPUBLIC HEALTH

MIRIAM LAUGESEN Financing Models for Bermuda’s Future Care Program (Kurron Shares of America, Inc, $86,449)

SIMIN LIU UCLA Inter-School Program in Metabolic Diseases (Burroughs Wellcome Fund, $2,500,000 for 8 years); Telomere and its BioRegulators as Predictors for Clinical Diabetes in Women (National Institute of Diabetes, Digestive and Kidney Disease, $445,000 for 2 years)

faculty

PATRICIA A. GANZ Biobehavioral Mechanisms of Fatigue in Patients Treated on NSABP B-45: A Phase III Clinical Trial Comparing Adjuvant Sunitinib Malate to Placebo in Women with Residual Invasive Breast Cancer Following Neoadjuvant Chemotherapy (National Cancer Institute & National Surgical Adjuvant Breast & Bowel Project Foundation, $566,093); A Model Clinical/Translational Research Program for Breast Cancer Survivors (The Breast Cancer Research Foundation, $250,000); Vitamin D in Breast Cancer (The Breast Cancer Research Foundation & Mount Sinai Medical Center, $67,439)

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news briefs UCLA Kaiser Permanente Center for Health Equity announced DID YOU KNOW...

UCLAPUBLIC HEALTH

You are a lifetime member of the UCLA School of Public Health Alumni Association if you are a graduate of the UCLA School of Public Health and its executive programs.

If you would like more information about the activities of the Public Health Alumni Association, please call (310) 825-6464 or e-mail phaa@support.ucla.edu.

Kaiser Permanente has made a $5.2 million gift to endow the Center for Health Equity, formerly known as the Center to Eliminate Health Disparities.

The gift will greatly enhance the center’s mission of improving the health of underserved populations through research, community collaboration and leadership development.

The UCLA Kaiser Permanente Center for Health Equity will increase partnerships with communitybased organizations to conduct innovative research that develops effective programs and strategies to eliminate health disparities. The center will also expand its training and technical assistance services, including the development and dissemination of in-language, culturally appropriate materials, and will place a heavy focus on attracting and training new talent in the fight to eliminate disparities. Kaiser’s stable support will allow community leaders and academics to devote sustained efforts toward raising awareness about health disparities, setting priorities, and developing shortand long-range solutions to urgent health issues.

The center was established in 2004 by its current co-directors, Dr. Roshan Bastani (above left) and Dr. Antronette Yancey (above right), in response to the increasing disparities in the health status and healthcare among Los Angeles County residents.

national H1N1 workshop convened at UCLA

wynn joins SPH team

More than 80 participants from the U.S. Centers for Disease Control and Prevention, state and local health departments, hospitals, emergency management, emergency medical services, and private industry participated in an intensive two-day workshop on novel H1N1 influenza hosted by the UCLA Center for Public Health and Disasters in September.

Participants discussed key actions taken as the epidemic unfolded, identified effective strategies, and examined processes that could have been handled differently in four thematic areas: epidemiology; public health risk communication; local public health actions (including non-pharmaceutical interventions); and providing healthcare. Those attending the workshop had the opportunity to interact with colleagues from all levels of the response and to participate in intensive working sessions to help identify gaps to be addressed in this and future national disease outbreaks. Participants also received updates on the current status of the novel influenza A H1N1 virus, both domestically and internationally, and what to expect for the 2009-10 influenza season.

Ted Wynn has joined the UCLA School of Public Health as associate director of development, and will focus on major donor and alumni support. Wynn brings nearly a decade of university fundraising and development experience, having served most recently as associate director and senior major gifts officer for the University of Pennsylvania, where he also ran its Western Region office. Previously, Wynn served as director of development for the College of Science at the University of Nevada-Reno, Los Angeles County development director for UC Santa Barbara and director of major gifts for the College of William and Mary. Wynn earned his B.A. from the College of William and Mary and his J.D. from Baltimore School of Law.

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The School of Public Health has received nearly $275,000 to increase the number of trained public health professionals working in underserved communities and to increase the number of professionals working in fields that are experiencing national and local shortages such as epidemiology, environmental health, toxicology, nutrition, biostatistics, and maternal and child health. The grant was awarded by the federal Health Resources and Services Administration (HRSA) and supplemented by the American Recovery and Reinvestment Act (ARRA) of 2009. The funds will provide $10,000 stipends to 26 students who are currently enrolled in graduate programs at the school, giving them more flexibility to pursue field training and internships. It will also increase the school’s applicant pool, particularly of disadvantaged or minority students.

news briefs

grant helps SPH address workforce needs

SPH a CDC center for preparedness and emergency response The School of Public Health has received a major grant from the U.S. Centers for Disease Control and Prevention to establish a center that will facilitate research to strengthen the ability of federal, state and local public health agencies to prepare for, respond to and recover from natural and human-induced disasters, including terrorism.

The award, $4.8 million over four years, will allow the school’s Center for Public Health and Disasters (CPHD) to build on more than two decades of experience in addressing the critical issues faced when a disaster hits a community. The new effort will be directed by Kimberley Shoaf, associate director of the CPHD and an associate professor of community health sciences at the school.

study on soda-obesity link prompts talk of ‘sin tax’

UCLAPUBLIC HEALTH

A recent study by the School of Public Health-based UCLA Center for Health Policy Research showing a strong association between soda consumption and weight sparked calls from politicians and policy makers for a “soda surcharge” to combat the effects of obesity.

The research brief, “Bubbling Over: Soda Consumption and Its Link to Obesity in California,” found that regardless of income or ethnicity, adults who drink a soda or more per day are 27 percent more likely to be overweight than those who do not drink sodas. Children were found to be particularly addicted: 41 percent of young children (2-11 years of age) drink at least one soda or sugar-sweetened beverage every day. Adolescents (12-17) represent the biggest consumers, with 62 percent (more than 2 million youths) drinking one or more sodas every day – the equivalent of consuming 39 pounds of sugar each year in soda and other sugar-sweetened beverages. The brief is available on the Center for Health Policy Research website (http://healthpolicy.ucla.edu).

After the study was published, Sen. Alex Padilla (D-Los Angeles) called for legislative hearings on the matter while San Francisco Mayor Gavin Newsom said he would introduce legislation to levy a surcharge on retailers who sell soda. Nationally, experts from Harvard Medical School and Yale University cited the UCLA study in a Los Angeles Times opinion editorial arguing for a national soda tax as a way of raising revenue for needed programs while lowering future healthcare costs.

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