November 2013 11 Tue, 3 Dec 2013 08:00:00 -0500 en-us Copyright 2000- 2020 RWJF (RWJF) <![CDATA[Engaging Patients in Research]]>

What happens when you engage patients in research? That’s a question RWJF is exploring with grants to Sage Bionetworks and PatientsLikeMe to build online, open-source platforms that give patients the opportunity to contribute to and collaborate on research.

Sage Bionetworks’ BRIDGE platform will allow patients to share and track their health data and collaborate on research into diseases and health problems that matter most to them. Three research projects will be piloted on BRIDGE in the coming year, focusing on diabetes, Fanconi anemia and sleeping disorders.

PatientsLikeMe’s Open Research Exchange (ORE) will give researchers and patients a space to work together to develop health outcome measures that better reflect outcomes that are meaningful to patients. After several months building the ORE, PatientsLikeMe is now in testing mode, putting the platform through its paces. But it’s not just an academic exercise. PatientsLikeMe has recruited four researchers to pilot the ORE. These researchers will be providing feedback on the site while working with patients in the PatientsLikeMe network to develop and test an initial set of health outcome measures.

Sage Bionetwork’s Stephen Friend discusses collaboration between patients and researchers

Historically, it’s been the researchers and providers who’ve collected and controlled the data that helps diagnose disease and develop treatments. Patients have largely been left to narrative recalls of what they’ve been experiencing and how they’ve been feeling. By drawing on patient wisdom eliciting patient goals and more effectively engaging patients in medical research, both projects will help researchers better understand diseases and open up important paths for the development of new therapies, leading to dramatic improvements in health.

For the ORE, the fact that we’ve got our first pilot users is truly a milestone—it means we’re that much closer to having patient-identified outcomes be the real definers and drivers of value in health care.

These stellar researchers are looking at some critical health problems that have either no established measures or have outdated measures that don’t meet patients’ needs.

For example, William Polonsky, PhD, CDE of the Behavioral Diabetes Institute, is developing a tool that will help researchers, doctors, and patients better understand how diabetes medications affect appetite. Currently, to see how well patients are managing their diabetes, you measure their Hemoglobin A1c—their blood sugar levels—and use that information to guide decisions about treatment, making adjustments to medicine and meal plans. But for patients, satiety is really important—it influences how well they eat, and how well they can control their blood sugar levels.

Another example: Thi Tranviet, MD and Phillippe Ravaud, MD, MSc., PhD., part of the METHODS research team in Paris, are using the ORE platform to develop a questionnaire designed to gather information from patients with multiple chronic diseases about their medications, exercise and diet. This information will help doctors know when treatment regimens become too burdensome for patients. For patients who are balancing and being treated for multiple chronic conditions, the ability to talk about their experience in a much more rigorous way and thus be able to really work with their care team to make decisions about the suite of treatments they are undergoing, is really powerful.

I’m eager to see how both of these projects unfold and to hear your thoughts on how we can better engage patients in research to make strides in health and health care improvement. Comment below to share your thoughts.

This commentary originally appeared on the RWJF Pioneering Ideas blog.

Tue, 3 Dec 2013 08:00:00 -0500 Paul Tarini Public and Community Health <![CDATA[National League for Nursing Aims to Bridge Gap Between Education and Practice]]>

Beverly Malone, PhD, RN, FAAN, is chief executive officer of the National League for Nursing (NLN). She was recently elected to the Institute of Medicine. Last month, the NLN announced the launch of Accelerating to Practice, a new program designed to help new nurses move more seamlessly from education to practice. It is the inaugural program of the NLN's Center for Academic and Clinical Transitions.


Human Capital Blog (HCB): Why is Accelerating to Practice needed?

Beverly Malone: We've always known that there is a difference between how nurse educators view graduates of nursing programs and how nursing directors view graduates. But we never knew how deep the divide was. A recent survey showed that 90 percent of educators thought that nurse graduates were doing just fine, but almost 90 percent of directors felt that nurse graduates did not have the skills that were needed to practice. That kind of a divide is not a small one. It has so much to do with how care is delivered, and the League felt compelled to do something about it.

HCB: What explains the divide?

Malone: We don't talk enough to one another. There are some exemplars out there where educators and administrators are on the same wavelength, and they have worked very hard to ensure that graduates are prepared in a way to move quality patient care forward. But overall, that's not the picture throughout the United States.

HCB: How are new demands on nurses affecting the divide?

Malone: New nurses now face many pressures that I didn't experience when I practiced in the 1960s and 1970s. Patients today are more complex, and are sicker than they ever have been. We're also looking at an older population of patients, and technology is more sophisticated than ever before. The rapid patient turnaround also adds pressure to new nurses. Nurses used to see seven or eight patients a day. Now, nurses race through 15 to 20 patients a day. That requires them to function at very high level.

When I was practicing, we certainly worked with our colleagues, but it wasn't called interprofessional collaboration then. That concept is bigger now. We understand that it takes a village to provide health care, it takes a team. And that team element adds another level of complexity. There's one other complexity: language. We now have a global society in our backyard. Diversity today is much broader, and it includes linguistic diversity too.

HCB: What do these new demands on nurses mean for patient care?

Malone: It means we've got to work harder at honing the preparation of that graduate from the practice side as well as the education side to make sure the best care is delivered. And we need a stronger emphasis on what patients need to do when they get out of the hospital. Community is a much larger part of health care than it ever has been before.

In some ways this is an old problem. The whole idea of moving out of education and into the hot water of practice has always been there. But we've never really paid attention to the root cause of it. We believe that part of the root cause is lack of communication and collaboration between education and practice. We believe it's solvable because we've got the right people at the right table looking at the issues and finding answers.

HCB: How will Accelerating to Practice solve the problem?

Malone: The National League for Nursing pulled together seven pairs of educators and practice partners to come together to determine what those gaps are and to find ways to bridge them. Our inaugural partners include:

  • Indiana University School of Nursing and Indiana University Health
  • Johns Hopkins University School of Nursing and Johns Hopkins University Medical Center
  • Miami Dade College and Jackson Health System, Florida
  • Northern Virginia Community College and Novant/ Health Prince William Hospital
  • University of Kansas School of Nursing and University of Kansas Medical Center
  • University of Texas, Arlington, College of Nursing and Texas Health Resources -Presbyterian Dallas
  • Western Governors University and Cedars Sinai Medical Center

HCB: What are your hopes for the program?

Malone: I think that it will be an opportunity to say, through the educational and the practice perspectives, that these are areas that we can work on together to refine the delivery of health care services through the nurse graduate. Our mission applies to nurse graduates at the baccalaureate level, the associate-degree level, and at the graduate level. The ultimate goal is to make a difference in the lives of patients and make sure that quality care is delivered. The question is how to do that as effectively, and as efficiently, as possible, and at as low a cost as possible, so that we have the highly skilled, and diverse, nursing workforce we need.

This program satisfies our core values at the League, which are: caring, integrity, diversity, and excellence. We're very excited about this initiative. We're sometimes seen as solely focused on education, but we really do see that link to practice. This is an exciting way to lay the foundation for that.

Read a news release about Accelerating to Practice.

This commentary originally appeared on the RWJF Human Capital Blog. The views and opinions expressed here are those of the authors.

Wed, 27 Nov 2013 12:00:00 -0500 Culture of Health Blog Nurses and Nursing Health Leadership Development Nursing <![CDATA[Behavior Change: The Motivation Bias]]>
Headshot of BJ Fogg BJ Fogg, director, Stanford Persuasive Tech Lab

Each month, What’s Next Health talks with leading thinkers about the future of health and health care. Recently, we talked with BJ Fogg, director of the Stanford Persuasive Tech Lab, to discuss motivation versus ability, and to better understand which matters more in creating long-term change. In this post, Debra Joy Pérez, former assistant vice president for Research and Evaluation at the Robert Wood Johnson Foundation, who is now working with the Annie E. Casey Foundation, shares her impressions of BJ’s model and how it might impact the work of organizations like ours.

By Debra Joy Pérez

There is something magically simple in how BJ Fogg’s Behavioral Model addresses behavior change. When just three elements coincide—motivation, ability and a trigger—behavior change happens.

From my own experience, I can tell you that BJ’s model can work in developing new and healthy habits. I heard from BJ that immediately after he pees, he does push-ups. He is attaching a new habit he wants to create to an old habit he already has. Every time he relieves himself, he is triggered to perform a simple action that has him looking and feeling healthier. Like BJ, I wanted to improve my health (motivation)—specifically, I wanted to drink more water. My trigger was green tea. I drink a lot of it, so after each cup, I remember to fill the empty cup with water. I’m pleasantly surprised when I see that I’m nearing half a gallon by the middle of the day. It's working.

What's Next Health Logo.

What does this mean for our field and trying to get more people to engage in healthy behaviors?  I’m afraid to say that there have been some biases in our approach that limit our effectiveness to increase healthy behaviors—and both have to do with motivation.

The first bias is that we too often emphasize the motivation part of the equation, thinking that healthy behavior is often just a question of personal choice or individual will. If we could motivate people to exercise more, or eat right, they would. According to BJ, this is the most difficult lever to move. It's really hard to motivate someone to do something they don't already want to do. If we increase people’s motivation but haven’t done anything to increase their ability, if we haven't made the behavior easier to do, then all we have to show for our effort is frustration—ours and theirs.

This leads to the second area of bias and perhaps the more dangerous one. If we believe that motivation is key, and that less healthy behaviors result from unmotivated people, then when we look at vulnerable populations who disproportionately suffer from poor health, we are led to think that this is a question of their own personal motivation or will. The reality is that when it comes to healthy behaviors, you can find motivated and unmotivated people equally spread across the socioeconomic and education spectrums. What you won’t find spread equally is ability (in the form of time, resources, and access). It’s also just as likely you won’t see nearly as effective triggers or prompts promoting healthy behavior for those more vulnerable among us.

So if we want to create more behavior change around healthy habits for all people, wouldn’t we be best served to find and invest in more ways to make healthy behavior easier to do—to increase ability? And then once people have the motivation and ability to change, to find the right triggers? Isn’t that what making the healthy choice the easy choice really comes down to?

We can already see how this happens across some of RWJF's grants. Working with the Safe Routes to School National Partnership, we don’t motivate kids to walk or bike to school without first making sure there is the ability to safely do so. With our work through the Partnership for a Healthier America, we don’t ask Americans to eat healthier or be more physically active. We first work with companies and organizations to make sure that healthier options are available and compelling triggers (like information on menus) are there to help them make the healthier choice.

Thanks to BJ, we are reminded that change is not only possible but can be more probable when we think differently about how it happens. For me, it started when I began thinking about my own habits. I realized that they weren’t just a question of motivation. Once I overcame this personal bias, I’ll never think about behavior change the same way again. And now, with this bias removed, I’m starting to see my work more clearly.

Like I said, magically simple.

This commentary originally appeared on the RWJF Pioneering Ideas blog.

What's Next Health Infographic: Who Will Change Their Behavior?
Wed, 27 Nov 2013 07:00:00 -0500 Pioneer Blog Team Disease Prevention and Health Promotion Built Environment and Health <![CDATA[A New Holiday Tradition—Tasty Recipes that are Healthy, Too]]>

Thanksgiving is almost upon us, ushering in a month-long season of holiday parties, groaning boards of food, favorite family recipes, cookie swaps, and an extra five pounds around the waistline. Instead of just giving in to the excess and making January the month of dieting, perhaps we could make a few adjustments. I’ve asked around the Foundation staff for some healthy holiday recipes instead of the usual green bean casserole and cream-laden sides. Here are some tried and true alternatives, that are kid–friendly as well!

In fact, why not invite any children about the house (or adults who are still kids at heart) to help whip up some of these dishes. Children love to grate, stir, and shake, and the older ones will go at chopping with a vengeance. It’s never too early to teach them to cook, as discussed on this blog a few days ago.

Besides the recipes below, you might also want to browse a few websites with healthy recipes:

  • The Mayo Clinic puts out a great cookbook and also has recipes online that are much, much better than you might expect from a hospital.
  • Eating Well is one of several commercial web sites that lists not only recipes but their nutritional breakdown.
  • The New York Times has put together a vegetarian Thanksgiving database, you can pick out one dish or build an entire meat-free meal.
  • If cooking intimidates you, then check out Bad Home Cooking, one of my favorite food blogs, where author Julie Tilsner shares some tasty recipes along with her haphazard efforts to make them, and get her kids to eat them.

If you have any favorite websites and recipes that are relatively healthy, please share in the comments. I think this should be a new holiday tradition--better living through cooking!

Zucchini "No Crust" Pie with Provolone 

  • 3-1/2 cup grated zucchini (use smaller ones)
  • 3 teaspoons fresh basil chopped
  • 3 eggs, beaten
  • 1 cup grated provolone cheese (reduced fat can be used)
  • 4 tablespoons grated parmesan cheese
  • 1 small yellow onion chopped
  • ¼ cup vegetable oil
  • 1 cup flour, sifted
  • 1 teaspoon baking powder
  • 1 pinch salt
  • 1 pinch pepper

Combine all the ingredients in a bowl and reserve one tablespoon of parmesan cheese. Spray pie plate with cooking spray and spoon in all of the ingredients. Bake at 350 for 45 minutes. Sprinkle the remaining parmesan on top of the warm pie (you can run under the broiler to brown if you want). Optional--garnish with whole basil leaves.

--Cyndy Kiely

Honey Mustard Onions

  • 1 pound boiling (small) onions
  • Honey
  • Champagne or sweet mustard

Wash, peel and boil onions. Drain and place in mixing bowl.

While onions are still warm, stir in honey and mustard to preferred taste.

Layers of onions may fall apart, but that is OK.

Serve immediately.

--Tanya Barrientos

Roasted Cauliflower and Apples with Herbs

(Tip: Just about any vegetable is better roasted, and this recipe can be adapted to all kinds--brussels sprouts, carrots, fennel,  squash, are a few suggestions.)

  • 1 head of cauliflower, chopped into florets
  • 1 red onion, cut into wedges
  • 2 tablespoons olive oil
  • 1 unpeeled apple, cored and cut into large cubes
  • Fresh basil, thyme or other fresh herb

Preheat oven to 450 degrees. Toss the cauliflower, apple and onion with olive oil and about a teaspoon of salt (or to taste) and freshly ground pepper. Spread on a baking sheet and roast for about 20 minutes, until cauliflower turns brown around edges. Put in a bowl and toss with torn up basil leaves or other fresh herb (thyme works very nicely).

--Cathy Arnst via The Herbal Kitchen cookbook

Frozen Chocolate-Covered Strawberries

  • One Pint of strawberries
  • One bag of chocolate chips
  • One clean ice cube tray
  • Place strawberries in ice cube tray, stem up
  • Place chocolate chips in a bowl and microwave on high until melted
  • Pour chocolate over berries
  • Freeze
  • Eat

--Erin Kelly

The following two recipes are from the great Chef Joe at the RWJF cafeteria, and they are delicious.

Hatch Chile Corn Pudding


  • 16 oz. frozen corn kernels thawed and drained, at room temperature
  • 1-2 Tbsp. of butter
  • 1.5 oz. diced onion
  • 2 clove garlic diced
  • 1 can (1.5 oz.) green diced chiles
  • 2 oz. liquid eggs or 2 eggs
  • 1 C. Greek yogurt
  • ½ C. Monterey jack cheese, grated
  • Seasonings (chili powder, onion powder, cumin, salt and pepper)


Preheat oven to 350 degrees. Sauté first five ingredients in butter and puree half the mixture in food processor. Add seasonings.Then blend together eggs and Greek yogurt in a separate bowl. Add the eggs and yogurt to the sautéed corn then pour the pureed corn in and blend. Lastly, blend in the grated Monterey jack cheese. Spray an 8-inch square baking dish with non-stick spray and bake 25-30 minutes until golden brown.

Serves 8

145 cal, 4 g fat, 60 mg cholesterol, 19 g carbs, 7 g protein, 2 g fiber, 300 mg sodium

Sweet Potato Cannelloni


  • 3 medium sweet potatoes (about 1 pound each)
  • ¾ C. low-fat cottage cheese
  • ¾ C. diced Fuji apple (skin on)
  • 3 Tbsp. chopped fresh chives
  • 1 piece (2 oz.) parmesan cheese, half grated and half shaved
  • ¼ Tsp. coarse salt
  • Freshly ground pepper, to taste
  • Vegetable oil cooking spray
  • 1 Tbsp. walnut oil
  • 1/3 C. chopped toasted walnuts (about 1 oz.)


Preheat oven to 375 degrees. Wrap 1 sweet potato in parchment, and then in foil. Pierce several times with a fork. Bake until tender, about 1 hour. Let cool. Reduce oven temperature to 350 degrees. Meanwhile, peel remaining sweet potatoes. Using a mandoline or a chef's knife, cut potatoes, lengthwise, into very thin slices until you have 30 slices. Trim each to a 2 x 4 inch rectangle.

Bring a large pot of water to a boil. Add half the sweet potato slices and cook until tender, about 2 minutes. Using a slotted spoon, place slices on a baking sheet to cool slightly. Repeat. Remove peel from baked sweet potato and puree flesh in a food processor until smooth. Add cottage cheese and puree until smooth. Transfer potato-cheese mixture to a large bowl. Stir in apple, chives, grated parmesan, salt and pepper.

Coat a 9 x 13 inch baking dish with cooking spray. Place 1 heaping tablespoon filling in center of a sweet potato slice and roll up. Place, seam side down, in dish. Repeat. (Cannelloni can be refrigerated, covered, overnight; bring to room temperature before baking).

Brush oil over cannelloni. Bake until heated through, 10-15 minutes. Sprinkle with walnuts and shaved Parmesan.

Serves 6

140 cal, 4 g fat, 27 mg cholesterol, 23 g carbs, 4 g protein, 1 g fiber, 207 mg sodium,  230 mg potassium

Tue, 26 Nov 2013 17:01:00 -0500 Catherine Arnst <![CDATA[Empathy and Appreciation for the Impact of the Social Determinants of Health]]>

Gretchen Hammer, MPH, is executive director of the Colorado Coalition for the Medically Underserved. She works with local and state health care leaders and policy-makers to improve Colorado’s health care system.


Healing is both an art and a science. On one hand, clinicians are intensely driven by the quantifiable, the measurable, and the evidence-based algorithms that lead to accurate diagnosis and treatment as well as allow us to develop new innovations in medicine. However, healing is also an art. Patients are not just a collection of systems that can be separated out and managed in isolation of the whole patient. Each patient and their family has a unique set of values, life experiences, and resources that influence their health and ability to heal. Recognizing the wholeness and uniqueness of each patient is where the art of healing begins.

Empathy is defined as “the ability to understand and share the feelings of another.” It takes presence of mind and time to be empathetic. For clinicians, finding the balance between the necessary detachment to allow for good clinical decision making and empathy can challenging.  This balance can be particularly difficult for students and new clinicians.

A number of studies, including one particularly large study of more than 20,000 patients in Italy, have been done over the past several years about the connection between a provider’s empathy for his or her patients and patient outcomes, and the results were clear: empathy is significantly associated with improved clinical outcomes. It’s important for both our health and our health care experiences that our doctors, nurses, and other health care providers are able to understand and appreciate our life circumstances. For patients with complex lives and complex health needs, empathy becomes even more important.

Unfortunately, additional studies show that medical students undergo a significant decline in empathy as they enter their third year of medical school. This decline is something we must find ways to address so that the providers of tomorrow are equipped to excel at both the science and art of healing. To this end, the Colorado Coalition for the Medically Underserved produced a video and accompanying educational materials that we hope will encourage new conversations about this important topic.

The video, targeted primarily to students in health professions programs in Colorado, follows a typical health care visit and interjects important information about the patient’s life that is impacting their ability to get their health care needs met. These factors—things like their income, education, access to transportation, and other social determinants of health—are a part of each patient’s story and are important for providers to be prepared to address. It features several doctors, a nurse, and a pharmacist from around our state who share personal experiences and suggest ways to care more effectively for patients facing barriers to care.

Along with the video, we’ve created a discussion guide intended for students and other small groups to discuss the impact of social determinants in their community. It is our goal to work with our local health professional schools to integrate these resources into their classrooms. We hope to see more newly-minted providers entering the workforce ready to embrace their patients’ lives—as complicated and challenging as they might be—and involve them in their health care.

We encourage you to watch the video, share it broadly, and consider what can be done in your community to increase empathy for all patients and decrease the barriers to good health.

This commentary originally appeared on the RWJF Human Capital Blog. The views and opinions expressed here are those of the authors.

Tue, 26 Nov 2013 11:00:00 -0500 Gretchen Hammer Health Care Quality and Value Social Determinants of Health Nursing <![CDATA[“An Educated Consumer is Our Best Customer:” Four Things to Know About Transparency In Health Care Prices, Costs and Quality]]>

Watch our December 6, 2013, FirstFriday Google+ Hangout archive on transparency in health care.

Panic about high health insurance premiums. Fears about high-cost health-care providers being cut out of health plan networks. Worries that the health plans now available through health insurance exchanges won’t cover the care that patients need.

Welcome to the rollout of Obamacare....right?

Actually, with the exception of the new health insurance exchanges, all of the phenomena described above have a long history. Similar concerns were voiced loudly in the late 1980s and 1990s, when “managed care” in health insurance became a dominant force on the health care and health insurance landscape.

What’s amazing to people who lived through both of these eras—then and now—is how little has changed.  

Health insurance premiums are relatively high now, as then, in large part because the prices and costs in U.S. health care are extraordinarily high.

Some health-care providers are being cut out of health plan networks because they are even pricier than others--with little if any data to back up their claims that they are providing care of superior quality to their lower-cost peers.

Consumers, meanwhile, are confused. Although some are embracing the lower-cost "narrow networks" offered by health plans, others worry that lower-cost providers won't provide the highest quality. The same consumers who might buy designer duds at outlet malls somehow feel jittery about discount health care.

Helping all of us understand what's driving high health care costs--and making the best choices about health insurance and health care as a result--is why we need more transparency in the prices, costs and quality of health care. Here are four things to know about the issue.

  1. "Transparency" means clear and accurate information, and having it is the key to an effectively functioning market. If there is information "asymmetry" in a given market--for example, if the seller knows more about the quality of a good or service than a buyer--the buyer may end up paying more for a product than is optimal (think about buying a used car as an example). The situation would be even worse if the buyer didn't know what the price was and only found it later, when the bill arrived. Yet that's the way much of the U.S. health care market works now--and as a result, patients or consumers and purchasers, such as health plans and large employers, often end up paying very high prices for health care of uncertain quality.
  2. U.S. prices for health care are far higher than prices in all other countries. "Prices are--when you look at the real numbers--the overwhelming difference between us and them," writes George Halvorson, the chairman and former CEO of Kaiser Permanente, in a forthcoming book, Don't Let Healthcare Bankrupt America: Strategies for Financial Survival.  Consider a simple appendectomy, for which many Europeans pay about $3,000, versus more than double that in the U.S.; even more startling, some U.S. hospitals and health systems charge nine times as much (see graphic below). What's more, it can be next to impossible for consumers to find out about prices ahead of time, with a few notable exceptions. In California, for example, hospitals by law now have to disclose prices for the 25 most common outpatient services or procedures.
  3. Despite what many U.S. consumers appear to believe--that higher cost institutions offer higher quality--there is no automatic correlation between the two. One study showed that hospitals that charged the most for sepsis care actually had the highest sepsis death rates (T. Lagu et al, Archives of Internal Medicine, 2011). Higher-cost institutions that imply that they must charge more than others often lack the quality data to back up their claims.  A recent Washington Post story noted that Seattle Children's Hospital was omitted from health plans competing in the Washington state health insurance exchange in large part because of its higher costs for providing care that could be purchased less expensively elsewhere. The story pointed out that a pediatric appendectomy at Children's costs $23,000, versus $14,100 at a nearby community hospital.
  4. When consumers are given clear information about costs and quality, they can make better choices about their health care. Judith Hibbard of the University of Oregon and colleagues have shown that presenting cost data alongside easy-to-interpret quality information--and highlighting high-value options--improved the likelihood that consumers would choose those options. And thanks to advances in quality reporting spurred in part by the Robert Wood Johnson Foundation's Aligning Forces for Quality initiative, consumers no longer need to make many health care purchasing decisions in a quality vacuum. For example, the Foundation's Comparing Health Care Quality: A National Directory, is an interactive tool listing 208 national, state and local public reports that can help consumers find reliable health care in their communities.                      

As Sy Syms, a pioneering New York discount retailer who died in 2009, used to say in television commercials for his chain of stores, "An educated consumer is our best customer." Transparency can help make all of us the kind of savvy health care shoppers of whom Syms--and maybe his doctor--would have been proud.

Appendectomy chart
Tue, 26 Nov 2013 10:14:00 -0500 Susan Dentzer Health Care Quality and Value <![CDATA[Get Out of the Drive-Thru Lane. Learn to Cook!]]>
A woman and her teenage daughter prepare vegetables in a kitchen.

Some statistics worth pondering: According to the U.S. Bureau of Labor Statistics, the average American spends only 33 minutes a day on food preparation. Just over half of Americans bother to cook every day. On the other hand, 33 percent of children and 41 percent of teenagers eat fast food, every single day.

These fast food children are consuming 126 additional calories, and the teens 310 extra calories, than if they had avoided the chains, says Fast Food Facts 2013, a new report by the Yale Rudd Center for Food Policy & Obesity and funded by RWJF. Most of these children are eating adult meals, too, not the smaller-portioned children’s meals on offer. Not that it would matter, since less than one percent of all kids’ meal served at fast food chains meet recommended nutrition standards.

It’s not much of a stretch to link the lack of home cooking, a diet of fast food, and the fact that a third of U.S. children and adolescents are obese. So, what’s a parent to do? Well for one thing, we could learn to cook.

I know very well that when both parents work it can seem daunting to carve out the time to shop for, plan and prepare a meal. But I think a lot of people simply don’t know how to cook, or don’t do it enough to feel comfortable in the kitchen.

That’s not surprising, given that a culinary education has fallen out of favor everywhere except on the Food Network. Up until the 1970s most high schools and many colleges offered home economics classes where the rudiments of cooking were taught. Those classed are now called Family and Consumer Sciences (FCS) and today only three states require FCS in middle or high school. A recent Boston Globe article reported that the number of U.S. secondary students taking FCS dropped by 45 percent in the last decade, to about 3 million students.

I say it’s time to Bring Back Home EC!, as Boston Globe writer Ruth Graham declared recently. Mother Jones food writer Tom Philpott joined in the call with Why Home Economics Should Be Mandatory. “I have witnessed firsthand the vexed state of basic cooking skills among the young,” Philpott wrote. “When I helped run the kitchen at Maverick Farms for seven years, I noticed that most of our interns couldn't chop an onion or turn even just-picked produce into a reasonably good dish in a reasonable amount of time. And these were people motivated enough about food to intern at a small farm in rural North Carolina. If I had their cooking skills, I'd be tempted to resort to takeout often, just to save time.”

Many programs designed to combat childhood obesity recognize that cooking skills can translate into healthy eating, and they aren’t waiting for parents or schools to teach those skills. Cooking With Kids, based in New Mexico, defines its mission as “motivate children and youth to make healthy food choices through hands-on cooking lessons with fresh, affordable foods from diverse cultures.” An elementary school in North Philadelphia reports that its students reluctantly learned to make fish tacos, and much to their surprise, liked them!

At the Rocky Boy Indian Reservation in north-central Montana, home to approximately 3,500 members of the Chippewa Cree Tribe, the RWJF-funded AH-WAH-SI-SAHK-O-CHI project runs a weekend day camp that teaches parents and children how to prepare traditional foods using healthy ingredients. Students learn to use whole wheat instead of white flour to make Indian frybread, and fresh berries instead of butter and jam. The program tries to get kids away from the microwave, and a reliance of processed foods. After taking some of those classes, 14-year-old Slayte enthused that “I like to cook for my family.” 

That’s encouraging on many levels. Not only is home cooking usually healthier than fast food, research has found that children who eat meals with their families have a lower risk of obesity. Cooking such a meal doesn’t have to be hard. Grilling a piece of chicken and microwaving some fresh vegetables can be as fast, or faster, than stopping at a fast-food outlet.

It can also be tastier. Here’s an easy recipe for a Filipino dish called Chicken Adobo that I have never known a child not to like. It tastes a lot better than chicken nuggets, it’s certainly healthier, and you can make a big batch and freeze the extra so it can be just as fast.  If anyone else has some easy home recipes, please share in the comments. 

Chicken Adobo 

Serves 6-8

  • 4-5 lbs. chicken pieces, (can be skinless)
  • 3 tablespoons vegetable oil
  • 1/2 cup white vinegar
  • 1/2 cup soy sauce
  • 4 cloves garlic, crushed
  • 1 tsp. black peppercorns
  • 3 bay leaves

Brown chicken in oil in a large pot. Drain the fat. Add rest of ingredients. Bring to boil, then lower heat. Cover and let simmer for 30 until chicken is cooked through, stirring occasionally. Uncover and simmer until sauce is reduced and thickened, and chicken is tender, about 20 more minutes. Serve with steamed rice if desired.

Fri, 22 Nov 2013 13:32:00 -0500 Catherine Arnst Childhood Obesity RWJF Staff Views <![CDATA[Minnesota’s Healthy Communities Conference 2013: Q&A with Paul Mattessich and Ela Rausch]]>

A conference in St. Paul, Minn., earlier this month examined ideas and emerging examples for building a healthier Minnesota by promoting the integration of health-related programs and community development to address health where we live, learn, work and play. The conference was convened by the Federal Reserve Bank of Minnesota and Wilder Research, the research arm of the Amherst H. Wilder Foundation. The gathering, which was a follow-up to an initial conference on the intersection of health and community development held in Minnesota a year ago, highlighted current successful cross-sector efforts throughout the state.

Elaine Arkin, manager of the Robert Wood Johnson Foundation Commission to Build a Healthier America, was a keynote speaker at the conference. Her remarks included the announcement that the Commission’s recommendations on early childhood and supporting healthy communities will be released in early 2013.

The highlighted projects included a task force on increasing access to healthier foods, often an obstacle in poorer communities; locating needed services alongside senior housing; a stable housing concept for people at risk of homelessness following a hospital stay; and a project underway to give kids living in trailer parks a safe place to play.

“The strategy that we used this year in engaging people with actual examples...was very effective in really acknowledging that this work is messy, that it does take time and that in order to keep people enthusiastic about it sometimes it does require giving people a pat on the back even just for the small progress that they’ve made,” said Ela Rausch, community development project manager of the Federal Reserve of Minnesota.

Following the conference, NewPublicHealth spoke with Ela Rausch and Paul Mattessich, PhD, Executive Director of Wilder Research.

NewPublicHealth: What were the key goals of this year’s meeting?

Paul Mattessich: The overarching goal is at the national level to bring together public health with community development finance in order to better address health issues, social determinants of health and improved community health. But what we did the first time a year ago was to try to get the two sectors to understand what each other does, what their vocabulary was, how best to work together and to start some networking.

This year the goal was to take the next step and highlight some examples where this cross-sector collaboration occurred, and to use that to try to further that even more and to underscore the fact that the two sectors really do address the same end goal, even though they do it in different ways. And if they team up they can do it more effectively.

NPH: What were some differences between last year’s meeting and this year’s meeting?

Ela Rausch: One thing that was different is that our initial meeting was an invitation-only meeting and we really targeted executive level leadership from the participating organizations to get the groups to the table and to get their buy-in to demonstrate the seriousness of the conversation. This year the conference was open to the public. We specifically wanted to draw in the people who do the work on the ground—at the Program Director, Program Manager and Program Coordinator levels—who are in communities implementing the strategies that we’re trying to promote. Last year’s meeting was more theoretical and this year’s meeting was very much focused on what we are doing together and the ingredients that make those projects successful.

NPH: What were some of the promising things that you heard?

Mattessich: My impression was that yes, people were saying “Oh, I  get it more now.” I think we still have a ways to go, but we’re a good distance down the road from last year when people were more likely to be puzzled on how the two sectors work together. Now they’re looking forward to the successes the collaborations can produce. What can do we do practically? How can we move ahead?  

Rausch: I would agree. I think in some ways this follow-up meeting was really a good temperature-taking or benchmarking for us to really understand where we are in bringing the two sectors together. Our conference this year was centered around a call for cross-sector projects that address social determinants of health, and we had some programs call ahead to say they were interested but weren’t sure how they fit into the collaboration. I think that’s one of the things that we’re still working on, providing people the tools to be able to tell their story or frame their story in a way that makes sense to the other sectors, and that allows them to see themselves as having a role at the table and being a valuable partner in those projects.

A good collaboration example is that the City of Minneapolis Public Health Department is giving grants to small businesses to improve environmental health. We also had a number of projects that address health through supportive housing. We’re continuing work on getting the developers to understand that they do play an important role in addressing these social determinants of health.

NPH: What’s next?

Rausch: One of the things that we talked about at our conference this year was building the evidence base for these cross-sector projects and what works. And a large majority of our participants indicated that they’d really like more information on using data and measures to evaluate the progress of these healthy community initiatives, so I think that’s one thing that we might look at.

When the Robert Wood Johnson Foundation’s Commission to Build a Healthier America releases their new recommendations early next year, I think we’ll all be looking to those to see what next steps we can take to help support their implementation.  

>>Bonus Links:

  • View the poster presentations showcasing examples of collaboration from the Minnesota Healthy Communities Conference.
  • Read a report on collaboration for healthier communities by Wilder Research and the Federal Reserve Bank of Minnesota prepared for the Robert Wood Johnson Foundation Commission to Build a Healthier America.
  • Read a recent NewPublicHealth interview with David Erickson of the Federal Reserve of San Francisco on health and community development cross collaboration. 

This commentary originally appeared on the RWJF New Public Health blog.

Thu, 21 Nov 2013 14:45:00 -0500 Culture of Health Blog Social Determinants of Health Public and Community Health Community Health <![CDATA[How Do You Transform a Community After a Century of Neglect?]]>

Bithlo, Fla. is a town of 8,000 that is just 30 minutes outside Orlando and not much farther from the “happiest place on Earth” — but is beset by poverty, illiteracy, unemployment and toxic dumps that have infiltrated the drinking water. The water is so bad that it has eroded many residents’ teeth, making it that much harder for them to find jobs. Streets filled with trash, frequent road deaths and injuries from a lack of transportation options and safe places to walk, and dropping out before 10th grade were all the norm.


In just a short time, a collection of partners and volunteers have begun to reverse some of the decades-old problems Bithlo has faced. And earlier this week, the town that had been forgotten for almost a century was the scene of a hubbub of activity as hundreds of volunteers descended on the town to continue work on “Transformation Village,” Bithlo’s future main street, which will sport a combination library/coffee shop, schools, shops and many other services, all long missing from Bithlo.

Over the last few months, NewPublicHealth has reported on initiatives of the participating members of Stakeholder Health, formerly known as the Health Systems Learning Group. Stakeholder Health is a learning collaborative made up of 43 organizations, including 36 nonprofit health systems, that share innovative practices aimed at improving health and economic viability of communities.

>>Read more on the Stakeholder Health effort to leverage health care systems to improve community health.

One of the Stakeholder Health members is the Adventist Health System, a not-for-profit health care system that has hospitals across the country. Recently, Adventist’s flagship health care provider, Florida Hospital in Orlando, began supporting United Global Outreach (UGO), a non-profit group aimed at building up communities in need, in their four-year-long effort to transform the town of Bithlo.

NewPublicHealth recently spoke with Tim McKinney, executive vice president of United Global Outreach, and Verbelee Neilsen-Swanson, vice president of community impact at Florida Hospital, about the partnerships and commitment that have gone into Bithlo’s transformation into a town that is looking forward to new housing stock, jobs, stores, better education and improved health outcomes for the its citizens.


NewPublicHealth: Not every problem in Bithlo is directly a health issue —unemployment and school drop-out rates, for example. Why has the hospital taken on such a full range of issues facing the community?

Verbelee Nielsen-Swanson: Those are all components to a healthy, vibrant community. Florida Hospital’s mission is to extend healing. And we see that as not only within the walls of our hospital, but extending it out to others.

It is also an opportunity to have a living laboratory, and really be able to measure the change. Our goal is to have replicable models, so that we can work in other communities here in Central Florida, as well as across the Adventist health system to help communities reach their full potential.

NPH: Tim, what are the issues you’re focusing on?

Tim: Our key areas include education, health care, transportation, housing, environmental issues, basic needs, and building a sense of community. We’ve been working on all of them simultaneously.

Highlights of improvements that have been achieved include…

file Orange County Academy in the new Transformation Village


We decided to immediately open a private school, Orange County Academy. The purpose of the school really wasn’t to stop the educational deficit, but rather to try to see if we could establish some best practices for educating the children of Bithlo, that for generations had not been succeeding, for a variety of reasons, in public schools. The public school has already started to take note. We’re helping them reshape the way that they’ve been addressing this population, so that these kids can actually get past the ninth grade and graduate with diplomas that are more than just certificates of completion.

Health Care

There had never been a permanent doctor’s office in the Bithlo community. It seemed like everybody was taking an ambulance to the emergency room. Florida Hospital is the closest hospital and that is fifteen miles away. We recruited a federally qualified health center to open a clinic and they’ve been open about a year now. It’s probably the most historic thing that’s happened in the community, to have their own primary medical home in their neighborhood.

file New bus service to Bithlo that stops at the new medical clinic


For years there was no public bus line for this community. This posed a danger because many people walked or biked and Bithlo is split down the middle by a major highway and there has been a high rate of accidents. But after two years of work, public bus service was restored earlier this year. They’ve set aside $9.1 million to fix a key bridge and put in a bike and pedestrian path next year. Additional funds will fix the road that runs through Bithlo and add sidewalks as well as street lights, and separate areas for bikers and walkers.


Verbelee Neilsen-Swanson: We’ve launched “Hire Local Bithlo.” Our contractors are interviewing individuals and then bringing them into the construction trade. These are entry-level jobs and if they prove themselves, then they’re provided with training and the goal is that they become hired full-time by an employer. It's also about restoring smiles. That’s not all, of course, but it’s a big start. The water has damaged just about everyone’s teeth — discoloration, teeth missing — it impacts many peoples’ opportunities to be hired. But we’re pulling teeth, getting dentures restored and creating opportunities for people to become employed.  

NPH: How did Bithlo get to be where it is in terms of health and social challenges?

Tim McKinney: Bithlo is a unique mess due to the fact that it was a municipality that went bankrupt in the late 1920s. There was no functioning government. However, it was an incorporated municipality until the end of the 1970s, so it was like a town with no sheriff.

NPH: How are partners beyond government critical for this initiative?

Tim McKinney: Our perspective is the government has a seat at the table, but they cannot be at the head of the table. Elected officials come and go. And so we’re only plugging them in, in areas where government should be working. And in other areas, we’re initiating public partnerships and grassroots movements.


NPH: What are some of the partners the hospital has brought to the table?

Verbelee Neilsen-Swanson: We have been able to bring in the University of Central Florida, which is the second largest university in the nation, including schools of engineering, nursing, administration, medical, education and public health. We’ve also been able to engage a number of our vendors and contractors to help us with facilities and renovations.

The hospital’s emergency medicine group helped provide uniforms for the students, conducted health screenings and bought bikes for each student so that they could get to and from school. Others we’ve brought to the table include bankers and realtors to help the revitalization. An important aspect of Florida Hospital’s involvement was in creating awareness, advocacy, and an urgency—letting our partners know that Bithlo was important to us.  

Tim McKinney: Having Florida Hospital as an anchor partners put us so far ahead. We realized we needed to build up influence and collaboration outside of the Bithlo community. Having Florida Hospital on board instantly caused elected officials and other key stakeholders to care.

It’s also important to understand the chronology. The medical clinic for Bithlo was already in the works when we approached the hospital. Our interest in the engaging the hospital was not health care-related. It was related to wanting the community to have access to a healthy lifestyle.

file A wooded area of Transformation Village, with the new community garden in the lower right

NPH: How are you measuring success?

Tim McKinney:  Because Bithlo is lacking so much in its infrastructure, it’s very easy to measure success because we identified, for example, that we needed buses. Now there are buses. The bridge needs to be widened. It’s now being widened. There is no medical clinic. Now there’s a medical clinic. Now, as we transition into the community engagement phase, we are working with sociology students from the University of Central Florida to do a community assessment so that we’ll have baseline data.  

NPH: In what ways is Bithlo a model for other communities?

Verbelee Neilsen-Swanson: It’s working across all aspects of the community — it’s a holistic approach.

What is unique in Bithlo is the goal to make it a vibrant healthy community, and not need to have us involved in future transformations — for Bithlo to be able to sustain itself.

Tim McKinney: From my perspective, it’s important that, not only in Bithlo, but in every community, you have to go in there believing that transformation is possible. We believe that every person can be transformed. Whether it is the kids in our school, or a 61 year old lady that asked me this week if she can get her GED. Because now she feels inspired to go forward.

Every community can be changed. I think sometimes we’ve had such problems for so long in some neighborhoods that we decide instead to develop over them. Because we’ve given up on them. Then that really only disperses the problem to someone else’s neighborhood. The uniqueness about Bithlo is, we want to help everybody. We work to help them turn around, so that they might become healthy, instead of developed over. Transformation efforts aren’t program-centered, they’re relationship-centered.

This commentary originally appeared on the RWJF New Public Health blog.

Wed, 20 Nov 2013 13:00:00 -0500 Culture of Health Blog Social Determinants of Health <![CDATA[Survey Shows a Shift in Physicians’ Compensation, But Not Their Disappointment]]>

The website Physicians Practice has released its annual Physician Compensation Survey, which for the third straight year shows that a majority of U.S. physicians view the income from their medical practice as “disappointing.” In 2013, 54 percent defined their net income this way, the same number as a year earlier, but 5 percent more than those who took the survey in 2011.

Physicians Practice surveyed 1,474 physicians and staff for the survey, asking about personal income, practice overhead, practice outlook, and other financial issues. For the first time, the survey acknowledged the shift from volume-based reimbursement to value-based reimbursement, asking respondents to share how much of their income is tied to factors other than the number of patients they see.

Thirty-three percent of respondents said a portion of their compensation is tied to value (quality and cost of care provided), with 8.5 percent of that group saying this was the only factor in their pay. Furthermore, 24 percent of respondents said a portion of their compensation was tied specifically to patient satisfaction.

However, productivity remained the dominant factor in physician compensation, with 28 percent of survey respondents saying that their entire compensation package was factored on productivity alone. Another 37 percent said it made up a portion of their annual pay.

See the 2013 Physician Compensation Survey results.
Read coverage of the survey in Becker’s Hospital Review.

This commentary originally appeared on the RWJF Human Capital Blog. The views and opinions expressed here are those of the authors.

Wed, 20 Nov 2013 13:00:00 -0500 Culture of Health Blog <![CDATA[Public Health Campaign of the Month: ‘Don’t Mess With Mercury’ Campaign]]>

>>NewPublicHealth continues a new series to highlight some of the best public health education and outreach campaigns every month. Submit your ideas for Public Health Campaign of the Month to

Glass thermometers. Compact fluorescent light (CFL) bulbs. Medical equipment. Gauges and other science equipment. Thermostats, switches and other electrical devices.

Mercury lives in all of these devices—and all can be found in schools. While it may be common, mercury is also incredibly dangerous. Mercury poisoning can negatively impact the nervous system, lungs and kidneys. It can even lead to brain damage or death.

Often mercury poisoning is the result of a kid thinking it’s “cool”— taking it, playing with, passing it around to friends. Metallic mercury easily vaporizes into a colorless, odorless, hazardous gas.

The Agency for Toxic Substances and Disease Registry (ATSDR), part of the U.S. Centers for Disease Control and Prevention (CDC), has released a new website that brings together a suite of tools to educate kids, teachers, school administrators and parents about the dangers of mercury poisoning. They include an interactive human body illustration and facts sheets, as well as a 30-second “Don’t Mess With Mercury” animated video to raise awareness about the dangers of mercury.

This commentary originally appeared on the RWJF New Public Health blog.

Tue, 19 Nov 2013 12:31:00 -0500 Culture of Health Blog Child and Family Well-Being <![CDATA[Childhood Lead Exposure: Piling Disadvantage onto Some of the Country’s Most Vulnerable Kids]]>

Sheryl Magzamen, PhD, MPH, is an assistant professor in the College of Veterinary Medicine and Biomedical Sciences at Colorado State University and an alumna of the Robert Wood Johnson Foundation (RWJF) Health & Society Scholars program (2007-2009). She recently published two studies exploring the link between early childhood lead exposure and behavioral and academic outcomes in Environmental Research and the Annals of Epidemiology. She discusses both below.


Human Capital Blog: What are the main findings of your study on childhood lead exposure and discipline?

Sheryl Magzamen: We found that children who had moderate but elevated exposure lead in early childhood were more than two times as likely as unexposed children to be suspended from school, and that’s controlling for race, socioeconomic status, and other covariates. We’re particularly concerned about this because of what it means for barriers to school success and achievement due to behavioral issues.

We are also concerned about the fact that there‘s a strong possibility, based on animal models, that neurological effects of lead exposure predispose children to an array of disruptive or anti-social behavior in schools. The environmental exposures that children have prior to going to school have been largely ignored in debates about quality public education.

HCB: Did the findings surprise you?

Magzamen: Yes, because they were so strong. We know, for example, that African Americans are more likely to be suspended from school than White children (often for reasons relating to poverty). But lead exposure explains almost a quarter of that disparity. This legacy of early childhood exposure to a neurotoxin that’s basically been banned in the United States since the 1970s is still having lasting effects on our most vulnerable populations: low-income children in urban environments.

HCB: And what were the main findings from the study on childhood lead exposure and educational outcomes?

Magzamen:  For this study, we looked at early childhood lead exposure and early childhood outcomes in fourth grade using standardized tests. What makes this analysis different from previous studies is that we surveyed parents to get more information about their child’s other health issues, such as the child’s health history, educational background, and socio-economic status. This kind of information was not included in earlier studies. We included it in our study so we could figure out some of the additional factors that may change the relationship between childhood lead exposure and educational outcomes.

HCB: Did the findings of this study surprise you?

Magzamen: We found a consistent relationship between early childhood lead exposure and end-of-school grades in fourth grade. What surprised us was how much other health factors were related to a child’s educational achievement.  For example, children whose health was rated “fair” by their parents scored 25 points lower on the reading section of the end-of-year exams than children whose health was rated excellent by their parents.

The relationship between self-reported health and educational outcomes was almost as strong as the relationship between race and educational outcomes. We don’t know the etiological link between health and success in school, but we know there’s an incredibly strong relationship. These kids, due to lead exposure and other factors, are starting school with an incredible disadvantage. We feel these issues have been really absent from the discussion about public education in this country.

HCB: Do these studies suggest that childhood lead exposure is more dangerous than most believe it to be?

Magzamen: I don’t know if it’s more dangerous, but I think it has broader implications than we initially thought. We don’t know what’s going to happen to these kids, but we do know that educational success is linked to so many things later in life—not only to one’s ability to earn a living but also to one’s long-term health. These children are starting with so many disadvantages, and it’s so much harder to make up for those disadvantages later in their lives. We have known the power of lead to effect negative health for so long, but we’re not doing much about it.

HCB: What more needs to be done?

Magzamen: Pediatricians are our first line of defense here. Lead screening is mandatory for children enrolled in Medicaid at first- and second-year checkups, but this is an unfunded mandate. Recent data suggests that about one-third of parents who go in for a well-child check-up spend 10 minutes or less with the doctor. These encounters are so important because lead screening data performed at the check-up are provided to state Childhood Lead Poisoning Prevention Programs, where trends in prevalence and the range of blood lead levels can be tracked over time and space, so we have a better idea of the scope of the problem, and possible efforts to mitigate exposures.

These kids aren’t in school yet, and on average, they don’t have high enough levels to have seizures or other physical signs of extreme lead poisoning, but they do have levels that relate to poor educational outcomes in schools. We need to support efforts to have pediatricians keep testing and keep surveying to make sure that policy-makers know this issue is not going away.

HCB: What can be done to prevent exposure in the first place?

Magzamen: The trick is really to get the lead out of the environment, not only in homes but also in the soil. Lead is often referred to as a legacy pollutant; we haven’t used lead in gas or house paint since the 1970s, but it is a persistent, heavy metal that remains in our environment. Generally, lead exposure has been seen as an inner-city problem or a low-income problem, and this population doesn’t have enough political capital to mitigate exposures. This is a power and environmental justice issue.

This commentary originally appeared on the RWJF Human Capital Blog. The views and opinions expressed here are those of the authors.

Tue, 19 Nov 2013 09:00:00 -0500 Culture of Health Blog Built Environment and Health Health Disparities Children (0-5 years) Urban Health & Society Scholars <![CDATA[A First in Moral Distress Research: A Study of Burn ICU Nurses]]>

Researchers at Loyola University Medical Center have conducted the first study of moral distress among nurses in an intensive care unit for burn patients, starting to address “a significant gap” in knowledge about responding to the painful feelings that arise in situations where people can’t act according to their ethical ideals, due to barriers such as lack of time and supervisory support, and policy and legal constraints.

Moral distress has been studied in various populations of health care providers, including neonatal ICU nurses, pediatric ICU nurses, genetic professionals, surgical residents, and medical residents. The Loyola study, published in the September/October issue of the Journal of Burn Care & Research, points out that the impact of moral distress on nurses during the provision of care, particularly in critical care settings, is well documented and can result in a wide variety of reactions, including depression, anxiety, emotional withdrawal, frustration, anger, and a variety of physical symptoms.

“Given the intense and potentially distressing nature of nursing” in a burn ICU, with patients who have been in disfiguring and painful accidents, may have self-inflicted injuries, or may have been harmed by another person, “it is reasonable to hypothesize that nurses in these setting are likely to experience some level of moral distress,” wrote authors Jeanie M. Leggett, RN, BSN, MA; Katherine Wasson, PhD, MPH; James M. Sinacore, PhD; and Richard L. Gamelli, MD.

The study included 13 nurses in Loyola’s burn ICU who participated in a four-week educational intervention, consisting of four one-hour weekly sessions intended to decrease moral distress.

Previous research on moral distress has demonstrated that nurses who experience it are more likely to make errors, change positions, become desensitized to moral aspects of care, or leave the profession altogether. The researchers conclude that burn ICU nurses “would be well-served by a larger and more broad-based study involving multiple burn centers and a larger population of nurses working in this important area of nursing.”

Read coverage of it in Medical Xpress.

This commentary originally appeared on the RWJF Human Capital Blog. The views and opinions expressed here are those of the authors.

Mon, 18 Nov 2013 13:00:00 -0500 Culture of Health Blog Nurses and Nursing Nursing <![CDATA[Promoting Rigorous Interdisciplinary Research and Building an Evidence Base to Inform Health Care Learning, Practice, and Policy]]>

By Mary D. Naylor, PhD, RN, FAAN, Marian S. Ware Professor in Gerontology, director of the NewCourtland Center for Transitions and Health at the University of Pennsylvania School of Nursing, and co-director of the Robert Wood Johnson Foundation’s Interdisciplinary Nursing Quality Research Initiative. This commentary originally appeared on the Institute of Medicine website.

The Institute of Medicine (IOM) established the Roundtable on Value & Science-Driven Health Care to accelerate the advancement and application of science to achieve the best possible health and health care outcomes and value for Americans. The work of the roundtable is predicated on the notion that our health care system must continuously learn from rigorous evidence in order to innovate and improve. To that end, it acknowledges and promotes the importance of identifying best practices in health and health care, developing and testing innovations, and—most importantly— promoting collaborative efforts.

This vision for improving health and health care is shared by the Robert Wood Johnson Foundation, which funds an innovative and unique initiative to improve patient care by examining the role nurses play in improving care quality: the Interdisciplinary Nursing Quality Research Initiative (INQRI). Mark Pauly of the University of Pennsylvania and I have had the great privilege of serving as co-directors of this program since its inception in 2005.

More than 3.1 million strong, nurses represent the largest segment of the health care professional workforce in the United States and are the professionals who provide the most direct patient care. But, until the launch of the INQRI program, there was little rigorous research linking nursing’s contributions to patient outcomes. INQRI has served to advance the science of health care by investigating those linkages and providing evidence to inform policies and practices that improve patient care and outcomes, thereby improving our health care system overall.

Since INQRI’s launch, the program has encouraged researchers to develop new strategies to improve health care value and demonstrate nursing’s role in accomplishing that aim. To date, INQRI has supported 48 multidisciplinary teams of scholars whose studies have dramatically increased the evidence linking nursing to quality of care. These teams not only examine the nursing practices and processes that affect the patients’ experience with care and outcome, but also design and implement nurse-led interventions to improve patient outcomes. Equally important, findings from INQRI teams have helped to distinguish effective ideas from solutions that are often popular, yet ineffective.

A series of articles recently published in a special supplement of Medical Care revealed that, collectively, these studies have helped to improve the rigor of research methodology, built a solid base of evidence demonstrating linkages between nursing care and patient outcomes, and helped advance interdisciplinary research and practice. To a large extent, INQRI’s contributions to our knowledge are a function of the singular requirement that every INQRI research team include investigators from more than one discipline. As IOM’s Roundtable on Value & Science-Driven Health Care has drawn on the insights of a multidisciplinary community, so have INQRI teams. By requiring that researchers collaborate across disciplines, the program raises the bar for the level of rigor, ensuring that diverse perspectives contribute to the design of each study and are also brought to bear in the analysis of the findings.

The roundtable has sought to accelerate progress through six stakeholder Innovation Collaboratives: 1) Best Practices; 2) Clinical-Effectiveness Research; 3) Evidence Communication; 4) Digital Learning; 5) Systems Approaches for Health; and 6) Value Incentives. To make significant change, we must look at all aspects of the health care system. To that end, INQRI attempts to understand the nurses’ role in delivering high-quality care across a variety of patient populations and settings.

INQRI has funded several studies that examined nursing practices and tested interventions that can improve patient care and safety, including

  • changes in nursing processes and the practice environment to facilitate nurses’ ability to intercept costly and dangerous medication errors;
  • nurse-led innovations to reduce the incidence of facility-acquired
  • pressure ulcers among residents in long-term care settings; and
  • strategies to improve intensive care unit patients’ ability to communicate with nurses and other health team members regarding their care needs and preferences.

INQRI grantees have also applied rigorous research methods to examine a broad range of approaches to improving the value of health care—increasing quality while reducing health care costs associated with issues such as patient falls, hospital-acquired infections, and rehospitalizations. Studies aimed at reducing events that drive up health care costs have included

  • an analysis of the factors that influence the quality of preparation of patients and family caregivers for the transition from hospitals to home and the impact of enhanced preparation on patients’ perceived readiness and rates of re-hospitalization;
  • relationships between the level of professional nursing practice, adoption of evidence-based care strategies, and the number and kind of injuries from falls;
  • effects on patients’ health of diabetes prevention information delivered by visiting nurses to residents in subsidized housing units; and
  • linkages between nurse staffing levels in neonatal intensive care units and outcomes for very-low-birth-weight infants in those units.

In addition to contributing to continuous learning in our nation’s health care system, improving the rigor of research, and identifying the linkages between nursing and the quality of patient care, INQRI has helped to define what we mean by “quality” in the context of health care and to identify new metrics and measures that should be used in future health care research. As any research endeavor should, INQRI has proven to be greater than the sum of its parts.

Suggested citation: Naylor, M. Promoting rigorous interdisciplinary research and building an evidence base to inform health care learning, practice, and policy. Commentary, Institute of Medicine, Washington, DC.

This commentary originally appeared on the RWJF Human Capital Blog. The views and opinions expressed here are those of the authors.

Fri, 15 Nov 2013 09:00:00 -0500 Mary Naylor Nurses and Nursing Nursing <![CDATA[Where the Docs Are: New Report Takes a State-by-State Look]]>

The Association of American Medical Colleges (AAMC) has released its 2013 State Physician Workforce Data Book, a biennial report that examines current physician supply, medical school enrollment, and graduate medical education in the United States.

Between 2008 and 2012, there were small increases in the state median number of active physicians and active patient-care physicians, the state median percentage of female physicians, and the percentage of physicians age 60 or older. While the median number of students enrolled in undergraduate medial education has increased relative to the population, the number of students enrolled in graduate medical education per population has remained flat.

Among key findings, in 2012 there were 260.5 active physicians per 100,000 population in the United States, ranging from a high of 421.5 in Massachusetts to a low of 180.8 in Mississippi. The states with the highest number of physicians per 100,000 population are concentrated in the Northeast.

Massachusetts also ranked first for primary care physicians per 100,000 population, with a value of 131.9. Nationally, there were 90.1 primary care physicians per 100,000 population. At 63.4, Mississippi also had the lowest number of primary care physicians per 100,000 population.

In terms of gender diversity, more than one-third (38.4 percent) of active physicians in Massachusetts were female. Utah had the lowest percentage of female physicians (21.9). Nationally, 31.9 percent of active physicians were female.

Read the AAMC report.
Read coverage of it in Becker’s Hospital Review, listing the 20 states with the most, least physicians by population.

This commentary originally appeared on the RWJF Human Capital Blog. The views and opinions expressed here are those of the authors.

Thu, 14 Nov 2013 16:20:00 -0500 Culture of Health Blog <![CDATA[Targeting Job Discrimination Against Former Offenders]]>
file Image courtesy of TakeAction Minnesota

During a town hall meeting in Minnesota last month, the Target Corporation, one of the largest employers in the United States, announced that the company will remove the criminal history question from its initial employment application. While Target has already removed this question in states where it is legally prohibited, this announcement will apply to all U.S. Target locations, even in areas where asking the question is permitted by state or local law. In Minnesota, the Ban the Box law will go into effect January 1, 2014.

“Over the past year, members of the Target team have had many productive conversations with TakeAction Minnesota,” says Molly Snyder, a spokesman for the company. “Many of our discussions have focused on Minnesota’s racial jobs gap and the barriers individuals with criminal records face when seeking employment.”

file Justin Terrell, TakeAction Minnesota

The decision by Target is in part the result of efforts led by the TakeAction Minnesota Education Fund, a Robert Wood Johnson Foundation (RWJF) Roadmaps to Health community grantee, to address job discrimination based on criminal background. Often tied to significant unemployment throughout the country, studies show that having a criminal record is a barrier to employment opportunities and depresses wages. And data from Minnesota finds that half of all former offenders are unemployed, with the rate higher for ex-offenders of color who disproportionately make up the prison population.

The Roadmaps to Health Community Grants are collaborations that have received two year funding of up to $200,000 to work with diverse coalitions of policy-makers, business, education, health care, public health, and community organizations. The grantees and their partners are pursuing policies or system changes that address the social, economic, and environmental factors that influence how healthy people are and how long they live. The Roadmaps to Health Community Grants project is a major component of the County Health Rankings & Roadmaps program—a collaboration of RWJF and the University of Wisconsin Population Health Institute.

TakeAction Minnesota is using its grant to promote new statewide fair hiring standards for businesses, such as persuading prospective employers to consider criminal records only when they directly relate to the position rather than asking questions on applications that promote blanket rejections. Earlier this year, the Minnesota legislature passed the “ban the box” legislation and it was signed into law in May, making Minnesota the third state in the nation to adopt “ban the box” in both the public and private sectors. Under the new law, an employer will no longer be allowed to include a check box about criminal background on the initial employment application. 

NewPublicHealth recently spoke with Justin Terrell, manager of the Justice 4 All program at TakeAction Minnesota, about the intersection of employment and health.

NewPublicHealth: What are the ways in which employment impacts health?

Justin Terrell:  One of the ways that employment impacts health is that if you have a job, you are more likely to have healthcare coverage or be able to be able to get coverage.  But income also has an impact on health — the more money you have left over after paying bills, the less you’re worried about housing, about what you’re eating if you’re not on assistance.

It’s surprising and people don’t often think about it, but income also has an impact on safety. In low-income, under-resourced communities of color like north Minneapolis, where we do a lot of our work, you have people who are ten times more likely to be incarcerated for the same crime committed compared with whites in other communities. Those with criminal records can’t find work. Well, now communities have a safety issue as well because our recidivism rate in Minnesota is 61 percent. We believe in the Homeboy Industries’ slogan: “nothing stops a bullet like a job.” [Editor’s Note: Homeboy Industries is a nonprofit that serves high-risk, formerly gang-involved men and women with free services and programs.]

So in that respect, having employment has a huge impact on health and it’s why we’re in the fight that we’re in — to try to create more fair access to employment for people with records so that we can lower our recidivism rate; expand the amount of wealth in our communities; keep more families together; and, in the end, have healthier communities.

NPH: Tell us about Justice 4 All.

Justin Terrell: There are people in the community, like myself, who have a criminal record and who have found it difficult to find employment. So we do education at places such as workforce agencies and halfway houses. One example is our free legal service to help people get their records expunged, or even just get access to their criminal records or help them do a search to see if websites are publishing their mug shots.

We’re very proud of our big policy win in Minnesota where legislators passed “Ban the Box,” which removed the question about criminal records from employment applications.  

We held an open, public conversation with Target last week, where they announced the change to their employment applications in Minnesota. These conversations are critical. What is the impact of that on the business community and what is the role of corporations in trying to close that gap?  And what is the role of the community?

NPH: What would you like to see happen next?  

Justin Terrell: I would like to see corporations like Target actually lead this discussion with their business partners, and I would like to see this conversation happening in the broader business community. We need a more equitable business model that takes into account people with criminal records. There are a million people in our state with criminal records — that’s about one in five people seeking employment. So, we have some serious issues if we don’t change our hiring practices, especially as the job market continues to rebound. You’re going to see a lot of qualified people being locked out of employment and some of the larger companies are already bringing people of color from out of state to work here for them even while so many residents of color are being locked out of jobs. North Minneapolis is home to 60,000 people and the majority are people of color and our largest employer is a grocery store. We cannot economically sustain a city as dynamic as Minneapolis when you have a community of 60,000 people with terribly high unemployment rates. In 2010, unemployment was 5.9 percent statewide, but for African-Americans it was 27 percent.

NPH: What are your barriers right now to achieving your goals?

Justin Terrell:  I think one of our biggest barriers is that it is accepted in society that it’s okay to legally discriminate against people with criminal records — even though we want them to be reintegrated into society. Being employed has a huge impact on health and it’s why we’re in the fight that we’re in — to  try to create more fair access to employment for people with criminal records so that we can lower our recidivism rate and increase income rates in our communities and keep more families together and have healthier communities.

This commentary originally appeared on the RWJF New Public Health blog.

Thu, 14 Nov 2013 14:53:00 -0500 Culture of Health Blog <![CDATA[Shielding Young Brains from the Effects of Toxic Stress]]>
Child First

Before the science on addiction was developed, we blamed smoking on bad choices. Once we understood how the brain worked, we were able to devise strategies to change behavior, and smoking plummeted. 

As David Bornstein points out in two outstanding recent New York Times columns, the science of toxic stress is setting the stage for another health revolution that is just as far-reaching. It is forcing us to rethink the way communities deliver services─health care, education, and more─to our most vulnerable.

Read the first column

Read the second column

Every day, there are young children who are abused. Who witness violence in their homes or neighborhoods. Who are malnourished. Or who have parents who struggle with drug or alcohol use. We now know that those adverse experiences change the way their young brains develop, and affect their mental and physical well-being later in life. These children are more likely to have heart disease, cancer, and hypertension as adults. They are more likely to use drugs, suffer from depression, and commit suicide. They are more likely to drop out of school, spend time in prison, and be homeless. 

Understanding the root of so many problems actually gives us hope that we can prevent them. One of the programs Bornstein highlights is Child First, an RWJF grantee that intervenes to stabilize the home environment and protect children who are at very high risk of being exposed to toxic stress. One reason why Child First works is that it treats the whole family, addressing issues like depression or housing instability with parents and caregivers while focusing on the needs of very young, very vulnerable children. By giving parents the tools and supports they need to be nurturing and stable caregivers, they realize that they are a powerful force for strengthening their child’s emotional, social, and physical development. That holistic approach has been shown to shield young brains from the effects of traumatic stress and enables healthy, strong family relationships to flourish.

We’re just now scratching the surface of what’s possible with new science and solutions on our side. We still have so much to learn. But the success of programs like Child First─and the rise of hundreds of other efforts to apply the science of how we prevent and mitigate exposure to toxic stress to the real world─tell us that this is the wave of the future.

Wed, 13 Nov 2013 15:45:00 -0500 Kristin Schubert Early Childhood Disease Prevention and Health Promotion <![CDATA[Engaging Communities of Faith to Help Americans Gain Health Insurance]]>
A pastor gives a sermon in Nashville, TN.

With the opening of health marketplaces and the Affordable Care Act’s partial expansion of Medicaid, our nation has an opportunity to substantially expand health insurance coverage for all Americans, and ultimately, to significantly reduce racial disparities in access to affordable coverage.

But to achieve that goal, communities of color must attain robust enrollment gains. That’s why RWJF is working with religious leaders and their congregations to help make sure that all who are eligible enroll.

The Problem

According to United States Census data for 2012, approximately 48 million Americans are uninsured. It is a problem that cuts across all racial and ethnic groups, but is most acute in two, resulting in 19 percent of African Americans and more than 29 percent of Hispanics living without health insurance.

In 2009, the Institute of Medicine documented what many suspected: The uninsured are much less likely to obtain preventive care; get timely diagnoses for illnesses, including cancer; receive treatments for chronic illnesses such as diabetes and asthma; and take prescription medications as recommended by physicians.

Beyond the health consequences of uninsurance, there are steep costs for our economy. We all pay the bill for indirect fiscal burdens associated with the uninsured—including illness and injury, decreased workforce productivity, developmental and educational losses among children, and shorter life spans, costing the U.S. economy between $100 and $200 billion each year.

Engaging Faith Communities

We recognize the significant role that faith communities play in American life, particularly among minority populations, so we are engaging religious leaders and their congregations to spread the word about new coverage options.

We recently made a grant to the NAACP to help fund national outreach to religious leaders to help them share information about opportunities for their congregants to enroll in new, affordable insurance options. A similar grant to the National Council of La Raza will support their efforts to educate the Latino community about enrollment opportunities.

In conjunction with Community Catalyst, RWJF works to strengthen the voices of people promoting comprehensive health coverage for all Americans through Consumer Voices for Coverage (CVC), which provides technical assistance and support to health advocates in 11 states. Examples of CVC-supported coalitions working with faith leaders and their congregations demonstrate what’s possible when people are engaged by neighbors they know and trust.

  • The Maryland Citizen’s Health Initiative has created a Faith Ambassadors Program, training local congregants to provide health insurance education in English, Spanish, French, Korean, and Arabic. The project began at the Koinoia Baptist Church in Baltimore and now includes over 50 trained ambassadors throughout Central Maryland and the Eastern Shore. More than 125 congregations across the state are on a waiting list for visits from Faith Ambassadors.
  • In Alabama, we support the Arise Citizens' Policy Project, which works with congregations, missionary boards, and gospel radio stations across the state to educate the uninsured about their coverage options. Recently, they created a handy pre-formatted guide about health insurance for clergy to drop in to their church bulletins.
  • In Virginia, we are investing in the commonwealth’s oldest faith-based advocacy group. A nonpartisan coalition of faith communities, the Virginia Interfaith Center for Public Policy, is working through a broad range of congregations to engage people of faith and educate Virginians about health coverage.

We also support the “Health Care from the Pulpit” program, which is part of Enroll America’s Get Covered America campaign. The program works with hundreds of local and national faith-based organizations across the country to host enrollment events and invite pastors to talk about the Affordable Care Act with members of their congregations. A “Health Care from the Pulpit” event in Florida was recently covered here.

Together with these and other grantees, we are committed to ensuring that 95 percent of Americans have access to stable, affordable health coverage by 2020. To achieve this, we’ll continue to work with minority- and faith-based organizations across the country with the goal of improving the health and health care of all Americans.

If you are a leader or active member of a congregation, we encourage you to explore how the programs highlighted in this post can help you develop your own approaches to the people you worship with, and help them learn about opportunities to enroll in new health insurance options. If you have related experiences you’d like to share with others, we welcome your comments below.

John Lumpkin

John Lumpkin, MD, MPH, is senior vice president and director, targeted teams for the Robert Wood Johnson Foundation.

Wed, 13 Nov 2013 14:46:00 -0500 John R. Lumpkin Health Care Coverage and Access Health Disparities Leadership Views <![CDATA[RWJF Scholar Discusses Sugary Drinks, Messaging and Taxation]]>

In the past four years, the U.S. beverage industry defeated efforts to levy taxes on sugary beverage sales in 22 states and six cities. University of Minnesota Professor Sarah Gollust, PhD, a Robert Wood Johnson Foundation (RWJF) Health & Society Scholars alumna, is exploring strategies that might help to offset the industry's messaging. Gollust specializes in researching public opinion dynamics and obesity prevention.

In the fifth video in a series of RWJF Clinical Scholars Health Policy Podcasts, Clinical Scholar Chileshe Nkonde-Price, MD, interviews Gollust about her recent work.

The video is republished with permission from the Leonard Davis Institute.

This commentary originally appeared on the RWJF Human Capital Blog. The views and opinions expressed here are those of the authors.

Wed, 13 Nov 2013 09:00:00 -0500 Culture of Health Blog Health & Society Scholars <![CDATA[Why You Should Get Your Flu Shot by Wednesday]]>

The flu season is pretty mild so far. The latest FluView report from the U.S. Centers for Disease Control and Prevention (CDC) shows that the current rate of flu cases across the country is below other years, and some states have yet to see any flu cases at all. But health experts worry those reports will make people who still haven’t gotten the vaccine complacent about getting their shot. And going without poses the risk of a multi-day illness; transmitting the flu to other people who may be more vulnerable to the virus than you; and the potential for serious side effects such as pneumonia and—in rare cases—death.

If you’re still shotless, health experts advise you to roll up your sleeves by Wednesday if at all possible. Here’s why: Immunity to the flu can take up to two weeks after you’ve received the injection. Get the shot by this Wednesday, November 13, and you’ll be protected by the day before Thanksgiving.

That’s the heaviest U.S. travel day of the year, when the possibility of encountering people with the flu at airports, train stations, or even at Thanksgiving dinner greatly increases.

“Visiting mom, grandma and that new baby can make for memorable holiday moments, as long as you don't bring the flu virus along to spoil the party,” says Jeff Golden, spokesman for the Madison, Wisc., health department which, like many other health departments, has sent out recent flu advisories.

CDC research adds another reason to get the shot this week. The agency has found that the momentum to get the flu vaccine wanes after Thanksgiving, perhaps because people assume that as the weather gets colder, if they haven't gotten influenza yet, they won’t. But that’s foolhardy thinking. The U.S. flu season runs from September through April, and the worst of it often hits in January and February. If you wait until cases increase, you may find that you don’t have enough time for the shot to protect you. And you may also find it hard to locate supplies of the vaccine. Knowing that interest in the shot drops after Thanksgiving, private and public clinics, as well as doctors’ offices, often return unused supplies toward the end of the year to free up storage space and in some cases get a refund on the unused doses. Health departments may then keep supplies centrally, but that location may not be convenient.

Wonder where to get the flu shot? Here are good ideas:

  • Key in your zip code at
  • Dial 211, a resource for local services in many communities
  • Check pharmacies to see if they have supplies on hand and what hours they give the shots
  • Call your local health department to ask if they have clinic hours for the flu vaccination
  • Key in “travel clinic” on a search engine to find private clinics in business districts, but call ahead to check on supplies and hours

Health departments may give the shot for free, or ask for payment on a sliding scale based on income. Pharmacies charge about $25, and private doctors’ offices may add a $10 or $20 administrative fee on top of that. The cost is typically covered by insurance, though you may have to file the paperwork yourself.

This commentary originally appeared on the RWJF New Public Health blog.

Tue, 12 Nov 2013 14:06:00 -0500 Culture of Health Blog Disease Prevention and Health Promotion Public and Community Health <![CDATA[Ending Healthcare Waste, Improving Healthy Lives: Q&A with the L.A. Department of Public Health’s Jonathan Fielding]]>
Physicians in a doctor's office, talking on the telephone.

In a report released last year, the Institute of Medicine found that the United States wastes billions of dollars each year on such unnecessary spending as inefficiently delivered services, excess administrative costs, fraud and missed prevention opportunities. In response, a group of senior public health scholars at the UCLA Fielding School of Public Health, led by Jonathan Fielding, MD, MPH, a professor at the school and the director of the Los Angeles Department of Public Health, published an article in the American Journal of Preventive Medicine on the improvements to population health the country might realize if only the wasted money was devoted instead to the social and environmental determinants of health. If the government could reap 45 percent of the wasted medical care costs, argues Fielding and his co-authors, and invested those resources in sectors such as education, jobs, healthier foods and transportation infrastructure, the health of millions could be markedly improved and society would see additional social benefits.

Jim Marks, Senior Vice President and Director, Health Group at the Robert Wood Johnson Foundation echoed this approach at the recent American Public Health Association (APHA) annual meeting in Boston.

"We know lots about the cost of illness, but very little about the value of health,” he said.

Marks also said that focusing on health as the ultimate goal tends to eclipse some of the social determinants that can have enormous impact on people’s lives. “Most people don’t want good health as their outcome, they want a quality life. They want to travel, take care of grandkids, have a rich family and social life—you can only do that if you’re healthy,” said Marks. “It’s unrelated to good quality medical care. It’s related to education, safe neighborhoods, [and other social factors].”

According to Marks, improving public health isn’t about curing individual diseases or fixing specific injuries. Rather, it’s about everything; the diseases are the end result of the system we live in. And with all the data we have available, we know it’s a system that needs fixing, said Marks.

Marks’ thoughts came at an APHA panel Fielding moderated in a closing day session about the health impact of investment in major social and environmental policies and interventions; information gaps and how they can be filled; and how the discussion of health spending can be re-framed so that U.S. resources can be invested most productively.

NewPublicHealth spoke with Fielding about better uses for the wasted health care spending just before the start of the APHA meeting.

NPH: What were your key goals in releasing the research article?

Jonathan Fielding: To stimulate thinking about a different paradigm. Also to get other sectors involved in arguing and discussing priorities in terms of how we spend money at the federal and state levels, as well as to be additional voices toward moderation in how much we’re spending on healthcare in this country.

NPH: What are some strong examples of ways to use that excess healthcare spending to help improve health?

Fielding: One example is taking 24 million students in elementary school and lowering class size from an average of 22-25 students to 13-17 students. That change could lead to between 70,000 and 140,000 additional high school graduates. And if you graduate from high school compared to not, you gain an average of 1.7 quality adjusted life years, and society reaps the economic benefits because the high school graduate pays more in taxes from a higher paying job.

Another example would be to increase funding for the anti-tobacco campaign to try to stop teens from starting to smoke. That could save millions of life years.

NPH: What is needed going forward?

Fielding: We need a set of careful analyses on a wide range of social investments and changes to our physical environment to see how that helps us. For the physical infrastructure, that would be items such as more bikeable, walkable communities and increases to mass transit.

And we also need to have active convenings of leaders in other sectors who can be advocates for their programs and speak eloquently to Congress and state legislatures to show that there are alternative uses that might, in fact, bring better results and reduce the terrible health disparities our country currently faces.

NPH: Do you have models in Los Angeles for absorbing/reducing healthcare spending waste and redirecting it to help improve population health?

Fielding: Unfortunately we don’t control the use of those funds for public health. But what we have done we’ve done with money from the Affordable Care Act’s Prevention and Public Health Fund, through the Community Transformation Grants. We’ve used some of that money to the city to focus on health in their general plan, so that now all major decisions are going to come through the planning department and they will have to consider the health consequences. Other cities have done that, as well.

NPH: How would communities begin if they were able to redirect health care funds toward improving population health?

Fielding: The first thing you need is a broad coalition that involves the various sectors. Second, you need reasonably good metrics, so that you have the information in ways that people can understand it, and what the tradeoffs are. Third, I would suggest starting by looking at policy opportunities, because in many cases the governmental costs are zero or low.

>>NewPublicHealth was on the ground throughout the APHA conference speaking to public health leaders and presenters, hearing from attendees on the ground and providing updates from sessions, with a focus on how we can build a culture of health. Find the complete coverage here.

This commentary originally appeared on the RWJF New Public Health blog.

Mon, 11 Nov 2013 15:03:00 -0500 Culture of Health Blog Disease Prevention and Health Promotion APHA <![CDATA[Veterans Get Help Pursuing Nursing Careers]]>

More than 1,000 veterans will obtain undergraduate degrees in nursing over the next four years with the help of a grant from the Health Resources and Services Administration. The grant was announced earlier this fall.

The multi-million-dollar effort, known as the Veterans’ Bachelor of Science in Nursing (VBSN) program, will allow veterans to build on their combat medical skills and experience and receive academic credit for prior military training and experience. The program provides funding to nine institutions to recruit veterans and prepare VBSN undergraduates for practice and employment in local communities, and also develop career ladders that include academic and social supports, career counseling, mentors, and linkages with veteran service organizations and community health systems.

Participating institutions include three in Florida: Jacksonville University, Florida International University, and the University of South Florida; two in Virginia: Hampton University and Shenandoah University; as well as the University of Texas at Arlington, the State University of New York at Stony Brook, Davenport University in Michigan, and the University of Alabama at Birmingham (UAB).

The VBSN program “recognizes the valuable skills and experience of our veterans, while addressing the nation’s nursing workforce needs,” HHS Secretary Kathleen Sebelius said in a news release.  “The education and training they receive helps qualify them for civilian nursing positions, while expanding Americans’ access to high-quality care.”

UAB recently announced that its VBSN program goals include increasing enrollment and retention rates of veterans, especially those from rural and underserved communities, and graduating eight students each year of the four-year grant.

“There are many veterans who served in the medical corps and have so much to offer patients, especially other veterans in both veteran and traditional hospital settings,” said Rhonda McLain, DSN, assistant professor and program director.

This commentary originally appeared on the RWJF Human Capital Blog. The views and opinions expressed here are those of the authors.

Mon, 11 Nov 2013 09:00:00 -0500 Culture of Health Blog Health Leadership Development Nurses and Nursing Nursing <![CDATA[New Mexico Governor Martinez Announces New Common Nursing Curriculum ]]>
New Mexico Governor Susana Martinez New Mexico Governor Susana Martinez. [Photo by permission of the state of New Mexico via Wikimedia Commons.]

At a news conference yesterday in Albuquerque, New Mexico Governor Susana Martinez announced the establishment of a statewide common nursing curriculum, designed to increase the number of nurses with Bachelor of Science in Nursing (BSN) degrees in the state. She was joined at the event by leaders from the New Mexico Nursing Education Consortium (NMNEC), which led the effort to develop the curriculum and build partnerships between community colleges and universities.

NMNEC’s work is supported by the New Mexico Academic Progression in Nursing (APIN) initiative, a grantee of the Robert Wood Johnson Foundation (RWJF).

Implementation of this curriculum in New Mexico will allow nursing students to more easily transfer credits from community colleges within the state, so they can pursue BSNs without having to physically attend large universities like the University of New Mexico in Albuquerque or New Mexico State University in Las Cruces. For the first time, state community colleges will be able to partner with one of these universities to offer bachelor’s degrees in nursing.

By the 2014-2015 academic year, 63 percent of nursing students at New Mexico higher education institutions will be using the new common curriculum. By the 2017-2018 academic year, the state intends to achieve 100 percent participation.

“As our diverse New Mexico community continues to face unprecedented changes in health care, it is our responsibility to proactively prepare for these challenging conditions. Together, we can meet a major need of our workforce and ensure we are providing the high level of care that New Mexican families and communities deserve. Thanks to the work of the NMNEC, the New Mexico Higher Education Department, and health care professionals across our state, New Mexico will be better prepared for today’s health care challenges, as well as those to come,” Governor Martinez said.

The state Secretary of Higher Education, José Z. Garcia, and Secretary of Health Retta Ward, attended the announcement, along with the NMNEC Leadership Council. The audience included nurse educators, nursing students, hospital/clinic nurse educators and clinicians, and nursing association leaders.

“These reforms that Governor Martinez has instituted are essential to both current and aspiring New Mexico nursing professionals, as well as to the communities we serve,” said Terry Keller, PhD, a nursing educator who teaches at New Mexico State University. “For too long, New Mexicans seeking to put their talents and passions to work serving their communities as nurses have had to deal with undue hardships when transferring credits from one institution to another due to the circumstances of everyday life. Now, aspiring nursing students will be able to pursue their dreams of serving as health care professionals much easier, in more underserved areas across our state. In turn, this will ease the burden on current health care professionals, who are already in short supply.”

New Mexico faces a shortage of primary care and family practice health care workers, especially in rural areas.

In its groundbreaking report, The Future of Nursing: Leading Change, Advancing Health, the Institute of Medicine (IOM) recommended that 80 percent of the nation’s nursing workforce be prepared at the baccalaureate level or higher by the year 2020.  RWJF is helping advance recommendations in the IOM report by supporting the Future of Nursing: Campaign for Action.

Learn more about APIN’s work in New Mexico, Texas, and Washington State.

This commentary originally appeared on the RWJF Human Capital Blog. The views and opinions expressed here are those of the authors.

Fri, 8 Nov 2013 16:23:00 -0500 Culture of Health Blog Health Leadership Development Nurses and Nursing New Mexico (NM) M Nursing <![CDATA[Lessons from Around the World at the APHA Annual Meeting]]>

Michelle L. Odlum, BSN, MPH, EdD, is postdoctoral research scientist at Columbia University School of Nursing in nursing informatics. She has more than ten years of experience as a disparities researcher working on a variety of research, evaluation, and health promotion initiatives affecting vulnerable populations. Odlum is a recent recipient of the Robert Wood Johnson Foundation’s (RWJF) New Connections Junior Investigator award. 

Michelle Odlum Michelle L. Odlum

At this time when our nation’s health care reform is promoting new approaches to primary care, an exploration of health care models from around the globe is essential. With my interest in the transformative role of nursing care, I decided to attend the scientific session [at the American Public Health Association’s annual meeting] entitled: Think Global, Act Local: Best Practices Around the World.  Panelists presented on a variety of interesting care models from Europe to Central America.

As we explore initiatives to improve care coordination, it was interesting to hear Erin Maughan, RN, PhD, APHN-BC, an RWJF Executive Nurse Fellow, talk about Scotland’s care coordination approach to children’s health. Maughan discussed home visitors, who provide care to children from birth to five years of age. An important aspect of the relationship forged with children and families is to allow for early identification of developmental needs, thus allowing for timely utilization of resources and services to address these needs. Interestingly, to support effective care outcomes for children with chronic illnesses over the age of five, each family is assigned a district nurse who is a chronic disease specialist.   

Scotland has also coordinated health forms utilized by police, schools, and health care facilities; this is a team-centered approach for identifying and working with at-risk children. Scotland’s pediatric care model demonstrates the effective utilization of public health nurses and the implementation of inter-agency care coordination. We, as a nation, can certainly benefit from further understanding of these approaches. 

The Affordable Care Act refers to integrative health care. However, holistic approaches for improved health outcomes, as part of health care reform, have not been defined. In her discussion of the Russian health care system, Luba Louise Ivanov, RN, PhD, spoke of the holistic approaches implemented in care. In fact, holistic health is a part of nursing and physician training programs.  Russian nurses administer herbal treatments, and provide massage therapy and acupuncture to patients. The Russian health care model consists of home visits by nurses and physicians. Home care includes respite care to support home living for the chronically ill, who would otherwise be placed in long term care facilities. Respite care is similar to the health reform initiative—Medicare Independence at Home Demonstration, which will reimburse physicians and nurse practitioners for at-home primary care. Valuable lessons can be learned from the Russian approach for our successful implementation of home-based and integrative health care initiatives.

Care coordination is further enhanced by the ability of consumers to securely obtain personal health information to share with providers and to support effective self care regimes. In the panelists’ presentations, it was fascinating to hear that health care consumers in Russia and Guatemala are responsible for their personal health records. In these care models, medical records are kept at home and brought to provider visits. We can certainly benefit from understanding how this approach enhances care and makes for informed health care consumers.

Health care reform is an evolving process and lessons learned from global approaches that align with our vision can both support and enhance U.S. efforts for health care equity. 

Read stories from the Human Capital website about RWJF scholars' work presented at the American Public Health Association's 2013 annual meeting.

This commentary originally appeared on the RWJF Human Capital Blog. The views and opinions expressed here are those of the authors.

Fri, 8 Nov 2013 09:00:00 -0500 Culture of Health Blog Nursing <![CDATA[Social Media and Hurricane Sandy: Q&A with Jay Dempsey and Vivi Abrams Siegel]]>

Hurricane Sandy made landfall last year during the American Public Health Association’s (APHA) annual meeting in San Francisco. Several sessions at the annual meeting this year in Boston, one year after the storm, focused on the response during the hurricane that killed dozens, injured hundreds and destroyed thousands of homes.

In a key session Monday, communications specialists from the U.S. Centers for Disease Control and Prevention (CDC) reported on a study of new media preparedness and response messaging implemented before and after the disaster. As Hurricane Sandy approached landfall, the CDC’s National Center for Environmental Health (NCEH) assisted state and local public health partners by developing and sharing storm-related messaging across several social media channels, including an SMS text subscription service to directly reach people affected by the storm.

CDC determined what topics would need coverage each day, ranging from preparing for the storm's arrival to post-storm safety and clean-up. Once messages were posted, they were retweeted across several CDC Twitter feeds and on social media channels of local health departments. The recent CDC study found that leveraging social media turned out to be very important for driving a steady increase in traffic to CDC emergency response web pages. For example, a message about safe clean-up of mold produced 14,881 visits. The number of NCEH Twitter followers also increased—there were 4,226 twitter followers at the beginning of October before the storm, and that grew to 5,215 followers—a 23 percent increase—once the storm hit.

>>NewPublicHealth was on the ground throughout the APHA conference speaking to public health leaders and presenters, hearing from attendees on the ground and providing updates from sessions, with a focus on how we can build a culture of health. Find the complete coverage here.

Ahead of the APHA meeting, NewPublicHealth spoke with Jay Dempsey, a health communications specialist in the National Center for Environmental Health who presented the data at the APHA meeting and Vivi Abrams Siegel, a health communications specialist in the CDC Office of Public Health Preparedness and Emergency Response about the findings and the growing importance of social media before, during and immediately after disasters.

NewPublicHealth: What’s most important about the recent study on social media and disaster preparedness and response?

Jay Dempsey: The case study is an overview of the lessons that we learned from using social media to disseminate emergency and preparedness messaging ahead of and during and immediately following Hurricane Sandy. Some of the things that we knew going in during the response to Hurricane Sandy was that a growing number of people are using social media to get information just before and during a disaster or an emergency. So knowing that, we leveraged our social media channels and the first thing we saw was a pretty substantial increase in web traffic. We’re able to track the number of page visits that come exclusively from social media and make a determination of approximately how much social media drove traffic to those particular pages.

NPH: Was your study pegged to see whether people acted on the information they learned through social media?

Dempsey: That is actually one of the limitations of this case study. We’re able to confirm that there was an increase in web traffic so we can demonstrate that there is value in using social media during emergency situations, but right now we’re not able to identify a mechanism that lets us determine how those people acted on the information.

NPH: What do you know for next time that you didn’t know before?

Dempsey: I’m actually pleased to report that I think we had a pretty good sense of what to do heading into this situation. We already had pre-developed content for social media ahead of a situation like the hurricane. So we knew what kind of messages people would need to get one to three days prior to the storm making landfall, what people would need to know during the actual storm itself and then what people would need to know immediately following and then in the two to three days of recovery following the storm. So we had messages ready to go for those designated periods of time.

Vivi Siegel: Phase-based messaging is a technique that CDC has used for a while, especially in the National Center for Environmental Health, which put it in place during Hurricane Katrina. Hurricane Sandy was the first large example of using the concept with social media and I think it worked really well, and we’ve actually had a lot of interests from other agencies to help them implement the strategy. The U.S. Department of Health and Human Services (HHS) has started a social media and emergency work group that is pulling together federal agencies that use social media during emergencies. A key thing the working group is looking at is how other agencies can use phase-based messaging on social media, as well as how can we develop and prepare phase-based messaging for other types of disasters.

NPH: What work is being done at the CDC to help you stay up to date with the various technology opportunities?

Dempsey: We maintain a council of communication professionals that have a specialization in social media across CDC and we meet on a monthly basis to discuss issues just like that. So we’re looking at things such as the changes that are taking place across social media channels. Are there new ones that we should focus on? Have numbers decreased on any certain channels so that we might not need to put as much effort into them?

NPH: At some point do you need to move people away from relying on older media, or is the reality of the situation that you need to meet them wherever they are?

Siegel: The most important thing that we try to keep in mind, especially during an emergency, is who our audience is—who are the people most affected and how can we best deliver information to them? Sometimes the best avenue is social media, sometimes it might be traditional media, sometimes it may be knocking door to door. For every emergency it’s different and we really try to keep the audience in mind when we’re thinking about what the best channel is to use.

That said, we’re really excited about being able to add social media tools to our toolbox of how best to reach people. It’s been really incredible to see the response. We started the @CDC emergency Twitter channel during H1N1 in 2009 and immediately got almost a million followers. Now we’re at 1.5 million and it’s one of the top three followed government Twitter channels.

So we know that people are out there listening and they’re retweeting our messages and that’s an exciting thing to see. Because it means that messages are not just coming from CDC down, but say it’s flu season and we really want to get the message out that people need to wash their hands, CDC can tweet that and then others—such as teenagers—retweet that or post it on their Facebook page, and that adds a personal element to a CDC message.

CDC also just became involved with Twitter alerts, a new concept that Twitter is rolling out and right now it’s just for government and nonprofit agencies that work in emergency response. CDC Twitter followers who sign up for Twitter alerts can actually receive certain tweets that we designate as alerts as SMS text messages on their phones.

NPH: What would be the determining factor for getting that SMS?

Siegel: We would make the determination whether a certain message is important enough that we don’t want anyone to have to wait or work to find this at all. It would be messages we wanted to push right away.

NPH: What else have you learned about social media during a disaster?

Siegel: We also see social media as a very valuable tool to gather information during an emergency. It gives us the ability to monitor and analyze the public conversation around an event as it’s happening, and we specifically look for themes—we look for rumors and misinformation—so that if there is something going on through social media we can quickly counter it. And it also helps us understand what the public’s hearing and saying about the event and what information gaps and needs there are that we need to address.

NPH: What’s a recent example of misinformation that you saw going out over social media that you were able to clamp down on?

Siegel: After the Fukushima reactor explosion in Japan, there was a lot of concern, especially on the west coast, that people would be getting doses of radiation and that they should take potassium iodide or KI. So one of the rumors was that you need to take this, and we knew that if you don’t need it and you take it, it can be very dangerous to people’s health. And so that’s something that we saw and we were able to direct people through social media to fact sheets on potassium iodide and when is, and is not, the appropriate time to take it. And it never got to the point thankfully where people needed to use it in the United States. So we were thankful that we were able to quickly address that and we saw the rumor go away.

This commentary originally appeared on the RWJF New Public Health blog.

Thu, 7 Nov 2013 15:11:00 -0500 Culture of Health Blog Public and Community Health Technology APHA <![CDATA[Making a Collective Public Health Impact through Diverse Partnerships]]>

It’s no secret that public health department budgets have been shrinking in the past few years. In the face of the recession, public health professionals must seek new and diverse partnerships in order to achieve greater impact despite the lack of funding. The topic of one session at the American Public Health Association (APHA) Annual Meeting held in Boston was just that—how to increase impact through strategic partnerships with unlikely partners.

“The need for austerity and efficiency opens up the conversation for collective impact,” said Joseph Schuchter of the University of California-Berkeley School of Public Health. Partnerships can include a wide array of non-public health entities, including non-profit organizations, businesses and schools. The APHA panel discussed different approaches to successful partnerships that advance public health programs.

Leadership Training

The Center for Health Leadership and Practice provides group leadership training for cross-sector teams that are working together to advance public health. “We may all be talking about the same thing, we’re just using different vocabulary and styles,” says VP of External Relations and Director Carmen Rita Nevarez. The Center provides existing partnerships with the tools and training needed to move forward in the same direction, while understanding that individual efforts may differ. More than 90 percent of program participants agree that the approach is effective in supporting intersectoral leadership development and most teams report regularly engaging other sectors as a result.

Networked and Entrepreneurial Approaches

Networked and entrepreneurial approaches to partnerships offer public health professionals with resources and allow them to reduce the negative externalities of the economy. The impact investment market constitutes an $8 billion industry that is eager to fund novel solutions to social problems. In order to succeed in these partnerships, the field of public health must work with social entrepreneurs and investors to highlight the potential return on investment for prevention programs and produce irrefutable outcomes.

Backbone Organizations

The Community Health Improvement Partners (CHIP) serves as a backbone organization for a larger, cross-sector childhood obesity initiative. Cheryl Moder of CHIP shared her insights into the role of such an organization and how to successfully grow a diverse partnership. A backbone organization must serve as mission leaders by recruiting and retaining partners and support aligned activities so that they connect to one another. In addition, backbone organizations must navigate the challenges of larger partnerships—such as developing and retaining trust, encouraging equal partner recognition and shared measurement and evaluation—in a way that suits the needs of partners from different sectors.

>>NewPublicHealth was on the ground throughout the APHA conference speaking to public health leaders and presenters, hearing from attendees on the ground and providing updates from sessions, with a focus on how we can build a culture of health. Find the complete coverage here.

This commentary originally appeared on the RWJF New Public Health blog.

Thu, 7 Nov 2013 13:36:00 -0500 Culture of Health Blog Public and Community Health APHA <![CDATA[The Country Doctor: Study Anticipates a Disappearing Breed that Doesn’t Bode Well for Rural America]]>

Rural counties throughout the United States may be hardest hit by the country’s anticipated shortage of primary care physicians (PCPs), according to a new study from the WWAMI (Washington, Wyoming, Alaska, Montana, and Idaho) Rural Health Research Center at the University of Washington School of Medicine.

Researchers point to several factors that have implications for rural counties:  PCPs deliver the majority of health care in those areas; a substantial percentage of primary care providers in the United States are approaching retirement age at the same time that fewer new medical school graduates are opting for primary care specialties; and demand for health care services is expected to increase as the population ages and millions gain health insurance coverage as a result of the Affordable Care Act.

The study, which used data from the American Medical Association and the American Osteopathic Association 2005 Physician Masterfiles, found a higher percentage of PCPs near retirement in rural counties than in urban ones, with the percentage increasing as the degree of rurality increased. (Physicians 56 or older in 2005 were considered to be near retirement and were the primary focus of analysis.) The 184 counties in the top 10 percent of near-retirement PCPs were characterized by lower population density and lower socioeconomic status, as measured by low education, low employment, and persistent poverty.

There were 166 rural counties without any PCPs at all. Also, at least 30 percent of rural PCPs were 56 or older in 11 states: Arkansas, California, Connecticut, Florida, Massachusetts, Nevada, North Dakota, Oklahoma, Oregon, Vermont, and West Virginia.

The study concludes that identifying states and counties at a particularly high risk for PCP attrition through retirement can help inform policy and planning decisions that may help avoid PCP shortages in vulnerable locations.

The WWAMI Rural Health Research Center is one of seven such centers funded by the Health Resources and Services Administration’s Office of Rural Health Policy.

Read the study.
Read coverage in the Daily Yonder.

This commentary originally appeared on the RWJF Human Capital Blog. The views and opinions expressed here are those of the authors.

Thu, 7 Nov 2013 09:00:00 -0500 Culture of Health Blog Rural <![CDATA[Regulating Tobacco: Q&A with FDA's Mitch Zeller]]>

Tobacco featured prominently as a public health issue at the American Public Health Association (APHA) meeting this week, including a regulatory update from Mitch Zeller, JD, who became director of the U.S. Food and Drug Administration’s (FDA) Center for Tobacco Products earlier this year. Zeller previously worked on tobacco issues in government as associate commissioner and director of FDA’s first Office of Tobacco Programs, and also as a U.S. delegate to the World Health Organization (WHO) Working Group for the Framework Convention on Tobacco Control.

NewPublicHealth spoke with Zeller ahead of the APHA meeting.

Mitch Zeller, JD, Director of the FDA’s Center for Tobacco Products Mitch Zeller, JD, Director of the FDA’s Center for Tobacco Products

Mitch Zeller: I think most broadly my goals are to help give the center and the agency the greatest chance of fulfilling the public health mission behind the law passed in 2009 giving the Food and Drug Administration authority over tobacco. This really is an important piece of legislation. It’s really stunning that in 2013—with everything that we know about the harms associated with tobacco use—that it remains the leading cause of preventable death and disease both in this country and globally.

There are some very powerful tools that Congress has given FDA to use wisely and supported by evidence. That’s where I think, the greatest opportunity lies: to use the tools relying on regulatory science to try to protect consumers and reduce the death and disease toll from tobacco.

There are two areas where I think these tools can make a profound positive impact on public health. The first is something called product standards, which is basically the power to ban, restrict or limit the allowable levels of ingredients in tobacco or tobacco smoke. We are exploring potential product standards in three areas: toxicity, addiction and appeal. And we are funding research in all three areas and working very hard behind the scenes to find out what our options are for potential product standards in those three areas.

The other example is if at the end of the day people are smoking for the nicotine, but dying from the tar, then there’s an opportunity for FDA to come up with what I’ve been calling a comprehensive nicotine regulatory policy that is agency-wide and that is keyed to something that we call the continuum of risk: that there are different nicotine containing and nicotine delivering products that pose different levels of risk to the individual.

Right now the overwhelming majority of people seeking nicotine are getting it from the deadliest and most toxic delivery system, and that’s the conventional cigarette. But if there is a continuum of risk and there are less harmful ways to get nicotine, and FDA is in the business of regulating virtually all of those products, then I think there’s an extraordinary public health opportunity for the agency to embrace some of these principles and to figure out how to incorporate it into regulatory policies.

NPH: The General Accounting Office (GAO) recently released a report saying that FDA needs clear timeframes for review of new tobacco product applications. Is setting clear timeframes on the center’s agenda?

Zeller: Yes, we are committed to improving our process and have set a goal that within six months we will have identified performance standards for substantial equivalence reports. We have thousands of pending applications. The overwhelming majority of those pending applications are for products that are already on the market. Since June we have started to make merit-based decisions “yay” or “nay”—something is substantially equivalent, something is not substantially equivalent—and we’re going to catch up with that queue.

GAO reported that from 2011 to 2012 we went from taking on average eight months to get from a critical phase in the review process down to two months, so we’re making progress and it’s all headed in the right direction. But this is all new for industry and us, and I’m not going to commit to any kind of timeframe for action on particular applications that I can’t stand behind.

What we can commit to is for that subset of the pending applications for which the products are not currently on the market, and that’s the highest priority for the industry because they want a “thumbs up” or a “thumbs down” on the products that currently are not being sold. We will be able to generate timeframes within six months. The companies are getting better in the quality of their submissions; historically going back two or three years there were deficiencies with virtually every single application that came in, and that’s where much of the delay came from.

The quality of the submissions is getter better. They’re more complete and so we’re able to do our job faster and that’s one of the reasons why the average review time has gone down dramatically. So we’ll catch up on the queue, and with a little more experience we will have timeframes that we can commit to for the subset of products that are not currently on the market.

NPH: What is the ongoing action for electronic cigarettes at the center right now?

Zeller: Let’s start with the regulatory status and then talk about questions that we have. If you go back to 2009, the agency tried to take an enforcement action against the import of electronic cigarettes, declaring that imports should be prohibited because the agency had concluded that these were unapproved drugs and devices. When it announced that action, FDA was sued by importers and there was litigation both in the Federal District Court and the Federal Court of Appeals. And what the courts ruled in 2010 is that it’s a tobacco product if it’s made or derived from tobacco and it doesn’t make a drug, therapeutic or treatment claim.

So the courts ruled that electronic cigarettes, even though they don’t have any tobacco in them, contain nicotine that is derived from tobacco and in the absence of therapeutic claim, the only way that FDA could regulate e-cigarettes is under this new tobacco authority, because the nicotine in e-cigarettes is derived from tobacco. So since the spring of 2011, we have been on record as saying we’re going to create the regulatory framework to regulate electronic cigarettes that don’t make therapeutic or cessation claims under the tobacco authority, and we remain very close to being able to issue a proposed rule for e-cigarettes and any other product that meets the definition of a tobacco product that we don’t currently regulate.

The only categories of products that Congress gave the FDA the authority to regulate when the law was passed were cigarettes, smokeless tobacco and roll-your-own tobacco. But there was this other really important provision in the law that’s called the Deeming Provision, which gives the agency, through rulemaking, the power to deem other categories of products that meet the definition of a tobacco product to be within the agency’s regulatory jurisdiction, and we are very close to being able to publish that proposed rule. And it’s now public information that we have submitted that proposed rule to the Office of Management and Budget where it is currently undergoing review.

NPH: What barriers to your efforts do you worry about?

Zeller: It’s not really about barriers. It’s about what is the reality if you're in the business of regulation and what do you need to be thinking about as set policy. At the end of the day we’re regulators and because there are potential violations of law that we’re talking about, both civil and criminal, what we have to think about when we take agency action is that any interested party that disagrees with a final decision that we’ve made through rulemaking can sue us.

So, we’re always thinking about the evidence base in support of any regulatory policy decision that we’re making, knowing that there is a potential for litigation, and we have to be able to prevail in whatever litigation comes down the road following final agency action through rulemaking. That’s why we’re constantly exploring the evidence. We’re making an enormous investment in research because with these new products such as e-cigarettes, we have far more questions than answers about how they work, what kind of nicotine is being delivered, who is using them and how they are being used.

But we can only rely on evidence that’s formally in an administrative record that we can cite for either a proposed or final action. And so the message to the research community is do your research, get it published. But if that research is not submitted to FDA on an administrative record, it’s like the tree that falls in the forest. If you weren’t there to hear it you wouldn’t know that it had fallen, and in the world of regulatory science and regulation and litigation we need to be able to make the strongest possible case relying on regulatory science to support our actions so that we can win in court.

That’s what it comes down to. I don’t call it a barrier—it is a reality. It’s a reality of the business that we’re in and we’re constantly thinking about it so that we can have the strongest possible case going forward.

NPH: The 50th anniversary of the Surgeon General’s report is coming up. What opportunities does that present for the work of the Center for Tobacco Products?

Zeller: I think that the 50th anniversary of the Surgeon General’s report is an opportunity for everybody who works at any level to reduce the death and disease toll from tobacco to pause and look both back and look forward. If we look back over the past 50 years, we have come a very long way since then in terms of denormalizing tobacco use and reducing both consumption and prevalence. Extraordinary progress has been made and a lot of that dates back to the first Surgeon General’s report, which called attention to the health consequences of tobacco use.

But then we need to pivot and say: But if it’s still the leading cause of preventable death and disease, what’s the plan? What are we going to do about this so that on the 100th anniversary of the first Surgeon General’s report we’re able to say that we really made tobacco use a part of history? FDA’s piece of that is to figure out how to maximize the positive public health impact of the authority that we have and the resources that we have. I hope that down the road history will record that we used these tools given to us by Congress to maximize their positive impact on public health.

But beyond the regulatory provisions we have other tools and resources at our disposal. One of the most important things that we are going to be launching early next year is a public education campaign aimed at reducing the number of kids that progress from experimenting with tobacco products to becoming regular tobacco users, to becoming addicted, and then those decades of tobacco use that lead to horrible disease and on average 13 years of life lost. When you make an investment in prevention the payoff is further down the road. If we reduce the number of kids that progress to regular smoking, we don’t see that payoff for decades because we have to wait to see the healthcare costs averted.

I’m optimistic that with what we’re going to be doing with public education, with the continued denormalization and with everything else that’s being done to dramatically reduce the number of kids that are tobacco users, that we’ll be able to look back 50 years from now and say, wow, Congress gave the agency an amazing opportunity both with statutory authority and financial resources to make a difference, and they used the money and they used the tools wisely and they made a difference. It’s why I came back to government. After a 13-year hiatus, I see this opportunity and can tell you, having been back at FDA for the last eight months and seeing the dedication and the commitment of the people that are working day in and day out to maximize what we’re doing with these tools, I am very optimistic despite all the challenges that we face, that we are going to make a difference.

>>NewPublicHealth will be on the ground throughout the APHA conference speaking to public health leaders and presenters, hearing from attendees on the ground and providing updates from sessions, with a focus on how we can build a culture of health. Follow the coverage here.

This commentary originally appeared on the RWJF New Public Health blog.

Wed, 6 Nov 2013 15:05:00 -0500 Culture of Health Blog APHA <![CDATA[Violence Prevention: Q&A with David Satcher]]>


David Satcher, MD, PhD, was a four-star admiral in the U.S. Public Health Service Commissioned Corps and served as the 10th Assistant Secretary for Health and the 16th Surgeon General of the United States—at the same time. He was Surgeon General from 1998 through 2001, and under his tenure he tackled disparities in tobacco use and overall health equity, sexual health and—critically—youth violence.

Satcher was a key speaker in a recent American Public Health Association (APHA) Annual Meeting Town Hall Meeting on a global approach to preventing violence. NewPublicHealth spoke with Satcher about approaches to preventing violence as a public health issue.

NewPublicHealth: How do you take a public health approach to preventing violence?

David Satcher: When you take a public health approach, public health experts pose four questions:

  • First, what is the problem and what is the magnitude, the nature and distribution of the problem?
  • The second question is: what is the cause of the problem or the major risk factors for the problem?
  • The third question is: what can we do to reduce the risk of the problem?
  • And finally, how can we then implement that more broadly throughout society?

So, when we say we’re taking a public health approach, that’s what we’re talking about.

What we’ve tried to do and what we need more of is to really study the different causes of violence and violent episodes. They’re not all the same. I’ve dealt with a lot of the mass murders; I was Surgeon General when Columbine took place and the Surgeon General’s Report on Youth Violence in part evolved from that. And obviously there, as in most mass murders, we’re dealing with, among other things, mental health problems and easy access to weapons combined. I don’t think the same is necessarily true for gang violence, which causes thousands of deaths each year. With youth violence and gangs, I think there you’re dealing with a culture of insecurity where young people feel that in order to protect themselves they need to be members of gangs and they need to be armed.

And suicide is also a gun violence issue. As Surgeon General I released the first report from that office on a call to action on suicide. What we find is that people who are suicidal are not often homicidal. But if somebody is depressed and they have easy access to a gun, they’re more likely going to be successful in a suicidal attempt, whereas if they don’t, they’re more likely to attempt suicide and then we see them in the emergency room can hopefully diagnose their mental health problem and often can treat them.

NPH: Where are we on research on gun violence?

Satcher: I don’t think we’ve had enough research on gun violence. CDC published some early studies by Art Kellerman and others showing that people who own guns, and had them in their homes, were actually less safe than people who didn’t own guns because they were more likely to use the guns against themselves or their family members in a rage of anger or depression.

After that and until recently, there was no money at the CDC to continue that kind of research. So I would have to admit that our research in this area is inadequate.

NPH: With your experience as the top public health officials, what approaches do you think might effectively reduce mass shootings?

Satcher: What I’ve been talking about for years, and I think we’re getting closer to, is ease of access to mental health services and creating a kind of environment that is stigma–free, or at least reduced stigma so that people don’t have as much hesitation about seeking treatment for mental health concerns. Stigma doesn’t just affect a person with a mental illness—it affects the whole health care system. People sit in the emergency room for hours waiting for mental health emergency care. Society is not supportive of easy access to mental health services and often it really leads people to hesitate to seek help. But I also think the other part of it is we’ve got to reduce the easy access to weapons.

NPH: Should we be taking a different approach for different kinds of violence, like mass violence versus community or gang violence?

Satcher: I’m not sure we fully understand that difference yet, and I think this is the kind of thing we need more research on. There is a huge problem with violence in the community where thousands of children even are killed every year. I think it’s more likely among poor, insecure populations where people feel that they need to protect themselves and so we see gang violence and such. That is different from somebody who feels safe and secure but who may be suffering a mental disorder.

NPH: Do the solutions, in part, lie in further research?

Satcher: Yes, the questions we need to ask are what is the nature of the problem, what’s the magnitude of the problem and how is it distributed in society? And what are the risk factors? Then we can develop real and evidence-based solutions.

>>Read the related post, "Violence: Can We End the Epidemic?"

>>NewPublicHealth will be on the ground throughout the APHA conference speaking to public health leaders and presenters, hearing from attendees on the ground and providing updates from sessions, with a focus on how we can build a culture of health. Follow the coverage here.

This commentary originally appeared on the RWJF New Public Health blog.

Wed, 6 Nov 2013 10:21:00 -0500 Culture of Health Blog Public and Community Health Violence Prevention APHA <![CDATA[Violence: Can We End the Epidemic?]]>

“We live in a culture of violence,” said Larry Cohen, MSW, founder and executive director of the Prevention Institute, in a morning session on violence prevention at the American Public Health Association (APHA) Annual Meeting, held this year in Boston, Mass.

“Just as air, water and soil affect our health, the social environment affects the spread of violence through our communities,” said Cohen.

One of the most important factors in the environment that influences the perpetration of violence is actually more violence. Basically, violence begets violence. It spreads like a disease.

“It’s like the flu,” said Gary Slutkin, MD, PhD, Founder and Executive Director of Cure Violence. “The greatest predictor of a case of the flu is a preceding case of the flu. It’s the same thing with violence. Violence is an infectious disease.”

Slutkin shared a study of one community that found that exposure to community violence in one form or another was associated with a 30 times increased risk of committing violence—but what was most striking is that statistic held true, even controlling for poverty, race, crowded housing and other factors that could have an impact on violence. The effect is also “dose dependent,” according to Dr. Slutkin. That is, the more violence you witness or experience, the more likely you are to perpetrate violence.

The good news is that “we know how to prevent epidemics,” said Slutkin. “We need to recognize that this is a preventable problem. We need to build a movement,” agreed Cohen.

Cure Violence focuses on the very same steps used to prevent the spread of infectious disease in their work to help prevent the spread of violence:

  1. Detect and interrupt the transmission of violence, by anticipating where violence might occur.
  2. Change the behavior of those most at risk for spreading violence.
  3. Change community norms to discourage the use of violence as an acceptable and even encouraged way to handle conflict.

“The day will come when it will not be the social norm to have easy access to guns and difficult access to mental health services,” said David Satcher, MD, PhD, former U.S. Surgeon General and Assistant Secretary for Health, who also served on the panel.

So how do we change norms? Several panelists talked about the drastic change around the social acceptability of smoking over the last few decades as a major success story. One of the reasons for that success was the change in policies and taxes, but “norms don’t only change because of laws—what truly changes behavior is changing what you think your friends expect of you. That is the principle driver of behavior. That’s why I wore my tie today. That’s the same thing people are doing in neighborhoods where they’re shooting,” said Slutkin. “It’s the unconscious force.”

Community-based work with intention is what will help change what people think is expected of them, said Slutkin.

This approach to violence as akin to an infectious disease has proven immensely effective as part of the work of Cure Violence, which is being implemented at more than 55 sites in 15 U.S. cities and eight countries abroad. In Chicago, Cure Violence was associated with reductions in violence between 41 and 73 percent, and some communities had a 100 percent reduction in retaliation homicides. In South Africa, there was a 78 percent reduction in shooting and a 66 percent reduction in killings in just the first five months of the program.

In addition to interrupting the spread of violence, the very design of our communities and built structures can help stem the spread of violence as well. For example, the Washington, D.C., Metro system was designed with safety in mind—it has clear, visible corridors; booth staff have a view down onto the platforms in many stations; and all are well-lit at all hours. As a result, said Cohen, the D.C. metro system has about one-third less violence than other public transit systems in major cities.

Other environmental changes to help curb violence include regulations on liquor outlets, according to Cohen. Diadema, Brazil, cut violence by more than 50 percent in a few years by closing late-night alcohol stores, and Los Angeles shut down 200 liquor stores in 3 years with a 27 percent reduction in crime in a four-block radius.

Every sector can play a role in violence prevention, too. Several presenters mentioned that businesses have a pretty large incentive to help: protecting their bottom line.

“Community safety is our number one concern,” said an executive at a major corporation, as quoted in Cohen’s slides. “If our employees feel unsafe or our patrons feel unsafe, we’re not going to open up a store.”

“Grass can’t grow if the field is burning,” said Slutkin, to make the point that violence prevention critical to help build healthy, economically viable communities.

>>Read the related post, "Violence: Q&A with David Satcher."

>>Read more about the long-term effects of violence on children.

>>NewPublicHealth will be on the ground throughout the APHA conference speaking to public health leaders and presenters, hearing from attendees on the ground and providing updates from sessions, with a focus on how we can build a culture of health. Follow the coverage here.

This commentary originally appeared on the RWJF New Public Health blog.

Wed, 6 Nov 2013 10:16:00 -0500 Culture of Health Blog APHA