Leonard Jack, Jr., PhD, MSc
Associate Dean for Research
Endowed Chair of Health Disparities Research
Director, Center for Minority Health & Health Disparities: Research and Education
College of Pharmacy
Xavier University of Louisiana
The Louisiana Healthy Communities Project: Environmental Change Interventions to Address Chronic Disease
Control and Prevention Across the Life Stages
The CDC Strategic Alliance for Health and ACHIEVE Action Institutes
April 28, 2010Houston, Texas
Today…
Framing Health Disparities East Jefferson Healthy Communities Key Partnerships Environmental Change Interventions Evaluation End Result… So, What?
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DEFINITION OF HEALTH DISPARITY
A Health Disparity should be viewed as a chain of events signified by a difference in:
• Environment
• Access to, utilization of, and quality of care
• Health status or a particular health outcome
- Public Health Reports Sept/Oct 2002 Vol 117 Pgs 426-4343
TERMINOLOGY
“Eliminate health disparity” – HP 2010 “Eliminate racial/ethnic disparities in
health” – DHHS Initiative “Racial/Ethnic differences in health” “Health inequality” “Health inequity”
*HOW “Health Disparity” is defined has policy implications—Who Is
Reached and What Is Done* 4
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Types of Diverse Groups
-- Current health disparities research focuses on differences across race/ethnic groups
-- Much prior research examined differences by socioeconomic status (SES):– Low income vs. others
– Low education vs. others
--Both are “vulnerable” populationsAnita Stewart, 2004
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Vulnerable and or Minority populations have worse health than their counterparts in….: -- Premature mortality including infant mortality-- Morbidity
– Chronic disease (heart disease, diabetes, cancer)– Communicable disease (TB)– Low birth weight– Physiological risk factors – Hypertension– Obesity/overweight
-- Functional limitations, disability-- Self-rated health-- Mental Health Outcomes-- Life Stage (children, young adults, adults, older adults)
Anita Stewart, 2007
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Phases of Disparities Research
DetectingDefine health disparitiesDefine vulnerablepopulations
UnderstandingIdentify determinants of disparities
ReducingInterveneEvaluateTranslate/disseminateChange policy
Adapted from Kilbourne et al, 2006
Anita Stewart, 2007
Three Broad Types of Conceptual Frameworks
-- Population science– Determinants of health in a population– Samples are populations or population subgroups
-- Health services research– How health care affects outcomes– Samples are patients or health plan members
-- Biology/physiology– Biological and genetic pathways to disease– In Vitro Systems (e.g., cellular and tissue level)
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Population-Based Determinants: Multiple Levels of Influence on Health
-- Individual
– biological, behaviors, attitudes, age, education, occupation
-- Family– size, structure, support, beliefs
-- Neighborhood, schools or community– resources, disinvestment, toxins, crime/poverty,
neighborhood desirability
Anita Stewart, 2007
Emmons, K Health behavior in a social context, in Social Epidemiology, 2000, ch. 11.
Depiction of Multi-level Determinants of Health Disparities
Psychosocial - compliance, coping
Lifestyle - exercise, diet, alcohol, smoking, sexual behavior, illicit drug use
Health care
Sociodemographics - age, race, ethnicity, education, income
Physical environment
Social environment
Healthdisparities
Psychological - beliefs, attitudes,personality
Contextual Individual-level
Organizational,institutional
Economic resources
Societal, political
Physical environment
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Physical Environment
-- Neighborhood safety attractiveness
-- Housing quality
-- Transportation
-- Segregation
-- Hazardous materials
-- Occupational hazards
-- # of liquor stores
-- # of full service grocery stores
-- Availability of fresh fruits and vegetables
-- # of areas for walking, bicycling
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Ecological, Multi-level Determinants
Psychosocial - compliance, coping
Lifestyle - exercise, diet, alcohol, smoking, sexual behavior
Health care
Sociodemographics - age, race, ethnicity, education
Physical environment
Social environment
Biological, physiological
Context Individual-level
Organizational,institutional
Economic resources
Societal, political
Psychological -beliefs, attitudes, personality
Healthdisparities
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Social Environment
Social opportunities Family environment Social support Discrimination or racism Neighborhood cohesiveness Community meeting places
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Framework: Socioeconomic Status Over the Lifecourse and Health
Lynch J and Kaplan G, Social Epidemiology, Oxford, 2000 (Ch 2, p. 28)
Socioeconomic Position
Birth Childhood Adulthood Old Age
Low birth weightGrowth retardation
Smoking,diet, exercise
Job stressInadequate
medical care
Intrauterineconditions
Education,environment
Work conditions,income
Income,assets
Atherosclerosis CVD Reducedfunction
East Jefferson Parish East Jefferson Parish Healthy Communities Healthy Communities
ProjectProject
Multi-Stage & Multi-Component
Intervention
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Mobilize Community Form a coalition that will work with the XU Health and
Wellness Center
Determine health related needs of the community by conducting needs assessment
Develop school-based and community-setting approaches to reduce childhood obesity on the results of needs
assessment
Identify methods for program sustainability
Develop evaluation plan to focus on measuring process and outcome variables
Objectives
Perform Assessment
Develop Sustainability
Evaluation Plan
Action Plan
Develop Budget
Develop budget plan for upcoming year
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Rank State EstimatedDiabetes
Prevalence (%)
1 Puerto Rico 12.5
2 Tennessee 11.9
3 Mississippi 11.1
4 West Virginia 10.8
5 Alabama 10.3
6 Texas 10.3
7 Louisiana 10.2
7 Oklahoma 10.2
8 Georgia 10.1
9 Kentucky 9.9
10 South Carolina 9.6
17Source: Louisiana 2007 Behavioral Risk Factor Surveillance System,
DHH Bureau of Primary Care and Rural Health
2007 BRFSS Diabetes Data
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DIABETES PREVALENCE, 2008DIABETES PREVALENCE, 2008
Source: CDC Behavioral Risk Factor Surveillance System, 200819
Obesity (BMI≥30) Trends Among U.S. Adults
19901999
2008
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
Source: CDC Behavioral Risk Factor Surveillance System
Jefferson Parish
26%26% African Americans
14%14% Below poverty level
Total Population: 436,181Total Population: 436,181
Source: www.census.gov, 2008Source: www.census.gov, 2008
9%9% Hispanics
14%14% Over age of 65
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Diabetes in Black America: Burden, Causes, and Solutions (June, 2010)
Relationship Between Obesity and Diabetes in the African American Community
Cassandra Arroyo, PhD, MS, Krista Mincey, MPH
Adiponection: A Potential Link Between Obesity and Diabetes
1. Research acknowledges that adipose tissue secretes a number of active protein (Pittas et al., 2004).
2. Adiponectin (adipose specific protein) shown to be highly abundant in health subjects, lower in obese subjects and people with type 2 diabetes (Yang et al., 2001).
3. Adiponectin is positively associated with glucose tolerance, insulin secretion, and insulin sensitivity (Cote et al., 2005)
4. African American men and women were found to have lower levels of adiponectin than their white counterparts (Hulver et al., 2004)
Adiponection: A Potential Link Between Obesity and Diabetes
“African-American youth (5-16 yrs) have significantly lower levels of adiponectic compared to whites, despite similar age,
BMI, and total adiposity.”
Source: Hulver, et al., 2004
EVALUATION
East Jefferson Parish Healthy Communities Project: Overall Goal
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Xavier UniversityDISEASE
MANAGEMENTBissonet Plaza
Elementary SchoolPOLICY, SYSTEMS,ENVIRONMENTAL
CHANGE STRATEGIES
East Jefferson Family YMCACOMMUNITY ENGAGEMENT
Reduce Occurrence of Chronic DiseasesReduce Occurrence of Chronic Diseases
LA DHH Chronic Disease Prevention & Control Unit
East Jefferson Healthy Communities Project: Key Stakeholder
LA DHH Chronic Disease Prevention & Control Unit
XU Center for Minority Health & Health Disparities: Research and Education
XU Health & Wellness Center East Jefferson Family YMCA Bissonet Plaza Elementary School
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Mission:
To improve the health of Louisianans by preventing chronic diseases and their risk factors through promoting healthy behaviors, utilizing evidence-based interventions and leveraging resources through collaborative private & public partnerships to maximize health outcomes among our citizens.
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Chronic Disease Prevention and Control Unit Programs:
Behavioral Risk Factor Surveillance System
Heart Disease and Stroke Prevention Program
Diabetes Prevention and Control Program
Asthma Management and Prevention Program
Tobacco Control Program
Healthy Communities Program
GOALS OF INTEGRATIONImprove program reach and impact by enhancing synergies among approaches to different diseases, risk factors, populations, and settings
Promote opportunities for greater flexibility, creativity and responsiveness by our partners
Increase collaborative efforts across Chronic Disease Unit programs
Maximize and leverage limited federal resources30
Utilizing Integration to Impact Healthy Communities
Louisiana’s Integrate Framework to Achieving Healthy
Communities
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CDC National Healthy Communities Program Overview
CDC funded program designed to create healthier communities
Focus on chronic disease reduction– Implement policy, systems, and environmental change
strategies to address the following risk factors associated with chronic diseases: physical activity, nutrition, and tobacco use
Mobilizing community resources
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Xavier University College of Pharmacy’s Center of Minority Health &
Health Disparities Research and Education
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About the Center The Center for Minority Health and Health Disparities
Research and Education (CMHDRE) began on January 14, 2002 with the endowment award from the National Center for Minority Health and Health Disparities (NCMHD) of the National Institutes of Health (NIH).
This award was used to establish the Xavier Pharmacy Endowment for Minority Health.
Subsequent proposals were submitted to NCMHD in order to increase the corpus of the fund resulting in the current total of approximately $29.2 Million.
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About the Center
The Xavier Pharmacy Endowment for Minority Health is used to support the activities of the CMHDRE in the College of Pharmacy.
The mission of the Center is to provide the infrastructure that is required to conduct research and provide clinical experiential training and community outreach aimed at eliminating health disparities.
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Four Objectives Four overarching objectives have been established for the
CMHDRE. The concrete steps to achieve these objectives are outlined in the CMHDRE Action Plan.– To provide an environment to support and strengthen the
research interest and activities of current and new faculty members related to health disparities with a specific focus on diabetes and cancer.
– To develop student-oriented programs to support student research and promote post-graduate education.
– To integrate health promotion, education, and disease prevention into primary care services.
– Conduct multi-disciplinary research to reduce health disparities.36
Cores The overall project is divided in to four
main cores:– Administrative Core
– Community Outreach Core
– Research Core
– Training/Mentoring Core
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Disease Management XU-COP Health & Wellness Center
Free/Low Cost Services – Provide screenings – Education– Nutritional counseling
Staffed by clinical pharmacists and P4 pharmacy students
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Community Engagement
Creating partnerships: Xavier University’s Center for Minority
Health & Wellness Center East Jefferson Family YMCA Bissonet Plaza Elementary School Overweight & Obese Children & their
Families
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Bissonet Plaza Elementary School(Pre-K – 5th Grade)
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School Demographic Data
67% of the students are of a minority race/ethnicity
Source: Greater New Orleans Community Data Center. www.gncdc.org 41
School Demographic Data (cont)
Source: Greater New Orleans Community Data Center. www.gncdc.org 42
Policy, Systems, and Environmental Change
Strategies
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Possible Environmental Change Strategies: Borrowing from States Utilizing Innovative Approaches
AK + TX – worksite wellness at schools CA – state standards for beverage snacks and side dishes – school gardens ME – vending machine policy initiative MI – milk vending, requirements for recess + PE/policy for healthy options outside school lunch MT – healthy vending options/recess before lunch NC – Sybershop/vending machine restrictions/focus groups with families MA – provides grants for Healthy Choice Program RI – works with school based health centers awards mini grants to lead policy + environmental change WA – awards for school districts who have made policy changes
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“Healthy America Initiative: wellness where we live, work, and play”
Encourage + assist state governors in developing + implementing wellness initiatives
Bring together public + private sectors Raise awareness of need for healthier lifestyles Bring together experts for solutions Seek out best practices + innovative programs Hold workshops and provide tools Improve state programs Urge governors to implement state employee health
initiatives
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CHILDREN’S EATING AND
ACTIVITY
Physicalenvironment
Rules and restrictions
Parental modeling
Parentalsupport and
encouragement
Foodavailability(exposure)
Parental modeling
Food involve-ment
Media exposure
Parentalfeeding
style
FAMILY ENVIRONMENT
CHILDREN’S EATING AND
ACTIVITY
Physicalenvironment
Rules and restrictions
Parental modeling
Parentalsupport and
encouragement
Foodavailability(exposure)
Parental modeling
Food involve-ment
Media exposure
Parentalfeeding
style
FAMILY ENVIRONMENT
Kathleen Colleran, 2010
Family influences on children’s eating
A range of factors have been shown in small scale studies in the USA to influence children’s eating:
– Parent-child feeding relationship
– Food availability and accessibility
– Media exposure
– Opportunities for modeling
Few population studies conducted Kathleen Colleran, 2010
Family influences on children’s activity
Evidence from limited number of studies in the USA
– Physical environment, e.g. play space, fencing, recreational equipment
– Family rules (activity and sedentary)
– Parental modelling
– Parental support and encouragement
Kathleen Colleran, 2010
The Family Characteristics andFamily Risk
Felicia Hill-Briggs, PhD, ABPP, Laura G. Daughterly, PhD, LICSW
Conceptual model of family roles and sociocultural influences in diabetes care.
Briggs-Hill, 2010
Family (Support) System Factors
Composition, member roles and responsibilities
“Culture” around health and illness
Resources
Communication and psychosocial functioning
Competing system needs and priorities
Individual Factors
Stage of cognitive, social, and physical development (childhood, adolescence, adulthood, older adulthood)
Independence in performing self-care
Preferences for assistance or support
Interrelatedness with family (support) system
Family Instrumental
Support Role
Diabetes caretaking or assisting with self-management behaviors
Appointment scheduling, transport
Managing sickness, medical crisis
Informational support (gathering and transfer)
Family Social and Emotional Support Role
Coping and emotional support
Creating a health-promoting and reinforcing home environment
Joining in health-promoting behaviors
Family Modeling Role
Health/disease awareness
Health-related attitudes, beliefs
Health behaviors, practices
Health risks and consequences
East Jefferson Family YMCAMetairie, Louisiana(Jefferson Parish)
Financial Assistance Health & Nutrition Active Older Adults Aquatics Exercise Classes Family-Centered After School Programs
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Melinda S. Sothern, PhDDirector, Section of Health Promotion
School of Public HealthLouisiana State University (LSU) Health Sciences Center
Childhood Obesity LaboratoryLSU Pennington Biomedical Research Center
Clinical Management of Pediatric Obesity:
Inter-disciplinary, Interactive Educational Interventions
Trim Kids
Incorporates short-term goal setting, regular feedback, and
motivational techniques to improve the diet and exercise behaviors of the family.
Recognized by the National Cancer Institute as a Research Tested Intervention Program
Acknowledged by the U. S. Surgeon General for its community dissemination in YMCA centers in Louisiana beginning in July, 2007:
Baton Rouge, East Jefferson, West Bank, North Shore, Luling, Uptown, Downtown, Shreveport
LSUHSC School of Public Health provided professional training
Sothern, M. (2010)
–
The best dietary approach is one that the child will most likely follow with a high level of compliance.
Trim Kids includes a combination of nutrients and daily calorie levels that best promote the optimal schedule of weight loss or maintenance based on the child’s : Medical & family history Current weight condition or obesity level Age
Sothern, M. (2010)
Trim Kids Nutrition Education
Educational and interactive sessions: Four 10-week sessions in all.
Each session is approximately 20 minutes.
Alternate educational activities to maintain participation: Cooking, games, classes, labs, etc.
Begin with simple topics and advance to applied activities.
Sothern, M. (2010)
Sample Topics
Snack Food Jeopardy: Children identify the healthy snacks by guessing the
calories and sugar grams Fast Food Follies
Dietician calculates fat and sugar grams of typical fast food meal; squeezes french fries
Stir Fry Cooking Students join in to cook and sample
Sugar Lab: Guess the Grams How many teaspoons in one soft drink?
Create Your Own Parfait Children create parfaits with low fat yogurt, sugar-
free topping, fruit and nuts
Sothern, M. (2010)
Methods to Increase Vegetable Intake
Three bite rule: Grade the vegetables:
A = excellent, let’s have this more often C = OK, we’ll try again F = No way
Involve children in grocery shopping and meal preparation. Skip the snack isle and let them choose their favorite fruit and veggie.
Sothern, Schumacher, von Almen, 2001
Nutrition for Overweight Children
Teach young children that it’s OK to leave food on the plate (Birch, 1980 and 1995; Spruijt-Metz, 2002; Rolls, 2004)
(It really won’t hurt the poor children in Africa) Don’t place a moral value on food. Teach children that all food is OK; some is “grow tall or
big” food and some is not. Never give food as a reward.
Sothern, Schumacher, von Almen, 2001
Bring your report card into your local Krispy Kreme and for every “A” we’ll give you a FREE doughnut!
What Does the Research Say? Behavioral counseling interventions
(Grade I & II): 25 RCTs; 14 other design
7 RCT’s compared behavioral counseling to standard care All showed significant reductions in adiposity
compared to standard care Many were based on well-established theories Most included basic behavioral techniques Only 2 studies examined the independent contribution
of different techniques
J Am Diet Assoc. 2006;106:925-945
The Trim Kids A-Factor Accountability – Staff checks records
weekly Availability – Individual sessions before
and after class Attention – Positive only Approach – Staff speaks to the level of
the participant with a sense of humor
Sothern, M. (2010)
Evaluation: Triangulation Model
Health Policy Analysis
Intervention Specific
Existing Data
Source
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Evaluation FrameworkEvaluation Framework
Evaluation TypesEvaluation TypesImpactImpact
Process
Process
Outcome
Outcome
Program - instructors?
- content? - methods?
- time allotments? - materials?
Program - instructors?
- content? - methods?
- time allotments? - materials?
Behavioral - knowledge gain? - attitude change?
- habit change? - skill development?
Behavioral - knowledge gain? - attitude change?
- habit change? - skill development?
Health - mortality? - morbidity? - disability?
- quality of life?
Health - mortality? - morbidity? - disability?
- quality of life?(Adapted from Green et al., 1980)(Adapted from Green et al., 1980)
En
vironm
ental P
olicyE
nviron
men
tal Policy
Integration Existing Evidence into
Practice Fine Tune Our Abilities to Work
Collaboratively Multi-Stage & Multi-Component
Intervention Engaging Families Disseminating Findings
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The Louisiana Contribution…
“Making Public Health Infectious…”
“Making It Difficulty to Resist Partnering…”
“Placing Emphasis on Results…”
“Improving the health status of communities…”
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The Louisiana Contribution…
Questions and Answers
Leonard Jack, Jr., PhD, MSc
Xavier University of Louisiana
Email: [email protected]
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