Category Archives: Social Determinants of Health
Healthography—or the health of the place where you live—is the theme of this year’s American Public Health Association (APHA) annual meeting, which is taking place in New Orleans this week.
During the opening session, Georges Benjamin, MD, Executive Director of APHA, announced that APHA’s goal is to create the healthiest generation in American history within one generation. Benjamin’s announcement was coupled with announcements from local and national public health leaders that collectively took another step forward in that effort.
For example, the Partnership for a Healthier America announced a new Healthier Campus Initiative, which calls on colleges and universities to adopt recommended guidelines on food, nutrition and physical activity.
“We know that going to college is a time of change for many students—we also know that means it’s a time when new habits are formed,” said Peter Soler, the partnership’s CEO. “By creating healthier food and physical activity environments today, campuses and universities are encouraging healthier habits that will carry over into tomorrow.”
Guidelines being adopted by participating campuses include promoting the consumption of water instead of soda on campus, offering a bicycle sharing program for all students and providing certified personal trainers and registered dietitian nutritionists on campus.
In addition, Louisiana’s Secretary of Health and Hospitals, Kathy Kliebert, discussed the state’s “Well-Ahead” initiative, which promotes and recognizes smart choices that are made in the spaces and places where people live and work, and which make it easier to live healthier lives. Kliebert told the audience that Well-Ahead promotes voluntary changes without imposing new taxes or creating new rules.
Within the host city of New Orleans, a couple of initiatives to improve health within the Crescent City were also discussed at APHA’s opening session.
One such initiative to combat obesity—known as Fit Nola—now has 100 miles of bike lanes throughout the city. Also, next week legislation will be introduced to ban smoking in the city’s bars, casinos and public spaces.
APHA’s opening session ended with a talk by Pulitzer Prize winner Isabel Wilkerson, who spoke about her book “The Warmth of Other Suns.” A book 15 years in the making, “The Warm of Other Suns” describes the migration of African Americans in the 20th century from the South to the North for a better life for themselves and their children. For example, the parents of Olympian Jesse Owens worried their son would not have the strength to work in the fields, so they moved north to Cleveland, Ohio, where he started running track—a sport that would take him around the world and across the global stage.
Whether the generation of migrants profiled in Wilkerson’s book realized it, their stories epitomize the power of place, and the influence of geography on health, wellbeing and opportunity of every individual.
>>Bonus Link: Also in attendance at yesterday’s opening session was Peter Salk, son of the world famous Jonas Salk, MD, who was on hand to accept a posthumous award from APHA for his father’s discovery of a vaccine for polio. Watch the trailer above for the film “The Shot Felt Round the World” to learn more about the elder Salk’s successful search for a cure.
A comment period has just opened, through September 30, on proposed minimum standards for medical respite centers for the homeless. Medical respite centers provide an indoor, supported home where discharged homeless hospital patients can convalesce instead of immediately returning to the street.
Experts on homelessness says strong standards and compliance with them can result in not just reducing hospital readmission for discharged homeless patients, but also an increase in permanent housing solutions for people who entered the hospital without a place to call home. In fact, about 80 percent of homeless people who enter a respite facility move onto housing options instead of back to the street, according to Sabrina Eddington, director of special projects at the National Health Care for the Homeless Council (NHCHC).
Eddington says that having the standards in place is critical. An estimated 150,000 people who have no permanent address are discharged from the hospital each year, based on state estimates. Going back to the street can mean reinfection, hospital readmission and an inability to keep up with care, such as daily medication that could improve, stabilize and even cure both physical and emotional health problems.
Medical respite care centers range from free-standing centers to sections of homeless shelters, and even vouchers for motels and hotels with home visits by medical and social support staff.
The proposed minimum standards were published on September 1 and a comment period runs through September 30. The NHCHC will hold a webinar tomorrow, September 12, from 1-2:30 EST. Click here to register.
The goals of the guidelines for the respite care centers are to:
- Align with other health industry standards related to patient care
- Represent the needs of the patients being served in the medical respite centers.
- Promote quality care and improved health
- Create standards for a range of respite center types with varying degrees of resources
NHCHC has dozens of stories about previously homeless patients who were discharged to medical respite care and are now living in stable housing, often with no need for hospital readmission. Take Ahmed. After losing his family and business, Ahmed moved to the street, where he struggled with alcoholism and depression. In 2005, Ahmed had a stroke and was hospitalized. Following discharge he was back on the street until an outreach team brought him to a medical respite program, where he was medically stabilized; received help for his depression; and referred to a program that specializes in treating co-occurring mental illness and addiction. Ahmed is now in supportive housing and participating in a recovery program. He continues to visit his primary care clinic and psychiatrist and has not been hospitalized since the stroke occurred.
There are now dozens of medical respite facilities throughout the community, and NHCHC is hopeful about expanding the models.
“We advocate that medical respite services be available in all communities serving homeless clients,” said Eddington.
Earlier this summer, NHCHC was one of 39 Health Care Innovation Award recipients announced by the U.S. Department of Health and Human Services. The $2.6 million award is administered by the Center for Medicare and Medicaid Innovation and will be used to demonstrate improved health outcomes and reduced spending when homeless patients have access to medical respite care following a hospital stay. The three-year project will test a model that will provide medical respite care for homeless Medicaid and Medicare beneficiaries, following discharge from a hospital, with the goal of improving health, reducing readmissions and reducing costs.
Earlier this year, Durham County, N.C., was chosen by the Robert Wood Johnson Foundation (RWJF) as a Culture of Health Prize winner for its efforts to ensure that its most vulnerable residents have access to the county’s repository of world-class health resources, high-skilled jobs and places to exercise. As part of an ongoing series, Health Affairs blog has featured a piece by local Durham leader Erika Samoff on the community’s health successes.
While Durham is home to a wealth of health care resources—so much so that it’s been dubbed “The City of Medicine”—a 2004 health assessment found high rates of cardiovascular disease and other chronic conditions; HIV/AIDS and other sexually transmitted diseases; and infant mortality. In addition, a 2007 evaluation found that nearly one in three of Durham’s adults were obese, with the rate especially high in its African-American population, at 42 percent. Half of the adults surveyed pointed to a lack of opportunities for physical activity as a contributing factor to their condition.
County leaders responded to these findings by creating the Partnership for a Healthy Durham. It is an alliance of more than 150 nonprofits, hospitals, faith-based organizations and businesses. The partnership’s efforts include:
- Turning an empty, run-down junior high school into the Holton Career & Resource Center, which offers mentoring programs, internships and hands-on career training to high school students
- Creating new bike lanes, bike racks and sidewalks to encourage physical activity and help combat chronic obesity
- Creating Project Access of Durham County to provide access to specialty care for uninsured residents
- Passing smoke-free legislation
To learn more about Durham’s prize-winning efforts to improve health, read the Health Affairs blog post.
- Learn more about the 2014 RWJF Culture of Health Prize winners and read NewPublicHealth coverage of the prize announcement.
- Read Everyday Health’s post, “How Healthy Is Your Hometown?: What you can do to create a culture of health in your community – and win a prize for it.”
>>Bonus Content: Watch a NewPublicHealth video on Durham’s efforts to build a Culture of Health.
This week, NewPublicHealth will run a series on new and creative public health campaigns that aim to improve the health of communities across the country through the use of public service announcements, infographics and more. Stay tuned to learn more about a new campaign each day.
It’s no secret that getting a better education is linked to having a longer, healthier life. But the flip side is also true: Habitual truancy—an excessive number of unexcused absences from school by a minor—has been identified as an early warning sign that kids could be headed toward delinquency; substance use and abuse; social isolation; early sexual intercourse; suicidal thoughts and attempts; and dropping out of high school, according to a 2009 report prepared for the U.S. Department of Justice Office of Juvenile Justice and Delinquency Prevention.
That’s why Hawaii’s Truancy Reduction Demonstration Project and the College of Education, University of Hawaii, launched a series of public service advertisements (PSAs) to try to inspire kids to stay in school. The 30-second spots emphasize that school is where kids’ dreams grow; that education is a gift; and that teachers, families and students are together accountable for kids’ learning.
Meanwhile, New York City launched the School Every Day Campaign to fight truancy, informing parents that students who miss 20 days of school or more in a single year have a significantly decreased chance of graduating from high school. The outdoor ads—created with support from the Ad Council and AT& T—address a hot topic, considering that one out of five public school students in New York City miss that much school in a given year.
Messages such as these really can make a difference. In 2006, the public school graduation rate in Spokane, Wash., was less than 60 percent; by 2013, it had leaped to nearly 80 percent, thanks largely to the “Priority Spokane” campaign. A 2014 winner of the Robert Wood Johnson Foundation’s Culture of Health Prize, the campaign emphasizes education as a catalyst for better health and brighter futures.
“We’re using educational attainment as a lens for improving health,” said Alisa May, executive director of Project Spokane. “We’re beginning to see real signs of success in our work.”
Spokane County Commissioner Shelly O’Quinn agrees: “Spokane County’s focus on educational success and other areas is improving the health of our children. Healthy children become healthier students and adults, and everything we are doing now gives them the foundation they need to succeed after they graduate.”
This week, David Fleming, MD, MPH, stepped down as public health director of Seattle and King County in Washington State after seven years leading the public health agency. Over that period, among many other accomplishments, he led the department’s efforts to sign up more than 165,000 residents under the Affordable Care Act and oversaw a 17 percent drop in obesity rates in partnering schools.
NewPublicHealth spoke with Fleming about his views on the mission of public health.
NPH: How has public health changed since you began your career?
David Fleming: The mission of public health has not changed—and that's to prevent unnecessary illness and death—but what has been changing is what the nature of that prevention is. Increasingly, it is in chronic diseases, injuries and, importantly, the driving force of underlying social determinants of health. So public health has changed from being more of a direct service agency where we have frontline public health workers who are out there providing treatment to people and preventing infectious diseases, to really more of a collaborative kind of agency where we need to be working with a wide range of partners outside of the traditional domains of public health to help them implement the changes that need to happen. It's a fundamental shift, I think, in the business model of public health that we're in the process of witnessing today.
NPH: When you point to some of the achievements that you've had, whether they're specific changes in the state or specific models of examples that you've given to other states, what would you point to?
Fleming: First off, I think it's important to say that public health is a team sport, and so when I talk about accomplishments, I'm talking about accomplishments of the department in which I work on this and the staff that work here. I think that we have been successful at pivoting to that future that we were talking about a moment ago, at looking at how health departments can attack the underlying social determinants of health.
Increasingly, it is health disparities that are driving poor health in this country. We have been successful here in beginning to figure out how to partner with other sectors—the education sector to reduce obesity in our poorest school districts, for example. We’ve also worked with the community development sector to begin making investments in our poorest neighborhoods to increase the healthiness of our communities, so that people who live in them can be healthy, as well. At the end of the day, I think that we have been trying to lead this new path where public health is a partner in communities with all of the other entities that are capable of influencing health and figuring out how to make that happen.
Helping the Homeless Quit Smoking: Q&A with Michael Businelle and Darla Kendzor, The University of Texas School of Public Health
Not surprisingly, a recent study in the American Journal of Public Health found that homeless smokers struggle with quitting more than economically disadvantaged smokers who have their own housing. The study compared homeless smokers receiving treatment at a shelter-based smoking cessation clinic to people enrolled in a smoking cessation program at a Dallas, Texas, safety-net hospital.
“On average, homeless people reported that they found themselves around about 40 smokers every day, while the group getting cessation care at the hospital reported that they were more likely to be around three to four smokers every day,” said Michael S. Businelle, PhD, assistant professor of health promotion and behavioral sciences at The University of Texas School of Public Health Dallas Regional Campus, and the lead author of the study. “Imagine if you had an alcohol problem and were trying to quit drinking—it would be almost impossible to quit if you were surrounded by 40 people drinking every day. That is the situation homeless folks have to overcome when they try to quit smoking.”
Businelle said research shows that about 75 percent of homeless people smoke and that smoking is a leading cause of death in this population. And although homeless smokers are just as likely to try to quit smoking as are other smokers, they are far less successful at quitting, according to Businelle’s work. He said tailored smoking cessation programs are needed for homeless people, including smoke-free zones in shelters.
NewPublicHealth recently spoke with Businelle and his wife, Darla Kendzor, PhD, who is a co-author of the recent study on smoking and the homeless, as well as an assistant professor at The University of Texas.
NPH: Why did you embark on the study?
Michael Businelle: The smoking prevalence in this population is so high and homeless people are not enrolled in clinical trials so we don’t know what will work best for them. We’ve developed, over the last 50 years, really good treatments for the general population of smokers, but there are very few treatments that have been tested in homeless populations.
Darla Kendzor: And cancer and cardiovascular disease, which are in large part due to tobacco smoking, are the leading causes of death among homeless adults. So quitting smoking would make a big difference for them.
In 2012, a new campus was constructed for the Buckingham K-5 public school in rural Dillwyn, Va., replacing the original middle and high school buildings that had stood since 1954 and 1962.
The Charlottesville, Va., architectural firm VMDO Inc., which constructed the campus, says the sites were transformed into a modern learning campus with the aim of addressing the growing concerns of student health and wellbeing. New facilities include a teaching kitchen; innovative food and nutritional displays; an open servery to promote demonstration cooking; a food lab; a small group learning lounge; scratch bakery; dehydrating food composter; ample natural daylight; flexible seating arrangements; and outdoor student gardens.
The firm took advantage of the school’s natural setting surrounding a pine and oak forest and wove them into the design and construction to showcase the “active landscape.” The school’s project committee and design team worked collaboratively to create a total learning environment in order to support learning both inside and outside the traditional classroom. Each grade level enjoys age-appropriate outdoor gardens and play terraces, which encourage children to re-connect and spend time in their natural surroundings. Inside the schools, in addition to core classrooms, each grade level has small group learning spaces that transform pathways into child-centric “learning streets” that have soft seating and fun colors that communicate both collaborative and shared learning experiences.
To study the impact of the healthy design features, VMDO teamed with Matthew Trowbridge, MD, MPH, an associate professor at the University of Virginia School of Medicine, with a special interest in the impact of the built environment on public health to study how health-promoting educational design strategies can support active communities and reduce incidence rates of childhood obesity.
NewPublicHealth recently spoke with Trowbridge about the project.
NewPublicHealth: How did the project come about?
Matthew Trowbridge: Through a collaboration between me and Terry Huang, who was a program officer at the National Institute of Child Health and Human Development and a leader in that institute’s childhood obesity research portfolio. [Editor’s note: He is now a Professor and Chair of the Department of Health Promotion, Social & Behavioral Health University of Nebraska Medical Center College of Public Health.] Back in 2007, Terry had been thinking about how architecture, and particularly school architecture, could be utilized as a tool for obesity prevention. The thinking behind that is that schools have always been a particularly interesting environment for child health very broadly, but also obesity prevention in particular, partly because children spend so much time at school and because the school day provides an important opportunity to help children develop healthy lifelong attitudes and behaviors.
One of the insights that Terry had was that while public health had done a lot to develop programming for school-based obesity prevention, the actual school building itself had really not been looked at in terms of opportunities to help make school-based obesity prevention programs work most effectively. In 2007, Terry actually wrote a journal article outlining ideas for ways in which architecture could be used to augment school-based childhood obesity prevention programs that was published in one of the top obesity journals. When I met Terry at NIH, we realized we both shared an interest in moving beyond studying the association between built environment and health toward real world translation. In other words, providing tangible tools and guidelines to foster collaboration between public health and the design community to bring these ideas into action.
Building a Culture of Health means building a society where getting healthy and staying healthy is a fundamental and guiding social value that helps define American culture...and it’s a mission that communities across the country are eagerly taking on. They include the six communities honored by this year’s Culture of Health prizes from the Robert Wood Johnson Foundation (RWJF), who are coming together today and tomorrow at RWJF’s Princeton, N.J. campus to celebrate their efforts and share the lessons learned. Picked from more than 250 submissions, these six communities are leading some of the nation’s most innovative public health efforts.
The RWJF Culture of Health Prize was launched to further the work of the County Healthy Rankings & Roadmaps program, which aims to educate the public and policy makers on the multiple factors that influence community health—such as education, economic conditions and the physical environment—and to provide solutions that will improve community health. The prizes honor communities that place a high priority on health and bring partners together to drive local change.
There are an estimated 7,350 homeless people living in San Francisco, yet there are only eight facilities in the city at which the homeless can shower. At each of these facilities, there are at most two shower stalls—meaning that there is at most one shower for every 460 homeless people.
Lava Mae developed a mobile approach to target this public health issue.
The refurbished San Francisco MUNI bus outfitted with two full-service bathrooms successfully made its first rounds on June 28. The bus will travel around the city providing the homeless with mobile public utilities and giving them much-needed access to clean water and sanitation. Without the limitations of stationary locations, Lava Mae is able to aide people across the city while also staying free from high real estate prices, rising rent and potential eviction.
"For at least a decade, bathrooms have stood in for the city's anxieties about homelessness, public utilities, and the changing economy," wrote Rachel Swan in a piece on public bathrooms in SF Weekly. Lava Mae founder Doniece Sandoval hopes that the program will take big steps in improving the health of the homeless and public sanitation by increasing the number and scope of available public restrooms.
The relationship between the health and wellbeing of the homeless population correlates directly with the health of the community as a whole. As the homeless population strives for a better quality of life, so does the community—one shower at a time.
Read the full story, “A Refurbished Bus Will Bring Showers to the Homeless in San Francisco.”
Health Beyond Health Care: RWJF-Sponsored Washington Post Live Event Sparks Conversation on Creating a Culture of Health
“Health Beyond Health Care” was the focus of a Robert Wood Johnson Foundation (RWJF)-sponsored Washington Post Live Forum today that looked at how creative minds in traditionally non-health fields—such as bankers, architects, designers and educators—are working together to build a Culture of Health in the United States.
“No matter where you live and how much money you have, you should have the opportunity to live a Culture of Health,” said RWJF President and CEO Risa Lavizzo-Mourey, MD, MBA.
>>View the full archived live stream of the forum.
Lavizzo-Mourey said RWJF began its work on the concept of a U.S. Culture of Health in 2009, when the foundation’s Commission to Build a Healthier America released a report recommending the concept. Last year, the Commission came together to see what progress had been made. Among the sites embracing the concept is Marvin Gaye Park in Washington, D.C. Once known as “Needle Park,” the community has transformed itself through lighting and landscaping. This was possible “because the community embraced the principles of a Culture of Health and demonstrated how, from the ground up, people partnering can change the nature of their community and make it healthier,” she said.
Pointing to the most recent Commission report, Lavizzo-Mourey said that looking at communities undergoing changes pushed the Commission to conclude that in order to improve health as a nation, we have to change communities—especially low-income communities—so that people can make healthy choices every day. That also means that health care has to connect with non-health care.
“Each of you,” she told the audience of thought leaders and policy makers, “is uniquely positioned to make changes that can get us to a nationwide Culture of Health.”
The day’s speakers spoke about innovations in their fields that are helping to create local changes in health, and which are often scalable for communities across the country.
“The most successful projects are those that start with bringing communities together to first assess the need, and then prioritize them and move forward with a particular project,” said Sister Susan Vickers, RSM, Vice President of Community Health, Dignity Health, who added that just about all the loans that Dignity Health has made to nonprofits in the community have been repaid.
Why a focus on health? “Health summarized all [of the other factors],” said David J. Erickson, PhD, Director, Center for Community Development Investments, Federal Reserve Bank of San Francisco. “The best predictor for future health for a third grader is whether they are reading on a grade level. Community development is big, but not big enough, and the medical system is not big enough either. We need to start aligning all of these sectors so we’re all working in the same direction to turn these neighborhoods around.” [Editor’s Note: Read a previous NewPublicHealth Q&A with Erickson.]
“We have to treat health as a national treasure—a natural resource—and put it up on the level of the seriousness of the economy,” said Rear Adm. Boris D. Lushniak, Acting U.S. Surgeon General. “The economy doesn’t do anything without a healthy people.”