Leonard Jack, Jr., PhD, MSc

Associate Dean for Research

Endowed Chair of Health Disparities Research

Director, Center for Minority Health & Health Disparities: Research and Education

College of Pharmacy

Xavier University of Louisiana

The Louisiana Healthy Communities Project: Environmental Change Interventions to Address Chronic Disease

Control and Prevention Across the Life Stages

The CDC Strategic Alliance for Health and ACHIEVE Action Institutes

April 28, 2010Houston, Texas

Today…

Framing Health Disparities East Jefferson Healthy Communities Key Partnerships Environmental Change Interventions Evaluation End Result… So, What?

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DEFINITION OF HEALTH DISPARITY

A Health Disparity should be viewed as a chain of events signified by a difference in:

• Environment

• Access to, utilization of, and quality of care

• Health status or a particular health outcome

- Public Health Reports Sept/Oct 2002 Vol 117 Pgs 426-4343

TERMINOLOGY

“Eliminate health disparity” – HP 2010 “Eliminate racial/ethnic disparities in

health” – DHHS Initiative “Racial/Ethnic differences in health” “Health inequality” “Health inequity”

*HOW “Health Disparity” is defined has policy implications—Who Is

Reached and What Is Done* 4

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Types of Diverse Groups

-- Current health disparities research focuses on differences across race/ethnic groups

-- Much prior research examined differences by socioeconomic status (SES):– Low income vs. others

– Low education vs. others

--Both are “vulnerable” populationsAnita Stewart, 2004

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Vulnerable and or Minority populations have worse health than their counterparts in….: -- Premature mortality including infant mortality-- Morbidity

– Chronic disease (heart disease, diabetes, cancer)– Communicable disease (TB)– Low birth weight– Physiological risk factors – Hypertension– Obesity/overweight

-- Functional limitations, disability-- Self-rated health-- Mental Health Outcomes-- Life Stage (children, young adults, adults, older adults)

Anita Stewart, 2007

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Phases of Disparities Research

DetectingDefine health disparitiesDefine vulnerablepopulations

UnderstandingIdentify determinants of disparities

ReducingInterveneEvaluateTranslate/disseminateChange policy

Adapted from Kilbourne et al, 2006

Anita Stewart, 2007

Three Broad Types of Conceptual Frameworks

-- Population science– Determinants of health in a population– Samples are populations or population subgroups

-- Health services research– How health care affects outcomes– Samples are patients or health plan members

-- Biology/physiology– Biological and genetic pathways to disease– In Vitro Systems (e.g., cellular and tissue level)

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Population-Based Determinants: Multiple Levels of Influence on Health

-- Individual

– biological, behaviors, attitudes, age, education, occupation

-- Family– size, structure, support, beliefs

-- Neighborhood, schools or community– resources, disinvestment, toxins, crime/poverty,

neighborhood desirability

Anita Stewart, 2007

Emmons, K Health behavior in a social context, in Social Epidemiology, 2000, ch. 11.

Depiction of Multi-level Determinants of Health Disparities

Psychosocial - compliance, coping

Lifestyle - exercise, diet, alcohol, smoking, sexual behavior, illicit drug use

Health care

Sociodemographics - age, race, ethnicity, education, income

Physical environment

Social environment

Healthdisparities

Psychological - beliefs, attitudes,personality

Contextual Individual-level

Organizational,institutional

Economic resources

Societal, political

Physical environment

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Physical Environment

-- Neighborhood safety attractiveness

-- Housing quality

-- Transportation

-- Segregation

-- Hazardous materials

-- Occupational hazards

-- # of liquor stores

-- # of full service grocery stores

-- Availability of fresh fruits and vegetables

-- # of areas for walking, bicycling

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Ecological, Multi-level Determinants

Psychosocial - compliance, coping

Lifestyle - exercise, diet, alcohol, smoking, sexual behavior

Health care

Sociodemographics - age, race, ethnicity, education

Physical environment

Social environment

Biological, physiological

Context Individual-level

Organizational,institutional

Economic resources

Societal, political

Psychological -beliefs, attitudes, personality

Healthdisparities

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Social Environment

Social opportunities Family environment Social support Discrimination or racism Neighborhood cohesiveness Community meeting places

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Framework: Socioeconomic Status Over the Lifecourse and Health

Lynch J and Kaplan G, Social Epidemiology, Oxford, 2000 (Ch 2, p. 28)

Socioeconomic Position

Birth Childhood Adulthood Old Age

Low birth weightGrowth retardation

Smoking,diet, exercise

Job stressInadequate

medical care

Intrauterineconditions

Education,environment

Work conditions,income

Income,assets

Atherosclerosis CVD Reducedfunction

East Jefferson Parish East Jefferson Parish Healthy Communities Healthy Communities

ProjectProject

Multi-Stage & Multi-Component

Intervention

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Mobilize Community Form a coalition that will work with the XU Health and

Wellness Center

Determine health related needs of the community by conducting needs assessment

Develop school-based and community-setting approaches to reduce childhood obesity on the results of needs

assessment

Identify methods for program sustainability

Develop evaluation plan to focus on measuring process and outcome variables

Objectives

Perform Assessment

Develop Sustainability

Evaluation Plan

Action Plan

Develop Budget

Develop budget plan for upcoming year

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Rank State EstimatedDiabetes

Prevalence (%)

1 Puerto Rico 12.5

2 Tennessee 11.9

3 Mississippi 11.1

4 West Virginia 10.8

5 Alabama 10.3

6 Texas 10.3

7 Louisiana 10.2

7 Oklahoma 10.2

8 Georgia 10.1

9 Kentucky 9.9

10 South Carolina 9.6

17Source: Louisiana 2007 Behavioral Risk Factor Surveillance System,

DHH Bureau of Primary Care and Rural Health

2007 BRFSS Diabetes Data

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DIABETES PREVALENCE, 2008DIABETES PREVALENCE, 2008

Source: CDC Behavioral Risk Factor Surveillance System, 200819

Obesity (BMI≥30) Trends Among U.S. Adults

19901999

2008

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Source: CDC Behavioral Risk Factor Surveillance System

Jefferson Parish

26%26% African Americans

14%14% Below poverty level

Total Population: 436,181Total Population: 436,181

Source: www.census.gov, 2008Source: www.census.gov, 2008

9%9% Hispanics

14%14% Over age of 65

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Diabetes in Black America: Burden, Causes, and Solutions (June, 2010)

Relationship Between Obesity and Diabetes in the African American Community

Cassandra Arroyo, PhD, MS, Krista Mincey, MPH

Adiponection: A Potential Link Between Obesity and Diabetes

1. Research acknowledges that adipose tissue secretes a number of active protein (Pittas et al., 2004).

2. Adiponectin (adipose specific protein) shown to be highly abundant in health subjects, lower in obese subjects and people with type 2 diabetes (Yang et al., 2001).

3. Adiponectin is positively associated with glucose tolerance, insulin secretion, and insulin sensitivity (Cote et al., 2005)

4. African American men and women were found to have lower levels of adiponectin than their white counterparts (Hulver et al., 2004)

Adiponection: A Potential Link Between Obesity and Diabetes

“African-American youth (5-16 yrs) have significantly lower levels of adiponectic compared to whites, despite similar age,

BMI, and total adiposity.”

Source: Hulver, et al., 2004

EVALUATION

East Jefferson Parish Healthy Communities Project: Overall Goal

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Xavier UniversityDISEASE

MANAGEMENTBissonet Plaza

Elementary SchoolPOLICY, SYSTEMS,ENVIRONMENTAL

CHANGE STRATEGIES

East Jefferson Family YMCACOMMUNITY ENGAGEMENT

Reduce Occurrence of Chronic DiseasesReduce Occurrence of Chronic Diseases

LA DHH Chronic Disease Prevention & Control Unit

East Jefferson Healthy Communities Project: Key Stakeholder

LA DHH Chronic Disease Prevention & Control Unit

XU Center for Minority Health & Health Disparities: Research and Education

XU Health & Wellness Center East Jefferson Family YMCA Bissonet Plaza Elementary School

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Mission:

To improve the health of Louisianans by preventing chronic diseases and their risk factors through promoting healthy behaviors, utilizing evidence-based interventions and leveraging resources through collaborative private & public partnerships to maximize health outcomes among our citizens.

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Chronic Disease Prevention and Control Unit Programs:

Behavioral Risk Factor Surveillance System

Heart Disease and Stroke Prevention Program

Diabetes Prevention and Control Program

Asthma Management and Prevention Program

Tobacco Control Program

Healthy Communities Program

GOALS OF INTEGRATIONImprove program reach and impact by enhancing synergies among approaches to different diseases, risk factors, populations, and settings

Promote opportunities for greater flexibility, creativity and responsiveness by our partners

Increase collaborative efforts across Chronic Disease Unit programs

Maximize and leverage limited federal resources30

Utilizing Integration to Impact Healthy Communities

Louisiana’s Integrate Framework to Achieving Healthy

Communities

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CDC National Healthy Communities Program Overview

CDC funded program designed to create healthier communities

Focus on chronic disease reduction– Implement policy, systems, and environmental change

strategies to address the following risk factors associated with chronic diseases: physical activity, nutrition, and tobacco use

Mobilizing community resources

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Xavier University College of Pharmacy’s Center of Minority Health &

Health Disparities Research and Education

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About the Center The Center for Minority Health and Health Disparities

Research and Education (CMHDRE) began on January 14, 2002 with the endowment award from the National Center for Minority Health and Health Disparities (NCMHD) of the National Institutes of Health (NIH).

This award was used to establish the Xavier Pharmacy Endowment for Minority Health.

Subsequent proposals were submitted to NCMHD in order to increase the corpus of the fund resulting in the current total of approximately $29.2 Million.

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About the Center

The Xavier Pharmacy Endowment for Minority Health is used to support the activities of the CMHDRE in the College of Pharmacy.

The mission of the Center is to provide the infrastructure that is required to conduct research and provide clinical experiential training and community outreach aimed at eliminating health disparities.

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Four Objectives Four overarching objectives have been established for the

CMHDRE. The concrete steps to achieve these objectives are outlined in the CMHDRE Action Plan.– To provide an environment to support and strengthen the

research interest and activities of current and new faculty members related to health disparities with a specific focus on diabetes and cancer.

– To develop student-oriented programs to support student research and promote post-graduate education.

– To integrate health promotion, education, and disease prevention into primary care services.

– Conduct multi-disciplinary research to reduce health disparities.36

Cores The overall project is divided in to four

main cores:– Administrative Core

– Community Outreach Core

– Research Core

– Training/Mentoring Core

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Disease Management XU-COP Health & Wellness Center

Free/Low Cost Services – Provide screenings – Education– Nutritional counseling

Staffed by clinical pharmacists and P4 pharmacy students

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Community Engagement

Creating partnerships: Xavier University’s Center for Minority

Health & Wellness Center East Jefferson Family YMCA Bissonet Plaza Elementary School Overweight & Obese Children & their

Families

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Bissonet Plaza Elementary School(Pre-K – 5th Grade)

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School Demographic Data

67% of the students are of a minority race/ethnicity

Source: Greater New Orleans Community Data Center. www.gncdc.org 41

School Demographic Data (cont)

Source: Greater New Orleans Community Data Center. www.gncdc.org 42

Policy, Systems, and Environmental Change

Strategies

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Possible Environmental Change Strategies: Borrowing from States Utilizing Innovative Approaches

AK + TX – worksite wellness at schools CA – state standards for beverage snacks and side dishes – school gardens ME – vending machine policy initiative MI – milk vending, requirements for recess + PE/policy for healthy options outside school lunch MT – healthy vending options/recess before lunch NC – Sybershop/vending machine restrictions/focus groups with families MA – provides grants for Healthy Choice Program RI – works with school based health centers awards mini grants to lead policy + environmental change WA – awards for school districts who have made policy changes

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“Healthy America Initiative: wellness where we live, work, and play”

Encourage + assist state governors in developing + implementing wellness initiatives

Bring together public + private sectors Raise awareness of need for healthier lifestyles Bring together experts for solutions Seek out best practices + innovative programs Hold workshops and provide tools Improve state programs Urge governors to implement state employee health

initiatives

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CHILDREN’S EATING AND

ACTIVITY

Physicalenvironment

Rules and restrictions

Parental modeling

Parentalsupport and

encouragement

Foodavailability(exposure)

Parental modeling

Food involve-ment

Media exposure

Parentalfeeding

style

FAMILY ENVIRONMENT

CHILDREN’S EATING AND

ACTIVITY

Physicalenvironment

Rules and restrictions

Parental modeling

Parentalsupport and

encouragement

Foodavailability(exposure)

Parental modeling

Food involve-ment

Media exposure

Parentalfeeding

style

FAMILY ENVIRONMENT

Kathleen Colleran, 2010

Family influences on children’s eating

A range of factors have been shown in small scale studies in the USA to influence children’s eating:

– Parent-child feeding relationship

– Food availability and accessibility

– Media exposure

– Opportunities for modeling

Few population studies conducted Kathleen Colleran, 2010

Family influences on children’s activity

Evidence from limited number of studies in the USA

– Physical environment, e.g. play space, fencing, recreational equipment

– Family rules (activity and sedentary)

– Parental modelling

– Parental support and encouragement

Kathleen Colleran, 2010

The Family Characteristics andFamily Risk

Felicia Hill-Briggs, PhD, ABPP, Laura G. Daughterly, PhD, LICSW

Conceptual model of family roles and sociocultural influences in diabetes care.

Briggs-Hill, 2010

Family (Support) System Factors

Composition, member roles and responsibilities

“Culture” around health and illness

Resources

Communication and psychosocial functioning

Competing system needs and priorities

Individual Factors

Stage of cognitive, social, and physical development (childhood, adolescence, adulthood, older adulthood)

Independence in performing self-care

Preferences for assistance or support

Interrelatedness with family (support) system

Family Instrumental

Support Role

Diabetes caretaking or assisting with self-management behaviors

Appointment scheduling, transport

Managing sickness, medical crisis

Informational support (gathering and transfer)

Family Social and Emotional Support Role

Coping and emotional support

Creating a health-promoting and reinforcing home environment

Joining in health-promoting behaviors

Family Modeling Role

Health/disease awareness

Health-related attitudes, beliefs

Health behaviors, practices

Health risks and consequences

East Jefferson Family YMCAMetairie, Louisiana(Jefferson Parish)

Financial Assistance Health & Nutrition Active Older Adults Aquatics Exercise Classes Family-Centered After School Programs

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Melinda S. Sothern, PhDDirector, Section of Health Promotion

School of Public HealthLouisiana State University (LSU) Health Sciences Center

Childhood Obesity LaboratoryLSU Pennington Biomedical Research Center

Clinical Management of Pediatric Obesity:

Inter-disciplinary, Interactive Educational Interventions

Trim Kids

Incorporates short-term goal setting, regular feedback, and

motivational techniques to improve the diet and exercise behaviors of the family.

Recognized by the National Cancer Institute as a Research Tested Intervention Program

Acknowledged by the U. S. Surgeon General for its community dissemination in YMCA centers in Louisiana beginning in July, 2007:

Baton Rouge, East Jefferson, West Bank, North Shore, Luling, Uptown, Downtown, Shreveport

LSUHSC School of Public Health provided professional training

Sothern, M. (2010)

–

The best dietary approach is one that the child will most likely follow with a high level of compliance.

Trim Kids includes a combination of nutrients and daily calorie levels that best promote the optimal schedule of weight loss or maintenance based on the child’s : Medical & family history Current weight condition or obesity level Age

Sothern, M. (2010)

Trim Kids Nutrition Education

Educational and interactive sessions: Four 10-week sessions in all.

Each session is approximately 20 minutes.

Alternate educational activities to maintain participation: Cooking, games, classes, labs, etc.

Begin with simple topics and advance to applied activities.

Sothern, M. (2010)

Sample Topics

Snack Food Jeopardy: Children identify the healthy snacks by guessing the

calories and sugar grams Fast Food Follies

Dietician calculates fat and sugar grams of typical fast food meal; squeezes french fries

Stir Fry Cooking Students join in to cook and sample

Sugar Lab: Guess the Grams How many teaspoons in one soft drink?

Create Your Own Parfait Children create parfaits with low fat yogurt, sugar-

free topping, fruit and nuts

Sothern, M. (2010)

Methods to Increase Vegetable Intake

Three bite rule: Grade the vegetables:

A = excellent, let’s have this more often C = OK, we’ll try again F = No way

Involve children in grocery shopping and meal preparation. Skip the snack isle and let them choose their favorite fruit and veggie.

Sothern, Schumacher, von Almen, 2001

Nutrition for Overweight Children

Teach young children that it’s OK to leave food on the plate (Birch, 1980 and 1995; Spruijt-Metz, 2002; Rolls, 2004)

(It really won’t hurt the poor children in Africa) Don’t place a moral value on food. Teach children that all food is OK; some is “grow tall or

big” food and some is not. Never give food as a reward.

Sothern, Schumacher, von Almen, 2001

Bring your report card into your local Krispy Kreme and for every “A” we’ll give you a FREE doughnut!

What Does the Research Say? Behavioral counseling interventions

(Grade I & II): 25 RCTs; 14 other design

7 RCT’s compared behavioral counseling to standard care All showed significant reductions in adiposity

compared to standard care Many were based on well-established theories Most included basic behavioral techniques Only 2 studies examined the independent contribution

of different techniques

J Am Diet Assoc. 2006;106:925-945

The Trim Kids A-Factor Accountability – Staff checks records

weekly Availability – Individual sessions before

and after class Attention – Positive only Approach – Staff speaks to the level of

the participant with a sense of humor

Sothern, M. (2010)

Evaluation: Triangulation Model

Health Policy Analysis

Intervention Specific

Existing Data

Source

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Evaluation FrameworkEvaluation Framework

Evaluation TypesEvaluation TypesImpactImpact

Process

Process

Outcome

Outcome

Program - instructors?

- content? - methods?

- time allotments? - materials?

Program - instructors?

- content? - methods?

- time allotments? - materials?

Behavioral - knowledge gain? - attitude change?

- habit change? - skill development?

Behavioral - knowledge gain? - attitude change?

- habit change? - skill development?

Health - mortality? - morbidity? - disability?

- quality of life?

Health - mortality? - morbidity? - disability?

- quality of life?(Adapted from Green et al., 1980)(Adapted from Green et al., 1980)

En

vironm

ental P

olicyE

nviron

men

tal Policy

Integration Existing Evidence into

Practice Fine Tune Our Abilities to Work

Collaboratively Multi-Stage & Multi-Component

Intervention Engaging Families Disseminating Findings

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The Louisiana Contribution…

“Making Public Health Infectious…”

“Making It Difficulty to Resist Partnering…”

“Placing Emphasis on Results…”

“Improving the health status of communities…”

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The Louisiana Contribution…

Questions and Answers

Leonard Jack, Jr., PhD, MSc

Xavier University of Louisiana

Email: Ljack@xula.edu