Delaware Journal of Public Health - LGBTQ+ Health by Delaware Academy of Medicine and the Delaware Public Health Association

Delaware Journal of

Volume 5 | Issue 3

June 2019

Public Health A publication of the Delaware Academy of Medicine / Delaware Public Health Association

LGBTQ+ Health Equity

Health in the Entire Human Family www.delamed.org | www.delawarepha.org

Delaware Academy of Medicine

Board of Directors:

OFFICERS Omar A. Khan, M.D., M.H.S. President S. John Swanson, M.D. Vice President Sandra P. Medinilla, M.D., M.P.H. Secretary

Delaware Journal of

Public Health

A publication of the Delaware Academy of Medicine / Delaware Public Health Association

David M. Bercaw, M.D. Treasurer

www.delamed.org | www.delawarepha.org

Daniel J. Meara, M.D., D.M.D. Immediate Past President Timothy E. Gibbs, M.P.H. Executive Director, Ex-officio DIRECTORS Stephen C. Eppes, M.D. Eric T. Johnson, M.D. Joseph F. Kestner, Jr., M.D. Professor Rita Landgraf Brian W. Little, M.D., Ph.D. Arun V. Malhotra, M.D. Joseph A. Napoli, M.D., D.D.S. John P. Piper, M.D. Albert A. Rizzo, M.D. EMERITUS Robert B. Flinn, M.D. Barry S. Kayne, D.D.S. Leslie W. Whitney, M.D.

Delaware Public Health Association

Advisory Council:

Omar Khan, M.D., M.H.S. President Timothy E. Gibbs, M.P.H. Executive Director Louis E. Bartoshesky, M.D., M.P.H. Gerard Gallucci, M.D., M.H.S. Richard E. Killingsworth, M.P.H. Erin K. Knight, Ph.D., M.P.H. Melissa K. Melby, Ph.D. Mia A. Papas, Ph.D. Karyl T. Rattay, M.D., M.S. Margot L. Savoy, M.D., M.P.H.

June 2019

Volume 5 | Issue 3

3 | In this Issue

28 | A Mother’s Story

Omar A. Khan, M.D., M.H.S., Timothy E. Gibbs, M.P.H.

Sally McBride

32 | G lobal Health Matters

4 | Guest Editors

Fogarty International Center

Timothy Rodden, M.Div., M.A., B.C.C., F.A.C.H.E. Anna Filip, M.D.

46 | Building Resilience, Reducing Risk: Four Pillars to Creating Safer, More Supportive Schools for LGBTQ+ Youth

6 | The Value of Identity: Providing Culturally-Responsive Care for LGBTQ+ Patients Through Inclusive Language and Practices

Rev. Karla Fleshman, L.C.S.W., M.Div.

10 | Delaware Hospitals and the Healthcare Equality Index since 2011: How do they rate?

Karla Bell, P.T., D.P.T.

Christopher Moore, B.A., LSSGB Catherine Dukes, Ph.D., M.S.W.

Timothy Rodden, M.Div., M.A., B.C.C., F.A.C.H.E. Tari Hanneman, M.P.A.

56 | Part of the Solution to Address Sexual and Gender Minority Health and Health Care Disparities: Inclusive Professional Education 64 | Why Count and Measure? Justin Glasgow M.D.

12 | Caring for Our Community: Telehealth Interventions as a Promising Practice for Addressing Population Health Disparities of LGBTQ+ Communities in Health Care Settings Alex Waad, M.A.

18 | Keep Trans Youth Alive: Considerations for Suicide Prevention of Gender Expansive Youth

68 | The Religious Landscape for LGBTQ+ Persons

The Rev. Dr. Douglas D. Gerdts, D.Min.

74 | LGBTQ+ Lexicon of Terms 76 | LGBTQ+R esources 80 | Index of Advertisers

Elise Mora, L.C.S.W., I.C.G.C.-I

24 | Improved Data Collection for Our LGBTQ Population is Needed to Improve Health Care and Reduce Health Disparities Karyl T. Rattay, M.D., M.S.

William J. Swiatek, M.A., A.I.C.P.

Delaware Journal of Public Health Timothy E. Gibbs, M.P.H. Publisher Omar Khan, M.D., M.H.S. Editor-in-Chief Timothy Rodden, M.Div., M.A., B.C.C., F.A.C.H.E. Anna Flipp, M.D. Guest Editors Liz Healy, M.P.H. Managing Editor Kate Smith, M.D., M.P.H. Copy Editor Suzanne Fields Image Director ISSN 2639-6378

COVER Health and wellness should be universal, but are not. Like the “Progress Pride Flag” shown on this issue’s cover, additional differentiation in the LGBTQ community recognizing the uniqueness of its constituent parts allows us to focus on the health opportunities and challenges of those groups. Designed by Daniel Quasar, the traditional 6 stripe flag is augmented by the trans flag stripes and marginalized community stripes shifted to the hoist of the flag and given a new arrow shape. The arrow points to the right to show forward movement, while being along the left edge shows that progress still needs to be made.

The Delaware Journal of Public Health (DJPH), first published in 2015, is the official journal of the Delaware Academy of Medicine / Delaware Public Health Association (Academy/DPHA).

only the opinions of the authors and do not necessarily reflect the official policy of the Delaware Public Health Association or the institution with which the author(s) is (are) affiliated, unless so specified.

Submissions: Contributions of original unpublished research, social science analysis, scholarly essays, critical commentaries, departments, and letters to the editor are welcome. Questions? Write ehealy@delamed.org or call Liz Healy at 302-733-3989.

Any report, article, or paper prepared by employees of the U.S. government as part of their official duties is, under Copyright Act, a “work of United States Government” for which copyright protection under Title 17 of the U.S. Code is not available. However, the journal format is copyrighted and pages June not be photocopied, except in limited quantities, or posted online, without permission of the Academy/ DPHA. Copying done for other than personal or internal reference use-such as copying for general distribution, for advertising or promotional purposes, for creating new collective works, or for resale- without the expressed permission of the Academy/DPHA is prohibited. Requests for special permission should be sent to ehealy@delamed.org.

Advertising: Please write to ehealy@delamed.org or call 302-733-3989 for other advertising opportunities. Ask about special exhibit packages and sponsorships. Acceptance of advertising by the Journal does not imply endorsement of products. Copyright © 2019 by the Delaware Academy of Medicine / Delaware Public Health Association. Opinions expressed by authors of articles summarized, quoted, or published in full in this journal represent

I N T H I S I S SU E

ifty years ago, the Stonewall Riots marked a watershed for many people in America, and around the world. In the early morning of June 28, 1969, New York City police raided a gay bar on Christopher Street called the Stonewall Inn. Police raids on gay bars were routine in those days, but this time, patrons fought back. Violent clashes spread out across Greenwich Village over the following days. By the time order was restored, one thing was clear: the LGBT community would no longer tolerate harassment and intimidation. As lesbian, gay, bisexual, transgender and many more individuals found their own voice, so the medical and public health community adapted, sometimes rapidly, other times slowly, to a segment of society heretofore unheard. Health equity in the scientific realm starts with visibility, leading to evidence, and action. We join the LGBTQ+ community in solidarity through the visibility this publication brings with guest editors Anna B. Fillip, M.D. and Timothy D. Rodden, M.Div., M.A., B.C.C., F.A.C.H.E. leading the way towards improved evidence. We look to you, our community, to help us translate this into action. From telehealth interventions to improved data collection; suicide prevention in trans youth to the religious landscape for LGBTQ+ individuals; an interview with Sally McBride (mother of Human Rights Campaign spokesperson Sarah McBride) and much more, we hope you enjoy this issue of the Journal. As always, we welcome your input and suggestions for future focus areas. Tim

Timothy E. Gibbs, M.P.H. Executive Director

Omar A. Khan, M.D., M.H.S. President

Timothy Rodden, M.Div., M.A., F.A.C.H.E., Director, Pastoral Services and System Coordinator, LGBTQ Health Initiatives, Christiana Care Health System Anna Filip, M.D., Family Physician, Christiana Care Health System

Throughout history, marginalized communities that are not part of the dominant culture have faced difficulties and challenges. There have been religious, legal, and political forces at work to keep such communities of people on the margins of society through systemic discrimination. The communities of people represented in this issue of the Delaware Journal of Public Health are no different in this regard. Lesbian, gay, bisexual, transgender/gender non-conforming, queer and others are not well represented in our heteronormative and cisgender normative culture and face daily challenges and barriers to achieving optimal health. These barriers and challenges cause significant health risks for the LGBTQ+ population as seen in national health data (higher suicide rates and lower cancer and preventive health screening rates). Despite this systemic discrimination, the remarkable resiliency of the LGBTQ+ community enables them to thrive in the face of an oftentimes unfriendly welcome in society, and in the institutions that form the foundation of our lives as a larger community. There are many organizations and individuals working to reverse this discrimination and these poor health statistics, and this issue of the DJPH demonstrates the exceptional work many are doing across the state to reverse these trends and support our LGBTQ+ community. Despite the many challenges in providing safe spaces and high quality healthcare for our LGBTQ+ community, the state of Delaware has made great progress in protecting LGBTQ rights, including passing the Gender Identity Non-Discrimination Act of 2013. Healthcare institutions are no different in this regard, and face the reality that transformation and cultural shifts need to occur so that LGBTQ+ identified people and populations are truly welcomed. Without these changes, health disparities will continue to occur, and optimal health will continue to challenge LGBTQ+ identified populations. As we look to the future, it is clear we have work to do to continue to support our LGBTQ+ family, friends, neighbors and patients in their health and well-being. In this journal, we hope to highlight the efforts of those working to bring about this much needed change, to outline some of the successes and challenges this vulnerable population faces in their communities and healthcare environments, and to highlight the importance of providing a safe space for patients, regardless of sexuality or gender identity. We also seek to describe resources currently in place to improve on overall well-being, to describe resources needing improvement or development, and to place this into the larger framework of innovation and transformation happening in society and in healthcare to address the unique needs of LGBTQ+ populations. Strides have been made, but advancements need to continue to occur. As we look to the future to ensure the equitable health and wellbeing for all LGBTQ+ Delawareans, collaboration is essential.

Timothy Rodden, M.Div., M.A., F.A.C.H.E., Director, Pastoral Services and System Coordinator, LGBTQ Health Initiatives, Christiana Care Health System

4 Delaware Journal of Public Health â&#x20AC;&#x201C; June 2019

Anna Filip, M.D., Family Physician, Christiana Care Health System

Registration and housing for #APHA2019 are open! Register now and join us Nov. 2-6, in Philadelphia to learn and network. www.apha.org/meeting-registration

APHA’s 2019 Annual Meeting and Expo takes place Nov. 2-6, in Philadelphia and will bring together nearly 13,000 public health professionals from around the world. APHA 2019 will be filled with engaging sessions, including those that align with the meeting’s theme, “Creating the Healthiest Nation: For science. For action. For health.” Attendees will learn the latest in research and practice, hear from inspirational keynote speakers, network with their peers, and build skills to advance in their careers. Register now and join us for this celebration of public health Learn more about APHA 2019 at www.apha.org/annualmeeting.

The Value of Identity: Providing CulturallyResponsive Care for LGBTQ+ Patients Through Inclusive Language and Practices Christopher Moore, B.A., LSSGB - Christiana Care Health System Catherine Dukes, Ph.D., M.S.W. - Upstream

INTRODUCTION The lesbian, gay, bisexual, transgender and queer/questioning (LGBTQ) people living in the United States are as diverse as the country itself. These individuals and their families represent every race, ethnicity, faith-based group, physical ability/disability, age and socioeconomic level.1 In 2018, Gallop reported that 4.5% of American adults identify as lesbian, gay, bisexual or transgender.2 Like many at-risk populations, LGBTQ people experience disparities in both the occurrence of certain physical/mental health issues, but also in the manner in which they receive care. The 2011 report, Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care for the Lesbian, Gay, Bisexual, and Transgender Community published by The Joint Commission, illustrates these disparities for LGBTQ individuals with experiences including: lower overall health status; higher rates of smoking, alcohol, and substance abuse; higher risk for mental health illnesses, such as anxiety and depression; and higher rates of sexually transmitted diseases, including HIV infection. To complicate this, LGBTQ people face challenges in receiving culturally appropriate healthcare. This may be due to providers and staff not receiving adequate education and training to override any bias or stigma and meet each person’s unique needs.1 The common gaps in training include best practice approaches, identifying needs, providing care for minority and vulnerable populations, and building professional competency around language. This all comes at a critical juncture, where identifying and addressing the healthcare needs of LGBTQ individuals has received increased attention from the Institute for Medicine, Healthy People 2020 and the Agency for Healthcare Research.3 As the landscape of healthcare evolves, so do definitions of gender and orientation; both of which grown well beyond just male/ female and straight/gay. It was only a matter of time before this expansion of language would intersect healthcare.

EVOLUTION OF LANGUAGE AND LGBTQ TERMS Near the third decade of the twenty-first century, a number of advancements have had an impact on healthcare, from technology to pharmaceuticals. Social advancements, too, have had impacts, especially as it relates to LGBTQ persons. Since the 1990s, those 5 letters have evolved in tandem with the progress this community has experienced regarding legal rights and societal acceptance. These letters are meant as an expression of inclusion.4 There isn’t standard agreement, though, for a definitive list. For example, the “Q” was added around the millennium: some choose to define it as “questioning,” representing people who were undecided, or unsure of their orientation. However, others have declared it was for “queer,” an umbrella term, repurposed from a pejorative, to represent a segment of this community.4 This lack of consensus poses a challenge, as anyone looking for greater understanding may not be able to determine a clear answer on what is currently acceptable. It is important to note, though, that the variance in terms and identities should not be viewed as “right” or “wrong.” 6 Delaware Journal of Public Health – June 2019

Rather, it is important, as www.Medium.com writer Jeffry J. Iovannone notes, “to encourage critical thinking around language as a vehicle of social change, and to recognize that people do not have to agree on all things to work communally.” Language, especially in this context, should not be used to exclude others. One should think critically about the words used to see if they are serving the intended purpose, or creating additional problems.5

IMPLICATIONS ON HEALTHCARE DELIVERY Addressing the health needs of any underrepresented population can present challenges for healthcare providers and systems of care — from messaging and access to staff/provider education and cultural competency. These topics are especially relevant as they have the potential for being barriers to care. Patients who identify as LGBTQ face “delayed or substandard care, mistreatment, inequitable policies and practices, little or no inclusion in health outreach or education, and inappropriate restrictions or limits on visitation.” 6 These inequalities are likely to be more prevalent for LGBTQ persons from racial/ethnic minorities or in relation to “education level, income, geographic location, language, immigration status, and cultural beliefs.”7 LGBTQ persons who experience discrimination and mistreatment are more likely to not trust health care systems and be less likely to seek treatment for medical issues.8 The key in building equity in healthcare starts with education around language, making all of this work education. The most cited barrier [to introducing LGBT education for staff] was perceived lack of need.9 One of the rewards of cultural competence in health care is physician [or staff] self-reported increases in confidence and comfort in delivering care for LGBTQ patients.10 By embracing the truth that there is always room to grow and improve, we have the opportunity to build a greater capacity to educate — both staff and clinicians, as well as our patients. The yield from increased education could be immeasurable.

BEST PRACTICE CARE Key aspects of best practice care must reach well beyond healthcare provider skills. Due to lack of readiness for the nation’s LGBTQ+ citizens, medical providers serving this population must work to remove existing barriers to healthcare; these include not just fear of discrimination resulting in delayed healthcare but actual discrimination, including but not limited to provider bias, lack of inclusiveness of body or gender representation, misdiagnosis, and reliance on prevailing stereotypes or myths about LGBTQ+ patients.11

WELCOMING-ENVIRONMENT LANGUAGE What do our patients see and read upon walking in? How do they experience their healthcare provider on the phone? Through their website text? What is their experience during the first office interaction with scheduling and asking questions? Are there inclusive bathrooms with signage posted? Checking the language related to these areas with an LGBTQ+ lens is a critical piece to assess when striving to make LGBTQ+ patients feel welcome and safe.

Who are the best consultants to give that guidance? LGBTQ+ community members themselves. Thoughtful inclusion of community members to guide the welcoming language process is critical, and paying them for their time and expertise is a baseline of respect. Showing that their work is valued will truly allow more patients to come through the door. Key areas to review in this venture are websites; internally and externally (community / vendor) displayed information, magazines and brochures; pictures; bathrooms and bathroom signage; and non-discrimination policies with language inclusive of LGBTQ+ displayed prominently. Other aspects of creating a welcoming environment regarding wording certainly involve provider knowledge and skills but those aspects will be covered in the next section. Providers who truly want to make their offices and practices “welcoming” need to consult with and pay for the expertise of those they want to serve.11,12

LANGUAGE GUIDELINES FOR FORMS & PATIENT-PROVIDER INTERACTIONS (GLMA) When LGTBQ+ individuals come in to a practice for the first time, an intake form can often give them a good picture of how inclusive and safe the medical practice is. Forms need to allow for the flexibility of human gender identity and expression, and allow for a great diversity of relationships and experiences. Some examples include using “gender____ (write in)” instead of “male ____ female___” and “parent 1_______ parent 2 _____”, etc. instead of “mother / father.” 11

Sample language guidelines for forms include: • “You” or “They” instead of “him/her,” • “Transgender” gender boxes on a form as well as “male/ female,” or using a fill-in-the-blank, • “Relationship status” instead of “marital status.” Add options like “partnered” and change “husband / wife” to “spouse,” • For sexual and/or romantic relations use terms like “partner” or “significant other” instead of boyfriend, girlfriend, husband, wife. For patient-provider interactions, create a safe and inclusive space to discuss sexual history and health by assuring all patients of confidentiality, and also explaining the rationale for the questions being asked.

More tips about patient-provider interactions include: • Use correct affirming pronouns and names13 • Check the form and/or please ask. Those who have usually been marginalized or excluded will notice the effort. • Mistakes: Were the wrong pronouns used? Apologize with a quick sincere apology meant to address the mistake. Invest in a culture where making mistakes and learning from them is welcome. • Do not use language which assumes or stereotypes which sexual behaviors go with which bodies and identities. Not all gay men have anal sex. Not all lesbians use phallic sex toys. • When discussing condoms, barriers, and/or birth control, avoid language which assumes heterosexuality or which may be irrelevant. Asking about partners and bodies will lead to better, more accurate information. Using open-ended questions may avoid accidents

• What if name and gender do not match in the records? For some LGBTQ+ patients who have changed their names and/or may be transgender, some issues with insurance and payment of services can get complicated. Some essential procedures may even be denied (i.e. prostate exams for a patient listed as female). Show empathy by doing everything possible to resolve this issue. In cases where a patient’s name does not match between documents, inquire with open questions like “could the insurance perhaps be listed under a different name?” Avoid asking a person what their “real name” is: “This could imply that you do not acknowledge their [affirming] name as “real.” 13 • Avoid asking unnecessary questions13 • Use the patient’s language and terminology when discussing behaviors and partners during sexual-history taking. Clarify and definitions or meanings to avoid assumptions. • Do not label a patient based on their stated behaviors. Just because a patient has noted they have sex with men and women does not mean that they identify as bisexual, gay or even straight. Behavior is not the same thing as identity.

LANGUAGE SKILLS - TRAINING Training is fundamental. But a “one and done” approach will not suffice. Training for language to better serve LGBTQ+ individuals requires time and engagement. Initial training, ongoing training, booster trainings and meaningful assessment of training skills and concepts are critical pieces of the training process if a provider or practice wants to make good on its promise to be a welcoming place for LGBTQ+ patients. Further, training every level of the organization in the concepts, knowledge, empathy, and sensitivity towards this group of people is essential to an organization that promotes itself as an LGBTQ+ welcome practice.13 Front line staff must have training in using the proper language, pronouns and terms, showing empathy, and avoiding stereotypes.11 All clinical staff, including front line and phone support staff, should use scripts and questions in a way that does not assume gender identity or orientation (e.g. even if a voice sounds feminine or masculine on the phone, female or male pronouns should not be used, and stereotypes should not be assumed). As previously noted, the LGBTQ+ community has experienced significant barriers to accessing welcoming comprehensive medical care. The training aspect of a program must be emphasized, and delivered in a quality manner. A one-hour LGBTQ+ 101, once or twice a year, will in no way suffice. With employee turnover and the constant evolution of affirming and accurate LGBTQ language, providers must commit to consistent quality training evaluation and adaptation in order to be current, relevant and effective. A provider’s medical care skills for the LGBTQ+ population will be measured by the quality of care given by the least-trained staff person. If quality LGBTQ training is not available within an organization, providers can reach out to sexuality training experts in their community to create a robust program.

CONCLUSION There is significant value in understanding the impact of language regarding sexual and gender identity and orientation. It is critical to provide accurate, up-to-date education for all members of the healthcare community in order to understand importance of adopting nuanced language to affirm an individual’s gender, or sexuality. Doing so builds equity, and provides a safe space for LGBTQ patients to receive the quality care they deserve. 7

REFERENCES 1. The Joint Commission. (2011). Advancing effective communication, cultural competence, and patient- and familycentered care for the lesbian, gay, bisexual and transgender (LGBT) community: A field guide. Retrieved from: https:// www.jointcommission.org/assets/1/18/LGBTFieldGuide.pdf 2. Newport, F. (2018). In U.S., estimate of LGBT population rises to 4.5%. Retrieved from: https://news.gallup.com/poll/234863/ estimate-lgbt-population-rises.aspx 3. Lim, F. A., Brown, D. V., Jr., & Justin Kim, S. M. (2014, June). Addressing health care disparities in the lesbian, gay, bisexual, and transgender population: A review of best practices. The American Journal of Nursing, 114(6), 24–34. https://doi.org/10.1097/01.NAJ.0000450423.89759.36 4. Gold, M. (2018). The ABCs of L.G.B.T.Q.I.A.+. The New York Times. Retrieved from: https://www.nytimes.com/2018/06/21/ style/lgbtq-gender-language.html 5. Iovannone, J. (2018). A brief history of the LGBTQ initialism. Retrieved from: https://medium.com/queer-history-for-thepeople/a-brief-history-of-the-lgbtq-initialism-e89db1cf06e3 6. Krehely, J. (2009). How to close the LGBT health disparities gap. Retrieved from: http://www.americanprogress.org/ issues/2009/12/lgbt_health_disparities.html 7. National Coalition for LGBT Health. (2011). All of the Above: LGBT People of Color. Retrieved from: http://lgbthealth. webolutionary.com/sites/default/files/LGBT%20POC.pdf

8. Institute of Medicine. (2011). The Health of lesbian, gay, bisexual, and transgender people: Building a foundation for better understanding. Washington, DC: National Academies Press. https://www.ncbi.nlm.nih.gov/books/NBK64806/ 9. Van Rensburg, G. H., & Botma, Y. (2015, November 26). Bridging the gap between self-directed learning of nurse educators and effective student support. Curationis, 38(2), 1503. https://doi.org/10.4102/curationis.v38i2.1503 10. Harbin, A., Beagan, B., & Goldberg, L. (2012, June). Discomfort, judgment, and health care for queers. Journal of Bioethical Inquiry, 9(2), 149–160. https://doi.org/10.1007/s11673-012-9367-x 11. Gay and Lesbian Medical Association. (2005). Guidelines for Care of Lesbian, Gay, Bisexual, and Transgender Patients. Retrieved from: https://npin.cdc.gov/publication/guidelines-care-lesbian-gaybisexual-and-transgender-patients 12. Kelly, M. K. (n.d.). Providing transgender and non-binary care at Planned Parenthood: A best-practice guide and start-up action kit. Planned Parenthood of the Southern Finger Lakes. 13. National LGBT Health Education Center. (n.d.). Providing inclusive services and care for LGBT people: A guide for health care staff. Retrieved from: https://www. lgbthealtheducation.org/publication/learning-guide/

LIST OF IDENTITIES L = Lesbian – A female-identified person who is attracted romantically, physically, and/or emotionally to female-identified people. G = Gay – A male-identified person who is attracted romantically, physically, and/or emotionally to male-identified people. B = Bisexual – A person who is attracted romantically, physically, and/or emotionally to both male-identified and femaleidentified people. Another term, Pansexual, refers to being attracted to persons across the entire gender spectrum. T = Transgender – A person who identifies as a member of a gender other than that expected based on sex assigned at birth. Q = Queer – Historically, this term has been derogatory and hurtful, however, many people who do not adhere to sexual and/ or gender norms are now using it to self identify in a positive way. Queer is an umbrella term which embraces a variety of sexual identities, orientations, and behaviors of those who do not adhere to the heterosexual. Q = Questioning – a person who identifies as questioning has not committed to a specific identity, but is not ruling out at least some of the non-heterosexual, non-cis-gender identities which exist I = Intersex – Someone whose physical sex characteristics, hormones and/or chromosomes are not categorized as exclusively male or exclusively female. A = Asexual – A person who may not be attracted to anyone, or a person who does not identify as having a sexual orientation. A = A-Gender – A-Gender individuals find that they have no gender identity, although some define this more as having a gender identity that is neutral. A = Ally – A person who may not identify as LGBTQ+ (or regardless of identity), but supports the rights and safety of those who do. “+” = This plus sign is meant to signify the wide range of evolving identifies and terms which help people accurately and authentically define themselves. Dukes, C., Moore, C. (2018). Who’s at the water cooler? Orientation: Teaching About Identity, Volume 2. Center for Sexuality Education. Source Materials available through Advocates for Youth and the Tahoe Safe Alliance web sites: http://www.advocatesforyouth.org/publications/607-glossary http://tahoesafealliance.org/for-lgbqtia/what-does-lgbtqia-mean/Scenario #1 See also: http://www.guidetogender.com/ 8 Delaware Journal of Public Health – June 2019

The DPH Bulletin

From the Delaware Division of Public Health

June 2019 Prepare for dangerous summer heat Extreme heat and high humidity can lead to lifethreatening heat disorders. At risk are older adults, young children, urban residents, those with chronic health conditions, and those who are overweight. The Federal Emergency Management Agency and the Ready Campaign provide these precautions:

During Lyme Disease Awareness Week (May 19-25, 2019), the Division of Public Health (DPH) presented tick bite prevention trail signs to the Town of Milton in Milton Memorial Park. From left: Milton Public Works Director Greg Wingo, Representative Steve Smyk, DPH Director Dr. Karyl Rattay, and Milton Mayor Ted Kanakos. DPH is providing the signs to all municipalities and parks while supplies last; call 302-744-4930.

Avoid tick bites to prevent the ill health effects of Lyme disease

Lyme disease is frequently characterized by an expanding red rash, commonly referred to as a “bull’s eye rash.” Rashes can occur anywhere on the body and vary in size and shape. Other symptoms can include fever and or chills, fatigue, muscle and joint aches, and headaches. In 2018, DPH reported 520 confirmed and probable cases of Lyme disease. Blacklegged or deer tick bites transmit the bacterium Borrelia burgdorferi and B. mayonii which cause Lyme disease. DPH recommends preventing tick bites by following the “BLAST” steps: Bathe or shower within two hours of coming indoors; Look for ticks on your body and remove them; Apply repellent to your body and clothes; Spray your yard; and Treat your pet with a veterinarian-approved medicine that kills ticks.

• Limit exposure to the sun by staying indoors and avoiding strenuous work. When working outside in extreme heat, use a buddy system and take frequent breaks. Wear sunscreen, light-colored clothing, and a wide-brimmed hat. • Never leave children or pets alone in closed vehicles even with the air conditioning on. • Drink plenty of water, even when not thirsty. Keep water for pets and livestock filled and fresh. Avoid drinks with caffeine; limit alcoholic beverages. Eat well-balanced, light, and regular meals. • Circulate air for cooling. Install window air conditioners snugly and insulate them. • Weather-strip doors and sills to keep cool air in. • Cover windows with drapes, shades, awnings, or louvers. • Get trained in first aid to learn how to treat heatrelated emergencies. Check on family, friends, and neighbors who do not have air conditioning and who spend much of their time alone. Listen to local weather forecasts often. For critical National Weather Service updates, visit https://www.weather.gov/safety/heat, Ready.gov, or the Spanish-language website Listo.gov, or listen to a National Oceanic and Atmospheric Administration Weather Radio. If your home loses power during a heat wave, go to a designated public shelter. Text SHELTER + your ZIP code to 43362 (4FEMA) to find the nearest shelter in your area (example: shelter 12345) and listen to local officials.

DPH is providing educational presentations to camps, schools, and other organizations. Call DPH at 1-888-295-5156. At De.gov/lyme, medical providers can access webinars with free Continuing Education Units, children can learn about Lyme disease on the “Kid’s Korner,” and adults can find detailed tick removal instructions and a printable poster of common symptoms. Parks and municipalities can receive free poly-vinyl tick bite prevention trail signs from DPH while supplies last; call 302-744-4930 to order. 9

Delaware Hospitals and the Healthcare Equality Index since 2011: How do they rate? Timothy Rodden, M.Div., M.A., B.C.C., F.A.C.H.E.; Director, Pastoral Services and System Coordinator, LGBTQ Health Initiatives, Christiana Care Health System Tari Hanneman, M.P.A.; Director, Health Equity Project, Human Rights Campaign

The Healthcare Equality Index (HEI) published by the Human Rights Campaign Foundation is the national LGBTQ benchmarking tool that evaluates healthcare facilities' policies and practices related to the equity and inclusion of their LGBTQ patients, visitors and employees. The HEI 2018 evaluated more than 1,600 healthcare facilities nationwide.1 Delaware hospitals have participated in the HEI since 2011. The following provides a snapshot by year of the active participation and results of Delaware hospitals in this annual survey (see Table 1). Beginning in 2011, the HEI awarded the “Leader in LGBT Healthcare Equality” designation to hospitals that met the following criteria: • have both sexual orientation and gender identity identified in the patients’ bill of rights/non-discrimination policy; • have explicitly inclusive visitation policy granting equal access for same-sex couples and for same-sex parents; • LGBT cultural competency training for key leaders and personnel; and • have sexual orientation and gender identity in the equal employment opportunity policy. In 2011, Christiana Care Christiana Hospital and Christiana Care Wilmington Hospital were the first two hospitals to participate in the HEI. Both hospitals achieved the designation of “Leader in LGBT Healthcare Equality in 2012.” They maintained their leader status in 2013, and were joined by Beebe Healthcare and Nemours/ Alfred I. duPont Hospital for Children in 2014.

LGBTQ-inclusive policies and practices. A score of 100 allowed a hospital to have the designation “Leader in LGBTQ Healthcare Equality”. Facilities receiving between 80-95 points were deemed “Top Performers.” Criteria 1 – includes the Non-Discrimination and Staff Training requirements from previous surveys (40 points) Criteria 2 - covers Patient Services and Support: LGBTQ patient services and support; transgender patient services and support; patient self-identification; and medical decision-making (30 points) Criteria 3 – covers Employee Benefits and Policies (20 points) Criteria 4 – covers Patient and Community Engagement (10 points) Christiana Care Christiana Hospital and Christiana Care Wilmington Hospital were the two Delaware facilities that achieved a score of 100 and attained Leader in LGBTQ Healthcare Equality status. Bayhealth Kent General Hospital, Bayhealth Milford Memorial Hospital, and Nemours/Alfred I. duPont Hospital for Children were in the Top Performer category with 80 points each. Beebe Health received 75 points. 2018 Leaders in LGBTQ Healthcare Equality: Bayhealth Kent General

Hospital, Bayhealth Milford Memorial Hospital, Christiana Care Christiana Hospital, Christiana Care Wilmington Hospital, and Nemours/Alfred I. duPont Hospital for Children achieved a score of 100. Beebe Healthcare achieved 75 points. 2019 Healthcare Equality Index is due to be published in the summer of 2019. New to the HEI this year was the additional requirement that participants will be required to have at least one firm-wide employee health insurance plan that affirmatively provides transgender-inclusive coverage to receive a score of 100 in the HEI and obtain the “LGBTQ Healthcare Equality Leader” designation.

There was a concerted effort on the part of the United Way of Delaware’s PRIDE Council’s LGBTQ Health Equity Task Force to visit the Delaware hospitals not participating in the survey in 2014. Information about the HEI survey as an organizing tool for working toward providing equitable care to LGBTQ+ Delawareans and for LGBTQ+ workforce inclusion was provided to key leaders in the five non-participating hospitals. As a result of this organizing effort, four out of the five hospitals participated in the 2016 HEI, which led to 8 out of the 9 hospitals in Delaware achieving Leader status.

REFERENCES

The 2017 HEI survey saw a rising of the bar, with a shift to a more comprehensive and demanding survey that scored facilities on their

1. The Healthcare Quality Index. (n.d.) The Human Rights Campaign. Retrieved from: https://www.hrc.org/hei

Table 1. Participation In and Results for Healthcare Equality Index by Delaware Hospitals Since 2011.

Year

Participation in HEI

Leader in LGBT Healthcare Equality Status (added 2012)

Top Performer Status (added 2017)

2011

CH, WH

2012

CH, WH

2013

CH, WH

2014

BH, CH, WH, NAIDHC

2015/ 2016

KG, MMH, BH, CH, WH, NMH, NAIDHC, VA

2017

KG, MMH, BH, CH, WH, NMH, NAIDHC, VA

CH, WH

KG, MMH, NAIDHC

2018

KG, MMH, BH, CH, WH, NMH, NAIDHC, VA

KG, MMH, CH, WH, NAIDHC

CH – Christiana Hospital (CCHS), WH – Wilmington Hospital (CCHS), KG – Kent General Hospital (Bayhealth), MMH – Milford Memorial Hospital (Bayhealth), BH – Beebe Hospital (Beebe), NMH – Nanticoke Memorial Hospital (Nanticoke), NAIDHC (Nemours/Alfred I. duPont Hospital for Children), VA – Veteran’s Association (Wilmington)

10 Delaware Journal of Public Health – June 2019

Announcing the Long-Term Care Equality Index www.thelei.org

SAGE, the world’s largest and oldest organization dedicated to improving the lives of LGBT older people, and the Human Rights Campaign Foundation (HRCF), the educational arm of the nation’s largest civil rights organization working to achieve equality for LGBT people, are joining forces to address these issues by launching the Long-Term Care Equality Index (LEI) to promote equitable and inclusive care for LGBT older people in residential long-term care communities.

WHY THE LONG-TERM CARE EQUALITY INDEX? DEMOGRAPHICS There are currently between 1.5 and 3.8 million adults over the age of 65 in the United States who identify as lesbian, gay, or bisexual1(LGB) and this number is projected to double by 2030.2 According to the 2010 census report, 99.3% of counties in the U.S. are home to LGB individuals, and estimates from The Williams Institute indicate that there are hundreds of thousands of older adults who are transgender3. While older lesbian, gay, bisexual and transgender (LGBT) adults confront the same issues everyone else does when choosing aging services — where to live, how

CONCERNS OF LGBT OLDER ADULTS REGARDING LONG-TERM SERVICES AND SUPPORT A recent national survey of LGBT older adults by AARP found that more than 60 percent of those surveyed were concerned about how they would be treated in a longterm care setting, including fear that they might be refused or receive limited care; be in danger of neglect or abuse; or face verbal or physical harassment, and being forced to hide or deny their identity once again.4 Many of today’s LGBT elders, particularly those who have faced severe prejudice in their lives, have chosen to remain closeted to service providers. This in turn often leads to service providers that do not realize that they are serving LGBT individuals, so they don’t take measures to make their facilities LGBT inclusive. The AARP survey found that more than 82 percent of respondents would be more comfortable if long-term care communities took actions to intentionally affirm LGBT adults.

to afford rising costs of housing and healthcare, and how to stay with loved ones — the reality of life in long-term care for LGBT people can be drastically different from their non-LGBT peers. Stigmatization, lack of identity-affirming treatment and experiences of discrimiLONG-TERM CARE nation and violence THE can lead to avoiding necessary EQUALITY INDEX (LEI) services, chronic stress and increased social isolation SAGE, the world’s largest approximately and oldest organization among LGBT older adults. Additionally, 20 dedicated to improving the lives of LGBT older people, percent of LGBT older adults are people of color who as and the Human Rights Campaign Foundation (HRCF), a group face increased health disparities, higher levels the educational arm of the nation’s largest civil of rights organization working to achieve equality discrimfor LGBTQ stigma and have experienced more LGBT-related people, are joining forces to address these issues by ination than their white counterparts, leaving themIndex more atto launching the Long-Term Care Equality (LEI) equitable inclusive they care for LGBT older risk of not seeking orpromote receiving theand services need.

people in residential long-term care communities. SAGE and HRCF believe that most long-term care communities do not want LGBT older adults to face discrimination or have to worry about the care that they will receive. But these communities may be unsure how to protect their LGBT residents from discrimination, provide them with optimal care and extend a warm welcome to allay their concerns. The LEI will encourage and help long-term care communities to adopt policies and best practices that provide culturally competent and

“WITHIN THE NEXT TWO WEEKS I WILL BE GOING INTO ASSISTED LIVING. DUE TO MY FINANCIAL SITUATION, I WILL HAVE TO SHARE A ROOM WITH ANOTHER MAN. THE THOUGHT OF GOING BACK INTO A CLOSET IS COMMITMENT TO LGBT INCLUSION MAKING ME AILL. FRANKLY, I’M AFRAID MAKES A DIFFERENCE OF TELLING ANYONE THAT I’M GAY.”

“OUR—Anonymous, LGBT RESIDENTS ARE GRATEFUL 73 years old, Sylmar, CA TO BE AFFIRMED IN THE MIDST OF THEIR COMMUNITY OF CARE AS THEY RECEIVE THE RESPECT AND SUPPORT FROM STAFF. WE HAVE ATTRACTED STAFF TO OUR ORGANIZATION, BOTH INDIVIDUALS of LGBT Older Adults are WHO IDENTIFY AS LGBTQ AND ALLIES concerned about how WHO PREFER TO WORK IN they will be treated in AN INCLUSIVE ” long-termENVIRONMENT. care settings

40+60

60%+

SAGECare Training Customer Rev. Beth Long-Higgins Executive Director Ruth Frost Parker Center for Abundant Aging United Church Homes

(over)

responsive care to LGBT older adults. More than just an assessment, the LEI will provide resources and technical assistance to bring these policies and practices to life. An exploratory study by the Human Rights Campaign Foundation and SAGE revealed that there is great interest by aging-services providers to participate in the Long-term Care Equality Index initiative. Participating aging service providers will benefit by: •

Learning best practices for LGBT equity and inclusion;

•

Access to quality training and education;

•

Gaining assistance with meeting state and federal regulatory requirements, including the new CMS Phase III Requirements of Participation;

•

Improved ability to develop culturally appropriate marketing for future staff, clients, and funders; and

•

Public recognition as a leading provider of LGBT welcoming services.

Residential Long-Term Care service providers that are interested in participating in the Long-Term Care Equality Index are invited to take the first step by signing the Commitment to Caring Pledge.

To be released in 2021, the LEI will encourage and help long-term care communities to adopt policies and best practices that provide culturally competent and responsive care to LGBT older adults. More than just an assessment, the LEI will provide resources and technical assistance to bring these policies and practices to life. For information about the issues that LGBTQ older people face follow this link to a two page summary. Why the LEI? (excerpted from www.thelei.org website)

Learn more at theLEI.org  1. Gallop, 2017. 2. SAGE (Services and Advocacy for GLBT Elders) and MAP (Movement Advancement Project) 2010. Improving the lives of LGBT older adults. 3. Flores, A.R., Herman, J.L., Gates, G.J. & Brown, T.N.T. (2016) How Many Adults Identify as Transgender in the United States? Los Angeles, CA: The Williams Institute 4. Houghton, Angela. Maintaining Dignity: Understanding and Responding to the Challenges Facing Older LGBT Americans. Washington, DC: AARP Research, March 2018.

Caring for Our Community: Telehealth Interventions as a Promising Practice for Addressing Population Health Disparities of LGBTQ+ Communities in Health Care Settings Alex Waad, M.A. Nemours Biomedical Research, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE

ABSTRACT While the United States has seen social and policy-based progress in the past two decades, the divisive political climate in the United States toward LGBTQ+ individuals highlights the prevalence of homophobia and transphobia that continues to harm and marginalize these communities. Within the context of health care, LGBTQ+ individuals face discrimination and mistreatment, further perpetuating a community narrative of mistrust in the health care system at large. Despite well-documented evidence of population-specific health needs and risks, LGBTQ+ individuals report less utilization of primary care than their heterosexual and cisgender counterparts. Initial studies of LGBTQ+ individuals’ engagement in telehealth interventions have largely focused within the realm of mental and behavioral health. Utilizing tenants and results seen in previous studies conducted regarding LGBTQ+ individual engagement with mental and behavioral telehealth interventions, this article explores the potential of utilizing telehealth as an interventional tool for addressing LGBTQ+ health disparities and reduced engagement within a primary care setting. Taking into consideration cost, geographic diversity, and implementation concerns, telehealth targeted toward LGBTQ+ individuals in a primary care setting could prove to be an effective method for reaching more LGBTQ+ individuals and providing them with population-specific, culturally-competent care.

INTRODUCTION Within the first two years of the 45th presidential administration in the United States, policy rollbacks and prevalence of hate speech directed toward marginalized communities have contributed to a fearful environment for many.1,2 The LGBTQ+ (lesbian, gay, bisexual, transgender, and queer +) communities have been some of the groups heavily affected, with many community members reporting increased emotional distress and anti-LGBTQ+ harassment.3–5 Prior to the 45th presidential administration, robust narratives existed that described LGBTQ+ people’s negative interactions with health care environments. One of the most prominent components of reported negative interactions with health care includes the need to “come out” to providers and the related fear of rejection or negative treatment by providers.6–13 While efforts have been made to create clearer pathways to help patients identify LGBTQ+-competent practitioners, access to said providers still proves a barrier to patients. Use of telehealth technologies by LGBTQ+-competent providers could reduce barriers to access in geographic regions where availability of culturally competent providers is scarce. Initial reports of telehealth use by LGBTQ+ individuals for behavioral health concerns positions its use in a physical health environment to be a promising practice.8,14 Through use of telehealth interventions targeting LGBTQ+ patients, providers may be able to reach patient populations that would otherwise not have access to the care they need or avoid pursuing care in fear of mistreatment and neglect.

REVIEW OF LGBTQ+ HEALTH CONCERNS LGBTQ+ individuals present a unique set of physical and behavioral health concerns. There is well-documented evidence of higher rates of coronary heart disease, asthma, and chronic inflammation among LGBTQ+ individuals in comparison with heterosexual and cisgender individuals.15–23 Research further parses out health disparities that exist among gay-identifying individuals reporting higher rates of 12 Delaware Journal of Public Health – June 2019

disordered eating, human papillomavirus (HPV), and anal cancer in comparison with their heterosexual counterparts. Lesbianidentifying individuals report higher rates of obesity, breast cancer, and cardiovascular disease in comparison with straight women. In addition to unique health needs of transgender individuals pursuing gender-affirming procedures, transgender individuals in a health care environment provide powerful narratives of neglect and exploitation by providers.13,24 In addition to subpopulation-specific experiences, a commonality among subpopulations of the LGBTQ+ community are high reports of mental health concerns. While significant societal progress has been made around LGBTQ+ activism and inclusive public policies, the sociopolitical climate for LGBTQ+ individuals in the United States remains precarious, and varies by geographic region. With a great deal of prejudice still in existence in the United States toward LGBTQ+ individuals, it should come as no surprise that the emotional microcosm that results places a great deal of mental stress on LGBTQ+ individuals. LGBTQ+ individuals report higher rates of depression, suicidal ideation, anxiety, self-harm behavior, and disordered eating.9,18–20,22,23 Following an alarming spike in LGBTQ+ suicides in 2010, digital resources such as suicide hotlines targeting LGBTQ+ youth began gaining public attention.25,26 Within the realm of behavioral health and mental health services, telehealth interventions have proven an effective strategy for outreach to LGBTQ+ individuals.8,14 However, minimal research has been done on the utility of telehealth services within a physical health setting, specifically for LGBTQ+ individuals.

TELEHEALTH INTERVENTIONS WITHIN BEHAVIORAL & MENTAL HEALTH Telehealth refers to technologically mediated health services that allow users to interact with various health care providers via computer or smartphone video services.27 By meeting with patients through digitally-mediated technology, providers are able to reduce patient wait time, reduce costs incurred by patients, and reach a

wider patient population who may not have access to a physical care environment. The convenience and accessibility of telehealth services are certainly a major draw to this intervention; however, for LGBTQ+ patients, telehealth services could potentially address some of the keystone issues that prevent LGBTQ+ patients from accessing care. Numerous studies have been conducted regarding LGBTQ+ individuals’ engagement with telehealth interventions as they pertain to mental and behavioral health.28–30 Overarching trends from these studies elucidate the helpfulness of having interventions that specifically address LGBTQ+ needs, in addition to taking the guesswork out of finding a provider who will understand LGBTQ+related issues. A particular area of interest has been outreach to LGBTQ+ individuals in rural locations.31–33 In addition to the increased stigma of being an LGBTQ+-identified person in a rural setting, the problem is compounded with the additional barrier of access to LGBTQ+-friendly health care providers.34,35 By providing rural LGBTQ+ individuals with access that is anonymous and confidential, patients are able to protect their safety in potentially hostile environments, while also accessing culturally-informed behavioral health interventions. The bodies of literature that address LGBTQ+ engagement in care with telehealth interventions for behavioral and mental health concerns point to a potentially promising practice in tackling LGBTQ+ health needs in the digital age. However, there has been minimal research as to how digital health interventions can benefit LGBTQ+ individuals outside behavioral and mental health.

LGBTQ+ ENGAGEMENT IN CLINICAL CARE A digital environment that is created through telehealth services has the potential to address the practitioner-based concerns that patients may have, in addition to mediating the health care delivery and compliance with directives. Access to LGBTQ+-friendly health care providers serves as a barrier for many LGBTQ+ patients. For more than a decade, the Human Rights Campaign (HRC) has conducted a Healthcare Equality Index (HEI) survey of health care facilities that focuses on health care delivery and policies that affirm and advocate for patients with LGBTQ+ identities.36 In a similar vein, GLMA (the Gay and Lesbian Medical Association), provides a directory on their website of health care practitioners who have pledged their commitment to LGBTQ+ health.37 Patients with access to the internet are able to easily search for health care practitioners in their area who are registered with GLMA; although, GLMA specifically cites that they do not individually screen practitioners for competent LGBTQ+ care.38 While the HRC and GLMA have made concerted efforts to identify LGBTQ+-friendly practitioners, the identification of practitioners does not necessarily address issues of geographic access to care. For LGBTQ+ patients who do not have access to urban areas where many LGBTQ+-friendly providers are, patients run the risk of seeking care from a culturally insensitive provider or foregoing care altogether.8,39,40 For health care organizations, this means treating patients in critical care settings (e.g., emergency department visits, immediate-care clinics, etc.) for conditions that may have been able to be addressed sooner and with less urgency had the patient pursued early care options. Treating patients for preventable conditions in a critical care setting yields more cost to the health care system, in addition to unnecessary allocation of time and personnel to treat conditions that could have been mitigated in a primary care setting.41,42 These costs are not only passed on to the patient, but are also incurred by the health care organization as a whole. Subsequently, the mere identification of practitioners who can provide LGBTQ+-friendly patient care is not enough; rather, health

care delivery methods to ensure that patients are aware of their care options and have access to them are key to addressing LGBTQ+ health disparities.

CONSIDERATIONS FOR IMPLEMENTING TELEHEALTH INTERVENTIONS FOR LGBTQ+ PATIENTS For health care practitioners and health care organizations that are interested in improving outreach and care of LGBTQ+ patients, telehealth could offer an opportunity to address many of the barriers to access that LGBTQ+ patients face. With proper consideration, telehealth interventions could offer LGBTQ+ patients culturally competent health care in a way that addresses negative community narratives toward seeking health care in a primary care setting.

Cost Avoidance in seeking care poses serious concerns for the economic well-being of health care organizations. For health care organizations, treating patients in a critical care setting for a condition that could have been treated in an outpatient setting incurs unnecessary cost.43,44 As a general tenant of health care delivery, identifying and treating a condition early, not only allows for better targeted treatment but also potentially halts disease progression from becoming more severe and, therefore, necessitating more aggressive treatment. By increasing access to LGBTQ+-friendly providers, health care organizations may begin to mitigate the costs of seeing patients in critical care settings when they could have been treated in an outpatient setting.

Provider Access As previously mentioned, the HRC compiles an annual index of health care facilities that have met certain criteria to be considered an “LGBTQ Healthcare Equality Leader.36” While some states, such as California, New York, Ohio, and North Carolina, have a robust number of facilities that have been identified as exemplars by the HRC in their 2019 annual report, other states, such as Georgia, South Carolina, Idaho, and Montana, do not have a single facility registered with the HRC. For LGBTQ+ patients, access to LGBTQ+friendly providers may be scarce in their geographic region, which may have an influence on their engagement in care.27,45 Telehealth services have the potential to alleviate geographic barriers by allowing patients, especially in rural communities, to access LGBTQ+-friendly providers from the comfort of their own homes.

Advertising and Community Outreach While telehealth interventions have great potential to alleviate access barriers for LGBTQ+ individuals seeking culturally competent care, one cannot ignore the effect that years of discrimination have had on LGBTQ+ community narratives in seeking care. The horror stories of LGBTQ+ discrimination in health care environments are pervasive and indicate fear and mistrust in the health care system.6–13 As individual practitioners and health care organizations aim to implement telehealth interventions specifically for LGBTQ+ communities, they must also be aware of the community outreach and engagement that will be necessary to help dispel current community narratives, and begin to build trust between health care providers and LGBTQ+ patients.

LIMITATIONS & FUTURE CONSIDERATIONS While telehealth services have been in existence for nearly a decade, their effect on marginalized communities remains relatively new and unexplored. Subsequently, careful implementation and diligent assessment are necessary to determine their effectiveness. As with 13

the development of any new clinical intervention or treatment method, rigorous pre- and post-assessment metrics should be collected. As previously noted, telehealth interventions specifically for LGBTQ+ patients outside mental and behavioral health have not been researched. As interventions are established, LGBTQ+ health needs must be at the forefront of development rather than retrofitted from existing models. Moreover, telehealth services should not be viewed as a panacea for LGBTQ+ health disparities. The root causes of health disparities (systemic oppression and subsequent prejudice) are still incredibly prevalent and powerful in affecting the lives of LGBTQ+ individuals. Telehealth interventions may be used as a countermeasure to begin addressing health disparities; however, increased practitioner education and training in cultural competency remain the key to addressing health disparities in a long-term, sustainable fashion.

CONCLUSION Different disciplines within the healing arts are showing promise for incorporating care practices that honor the growing diversity of patient populations within the United States. However, there is still a great deal of work that needs to be done to address pervasive population health disparities that are ever present within the United States. Foundational causes of systemic oppression that propel the trajectories of population health disparities are still very much alive and well within the United States. Efforts to educate health care practitioners and provide them with interventional resources necessary to tackle population health disparities are pivotal in changing the way that health care access is gate kept in the United States. Specifically for LGBTQ+ individuals, systemic barriers instill narratives of fear and subsequent neglect for individuals seeking health services. Until LGBTQ+ individuals can confidently show up authentically in the offices of their health care providers and receive culturally competent, population-specific care, the need for education and interventional countermeasures will exist. Telehealth services offer a promising avenue for targeted outreach to LGBTQ+ individuals to begin changing the community narratives of mistrust and neglect and allow LGBTQ+ individuals to seek care without fear of mistreatment.

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19. Hamilton, C. J., & Mahalik, J. R. (2009). Minority stress, masculinity, and social norms predicting gay men’s health risk behaviors. Journal of Counseling Psychology, 56(1), 132–141. https://doi.org/10.1037/a0014440 20. Lick, D. J., Durso, L. E., & Johnson, K. L. (2013, September). Minority stress and physical health among sexual minorities. Perspect Psychol Sci, 8(5), 521–548. https://doi.org/10.1177/1745691613497965 21. Meyer, I. H. (1995, March). Minority stress and mental health in gay men. Journal of Health and Social Behavior, 36(1), 38–56. https://doi.org/10.2307/2137286 22. Meyer, I. H. (2003, September). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin, 129(5), 674–697. https://doi.org/10.1037/0033-2909.129.5.674 23. Tebbe, E. A., & Moradi, B. (2016, October). Suicide risk in trans populations: An application of minority stress theory. Journal of Counseling Psychology, 63(5), 520–533. https://doi.org/10.1037/cou0000152 24. Bradford, J., Reisner, S. L., Honnold, J. A., & Xavier, J. (2013, October). Experiences of transgender-related discrimination and implications for health: Results from the Virginia Transgender Health Initiative Study. American Journal of Public Health, 103(10), 1820–1829. https://doi.org/10.2105/AJPH.2012.300796 25. Haas, A. P., Eliason, M., Mays, V. M., Mathy, R. M., Cochran, S. D., D’Augelli, A. R., . . . Clayton, P. J. (2010). Suicide and suicide risk in lesbian, gay, bisexual, and transgender populations: Review and recommendations. Journal of Homosexuality, 58(1), 10–51. https://doi.org/10.1080/00918369.2011.534038 26. McKinley, J. (2010, October 3). Suicides put light on pressures of gay teenagers. The New York Times. Retrieved from https://www.nytimes.com/2010/10/04/us/04suicide.html 27. Nelson, R. (2017, June). Telemedicine and telehealth: The potential to improve rural access to care. The American Journal of Nursing, 117(6), 17–18. https://doi.org/10.1097/01.NAJ.0000520244.60138.1c 28. Leluțiu-Weinberger, C., Manu, M., Ionescu, F., Dogaru, B., Kovacs, T., Dorobănțescu, C., . . . Pachankis, J. E. (2018, November 14). An mHealth intervention to improve young gay and bisexual men’s sexual, behavioral, and mental health in a structurally stigmatizing national context. JMIR mHealth and uHealth, 6(11), e183. https://doi.org/10.2196/mhealth.9283 29. Lucassen, M. F. G., Hatcher, S., Stasiak, K., Fleming, T., Shepherd, M., & Merry, S. N. (2013). The views of lesbian, gay and bisexual youth regarding computerised self-help for depression: An exploratory study. Advances in Mental Health, 12(1), 22–33. https://doi.org/10.5172/jamh.2013.12.1.22 30. Lucassen, M., Samra, R., Iacovides, I., Fleming, T., Shepherd, M., Stasiak, K., & Wallace, L. (2018, December 21). How LGBT+ young people use the internet in relation to their mental health and envisage the use of e-therapy: Exploratory study. JMIR Serious Games, 6(4), e11249. https://doi.org/10.2196/11249 31. Institute of Medicine. (2011). The health of lesbian, gay, bisexual, and transgender people: Building a foundation for better understanding. Washington, DC: The National Academies Press. https://doi.org/10.17226/13128

32. Warren, J. C., Smalley, K. B., & Barefoot, K. N. (2015). Recruiting rural and urban LGBT populations online: Differences in participant characteristics between email and Craigslist approaches. Health and Technology, 5(2), 103–114. https://doi.org/10.1007/s12553-015-0112-4 33. Whitehead, J., Shaver, J., & Stephenson, R. (2016, January 5). Outness, stigma, and primary health care utilization among rural LGBT populations. PLoS One, 11(1), e0146139. https://doi.org/10.1371/journal.pone.0146139 34. Brotman, S., Ryan, B., Jalbert, Y., & Rowe, B. (2002). The impact of coming out on health and health care access: The experiences of gay, lesbian, bisexual and two-spirit people. Journal of Health & Social Policy, 15(1), 1–29. https://doi.org/10.1300/J045v15n01_01 35. Tiemann, K. A., Kennedy, S. A., & Haga, M. P. (1998). Rural lesbians’ strategies for coming out to health care professionals. Journal of Lesbian Studies, 2(1), 61–75. https://doi.org/10.1300/J155v02n01_05 36. Human Rights Campaign. (n.d.). Healthcare Equality Index 2018. Retrieved February 23, 2019, from https://www.hrc.org/hei/ 37. GLMA. (n.d.) GLMA - Find a Provider. Retrieved February 23, 2019, from http://www.glma.org/index.cfm?fuseaction=Page. viewPage&pageId=939&grandparentID=534&parentID=938&nodeID=1 38. GLMA. (n.d.) GLMA - Impak - Ensure Quality. Retrieved February 27, 2019, from http://www.glma.org/index.cfm?fuseaction=Page.viewPage&pageID=824 39. LaVeist, T. A., Isaac, L. A., & Williams, K. P. (2009, December). Mistrust of health care organizations is associated with underutilization of health services. Health Services Research, 44(6), 2093–2105. https://doi.org/10.1111/j.1475-6773.2009.01017.x 40. Thoreson, R. (2018, July 23). “You Don’t Want Second Best” | Anti-LGBT discrimination in US health care. Retrieved February 27, 2019, from https://www.hrw.org/report/2018/07/23/you-dontwant-second-best/anti-lgbt-discrimination-us-health-care 41. Diamant, A. L., Wold, C., Spritzer, K., & Gelberg, L. (2000, November-December). Health behaviors, health status, and access to and use of health care: A population-based study of lesbian, bisexual, and heterosexual women. Archives of Family Medicine, 9(10), 1043–1051. https://doi.org/10.1001/archfami.9.10.1043 42. Ward, B. W., Dahlhamer, J. M., Galinsky, A. M., & Joestl, S. S. (2014, July 15). Sexual orientation and health among U.S. adults: National health interview survey, 2013. National Health Statistics Reports, 77(77), 1–10. Retrieved from https://stacks.cdc.gov/view/cdc/24087 43. Green, C. A., Johnson, K. M., & Yarborough, B. J. (2014, May-June). Seeking, delaying, and avoiding routine health care services: Patient perspectives. Am J Health Promot, 28(5), 286–293. https://doi.org/10.4278/ajhp.120702-QUAL-318 44. Maciosek, M. V., Coffield, A. B., Flottemesch, T. J., Edwards, N. M., & Solberg, L. I. (2010, September). Greater use of preventive services in U.S. health care could save lives at little or no cost. Health affairs (Project Hope), 29(9), 1656–1660. https://doi.org/10.1377/hlthaff.2008.0701 45. Rosenkrantz, D. E., Black, W. W., Abreu, R. L., Aleshire, M. E., & Fallin-Bennett, K. (2017). Health and health care of rural sexual and gender minorities: A systematic review. Stigma and Health, 2(3), 229–243. https://doi.org/10.1037/sah0000055 15

DHSS Press Release Dr. Kara Odom Walker, Secretary Jill Fredel, Director of Communications 302-255-9047, Pager 302-357-7498 Email: jill.fredel@delaware.gpv

Date: June 13,2019 DHSS-6-2019

DPH Media Contact: Jennifer Brestel 302-744-4907, Cell 302-612-6223 Email: Jennifer.brestel@delaware.gov

DPH REMINDS DELAWAREANS TO AVOID CONSUMING RAW DAIRY PRODUCTS; ANNOUNCES POSITIVE CASE OF BRUCELLOSIS DOVER, DE (June 13, 2019) The Delaware Division of Public Health (DPH) is reminding Delawareans to avoid consuming raw dairy products as it announces a confirmed case of brucellosis caused by Brucella melitensis in a 46-year-old Sussex County woman. The illness is a bacterial infection, which primarily affects those consuming, or coming into contact with, contaminated animals or animal products. The most common source of infection is through the consumption of raw, unpasteurized dairy products. Prior to becoming ill, the patient in this case had consumed unpasteurized homemade dairy products from Mexico. No other risk factors have been identified. The individual was hospitalized and is recovering after being treated for the illness. A second, related case of brucellosis is also pending confirmation by the Centers for Disease Control and Prevention (CDC). Brucellosis infection is most frequently transmitted by eating or drinking raw/unpasteurized dairy products such as milk and cheese, yet can also be contracted through inhalation or physical contact with infected animals or animal products. When sheep, goats, cows or camels are infected, their milk becomes contaminated with the bacteria. If the milk from infected animals is not pasteurized, the infection will be transmitted to people who consume the milk and/or cheese products. Brucellosis is not common in the United States. Nationally, the average is less than 200 human cases each year. Person to person transmission is rare. Prior to this case, DPH has confirmed three cases since 2010; those cases occurred in 2010, 2017 and 2018. The case in 2010 was associated with consumption of unpasteurized milk while the nature of exposure in the 2017 and 2018 cases is unknown. “Cases such as this one can serve as an unfortunate reminder that we are vulnerable to certain bacteria and should take precautions to protect ourselves,” said DPH Medical Director Dr. Rick Hong. “Delawareans are encouraged to avoid purchasing and consuming unpasteurized dairy products. Consuming questionable food items is not worth the risk to your health.” Raw milk and milk products are those that have not undergone a process called pasteurization that kills disease-causing germs. These types of products are common outside the United States and are increasingly being sold in mainstream supermarkets in the United States as well, though sales are not permitted in Delaware. A wide variety of germs that are sometimes found in raw milk can make people sick. These germs include Brucella, Campylobacter, Cryptosporidium, E. coli, Listeria, and Salmonella.

16 Delaware Journal of Public Health – June 2019

The state’s Milk Safety Program, as well as statewide inspections of retail food establishments, are in place to protect consumers from purchasing or consuming raw dairy products, but unlawful distribution may still occur. Some neighboring states allow for the sale of raw dairy products, therefore residents should be aware of the health risks associated with consuming these products before purchasing and consuming them. Signs and Symptoms of brucellosis are similar to the flu. Initial symptoms include fever, sweats, malaise, anorexia, headache, muscle or joint pain, and fatigue. Antibiotics are typically prescribed to treat brucellosis. In pregnant women, Brucella infections can be associated with miscarriage. Symptom onset can occur anywhere from five days to six months following exposure. Depending on the timing of treatment and the severity of illness, recovery may take several weeks. No vaccine is available to prevent developing brucellosis, but preventive measures can be taken: · Do not eat, drink, or purchase unpasteurized milk or dairy products, especially while traveling outside the U.S. Locations that commonly sell dairy products include supermarkets, farmers’ markets and dairy farms. · Read the label on milk or milk products before you buy them. Many companies put the word “pasteurized” on the label. If you are not sure, ask a store employee if specific brands are pasteurized. · At farm stands or farmers’ markets, ask if the milk and cream being sold have been pasteurized. If the market sells yogurt, ice cream, or cheese, ask if they were made with pasteurized milk. · Meat packers, hunters and slaughterhouse employees should wear protective gloves and wash their hands thoroughly when handling raw meat. For more information about brucellosis, visit https://www.cdc.gov/brucellosis/index.html. For more information about the risks of consuming raw milk and unpasteurized dairy products, visit https://www.cdc.gov/foodsafety/rawmilk/raw-milk-index.html.

A person who is deaf, hard-of-hearing, deaf-blind or speech-disabled can call the DPH phone number above by using TTY services. Dial 7-1-1 or 800-232-5460 to type your conversation to a relay operator, who reads your conversation to a hearing person at DPH. The relay operator types the hearing person's spoken words back to the TTY user. To learn more about TTY availability in Delaware, visit http://delawarerelay.com Delaware Health and Social Services is committed to improving the quality of the lives of Delaware's citizens by promoting health and well-being, fostering self-su ciency, and protecting vulnerable populations. DPH, a division of DHSS, urges Delawareans to make healthier choices with the 5-2-1 Almost None campaign: eat 5 or more fruits and vegetables each day, have no more than 2 hours of recreational screen time each day (includes TV, computer, gaming), get 1 or more hours of physical activity each day, and drink almost no sugary beverages. Delaware Health and Social Services is committed to improving the quality of the lives of Delaware's citizens by promoting health and well-being, fostering self-su ciency, and protecting vulnerable populations.

Keep Trans Youth Alive: Considerations for Suicide Prevention of Gender Expansive Youth Elise Mora, L.C.S.W., I.C.G.C.-I; AIDS Delaware, the National Association of Social Workers

ABSTRACT Objective. This article examines suicidality of gender expansive youth and identifies evidence-based, practical interventions for healthcare professionals and other adults who interact with gender expansive youth. Methods. Research methods included an interview, literature review, articles from peer-reviewed journals, and application of clinical experience. Based on the interview, a case study is included, which describes one transgender man’s suicidal adolescence and early adulthood. Following the case study, statistics are presented, and then theories are applied for deeper understanding of the etiology. The population studied included gender expansive individuals age 24 and younger from the United States. Literature on adult transgender suicidality, as well as recommendations for general populations, was also taken into consideration due to limitations in the research. Results. Gender expansive youth are at significantly heightened risk of suicide compared to their cisgender peers. Nonbinary youth are the most vulnerable of all subgroups. Conclusion. Explicit recommendations for enhancing resilience for this population complete the article. More research is critical for this demographic, as current literature is severely limited.

ERIC: A CASE STUDY “Eric” (names and personal details have been changed to protect confidentiality) was twelve years old the first time he tried to commit suicide. He had just “come out” to his parents as a lesbian. He did not know what it was to be transgender. All he knew was that he was AFAB (assigned female at birth), he was socialized as a girl, and he did not realize he could even question his gender. By age 12, he knew that he was attracted to “other girls.” Eric believed that it was wrong to be gay, and he was deeply ashamed of his sexuality. When Eric finally gained the courage to come out to his friends at school, news spread rapidly and many of his peers became hostile toward him. Being gay made Eric an easy target. Eric became very depressed. He started to have periods of dissociation. He would go into rage-fueled blackouts, unable to remember what had transpired when he settled back into reality. He began isolating himself because he was afraid he would hurt the people around him. Eric’s parents felt helpless. He developed severe anxiety including an intense fear of going outside, and his parents ultimately decided to homeschool him for the remainder of middle school. Between the ages of 12 and 14, Eric attempted suicide two times. After the second attempt, Eric’s parents found him a therapist. They began to work on addressing the impact of the homophobia he experienced when he came out. Eric felt slightly better after a while, but his depression and suicidal thoughts persisted. When Eric was 14, he enrolled in the local public high school. Around the same time, he began to feel gender dysphoric (a type of distress caused by the misalignment of one’s sex assigned at birth and their gender identity) although he did not have the language to articulate the concept, nor did he know about gender variance. What made a significant difference for Eric was being part of his local LGBTQ community center. Being there made Eric feel at 18 Delaware Journal of Public Health – June 2019

home, gave him joy and put him at ease. Eric met other youth there, including some transgender teens. As he got to know them more, and realized how much he related to them, he developed an understanding of himself. Eric came out as transgender at the age of 16. Upon gaining this insight, Eric felt excitement, relief, and terror. He knew that transitioning (the process some gender expansive people may undergo in order to align themselves with their gender identity through social and/or medical interventions) was an option he could explore, but he had no idea how to get started. He was terrified of being disowned by friends or family. The recent insufferable pain of being rejected and mistreated by many of his friends when he came out as gay was still present. On top of being worried about the social cost of transitioning, Eric was concerned about the financial aspect. Eric’s fears were confirmed when he told his peers that he was considering medically transitioning. Responses ranged from telling him that he would not be attractive if he took steps toward masculinization, to others saying they would not like him anymore, to laughter. The deeper the connection, the more it hurt if someone was not supportive. Eric was let down repeatedly. He doubted that he could ever truly “become himself ” and he internalized the belief that he would be unlovable. During high school, Eric attempted suicide four more times. He was hospitalized for a period of time, and he began seeing a new mental health provider. Eric took antidepressant medication, but his symptoms persisted until he began medically transitioning. Finally, Eric’s mental health became manageable. Eric is exceptionally lucky that his immediate family was always supportive. Attributable to the relationships with his parents, siblings, and friends from the community center, Eric felt a sense of connectedness that was tremendously fulfilling. Eric also began working with GLSEN (the Gay, Lesbian, Straight Education

Network, a nonprofit organization that aims to improve school safety nationally), which made a positive impact on his mental health. GLSEN gave Eric a place to help other LGBTQ youth and to advocate for LGBTQ rights. His work instilled pride and empowered him; it gave him purpose. Eric graduated high school. Without any regrets today, Eric has transitioned to an extent that feels comfortable to him. He sees being transgender as a cornerstone of his identity, connected to everything else about him and ever-present in his day-to-day life. He still manages symptoms of depression and has suicidal thoughts sporadically. Today, he acknowledges them, but he knows they will pass; they always do. Devastatingly, in 2018, Eric’s best friend Cody died by suicide. Cody realized he was transgender and came out to Eric within a year of them meeting. Cody seemed so optimistic after he came out that Eric never expected Cody’s depression to reach such a lethal place. Cody also dealt with PTSD (Post-Traumatic Stress Disorder) and never received adequate care for his mental health. Cody made it clear that discovering he was transgender and then transitioning kept him living as long as he did. Before his death, Cody told Eric that, had he never transitioned, he would have killed himself years prior. However, as Eric summarizes, “knowing who you really are and transitioning can save your life, but it’s not everything. It is a part of it, but you still have to make the rest of your life work. I miss [Cody] every day but when I think about him, it’s a reminder that I need to make the rest of my life work better so I don’t end up like that. I have been on testosterone for nine years. I had top surgery. I look the way I want to, sound the way I want to, but the rest of my life is still very far from perfect, and that’s the part I need to be focusing on.”

values, minority group members may experience internal and environmental conflict as a result of having different belief systems from the majority. Each minority group has a unique set of relevant stressors associated with poorer health outcomes for members of that particular group. Hendricks and Testa identified minority stressors for this population by considering adverse experiences due to societal transphobia including: rejection, victimization, and/or internalized transphobia.7 Minority stress studies with gender expansive samples show that being disenfranchised, victimized or experiencing transphobia increases suicide risk.8,9 Another stressor particular to this population is the experience of being referred to by a pronoun or name that is not affirming, especially when done maliciously or repetitively. To be misgendered (to have one’s gender identity misclassified) is an adverse experience uniquely damaging to those who are gender expansive.10,11 Being gender expansive represents just one aspect of identity out of many that one might hold, and if other identities also have minority status, they too will come with their own set of stressors. A tremendous number of people are part of multiple minority groups. Gender expansive youth might also be: black or another racial minority, disabled, mentally ill, a member of a non-dominant religion, an immigrant, of low socioeconomic status, and so on. The greater the difference between one’s value system and that of the majority, the more distress one is likely to experience as a result. One value that segments the gender expansive community is identification as either binary (male- or female-identified, as a majority of people in society), or not. Those who are nonbinary (people who identify as neither ‘male’ nor ‘female’) in particular, seems be most at risk of suicide.12,13 This demonstrates another application of minority stress for this population.

PREVALENCE

RISK FACTORS

Current suicide rates of young people in general reflect a large public health problem. Sadly, suicide rates for individuals who are gender expansive are several times higher. Between 2015–2016, 7.2% of the general population of high school students in Delaware reported attempting suicide.1 In contrast, over one-third (35%) of gender expansive high school students reported attempting suicide in 2018.2 In Delaware, 1,100 youth are estimated to be gender expansive.3 Throughout the US, approximately 2% of high school students surveyed reported being transgender.2 Even though the gender expansive community is a small minority, they are affected so disproportionately by suicide that specific consideration is warranted.

Suicidal Risk Factors are characteristics, internal or external, that make it more likely that one might consider, attempt, or die by suicide.14 According to the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Suicide Prevention Resource Center, they include14,15:

ETIOLOGY Being gender expansive is not the cause of mental illness. On the other hand, experiencing regular hostility and discrimination, like so many who are gender expansive do, can be traumatic and increase the likelihood of having mental health problems as a result.4 Psychological distress for most people who are gender expansive is thus due to a lack of social acceptance and the pervasiveness of transphobia. This response makes sense if considered from the perspective of the minority stress model.5,6 This model explains that, because of differences between minority and dominant cultural

Personal/psychological Factors • Presence of mental health disorder(s) and/or alcohol/ substance abuse • Antisocial and/or maladaptive behaviors, including self-injury • Previous suicide attempts • Genes/neurobiology predisposing one to suicidality • Impulsive, risk-taking, reckless tendencies • Feeling hopeless, lonely/isolated/alienated, like a burden, and/or having low self-esteem • Lacking adaptive coping skills • Seeing oneself as severely overweight or underweight • Risky sexual behavior, delinquency, and/or aggressive or violent behavior

Adverse Experiences • Grief, loss, or other interpersonal challenges (risk is especially heightened for those exposed to a peer dying by suicide) 19

• • • •

Victimization (bullying, abuse, etc.) Legal or discipline problems Challenges at school or work Chronic illness or disability

Familial Factors • Parental divorce, death, mental health problems, or relationship problems • Relatives with suicidal behavior

Environmental Characteristics • Lack of: community-wide acceptance of differences, common value of equality, positive relationships with school staff & students, pro-social beliefs, safety/security, and/or mental health care. • Presence of: bullying, violence, other hostile behaviors, weapons (particularly if accessible within the home), peer suicide, stigma or discrimination based on gender/sexual identity, race, disability, or physical traits

ENHANCING RESILIENCE Protective factors are personal or environmental characteristics that reduce the probability that someone will consider, attempt, or die by suicide. Protective factors can minimize the effects of risk factors. The capacity to cope adaptively with the effects of risk factors or adverse experiences is called resilience. Actions to enhance protective factors serve to boost resilience and are an essential element of an effective suicide prevention effort. Strengthening these factors also protects youth from other risks, including violence, substance abuse, and academic failure.14 Protective Factors suggested for the general population are listed below15:

Individual Characteristics and Behaviors • Adequate self-esteem, self-efficacy, optimism, and an overall upbeat affect • Emotional intelligence, easy-going temperament • Coping skills including problem-solving abilities, conflict resolution, emotional regulation, and frustration tolerance • Cultural and religious beliefs that respect and value life and discourage suicide • Healthy relationship with one’s body to include: perception of body image, personal care/hygiene, regular physical activity, and overall concern for one’s physical self

Family and Other Social Support • Connection to supportive parents and other family members, and parental involvement (especially as connected to school) • Close friends or family members, a caring adult, and other social support(s) • Pro-social norms within the householdSchool • Positive relationship with school, including average or better academic achievement • Real and perceived safety at school (especially relevant for this population) • A school environment that promotes diversity and respect 20 Delaware Journal of Public Health – June 2019

Health • Easy access to mental health services, physical healthcare, and treatment (if needed) for substance abuse disorders • Positive relationship with providers

Environment • Restricted access to means including guns, medications, alcohol, and firearms • Safety barriers in place at dangerous locations in the community (such as bridges)

SPECIFIC IMPLICATIONS FOR GENDER EXPANSIVE YOUTH A swift and effective response to this crisis is urgently needed. Those with the ability to create impactful change, small or large, should consider taking action to enhance the resilience and wellbeing for the gender expansive community. Moody, Fuks, Peláez and Smith organize trans-specific protective factors into categories of social support, gender identity-related, transitionrelated, individual differences, and reasons for living.16 This article will utilize those categories and expand upon recommendations for suicide prevention specifically for gender expansive youth based on the literature. As seen in most cultures and subcultures, those with multiple minority identities face a heightened risk of experiencing adversity. Thus, for those who are marginalized or oppressed in ways other than gender, meaningful, supportive relationships are vital to combating minority stress. If social support is inadequate, strengthening it is an important goal. There is also great benefit from exploring and processing gender/identity, reviewing reasons for living, and for some, transitioning. Through affirming referrals to healthcare providers and community resources, gender expansive youth will have options available to increase their resilience.

SOCIAL SUPPORT There is a positive correlation between perception of support and mental health for gender expansive youth.17 Those who report feeling accepted do not have disproportionately high rates of depression compared to cisgender peers.12 In contrast, not feeling accepted is associated with higher rates of mental illness. This is part of the reason it is important to connect gender expansive youth with those they can relate to, as well as other community supports. It is helpful to have knowledge of resources for social and/or support groups, education, assistance, and other needs of this population, their families, and their communities. If one seeks to be a support for those who are gender expansive, being affirming is the first step. When the name and pronoun that feel affirming are used, gender expansive youth feel accepted and safe. Incorrectly addressing or misgendering a gender expansive youth can be harmful and should be avoided. Modeling gender-affirming behavior helps to normalize it, which can be beneficial for families. However, not all families are going to be supportive – rejection is a reality for many of these youth. As mentioned, if family support is lacking, other positive relationships become a critically-important protective factor.18

GENDER IDENTITY-RELATED FACTORS

CONCLUSION

Gender education is essential. When gender expansive youth gain awareness and develop insight into their gender identity, their risk of suicide declines.16 It is also protective to increase acceptance (of self and gender), and to transition, if/as desired. It is a myth that everyone knows their gender identity by a young age.19 For many, gender evolves over time, and childhood gender experimentation is a part of typical development. It is important for all youth to feel safe to learn about and explore gender, so they can better understand themselves and the world. For those who are not cisgender, it is an essential prerequisite to developing a sense of self, and (ideally) of pride in one’s identity. Those who wish to make the world a safer place for gender variance can address environmental factors that might be harmful to this population, and do what is possible to increase inclusivity of spaces. It is also important to have current, accurate knowledge, including of gender-affirming resources, particularly those that promote identity development and provide community education.

Suicide rates of gender expansive youth are devastatingly high and require attention. Societal transphobia is ultimately the cause of the disparity of the rates. While overcoming transgender discrimination might seem daunting, there are many steps that can be taken to positively impact health outcomes for this population. Everyone should ask and use gender-affirming name and pronouns. Families, schools, and communities need resources to become more informed and supportive. Gender expansive youth should be connected with affirming, competent medical providers. Participating in therapy can make a profound impact on resilience. It provides a meaningful relationship that might itself be protective, and often considered an essential part of a support system. Therapy helps clients learn coping skills, recognize reasons for living, correct problematic thinking, build hope, and improve relationships. Linking this population to mental health support, including crisis services should be prioritized. If suicidality is disclosed, find emergency help right away by calling 9-1-1 or your local crisis response department. For other times, there are two gender-affirming suicide helplines available throughout the US: The Trans Lifeline at (877) 565-8860, and the Trevor Project at (866) 488-7386 or online via instant message, chat or text at http://www.thetrevorproject.org/section/get-help

TRANSITION-RELATED FACTORS Not everyone who is gender expansive decides to transition, but for those who do, each journey is unique. Risks and benefits of various options are examined, desired outcomes are considered, and accessibility is taken into account. For those who choose to transition, there are three aspects of the process that can be protective, including coming out/disclosing, hope of transitioning, and actively transitioning. When gender expansive youth are able to socially transition and use a name that is affirming, they are 65% less likely to attempt suicide compared to those who are not, and their suicidal thoughts decline by 35%.12 Make it standard practice to ask about, rather than assume, pronouns as well. Direct advocacy might include asking about and respecting what is affirming, but there are endless other ways to make the world a safer place for those who are gender expansive. Some examples are improving school safety and inclusivity, building/sharing accurate education about this population, or donating time or money to gender-affirming programs or groups.

INDIVIDUAL DIFFERENCE FACTORS Some individual differences are unlikely to be influenced by external sources, such as the personality trait of being optimistic or one’s genetic capacity for resilience. However, effective therapeutic interventions can positively impact other protective factors including one’s use of effective coping strategies, problem solving skills, and ability to self-regulate. A qualified mental health provider can help clients acquire cognitive tools to negate problematic thinking and eliminate maladaptive behavior.

REASONS FOR LIVING An effective therapist will encourage their suicidal client to explore reasons for living. Clients might be asked to share their beliefs about survival, and about suicide, allowing the clinician to search for embedded protective factors or areas that should be more protective. A client might also be asked to discuss negative aspects of suicide. If they are afraid of dying, fear can be protective and should be explored. Having a sense of responsibility toward meaningful individuals as well as being a role model to others are both protective. For some, spiritual/religious beliefs offset suicidality as well.

REFERENCES 1. Centers for Disease Control and Prevention (CDC). (2017). 2017 High School Youth Risk Behavior Survey Data. Retrieved 2 March 2019 from: https://nccd.cdc.gov/youthonline/App/Results.aspx?LID=DE 2. Johns, M. M., Lowry, R., Andrzejewski, J., Barrios, L. C., Demissie, Z., McManus, T., . . . Underwood, J. M. (2019, January 25). Transgender identity and experiences of violence victimization, substance use, suicide risk, and sexual risk behaviors among high school students— 19 states and large urban school districts, 2017. MMWR Morb Mortal Wkly Rep, 68(3), 67–71. https://doi.org/10.15585/mmwr.mm6803a3 3. Herman, J., Flores, A., Brown, T., Wilson, B., & Conron, K. (2017). Age of individuals who identify as transgender in the United States. Los Angeles, CA: The Williams Institute. Retrieved 4 January 2019 from: https://williamsinstitute.law. ucla.edu/wp-content/uploads/TransAgeReport.pdf 4. Baum, J., Brill, S., Brown, J., Delpercio, A., Kahn, E., Kenney, L., & Nicoll, A. (2013). Supporting and caring for our gender expansive youth. Human Rights Campaign. Retrieved 2 February 2019 from: https://issuu.com/humanrightscampaign/ docs/gender-expansive-youth-report-final/28 5. Meyer, I. H. (1995, March). Minority stress and mental health in gay men. Journal of Health and Social Behavior, 36(1), 38–56. https://doi.org/10.2307/2137286 6. Meyer, I. H. (2003, September). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin, 129(5), 674–697. https://doi.org/10.1037/0033-2909.129.5.674 7. Hendricks, M., & Testa, R. (2012). A conceptual framework for clinical work with transgender and gender nonconforming clients: An adaptation of the Minority Stress Model. Professional Psychology, Research and Practice, 43(5), 460–467. https://doi.org/10.1037/a0029597 21

8. Clements-Nolle, K., Marx, R., & Katz, M. (2006). Attempted suicide among transgender persons: The influence of gender-based discrimination and victimization. Journal of Homosexuality, 51(3), 53–69. https://doi.org/10.1300/ J082v51n03_04

14. Suicide Prevention Resource Center. (2008). Suicide risk and prevention for lesbian, gay, bisexual, and transgender youth. Newton, MA: Education Development Center, Inc. Retrieved 21 January 2019 from http://www.sprc.org/sites/default/files/ migrate/library/SPRC_LGBT_Youth.pdf

9. Nuttbrock, L., Hwahng, S., Bockting, W., Rosenblum, A., Mason, M., Macri, M., & Becker, J. (2010, January). Psychiatric impact of gender-related abuse across the life course of maleto-female transgender persons. Journal of Sex Research, 47(1), 12–23. https://doi.org/10.1080/00224490903062258

15. Substance Abuse and Mental Health Services Administration (SAMHSA). (2012). Preventing Suicide: A Toolkit for High Schools. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration. Retrieved 29 January 2019 from: https://store.samhsa.gov/ product/Preventing-Suicide-A-Toolkit-for-High-Schools/ SMA12-4669

10. Ansara, Y., & Hegarty, P. (2014). Methodologies of misgendering: Recommendations for reducing cisgenderism in psychological research. Feminism & Psychology, 24, 259– 270. https://doi.org/10.1177/0959353514526217 11. McLemore, K. (2018). A minority stress perspective on transgender individuals’ experiences with misgendering. Stigma and Health, 3(1), 53–64. https://doi.org/10.1037/ sah0000070 12. Russell, S. T., Pollitt, A. M., Li, G., & Grossman, A. H. (2018, October). Chosen name use is linked to reduced depressive symptoms, suicidal ideation, and suicidal behavior among transgender youth. J Adolesc Health, 63(4), 503–505. https:// doi.org/10.1016/j.jadohealth.2018.02.003 13. Toomey, R. B., Syvertsen, A. K., & Shramko, M. (2018, October). Transgender adolescent suicide behavior. Pediatrics, 142(4), e20174218. https://doi.org/10.1542/peds.2017-4218

16. Moody, C., Fuks, N., Peláez, S., & Smith, N. (2015). “Without this, I would for sure already be dead”: A qualitative inquiry regarding suicide protective factors among trans adults. Psychology of Sexual Orientation and Gender Diversity, 2(3), 266–280. https://doi.org/10.1037/sgd0000130 17. Olson, K. R., Durwood, L., DeMeules, M., & McLaughlin, K. A. (2016, March). Mental health of transgender children who are supported in their identities. Pediatrics, 137(3), e20153223. https://doi.org/10.1542/peds.2015-3223 18. Moody, C., & Smith, N. G. (2013, July). Suicide protective factors among trans adults. Archives of Sexual Behavior, 42(5), 739–752. https://doi.org/10.1007/s10508-013-0099-8 19. Erickson-Schroth, L., & Jacobs, L. (2017). "You're in the wrong bathroom!" and 20 other myths and misconceptions about transgender and gender nonconforming people. Boston, MA: Beacon Press.

Health Science Career Panel With a focus on Medicine and Public Health Sunday, September 15, 2019 1:00 to 2:30pm Wilmington Friends School Theater • For students in middle and high school • Featuring a panel of health science professionals • Learn about career opportunities • Hear what you can do in high school and beyond Visit www.wilmingtonfriends.org to register No registration fee

22 Delaware Journal of Public Health – June 2019

SAVE THE DATE October 3, 2019 7:30 AM to 12:30 PM

John Scholz Stroke Education Conference John H. Ammon Medical Education Center Christiana Hospital Registration opening July 2019 23

Improved Data Collection for Our LGBTQ Population is Needed to Improve Health Care and Reduce Health Disparities Karyl T. Rattay, M.D., M.S. Director, Division of Public Health, Delaware Department of Health and Social Services

Providing the best possible health care and interventions to Delawareans requires us to understand the health disparities that may exist among populations. When data collection efforts include demographics for lesbian, gay, bisexual, transgender and questioning (LGBTQ) individuals, our health systems can become more culturally responsive and inclusive. However, information on health conditions by sexual orientation and gender identity is hard to find because the data are not routinely collected. Approximately 4.5 percent of the U.S. population identified themselves as LGBT in an analysis of 2017 Gallup poll data by Williams Institute of the School of Law at University of California, Los Angeles (UCLA).1 Overall, 5.1 percent of women and 3.9 percent of men identified as LGBT. LGBT identification is also higher in those with lower incomes, and among racial and ethnic minorities.2 Survey data on LGBT populations are available and collected in several national and state surveys such as the Centers for Disease Control (CDC)-funded Behavior Risk Factor Surveillance System (BRFSS) and the Youth Risk Behavior Survey (YRBS). Among Delaware adults, about 5.2 percent identify as LGBT, according to the 2017 Delaware Behavioral Risk Factor Survey (BRFS), an annual survey of about 4,000 adults that reports both state and national data. It has only been in the last four years that BRFS has included questions which allow individuals to identify as LGBT. Much of Delaware’s state-level data related to LGBT individuals are suppressed, meaning that they cannot be used to interpret data specific to this population when looked by a single year because the sample size is not large enough to be valid. Eventually, DPH will be able to aggregate three or four years of data and do rolling averages for adults.3 The Delaware YRBS that is completed every other year in public high schools asks questions about LGBTQ, with the Q referring to “Questioning” – which is much more common in this age group. Eleven percent of respondents to the 2017 High School YRBS identified as lesbian, gay, or bisexual; an additional three percent were unsure of their sexual orientation and just over one percent identified as transgender.4 Asking about sexual orientation is slowly becoming more common in surveys. Federal health forms typically do not include sexual orientation questions, and gender questions are limited to male/ female. Eight national data systems collect sexual orientation data, including the National Health Interview Survey (added in 2013), and the National Survey of Drug Use and Health (added in 2015).5 A gender identity question was included in the Health Resources and Services Administration’s 2013 and 2014 National Health Service Corps Patient Satisfaction Surveys and the 2014 NURSE Corps Participant Satisfaction Survey.6 Public health workers generally agree that sexual orientation and gender identity data are limited and mainly regard adolescents. The LGBT companion document to Healthy People 2010 recognized the need for sexual orientation and gender identity data “to document, understand, and address the environmental factors that contribute to health disparities in the LGBT community.”7,8 The Institute of Medicine raised the need for further gender 24 Delaware Journal of Public Health – June 2019

minority research in the 2011 report, The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding9 as well as in a 2012 workshop summary.10 Its authors, a committee of experts, recommended collecting sexual orientation and gender identity data in U.S. health surveys and other federally funded surveys, in electronic health records among other demographic information collected. HHS’ Agency for Healthcare Research and Quality has included LGBT information in its National Healthcare Quality and Disparities Reports since 2011, but in 2017 noted that few databases support LGBT analyses.11 Currently, the nation’s Healthy People 2020 (HP 2020) initiative contains seven LGBT data objectives. Objective LGBT-2.2 is to increase the number of states, territories, and the District of Columbia that use a provided module on sexual orientation and gender identity questions in the BRFSS from 20 in 2014 to 22 in 2020. Objective 2.3 is to do the same in the Youth Risk Behavior Surveillance System (YRBSS) from 28 in 2015 to 31 in 2020 (see Table 1).12 Table 1. Healthy People 2020 LGBT Data Initiatives Initiative

Description

1.0

Increase the number of population based data systems used to monitor Healthy People 2020 objectives that include in their core a standardized set of questions that identify lesbian, gay, bisexual, and transgender populations

1.1

Increase the number of population based data systems used to monitor Healthy People 2020 objectives which collect data on (or for) lesbian, gay and bisexual populations

1.2

(Developmental) Increase the number of population based data systems used to monitor Healthy People 2020 objectives which collect standardized data that identify lesbian, gay and bisexual populations

1.3

Increase the number of population based data systems used to monitor Healthy People 2020 objectives which collect data on (or for) transgender populations

1.4

(Developmental) Increase the number of population based data systems used to monitor Healthy People 2020 objectives which collect standardized data that identify transgender populations

2.0

Increase the number of states, territories, and the District of Columbia that include questions that identify sexual orientation and gender identity on state level surveys or data systems

2.1

Increase the number of states, territories and the District of Columbia that include questions on sexual orientation and gender identity in the Behavioral Risk Factor Surveillance System (BRFSS)

2.2

Increase the number of states, territories and the District of Columbia that use the provided module on sexual orientation and gender identity in the Behavioral Risk Factor Surveillance System (BRFSS)

2.3

Increase the number of states and territories that use the provided module on sexual orientation and gender identity in the Youth Risk Behavior Surveillance System (YRBSS)

Other than BRFS and the YRBS, which are administered through the Division of Public Health (DPH), our agency does not collect sexual orientation or gender identity data on its forms and data surveys, but may gather such data via risk assessments and key informant surveys. Whenever possible, DPH analyzes sexual orientation data and includes it in data reports, data briefs, and professional articles when the sample sizes are large enough. Small data pools prevent the analysis of risk factors, diseases, and lifestyles, especially if there is already low prevalence. For the most accurate data representations, researchers must aggregate several years of data to overcome wide confidence intervals. For example, DPH is aggregating multiple years of BRFS data and reviewing the LGBT responses to determine adult LGBT smoking prevalence in comparison to the general adult population. “By asking these questions, you are legitimizing the LGBT community,” said Salvatore Seeley, Director of Health and Wellness for CAMP Rehoboth,13 a 501(c)(3) nonprofit community service organization dedicated to creating a positive environment inclusive of all sexual orientations and gender identities. “It’s altruistic in a way, but it’s also empowering to a community that is largely excluded.” Demographic survey questions, typically limited to binary (male/ female) choices, should become more culturally appropriate and centric, Seeley said. He noted the importance of giving people the opportunity to self-describe their sexual orientation and their gender. Transgender individuals express their gender differently; others might be agender (no particular gender) or bi-gender (any two genders) individuals. CAMP Rehoboth suggests these sample answers through its culturally inclusive trainings: • Male/Female, Prefer to self-describe, Prefer not to say • Male/Female, Non-binary, Third gender • Do you identify as transgender? Yes/No, Prefer not to say. While it would be inclusive for data collection points to ask if one is heterosexual or other (lesbian, gay, bisexual), having those data might not change how we address a health problem. For instance, Delaware’s HIV Program collects “men having sex with men” data because it is a risk factor. Women having sex with women are at much lower risk. In other areas, such as infant mortality, sexual orientation variables may not be needed for health care professionals to do their work. Expanding data collection tools to include sexual orientation and gender identity could result in the public health community being aware of disease and health behaviors that it may or may not be adequately addressing. LGBT Delawareans represent many distinct population groups, each with their intrinsic health needs. Having LGBT data to access can assist health providers and educators in streamlining their care and outreach efforts. Customized, culturally competent interventions can reduce LGBT health disparities. “Delaware is losing out by not truly understanding the needs and wants of the LGBTQ population,” Seeley said. “LGBT people have specific health needs and we get clumped in the general group [of respondents].” Let’s look at some of the health issues that have been identified through data collection. Nationally, among gay, bisexual, and other men who have sex with men, there are higher risks of sexually transmitted diseases, especially among communities of color. HIV

prevalence among gay and bisexual men is 40 times that of sexual partners of heterosexual men. Seventy-five percent of reported 2012 syphilis cases were among gay and bisexual men.14 Gay, bisexual, and other men who have sex with men are 17 times more likely to get anal cancer than heterosexual men and face major depression, generalized anxiety disorder, and bipolar disorder.15 Based on national data, tobacco use is also higher among gay and bisexual men than heterosexual men. Also nationally, lesbians and bisexual women are more likely to be overweight or obese, and lesbians are less likely to get cancer screenings, according to the U.S. Department of Health and Human Services (HHS).16 Transgender individuals are at risk of acquiring HIV and STDs, being victimized, having mental health issues, and attempting suicide, as well as not having health insurance. Elderly LGBT individuals must overcome isolation and at times, a lack of social services and culturally competent providers.5 Turning our focus to LGBTQ youth, it is clear that an additional set of issues present themselves, some that are addressed through a social determinants of health lens. For LGBTQ youth, interpersonal and internal conflicts – and not sexual orientation itself – may increase substance use risk behaviors and poor mental health due to stigma and stress as contributing risk factors.17,18 LGBTQ youth are also more likely to be homeless.5 Two meta-analytic reviews of national data found that on average, lesbian, gay, and bisexual youth were 190 percent more likely to misuse substances than heterosexual youth; and they were significantly more prone to depression and suicide attempts, as they noted that they suffered from victimization, discrimination, and stress.17,18 Data from Delaware’s 2017 YRBS, which sampled 2,906 public high school students, show that the rate of current cigarette use is more than double among Delaware LGBTQ youth compared to heterosexual youth. Thirty-two percent of sexual minority youth surveyed reported using marijuana in the past 30 days, compared to 23 percent of their heterosexual peers. The reported use of prescription pain medicine in the past month was twice as high among LGBTQ students compared to heterosexual students.4 Regarding mental health, 52.5 percent reported feeling sad or hopeless for two weeks or more in the preceding year. Nearly 39 percent of LGBTQ students and 10 percent of heterosexual youth purposefully injured themselves (without intending death) at least once in the past year. Slightly more than 30 percent of Delaware LGBTQ youth planned suicide within the past year, compared to 9 percent of their heterosexual peers; and 18 percent attempted suicide at least once within the last year, compared to 5 percent of their heterosexual peers. Getting bullied on school property and electronically on social media occurred less among heterosexual students and more among LGBQ students, who also reported being more likely to bring a weapon to school.4 How can these data be useful to health care providers? Providers who are aware of their patients’ gender identity and sexual orientation are more likely to screen them for certain conditions identified based on data trends. Additionally, particularly for younger patients, providers would be more likely to monitor them for signs of struggling with emotional issues or substance use disorder, and refer them to counseling or connect them with appropriate treatment sooner. Cultural competency plays a huge role in positive provider-patient interactions and welcoming LGBT individuals to health care delivery sites. When LGBT persons are mistreated or ostracized by society, 25

they tend to avoid doctor’s visits. Many LGBT individuals may be reluctant to disclose their true orientation to health care providers because they fear rude and discriminatory reactions, or that their status could become public. When kindness and respect pervade care delivery sites, LGBT persons are more comfortable with disclosing their orientation, allowing providers the opportunity to screen them for relevant behaviors and conditions. Sharing sexual orientation and gender identity on a form, rather than verbally to a nurse, was nearly three times more likely to result in patients identifying as LGBTQ than among non-LGBT patients.19 However, they have a very real concern that their personal information could be made public. It would be immensely helpful if a national assembly of federal and state data professionals, would formally discuss sexual orientation and gender identity data collection and provide recommendations. State and federal agencies can be surveyed about current data collection efforts. The group can study the value and feasibility of collecting such data and issue guidance that includes model survey questions and how to interpret LGBT findings correctly, especially when numbers are small and confidence intervals are wide. The National Institutes of Health’s Office of Sexual and Gender Minority Research (OSGMR), established in 2015 to increase sexual and gender minority (SGM) knowledge and remove research barriers, might be an appropriate lead agency.20 Not too long ago, it was a big step for Delaware to include persons of Hispanic ethnicity in its data collections. It’s time to expand data collections to include sexual orientation and greater gender choices to enhance our knowledge of health needs that we may not be addressing – or on the flip side, of prime LGBTQ health behaviors of which we are unaware. Data collections should represent all Delawareans with dignity.

REFERENCES 1. LGBT Demographic Data Interactive. (2019, Jan). The Williams Institute, UCLA School of Law. Retrieved from https://williamsinstitute.law.ucla.edu/visualization/lgbtstats/?topic=LGBT#density 2. Streed, C. G., Jr., McCarthy, E. P., & Haas, J. S. (2018, October). Self-reported physical and mental health of gender nonconforming transgender adults in the United States. LGBT Health, 5(7), 443–448.https://doi.org/10.1089/lgbt.2017.0275 3. Delaware Department of Health and Social Services. Division of Public Health, Delaware Behavioral Risk Factor Survey (BRFS), 2017. Retrieved from: https://dhss.delaware.gov/dhss/dph/dpc/brfsurveys.html 4. 2018 Delaware State Epidemiological Profile: Substance Use and Related Issues, prepared by the University of Delaware Center for Drug and Health Studies and its State Partners for The Delaware SPF-PFS Program, Delaware Division of Substance Abuse and Mental Health, and The State Epidemiological Outcomes Workgroup, p. 18. https://www.cdhs.udel.edu/seow/reports-and-products

7. Gay and Lesbian Medical Association and LGBT health experts. (2001). HealthyPeople 2010 Companion Document for Lesbian, Gay, Bisexual, and Transgender (LGBT) Health. 8. National Institutes of Health FY 2016-2020 Strategic Plan to Advance Research on the Health and Well-being of Sexual and Gender Minorities https://dpcpsi.nih.gov/sites/default/files/sgmStrategicPlan.pdf 9. Institute of Medicine. (2011). The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. Retrieved from: http://nationalacademies.org/hmd/reports/2011/the-health-oflesbian-gay-bisexual-and-transgender-people.aspx 10. IOM (Institute of Medicine). (2012). Collecting Sexual Orientation and Gender Identity Data in Electronic Health Records: Workshop summary. Washington, DC: The National Academies Press. Retrieved from: http://nationalacademies.org/ hmd/reports/2012/collecting-sexual-orientation-and-genderidentity-data-in-electronic-health-records.aspx 11. 2017 National Healthcare Quality and Disparities Report – Introduction and Methods, U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality, p.8. Retrieved from: https://www.ahrq.gov/sites/default/files/ wysiwyg/research/findings/nhqrdr/2017nhqdr-intro-methods.pdf 12. Healthy People. 2020. (2019). Retrieved from https://www.healthypeople.gov/2020/data-search/Search-theData#topic-area=3494 13. Rehoboth, C. A. M. P. https://www.camprehoboth.com/ 14. Centers for Disease Control and Prevention (CDC). (2019). For your health: Recommendations for a healthier you. Retrieved from https://www.cdc.gov/msmhealth/for-your-health.htm 15. CDC. (2019). Mental Health. Retrieved from https://www.cdc.gov/msmhealth/mental-health.htm 16. Struble, C. B., Lindley, L. L., Montgomery, K., Hardin, J., & Burcin, M. (2010). Overweight and obesity in lesbian and bisexual college women. J Am Coll Health, 59(1), 51–56. https://doi.org/10.1080/07448481.2010.483703 17. Marshal, M. P., Friedman, M. S., Stall, R., King, K. M., Miles, J., Gold, M. A., . . . Morse, J. Q. (2008, April). Sexual orientation and adolescent substance use: A meta-analysis and methodological review. Addiction (Abingdon, England), 103(4), 546–556. https://doi.org/10.1111/j.1360-0443.2008.02149.x 18. Marshal, M. P., Dietz, L. J., Friedman, M. S., Stall, R., Smith, H. A., McGinley, J., . . . Brent, D. A. (2011, August). Suicidality and depression disparities between sexual minority and heterosexual youth: A meta-analytic review. J Adolesc Health, 49(2), 115– 123. https://doi.org/10.1016/j.jadohealth.2011.02.005

5. U.S. Department of Health and Human Services. (2019). Office of Disease Prevention and Health Promotion, Healthy People 2020, https://www.healthypeople.gov/2020/topics-objectives/topic/ lesbian-gay-bisexual-and-transgender-health

19. Haider, A., Adler, R. R., Schneider, E., Uribe Leitz, T., Ranjit, A., Ta, C., . . . Lau, B. D. (2018, December 7). Assessment of patient-centered approaches to collect sexual orientation and gender identity information in the emergency department. The EQUALITY Study. JAMA Network Open, 1(8), e186506. https:// doi.org/10.1001/jamanetworkopen.2018.6506

6. U.S. Department of Health and Human services. (2019). www.hhs.gov

20. Sexual and Gender Minority Research Office. (2019). National Institutes of Health. https://dpcpsi.nih.gov/sgmro

26 Delaware Journal of Public Health – June 2019

Did you know that according to CDC data, Delaware still has 13.49/100,000 cases of HPV cancers annually despite the launch of the Human Papillomavirus (HPV) vaccine in 2006? Even with Delaware surpassing the nation in HPV vaccination and series completion, we still have opportunities to achieve the Healthy People 2020 HPV vaccination goals of 80%. These goals look to increase the percentage of female and male adolescents receiving the ACIP-recommended number of appropriately spaced doses of HPV vaccine based on their age at initiation of HPV vaccination. Quality Insights is actively working with the Division of Public Health (DPH) Immunization Department to increase HPV vaccination rates. Through collaborative discussions and by using the Delaware Immunization Information System (IIS), DelVAX, practices are identifying opportunities for both initiation of the HPV series and series completion. Although Delaware has an initiation rate of 75.3 and an UTD (up to date) rate of 58.1% according the National Immunization Survey (NIS) teen data, opportunities exist for meeting the Healthy People 2020 goal of 80%. Small practices and health systems have begun to successfully review their DelVAX data and reports and implement workflows to increase rate today, to help prevent cancer tomorrow. One health system identified the need to remind patients of the 2nd/3rd dose. They are now implementing patient reminders for nurse visits as a system implementation. At a practice level, they are identifying goals for first and second dose and identifying workflows that fit the needs of their population, including using electronic health record (EHR) inbox reminders, running patient lists, and scheduling patients before they leave.

CONTACT INFORMATION For more details about the Quality Insights Improving HPV Vaccination Rates in Delaware project, please email Lisa Gruss or call 1.800.642.8686, Ext. 138. 27

A Mother’s Story Sally McBride

Sally and David McBride’s youngest child came out as transgender on Christmas Day 2011 as a junior at American University. The news rocked their world. Here is their story as told by Sally.

We have three children. Our oldest child, Sean, told us at his college graduation in 2003 that he was in love, but that it was complicated. He wasn’t ready to give us the details. We told him that when he was ready, we would be there for him. Three months later, as a first year medical student, he told us he was in love with a man. We were shocked, but told him we loved and supported him. My biggest concern was that he would be defined by being gay; being gay is a part of who he is, but he is so much more. My husband was looking forward to being a grandfather, and Sean assured him that he wanted to have children. We weren’t worried about his future, as he was at Yale Medical School on his way to becoming a doctor, and we knew many gays and lesbians who were happy, healthy and fulfilled. And then on Christmas Day 2011, our youngest child, then a junior at American University, president of the student body, and who we believed to be our son at the time, came out to us as transgender. We were totally blindsided. I was devastated, crying uncontrollably. I saw my child’s future crumble, feared violence and envisioned discrimination at every turn. Dave went online immediately to the National Center for Transgender Equality, one of the leading transgender advocacy groups in the country. When he read that more than 40% of transgender people attempt suicide, his heart dropped. But he also read that that with a loving and supportive family, that percentage drops in half. And with a supportive community, it drops even further. We knew that we would support her and do everything possible to make sure that she felt loved and respected and that she would be safe. But this news was life changing. My first response on hearing her news was, “please don’t do this. I don’t want to lose my son.” Sarah responded with, “you are keeping your son, and gaining a daughter.” Sarah was the name she gave us that first day - her true authentic self.

“Can’t you wait until you graduate?” I asked. “No. I have waited 21 years to be who I truly am. If I wait any longer, I could become depressed, start using drugs or attempt suicide.” Dave, Sarah and I spent the next three days talking. We asked our daughter question after question, trying to understand what she was going through, and what being transgender meant. She explained that she had known since she was five years old that she was different, that she was a girl. In every dream, she was a girl. At ten, while watching a sitcom with a transgender woman, she asked me who the woman was. It was the first time that she realized that someone like her existed. She wasn’t alone. At 13, her love of politics blossomed while working as a volunteer on a political campaign in our home state of Delaware. As her passion for politics and her own political aspirations grew, she feared that her dreams and being transgender were mutually exclusive, so she hid her true authentic self. She appeared to be a happy kid. Sarah explained that it was as student body president at American University starting in the fall of 2011, while working on such issues as gender neutral housing at an extremely diverse and inclusive school, that she realized that she needed to come out as transgender. Our sons rallied around the three of us. Our middle child, Dan, assured us that he was straight, adding a bit of levity and humor to a difficult situation. And Sean and his husband immediately drove from Brooklyn to be with us. Though I would never equate the death of a child with this situation, I felt like I was losing my child. Over the next several months, I went through the stages of grief: first denial and anger, feeling sorry for myself, and pity, but finally acceptance. During those first several days, Dave and I decided that we needed to be proactive in our journey to understanding what Sarah was experiencing, and making sure that she was healthy emotionally and physically. To that end, Sean reached out to one of the leading psychiatrists in this country who treats transgender children, Dr. Edgardo Menvielle, at Washington DC Children’s Hospital, and set up an appointment for the three of us just five days after Christmas. Dr. Menvielle met with Sarah first, then Dave and me next, and finally the three of us together. He confirmed that Sarah was transgender, and that she did not have any other psychological issues other than the gender dysphoria. He felt confident that she could reach her full potential and that her future was still bright. For the first time over the last several days, he gave us hope for our child.

Sarah, Sally, and Dave

28 Delaware Journal of Public Health – June 2019

The following week, Dave and I met with two sets of parents who lived nearby who have transgender adult children. They were

introduced to us by the pastors at our progressive Presbyterian Church. It was so affirming to meet parents who had made it successfully through this journey and whose children were happy. Sarah had gone back to college and begun to tell her friends and some professors that she was transitioning, and was met with total acceptance. But she wanted to wait to tell everyone until the end of her term as student body president on April 30. She didn’t want her news to embarrass the school she had come to love. At home, we began to tell our extended family and close friends, and asked everyone to keep it confidential until Sarah gave us permission to tell all. I met individually and in small groups with my friends to tell them about Sarah. This news is not something that is quickly told. There are so many myths and misconceptions about what it means to be transgender, and we felt it important to educate people on the facts. Dave told several members of his law firm, and we both told our closest friends at our church. We wanted to show our friends that we were proud of our daughter, respected her, and so admired the courage it took to be her true authentic self. It was important not to present ourselves as victims, but to present a united, loving and supportive family. We were met with nothing but acceptance. I don’t want to leave you with the impression that the several months after learning that Sarah was transgender was a smooth ride. As I mentioned, in the beginning I was angry. Sean called Dave and me every week the first several months to make sure we were ok. He knew Sarah would be fine but was worried about us. One day he called me and I told him I was angry and felt sorry for myself. I asked him what were the chances of having a gay and transgender child? At that time, he was doing a fellowship treating pediatric brain tumor patients. He replied to my question with “Slim, but what are the chances of a nine year old girl coming into my office with a terminal brain tumor? Your child is healthy and not going to die.” This was a pivotal moment for me. This put everything into perspective. Two more important events occurred over the next several months that helped to calm some of our anxiety about Sarah transitioning. Sarah had worked for Delaware Governor Jack Markell during his election in 2008 and the two became very close. The Governor has been a mentor to Sarah ever since, and he and his wife have become friends of our family. Three months after coming out to us, Sarah came out to the Governor and his wife and asked the Governor to write one of two recommendations for Sarah for her application to become an intern at the Obama White House. The Governor wrote the recommendation, and both he and his wife offered their unyielding support for our family. Sarah’s second recommendation written by Attorney General Beau Biden. Sarah had worked for Beau when he ran for Delaware Attorney General in 2006. Both were such affirming moments. Sarah got the internship, and was the first transgender woman to work in the White House. In early April, Sarah announced her plan to come out on Facebook and in the school newspaper on the last day of her term as student body president. We were very concerned that coming out on Facebook would make her too vulnerable. When she assured us that her psychologist was on board with this plan, we supported her decision to do so. On April 30, both the Op-Ed in her school newspaper and the post on Facebook were met with mostly positive reactions. The post went viral, with so much support from all over the world.

As a family, Sarah, Dave and I lobbied for the Gender Identity Non-Discrimination Bill in the Delaware General Assembly from January to its passage in June of 2013. It was important for us to do this as a family, so the legislators and the community could see us as a loving family, with a child who possessed the same hopes and dreams as any other child, and who wanted to be treated with fairness and dignity. In 2016, Sarah was the first transgender person to speak at a national political convention when she spoke at the Democratic National Convention. So many transgender people have said that seeing her announce that she is a “proud transgender American” gave them hope for their future. In 2018, Sarah published her first book, Tomorrow Will Be Different: Love, Loss and the Fight for Trans Equality. Finally, I would be remiss if I didn’t mention one of the most defining experiences of the past seven years (and of our entire lives): Sarah fell in love with Andy Cray, a transgender man, and one of the leading LGBT health care advocates in the country. While working at the White House, Sarah met Andy at a pride reception. For him it was love at first sight. It took Sarah a little longer to realize she was in love with him, too. Andy was brilliant, thoughtful, kind, and lit up a room with his smile. They moved in together nine months after meeting. One month later, Andy was diagnosed with cancer. Sarah became his main caregiver after his surgery and while he underwent radiation and chemotherapy. She showed the same courage, strength and resiliency in helping Andy recover that she showed in coming out and transitioning. Four months after finishing his treatment, Andy was cancer free, but three months later he learned that his cancer had returned, and he had twelve months to live. How does a 27-year-old face his imminent death? With the support of family and friends, with guidance and advice from Sean, who is now a radiation oncologist, with immeasurable fear, and with the hope that he could beat the odds. As it became increasingly clear that Andy’s cancer was more aggressive than previously suspected, he asked Sarah to marry him. Dave and I gave our blessing. With the help of friends on both sides, Sarah and Andy married on the rooftop of their apartment building, on a beautiful summer day, surrounded by fifty family and friends. For Dave, walking Sarah down the aisle was one of the proudest moments of his life. For all of us, the ceremony was both beautiful and tragic. Four days later, Andy died. It has been more than seven years since that Christmas Day in 2011. We have been so privileged and blessed to have been embraced and supported by so many. Ours has been such a positive journey, and that journey continues. Sarah has become one of the leading transgender advocates in the country through her work at the Center for American Progress, and since 2015 she has been the National Spokesperson for the Human Rights Campaign. Our daughter has experienced more in the past seven years than most people do in a lifetime. Her courage and resiliency continue to astound us. Dave and I speak about our journey to churches, companies and community groups, continuing to educate and dispel misinformation. And in the summer of 2016, along with three other mothers of transgender children, I started a support group for parents of transgender kids that meet at our local children’s hospital. We are so privileged and blessed as a family. And each day, we celebrate our diversity as a family, too! 29

Call to Action to Promote the All of Us Research Program to People with Disabilities WHY SHOULD YOU PARTICIPATE IN THE ALL OF US RESEARCH PROGRAM? “Nothing About Us Without Us”: This slogan is used to communicate the notion that no policy or practice, which affects the disability community, should be created without full and direct participation of members of the disability community. Historically, people with disabilities have been excluded and ignored from research studies. That ends NOW because of the All of Us Research Program! Congratulations! The All of Us Research Program is YOUR chance to make an impact and get involved in direct, cutting-edge research to find solutions that could help people with disabilities. For the first time, people with disabilities are being encouraged to participate and are being asked to enroll in a study that can directly impact how health care is received in the future. If we truly believe in the concept of “nothing about us without us,” then we must answer the call when asked to participate.

What is this Call to Action? The American Association on Health and Disability (AAHD) is calling on YOU to learn more about and consider involvement in the National Institutes of Health’s (NIH) All of Us Research Program. If you are interested in participating in the research program, enroll at https://www.JoinAllofUs.org/together. What is the All of Us Research Program? The NIH has created a nationwide research program focused on precision medicine, also known as personalized medicine, to help researchers understand more about why people get sick or stay healthy. The All of Us Research Program plans to recruit one million or more people to share their health and lifestyle data. The program recognizes the importance of recruiting traditionally underrepresented populations living in the United States (U.S.), providing the disability community a unique opportunity. When you join the program you will be contributing to an effort to improve the health of future generations while also advancing precision medicine and learning more about your own health, through better testing, better medicine and more information presented to you. The All of Us Research Program will provide researchers more information about people’s health and habits. By looking for patterns in biological, environmental and behavioral factors, researchers may learn more about what affects people’s health and, in turn, the best way to treat them. Currently, all eligible adults over the age of 18 who live in the U.S. can join the All of Us Research Program.

30 Delaware Journal of Public Health – June 2019

What is precision medicine? Health care has traditionally followed the same approach using a “one—size–fits—all” method, by prescribing treatment for diagnoses based on the average patient. Now, thanks to recent precision medicine initiatives, physicians are working toward tailoring treatment plans to the individual. For instance, many medical conditions, such as high blood pressure, are treated with a standard medication given to all patients and then trial and error is used to determine the best medication and/or dosage. Imagine a scenario where the individual’s treatment is already customized for the person based on factors known about them, including any disabilities. This research program will advance precision medicine and focus on the individual. Precision medicine ensures that lifestyle, environment and genetic factors are considered when physicians determine the course of treatment in order to provide the best possible care for each patient. What is the connection between All of Us, precision medicine and people with disabilities? The program is looking at a diverse group of people with a variety of health statuses, who will aid in moving the health care profession toward a more comprehensive, individualized approach. As a community engagement partner with All of Us, AAHD is focusing outreach efforts on educating people with disabilities about the importance of participating in the All of Us Research Program. Researchers are emphasizing the importance of recruiting traditionally underrepresented populations living in the U.S., providing the disability community a unique opportunity to improve the health of people with disabilities. No one understands “underrepresented and underserved” like the disability community. Participation is especially important when you consider that people with disabilities have been previously left out of biomedical research either because researchers did not actively recruit them, or they were not prepared to provide the accommodations people with disabilities need to participate. Why should people with disabilities participate in All of Us? People with disabilities know all too well that health status isn’t just dependent on a medical diagnosis. The “one—size—fits—all” method is not effective, as each person is unique and requires individualized care and treatment. There are many physical and environmental barriers that are unique to the disability community, and the presence of secondary conditions and health disparities is often overlooked by health care providers. A visit to a health care provider can become an all-day event if a bus’s wheelchair lift is broken. A medication can be taken incorrectly if the instructions aren’t written in a format that a person can read, such as braille or large print. A serious medical condition can be misdiagnosed if a physician isn’t trained to understand all aspects of the primary and/or secondary condition. These issues can be detrimental to the health of people with disabilities. This is YOUR chance to change how medicine works. YOUR chance to solidify the slogan, “nothing about us without us.” For more information about how you can get involved in the All of Us Research Program, please visit the American Association on Health and Disability website https://www.aahd.us/initiatives/allof-us-research-program/ or visit the program’s website https://www.JoinAllofUs.org/together.

www.fic.nih.gov www.fic.nih.gov www.fic.nih.gov

GLOBAL GLOBAL GLOBAL HEALTH HEALTH HEALTH M AT TERS M M AT AT TERS TERS

Inside this issue Inside this issue Inside this issue Scientists urge

Scientists urge cross-cutting Scientists urge cross-cutting stigma research . . . p. 3 MAR/APR 2019 cross-cutting stigma research . . . p. 3 MAR/APR 2019 34HUMAN SERVICES stigma OF research . . .AND p. 3 MAR/APR 2019 • DEPARTMENT FOGARTY INTERNATIONAL CENTER • NATIONAL INSTITUTES OF HEALTH HEALTH FOGARTY INTERNATIONAL CENTER • NATIONAL INSTITUTES OF HEALTH • DEPARTMENT OF HEALTH AND HUMAN SERVICES this issue FOGARTY INTERNATIONAL CENTER • NATIONAL INSTITUTES OF HEALTH • Inside DEPARTMENT OF HEALTH AND HUMAN SERVICES

www.fic.nih.gov

GLOBAL CUGH examines implementing solutions for impact CUGH examines implementing solutions for impact HEALTH CUGH examines implementing solutions for impact Scientists urge

By Ann Puderbaugh

M AT TERS

By Ann Puderbaugh CHICAGO—With a mandate to improve health across MAR/APR 2019 By Ann Puderbaugh

the planet, attendees of the 10th annualhealth meeting CHICAGO—With a mandate to improve across of the Consortium of Universities for Global Health FOGARTY INTERNATIONAL CENTER • NATIONAL INSTITUTES OF the planet, attendees of the 10th annual meeting CHICAGO—With a mandate to improve health across (CUGH) were encouraged to 10th unleash unique power of Consortium of Universities for the Global Health thethe planet, attendees of the annual meeting of their institutions to enhance the translation and (CUGH) were encouraged to unleash unique power of the Consortium of Universities for the Global Health implementation of knowledge sothe thetranslation world’s underserved of their institutions to enhance and (CUGH) were encouraged to unleash the unique power can benefit. know that putting works into By Ann “We Puderbaugh implementation of knowledge sothe thewhat world’s underserved of their institutions to enhance translation and scalebenefit. will save millions of lives,” said CUGH chair, can “We know putting works intoDr. implementation of knowledge so thewhat world’s underserved CHICAGO—With a that mandate to improve health across Ann benefit. Kurth, in her opening address. “We need to work scale will save millions of lives,” said CUGH chair, Dr. can “We know that putting what works the planet, attendees of the 10th annual meeting into together across borders and across ideologies,” she said, of the Consortium of Universities for Global Health Ann in her opening address. need to work scaleKurth, will save millions of lives,” said“We CUGH chair, Dr. (CUGH) were encouraged to unleash the unique power encouraging attendees to synergize efforts to improve together across borders andaddress. across ideologies,” said, Ann Kurth, in her opening “We need toshe work of their institutions to enhance the translation and health for all.attendees encouraging synergize to improve together across borderstoand across efforts ideologies,” she said,

cross-cutting

stigma research . . . p. 3

HEALTH • DEPARTMENT OF HEALTH AND HUMAN SERVICES

CUGH examines implementing solutions for impact

implementation of knowledge so the world’s underserved

health for encouraging attendees to that synergize to improve can all. benefit. “We know putting efforts what works into More 1,750 academics, practitioners, scaleall. will save millions of lives,” said CUGH administrachair, Dr. healththan for Ann Kurth, in her opening address. “We50 need to work tors, students and others, representing countries, More than 1,750 academics, practitioners, administratogether across borders and acrosswith ideologies,” she said, attended the gathering. In representing keeping thecountries, conference’s tors, students and others, 50 More than 1,750 academics, practitioners, administraencouraging attendees to synergize efforts to improve implementation science In theme, Fogarty’s Center for attended the for gathering. keeping with 50 the conference’s tors, students and representing countries, health all. others, Global Health Studies (CGHS) organized a panel implementation science In theme, Fogarty’s Center for attended the gathering. keeping with the conference’s discussion to explore ways to advance the field. More than 1,750 academics, practitioners, administraGlobal Health Studies (CGHS) organized aCenter panel for implementation science theme, Fogarty’s

collaboration hasdisease been established to enhance enhance effective collaboration has for been established to effective a key population transmission in Africa, a collaboration has been established to enhance effective

FOCUS FOCUS FOCUS FOCUS 32 Delaware Journal of Public Health – June 2019

investigators, has already generated two funded . . . continued on p.NIH 2 investigators, NISA has already generated two funded researchNISA productivity and development ofNIH independent . . . continued p. 2two funded investigators, NISA has already generated on on nextp.NIH page .. .. .on .continued continued 2

. . . continued on p. 2 Fogarty programs build capacity NCD research Fogarty programs build capacity and spur and NCD spur research Fogarty programs build capacity and spur NCD research • Evaluation shows 600 researchers trained, 982 publications produced • Evaluation shows 600 researchers trained, 982 publications produced Fogarty programs build capacity and spur NCD research • Broad range of diseases and conditions studied across the lifespan • Evaluation Broad range of diseases and conditions studied across the lifespan • shows 600 researchers trained, 982 publications produced • Ongoing challenges and unmet needs require continued support • Broad Ongoing challenges unmet needs require support • range of diseases and conditions studied across the lifespan Evaluation shows 600and researchers trained, 982continued publications produced

Read more on pages 6 – 9 • Ongoing challenges and and unmet needs require continued support Broad range of diseases conditions studied across the lifespan Read More pages 37 Read more on on pages 6 –– 40 9

• Ongoing challenges and unmet needs require continued Read more onsupport pages 6 – 9

Read more on pages 6 – 9

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Photo courtesy of CUGH

students andways others, 50 discussion to explore torepresenting advance the field. Global tors, Health Studies (CGHS) organized a countries, panel Consortium of Universities for Global Health Chair Dr. Ann Kurth opened the 2019 attended thecoordinated gathering. In keeping with to theimplementation conference’s “We need a more approach discussion to explore ways to advance the field. annual meeting with a call for action to advance implementation science. implementation science theme, Fogarty’s Center for Consortium of Universities for Global Health Chair Dr. Ann Kurth opened the 2019 science capacity building thatapproach identifies to the most useful “We need a more coordinated implementation annual meeting with a call for action to advance implementation science. Global Health Studies (CGHS) organized a panel Consortium of Universities for Global Health Chair Dr. Ann Kurth opened the 2019 content for said Dr. Rohit Ramaswamy use of evidence to improve HIV prevention, screening and science capacity building that identifies the most useful “We need a stakeholders,” moreto coordinated approach to implementation discussion explore ways to advance the field. annual meeting with a call for action to advance implementation science. of the University of North that Carolina. He’s the been treatment of young Africans, aged 15-24. The Adolescent content for stakeholders,” saididentifies Dr. Rohit Ramaswamy science capacity building most useful Consortium use of evidence to improve HIV prevention, screening and of Universities for Global Health Chair Dr. Ann Kurth opened the 2019 “We need a more coordinated approach to implementation developing multi-tiered toRohit provide different, annualHIV meeting with a call for action to advance implementation science. Prevention and Treatment Implementation Science of the University of North concept Carolina. He’s been content for astakeholders,” said Dr. Ramaswamy treatment of young Africans, aged 15-24. The Adolescent use of evidence to improve HIV prevention, screening and science capacity building that identifies the most useful but complementary, levelsconcept of training forbeen researchers, Alliance (AHISA) provides a space to facilitate dialogue developing a multi-tiered to provide different, of the University of North Carolina. He’s HIV Prevention and Treatment Implementation Science treatment of young Africans, aged 15-24. The Adolescent content for stakeholders,” said Dr. Rohit Ramaswamy use of evidence to improve HIV prevention, screening and implementers, policymakers and those involved in care treatment and exchange ofand ideas among researchers, implementers but complementary, levels ofCarolina. training for researchers, developing multi-tiered concept to He’s provide different, Alliance (AHISA) provides a space to facilitate dialogue HIV Prevention Treatment Implementation Science of theaUniversity of North been of young Africans, aged 15-24. The Adolescent delivery. It’s not helpful if trainees return home ready and decision makers, said Fogarty’s Dr. Rachel Sturke, developingpolicymakers a multi-tiered to provide different, implementers, and those involved in care HIV Prevention but complementary, levels ofconcept training for researchers, and Treatment Implementation and exchange of ideas among researchers, implementers Alliance (AHISA) provides a space toScience facilitate dialogue but complementary, levels of training for researchers, Alliance (AHISA) provides a space to facilitate dialogue to put implementation science theories into practice but who decision managesmakers, the program. delivery. It’s notpolicymakers helpful if trainees return home ready implementers, and those involved in care and said Fogarty’s Dr. Rachel Sturke, exchange of ideas among researchers, implementers implementers,don’t policymakers and those involved in care of ideas among researchers, implementers their understand what they’re talking to putstakeholders implementation theories into practice but and exchange delivery. It’s not helpfulscience if trainees return home ready who managesmakers, the program. and decision said Fogarty’s Dr. Rachel Sturke, delivery. It’s not helpful if trainees return home ready and decision makers, said Fogarty’s Dr. Rachel Sturke, about, Ramaswamydon’t noted. An initiative tothe prevent mother-to-child-transmission of their understand what talking to putstakeholders implementation science theories into practice manages program. to put implementation science theories intothey’re practice butbut who who manages the program. HIV—another CGHS project—resulted in formation of of the about, Ramaswamy noted. their stakeholders don’t understand what they’re talking An initiative to prevent mother-to-child-transmission their stakeholders don’t understand what they’re talking Two case studies of HIV-related implementation Nigeria Implementation Science Alliance (NISA), a national about, Ramaswamy noted. An initiative to prevent mother-to-child-transmission of about, Ramaswamy noted. HIV—another project—resulted in formation of of the An initiative toCGHS prevent mother-to-child-transmission HIV—another CGHS project—resulted inand formation of (NISA), the science projects were shepherded by Fogarty’s effort toImplementation coordinate capacity building efforts Two case studiesthat of HIV-related implementation Nigeria Science Alliance a national HIV—another CGHSresearch project—resulted in formation of the Two case studies of With HIV-related implementation Nigeria Implementation ScienceEstablished Alliance (NISA), national CGHS were presented. adolescents among in a2015 with aafocus on science projects that were shepherded byidentified Fogarty’sas Two case studies of HIV-related implementation effort tostakeholders. coordinate research andAlliance capacity building efforts Nigeria Implementation Science (NISA), national science projects that were shepherded by Fogarty’s effort to coordinate research and capacity building efforts a key population for disease transmission in Africa, a research productivity and development of independent CGHS presented. With adolescents identified sciencewere projects were shepherded byidentified Fogarty’s among Established ina 2015 with a focus on effort tostakeholders. coordinate research and capacity building efforts CGHS were that presented. With adolescents as as among stakeholders. Established in 2015 with focus on collaboration has for been established to enhance effective investigators, NISA has already generated two funded a key population disease transmission inAfrica, Africa, a CGHS were presented. adolescents identified research productivity and development of independent among stakeholders. Established in 2015 with a focusNIH on a key population forWith disease transmission in aas research productivity and development of independent

MARCH/APRIL MARCH/APRIL 2019 2019 MARCH/APRIL 2019

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.. ... .continued from previous continued from p.1 page grant grant proposals proposals and and more more than than seven seven grant proposals and more than seven published published research research papers. papers. Projects Projects published research papers. Projects are are always always multi-site, multi-site, multi-partner multi-partner are always multi-site, multi-partner and and involve involve issues issues that that have have potential potential and involve issues that have potential forfor national national scope scope and and impact, impact, said said for national scope and impact, said Dr.Dr. Nadia Nadia Sam-Agudu, Sam-Agudu, of of Nigeria’s Nigeria’s Dr. Nadia Sam-Agudu, of Nigeria’s Institute Institute of of Human Human Virology. Virology. Institute of Human Virology.

Photo courtesy of CUGH Photo Photo courtesy courtesy of of CUGH CUGH

like like and and recommended recommended a shift a shift in in like and recommended a shift in focus focus and and ownership ownership of of health health to to focus and ownership of health to the the communities, communities, said said Dr.Dr. Marcel Marcel the communities, said Dr. Marcel Yotebieng, Yotebieng, anan author author of of the the report report Yotebieng, an author of the report and and faculty faculty member member of of Kinshasa Kinshasa and faculty member of Kinshasa University University and and Ohio Ohio State. State. NIH NIH funds funds University and Ohio State. NIH funds a broad a broad range range of of studies studies onon how how to to a broad range of studies on how to improve improve quality quality of of care care through through 1818 improve quality of care through 18 ToTo strengthen strengthen NIH’s NIH’s global global mental mental grants grants in in 1414 LMICs, LMICs, said said Fogarty’s Fogarty’s To strengthen NIH’s global mental grants in 14 LMICs, said Fogarty’s health health initiatives initiatives concerning concerning children, children, Dr.Dr. Linda Linda Kupfer, Kupfer, who who helped helped health initiatives concerning children, Dr. Linda Kupfer, who helped the the National National Institute Institute of of Mental Mental coordinate coordinate NIH’s NIH’s participation participation in in the the the National Institute of Mental coordinate NIH’s participation in the Health Health (NIMH) (NIMH) co-hosted co-hosted a workshop a workshop NASEM NASEM report. report. Health (NIMH) co-hosted a workshop NASEM report. during during the the conference conference to to gain gain during the conference to gain insights insights that that will will inform inform itsits future future insights that will inform its future programs. programs. Eighty-five Eighty-five percent percent of of the the programs. Eighty-five percent of the world’s world’s youth youth live live in in lowlowand and middlemiddleworld’s youth live in low- and middleincome income countries countries (LMICs), (LMICs), where where income countries (LMICs), where access access to to diagnosis diagnosis and and treatment treatment access to diagnosis and treatment is is lacking. lacking. “Youth “Youth mental mental illness illness is is is lacking. “Youth mental illness is one one of of the the most most urgent urgent mental mental health health one of the most urgent mental health problems problems worldwide,” worldwide,” according according to to problems worldwide,” according to NIMH NIMH Director Director Dr.Dr. Joshua Joshua Gordon. Gordon. NIMH Director Dr. Joshua Gordon. “Early “Early interventions interventions can can improve improve “Early interventions can improve outcomes,” outcomes,” hehe said, said, yetyet there there has has Fogarty’s Fogarty’s Dr.Dr. KenKen Bridbord Bridbord was was awarded awarded CUGH’s CUGH’s outcomes,” he said, yet there has Fogarty’s Dr. Ken Bridbord was awarded CUGH’s been been little little research research onon how how to to apply apply highest highest honor honor by by its its director, director, Dr.Dr. Keith Keith Martin. Martin. been little research on how to apply highest honor by its director, Dr. Keith Martin. (see page page 11)11) existing existing knowledge knowledge and and practices practices forfor (see (see page 11) existing knowledge and practices for use use in in low-resource low-resource settings. settings. Proven Proven AtAt another another session, session, Fogarty Fogarty Fellows Fellows use in low-resource settings. Proven At another session, Fogarty Fellows diagnostic diagnostic techniques—such techniques—such asas using using and and Scholars Scholars shared shared their their stories stories diagnostic techniques—such as using and Scholars shared their stories mobile mobile devices devices to to track track eye eye contact contact of of their their early-career early-career experiences experiences mobile devices to track eye contact of their early-career experiences in in young young children—could children—could bebe adapted adapted at at NIH NIH research research sites sites and and the the in young children—could be adapted at NIH research sites and the forfor use use in in LMICS LMICS soso that that diagnosis diagnosis positive positive outcomes outcomes that that resulted. resulted. for use in LMICS so that diagnosis positive outcomes that resulted. and and treatment treatment of of autism autism could could begin begin The The program’s program’s first first landscape landscape and treatment of autism could begin The program’s first landscape earlier, earlier, hehe said. said. Using Using cellphones cellphones architect, architect, Dr. Dr. Leann Leann Andrews Andrews of of earlier, he said. Using cellphones architect, Dr. Leann Andrews of oror other other portable portable devices devices to to the the University University of of Washington, Washington, or other portable devices to the University of Washington, administer administer such such tests tests “is“is imminently imminently presented presented her her successful successful efforts efforts administer such tests “is imminently presented her successful efforts implementable implementable worldwide.” worldwide.” to to improve improve a Peruvian a Peruvian slum slum implementable worldwide.” to improve a Peruvian slum community’s community’s health health byby working working community’s health by working But But implementation implementation without without with with residents residents to to construct construct gardens gardens But implementation without with residents to construct gardens maintaining maintaining quality quality of of care care is is also also full full of of herbs, herbs, medicinal medicinal plants, plants, maintaining quality of care is also full of herbs, medicinal plants, anan enormous enormous problem problem in in LMICs. LMICs. fruits fruits and and vegetables. vegetables. ByBy making making an enormous problem in LMICs. fruits and vegetables. By making InIn a session a session organized organized byby Fogarty, Fogarty, their their surroundings surroundings safer safer and and more more In a session organized by Fogarty, their surroundings safer and more panelists panelists presented presented the the results results of of a a attractive, attractive, boosting boosting food food security security and and panelists presented the results of a attractive, boosting food security and recent recent U.S. U.S. National National Academies Academies of of access access to to medicines, medicines, and and improving improving recent U.S. National Academies of access to medicines, and improving Sciences, Sciences, Engineering Engineering and and Medicine Medicine water water quality, quality, she she found found residents residents Sciences, Engineering and Medicine water quality, she found residents (NASEM) (NASEM) report report that that shows shows upup to to reported reported a decrease a decrease in in depression depression (NASEM) report that shows up to reported a decrease in depression 8 million 8 million deaths deaths occur occur each each year year and and gastrointestinal gastrointestinal illness, illness, asas well well 8 million deaths occur each year and gastrointestinal illness, as well from from lack lack of of access access and and poor poor quality quality asas fewer fewer falls falls and and injuries. injuries. from lack of access and poor quality as fewer falls and injuries. of of care care in in developing developing countries— countries— of care in developing countries— more more than than HIV, HIV, TBTB and and malaria malaria Other Other Fogarty Fogarty Fellows Fellows presented presented their their more than HIV, TB and malaria Other Fogarty Fellows presented their combined. combined. The The study study examined examined what what studies studies of of cervical cervical cancer cancer in in Malawi, Malawi, combined. The study examined what studies of cervical cancer in Malawi, anan ideal ideal health health system system would would look look mental mental illness illness in inKenya, Kenya, HIV/AIDS HIV/AIDS an ideal health system would look mental illness in Kenya, HIV/AIDS

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in in Peru Peru and and TBTB in in Tanzania. Tanzania. Fogarty Fogarty in Peru and TB in Tanzania. Fogarty Director Director Dr.Dr. Roger Roger I. Glass I. Glass said said hehe Director Dr. Roger I. Glass said he was was encouraged encouraged byby the the caliber caliber of of these these was encouraged by the caliber of these emerging emerging global global health health leaders. leaders. “I’m “I’m emerging global health leaders. “I’m soso proud proud of of you you allall and and to to see see that that byby so proud of you all and to see that by investing investing in in youth, youth, through through the the impact impact investing in youth, through the impact of of this this program, program, wewe are are launching launching of this program, we are launching careers careers that that will will endure endure forfor 3030 years.” years.” careers that will endure for 30 years.” Mentoring—essential Mentoring—essential forfor earlyearlyMentoring—essential for earlycareer career scientists—is scientists—is not not often often part part career scientists—is not often part of of the the culture culture at at LMIC LMIC research research of the culture at LMIC research institutions. institutions. That That was was the the topic topic of of institutions. That was the topic of a session a session to to launch launch a supplement a supplement a session to launch a supplement published published byby the the journal journal of of the the published by the journal of the American American Society Society of of Tropical Tropical Medicine Medicine American Society of Tropical Medicine and and Hygiene Hygiene (ASTMH) (ASTMH) that that provides provides and Hygiene (ASTMH) that provides recommendations recommendations and and case case studies studies recommendations and case studies to to spur spur mentorship mentorship programs programs in in lowlowto spur mentorship programs in lowresource resource settings. settings. resource settings. “This “This is is a call a call to to action, action, not not just just anan “This is a call to action, not just an academic academic discussion,” discussion,” said said ASTMH ASTMH academic discussion,” said ASTMH CEO CEO Karen Karen Goraleski, Goraleski, who who introduced introduced CEO Karen Goraleski, who introduced the the session. session. “We “We have have to to change change the session. “We have to change the the way way business business is is being being done.” done.” the way business is being done.” LMIC LMIC scientists scientists need need a mentoring a mentoring LMIC scientists need a mentoring approach approach tailored tailored to to their their unique unique approach tailored to their unique circumstances, circumstances, which which often often include include circumstances, which often include very very divided divided gender gender roles, roles, respect respect forfor very divided gender roles, respect for hierarchy hierarchy and and seniority, seniority, and and a colonial a colonial hierarchy and seniority, and a colonial history history that that has has left left a legacy a legacy of of history that has left a legacy of authoritarian authoritarian attitudes, attitudes, said said Dr.Dr. Willy Willy authoritarian attitudes, said Dr. Willy Lescano, Lescano, a co-author a co-author and and professor professor at at Lescano, a co-author and professor at Peru’s Peru’s Cayetano Cayetano Heredia Heredia University. University. Peru’s Cayetano Heredia University. The The publication publication was was inspired inspired byby a a The publication was inspired by a series series of of “Mentoring “Mentoring the the Mentor” Mentor” series of “Mentoring the Mentor” workshops workshops hosted hosted in in LMICs LMICs byby faculty faculty workshops hosted in LMICs by faculty of of Fogarty’s Fogarty’s Global Global Health Health Program Program of Fogarty’s Global Health Program forfor Fellows Fellows and and Scholars. Scholars. “We “We spend spend for Fellows and Scholars. “We spend a tremendous a tremendous amount amount of of our our time, time, a tremendous amount of our time, resources resources and and thought thought in in training training resources and thought in training the the next next generation generation of of global global health health the next generation of global health leaders,” leaders,” said said Glass, Glass, “so“so wewe really really leaders,” said Glass, “so we really dodo have have anan investment investment in in doing doing this this do have an investment in doing this better, better, in in developing developing a mentoring a mentoring better, in developing a mentoring roadmap roadmap forfor the the future, future, to to ensure ensure roadmap for the future, to ensure the the satisfaction satisfaction and and success success of of our our the satisfaction and success of our trainees, trainees, and and to to keep keep them them onon the the trainees, and to keep them on the research research track.” track.” research track.” RESOURCES RESOURCES RESOURCES http://bit.ly/cugh2019 http://bit.ly/cugh2019 http://bit.ly/cugh2019

MARCH/APRIL 2019 MARCH/APRIL MARCH/APRIL 2019 2019 MARCH/APRIL MARCH/APRIL 2019 2019

Scientists urge crossScientists Scientists urge urge crosscrossScientists Scientists urge urge crosscrosscutting stigma research cutting cutting stigma stigma research research cutting cutting stigma stigma research research By Karin Zeitvogel By Karin Zeitvogel By Karin Zeitvogel By Karin Zeitvogel By Karin Zeitvogel

© 2016 Sean G. Smith / Critical-Care Professionals © 2016 Sean G. Smith / Critical-Care Professionals © 2016 Sean G. Smith / Critical-Care Professionals International, Courtesy of Photoshare Photoshare International, Courtesy of Photoshare International, Courtesy of

Stigma is aisbarrier toisto better health forfor vulnerable Stigma aStigma barrier abetter barrier health to better vulnerable health for vulnerable populations worldwide, despite many new Stigma is a Stigma barrier is to a better barrier health to better for vulnerable health fornew vulnerable populations populations worldwide, worldwide, despite many despite new many interventions and scientific discoveries making populations populations worldwide, worldwide, despite many despite new many new interventions interventions and scientific anddiscoveries scientific discoveries making making interventions interventions and scientific and discoveries scientific discoveries making ranging making strides against stigmatized conditions ranging strides against strides stigmatized against stigmatized conditions conditions ranging strides against strides stigmatized against stigmatized conditions conditions ranging ranging from HIV/AIDS to to depression. a series ofIn from HIV/AIDS from HIV/AIDS depression. toIn depression. In a series of a series of from published HIV/AIDS from to HIV/AIDS depression. to depression. InBioMed a (BMC), series In of a series of articles in BioMed Central articles published articles in published BioMed Central in (BMC), Central (BMC), articles published articles in published BioMed Central in BioMed (BMC), Central (BMC), scientists areare calling forare stigma research totobe scientists scientists calling for stigma calling research for stigma research be to be scientists scientists are for stigma calling for stigma to research be be broken outout ofare silos that focus onon aresearch single condition broken broken of calling silos out that offocus silos that a focus single on condition a single to condition broken out broken of silos out that of focus silos that on a focus single on condition a single condition or population and instead develop approaches or population or population and instead and develop instead approaches develop approaches orcut population or illnesses, population and instead and develop instead approaches develop approaches that across demographics and that cut across that cut illnesses, across demographics illnesses, demographics andscientific scientific and scientific brainstormed how stigma brainstormed brainstormed how to to reduce reduce howhealth-related health-related to reduce health-related stigma stigma that cut across that cut illnesses, across demographics illnesses, demographics and scientific and scientific disciplines. Effective solutions will require the of disciplines. disciplines. Effective solutions Effective will solutions require will theexpertise require expertise the ofexpertise of brainstormed brainstormed how to populations reduce how health-related to reduce health-related stigma stigma across disease areas, and settings, and across disease across areas, disease populations areas, populations and settings, andand settings, and disciplines. disciplines. Effective solutions Effective will solutions require will the require expertise the of expertise of researchers, practitioners, policymakers and researchers, researchers, practitioners, practitioners, policymakers policymakers andcommunity community and community across disease across areas, disease populations areas, populations and settings, and and settings, and refinedthe theagenda refined agendathe for global agenda global stigma stigma for global research. stigma“The research. “The refined for research. “The researchers, researchers, practitioners, practitioners, policymakers policymakers and community and community members, and members, transdisciplinary and transdisciplinary teams scientists teams of scientistsrefined therefined members, and transdisciplinary teams ofof scientists agenda the for agenda global stigma for global research. stigma “The research. “The collectionreflects reflects collection thereflects challenges, the challenges, priorities and priorities and collection the challenges, priorities and members, and members, transdisciplinary and transdisciplinary teams ofsociology, scientists teams of scientists from public from health, public medicine, health, psychology, medicine, psychology, sociology, sociology, from public health, medicine, psychology, collection reflects collection thereflects challenges, thethe challenges, priorities and priorities and opportunities opportunities identified during identified the during workshop—including the workshop—including opportunities identified during workshop—including from public from health, public medicine, health, psychology, medicine, psychology, sociology, sociology, anthropology anthropology and other fields, and working other working fields, together, working according together, according anthropology and other fields, together, according opportunities opportunities identified during identified the during workshop—including the workshop—including dealingwith with dealing theethical ethical with challenges the challenges ethical challenges we face when dealing the we face when when anthropology anthropology and other fields, and other working fields, together, working according together, according to the authors toofthe of authors the “Collection of the “Collection on Stigma Research on Stigma and Research and with to the authors the “Collection on Stigma Research and dealing dealing the ethical with the challenges ethical challenges we face when we face when conducting conducting stigma research, stigma developing research, developing strategies strategies conducting stigma research, developing strategies to the authors to the of authors the “Collection of the “Collection on Stigma on Research Stigma and Research and Global Health.” Global Health.” Global Health.” conducting conducting stigma research, stigma developing research, developing strategies strategies engagestakeholders stakeholders to engage stakeholders and community community and community members, Global Health.” Global Health.” totoengage and members, members, to engage stakeholders to engage stakeholders and community andstigma community members, determining determining how to study study how stigma to study across conditions, acrossmembers, conditions, and and determining how to stigma across conditions, and Making such Making changes such changes stigma research to stigma would research helpto would to help to Making such changes to to stigma research would help determining determining how to study how stigma to study across stigma conditions, across conditions, and and deciding which deciding interventions which interventions are the most are effective the most at effective at Making such Making changes such to changes stigma research to stigma would research help would to help to interventions are the most effective at advance understanding advance understanding the drivers, of manifestations the manifestations drivers, manifestations and deciding and which advance understanding of of the drivers, and deciding which deciding interventions which interventions are the most are effective the most at effective at reducing stigma,” reducing said stigma,” Birbeck. said “Ultimately, Birbeck. “Ultimately, the advance understanding advance understanding oflead theto drivers, oflead the manifestations drivers, manifestations and reducing said Birbeck. “Ultimately, the aim aim of of the aim of outcomes of outcomes stigma, and of lead stigma, a unified to response a unified to and it, stigma,” outcomes of stigma, and to aand unified response totoresponse it,it, reducing stigma,” reducing said stigma,” Birbeck. said “Ultimately, Birbeck. “Ultimately, the aim ofisthe aim of the workshop the and workshop the collection and the of collection articles is of to articles improve outcomes of outcomes stigma, and of stigma, lead to and a unified lead to response a unified to response it, to it, the workshop and the collection of articles is to improveto improve collection the says. collection The impact says.ofThe of such impact shift of such stigma a shift in stigma thethe collection says. The impact such aa shift ininstigma the workshop the and workshop the collection and the of collection articles is of to articles improve is to improve livesaround around lives thearound world by by the catalyzing world by new new catalyzing research new research the collection the says. collection The impact says. The ofbesuch impact athe shift ofresearchers such in stigma athe shift in stigma lives the world catalyzing research research focus research would focus be would worldwide, feltthe worldwide, researchers research focus would be feltfelt worldwide, researchers lives around lives thearound world and by thecatalyzing world byhelp new catalyzing research new to research approaches approaches and collaborations collaborations that to that move help research focus research would focus be felt would worldwide, be felt worldwide, the researchers the researchers approaches and collaborations that help to move the the move the note, because, note, although because, although burden of stigma burden ofheaviest stigma is heaviest approaches approaches and collaborations and collaborations that help to that move help the to move the note, because, although thethe burden ofthe stigma isisheaviest criticalfield fieldcritical ofstigma stigma fieldresearch research of stigma forward.” research forward.” note, because, although because, the although burdenthe of(LMICs), stigma burdenit isof(LMICs), heaviest stigma is heaviest critical of forward.” in lowandnote, inmiddle-income lowand middle-income countries countries also it also critical field critical of stigma fieldresearch of stigmaforward.” research forward.” in lowand middle-income countries (LMICs), it also in low- in and in middle-income low- in and middle-income countries (LMICs), countries it (LMICs), alsothe U.S. it also occurs developed occurs countries, developed including countries, the including U.S. occurs in developed including the U.S. The workshop The also workshop informed alsoainformed stigma research a stigmaprogram research program occurs in developed occurs countries, in countries, developed including countries, the including U.S. the U.S. The also informed stigma research program program Theworkshop workshop The also workshop informed alsoaaaimed informed stigma aaimed stigmaprogram launched by launched Fogarty by in Fogarty 2018, in 2018, atresearch improving atresearch HIV/ improving HIV/ “Breaking down “Breaking disease down silos disease and working silos and across working across launched by Fogarty in aimed at improving HIV/ launched by launched Fogarty by in 2018, Fogarty 2018, aimed in 2018, at improving aimed improving HIV/ “Breaking down disease silos and working across AIDS prevention, AIDS prevention, treatment and treatment care inand LMICs. care at This inHIV/ LMICs. This “Breaking down “Breaking disease down silos disease and working silos and across working across disciplines disciplines and scientist-community and scientist-community member boundaries member boundaries AIDS prevention, treatment and care in LMICs. This AIDS prevention, AIDS prevention, treatment and treatment care in and LMICs. care This in LMICs. This disciplines and scientist-community member boundaries effort builds effort on the builds Center’s on the previous Center’sstigma previous program, stigma program, disciplines and scientist-community and scientist-community member boundaries member boundaries would allowdisciplines would us to allow effectively us to address effectively health-related address health-related stigma stigma effort builds on Center’s previous stigma program, effort builds effort onthe the builds on that the previous Center’s stigma previous program, stigma program, would allow us to to effectively address health-related stigma begun in 2002, begun that in Center’s 2002, awarded $17 awarded million $17 through million 18through 18 would allow would us allow effectively us to address effectively health-related address health-related stigma stigma and enhance and health enhance equity health globally,” equitysaid globally,” Fogarty said advisory Fogartybegun advisory inin2002, that awarded $17 million through 18through 18 begun 2002, begun that in 2002, awarded that $17 awarded million $17 through million 18 andand enhance health equity globally,” said Fogarty advisory awards. awards. enhance and health enhance equity health globally,” equity said globally,” Fogarty said advisory Fogarty advisory board member board and member grantee, and Dr. grantee, Gretchen Dr.Birbeck, Gretchen who Birbeck,awards. who awards. awards. board member and grantee, Dr.Dr. Gretchen Birbeck, who board member board and member and grantee, Gretchen Dr. Birbeck, Gretchen who Birbeck, who edited the collection. edited thegrantee, collection. “While medical “While advances medical put advances better put better stigma For science stigma to continue science totocontinue advance,toscientists advance, scientists edited thethe collection. “While medical advances put better edited collection. edited the “While medical advances medical put advances better put For better health within health reach within ofcollection. many, reach stigma of“While many, deters stigma care-seeking, deters care-seeking, For to advance, scientists Forstigma stigma For science to continue continue science toto tocontinue advance, toscientists advance, must focusscience must on stigma developing, focus on developing, securing funding securing for, fundingscientists for, health within reach of many, stigma deters care-seeking, health within health reach within of many, reach stigma of many, deters stigma care-seeking, deters care-seeking, which generates which or generates perpetuates or perpetuates health inequities,” health inequities,” added added must focus on developing, securing funding for, must focus must on developing, focus on developing, securing securing for, funding said for, implementing implementing and scalingand up scaling interventions, up interventions, said which generates or perpetuates health inequities,” added which generates which or generates perpetuates or perpetuates health inequities,” health inequities,” added added Birbeck, a Birbeck, University a University of Rochester of professor Rochesterwho professor spendswho spends implementing and scaling up interventions, said implementing implementing and scaling and up scaling interventions, up interventions, said said Birbeck. These Birbeck. interventions These interventions must take into mustaccount take into account Birbeck, a her University of Rochester professor spends Birbeck, a Birbeck, University a University of Rochester of professor Rochester who professor spends who spends most of most timeof providing her time clinical providing care clinical andwho conducting care and conducting Birbeck. These must take must into account Birbeck. These Birbeck. interventions interventions must account take account new challenges. newinterventions challenges. ForThese example, For asexample, treatments as treatments for HIVinto for HIV most of her time providing clinical care and conducting most of her most time of providing her time clinical providing care clinical and conducting care and conducting research inresearch Zambia. in Zambia. new challenges. new challenges. For example, For as example, treatments as treatments for HIV for HIV new challenges. For example, as treatments for HIV improve, people improve, withpeople the virus withare theliving viruslonger are living and longer and research inresearch Zambia.in Zambia. research in Zambia. improve, people improve, with people the virus with are the virus are living and longer and improve, people with the virus are living longer and are at greater are risk at greater of becoming risk of disabled becoming ordisabled developing or developing Often ingrained Oftenin ingrained cultural in norms cultural andnorms institutional and institutionalare at greater are risk ator greater of becoming risk of disabled becoming developing or developing are at greater risk of becoming disabled ordisabled developing cancer, epilepsy cancer, epilepsy another or noncommunicable another noncommunicable disease disease Often ingrained Often in ingrained cultural in norms cultural and norms institutional and institutional Often ingrained in is cultural norms and to institutional policies, stigma policies, astigma powerful is abarrier powerful better barrierhealth to better health cancer, epilepsy cancer, or epilepsy another or noncommunicable another noncommunicable disease disease cancer, epilepsy or another noncommunicable disease that also carries that also a burden carries of a stigma. burden “The of stigma. next stage “The next stage policies, stigma policies, is a stigma powerful is a barrier powerful to better barrier health to better health policies, a Community, powerful to better health for all.stigma Community, for is all. culturalbarrier and cultural institutional and institutional attitudes attitudes that also carries that also a burden carries of a stigma. burden “The of stigma. next stage “The next stage that also carries a burden of the stigma. next stage for stigma science for stigma has science to be has development to be the development and and for all. Community, for all. Community, cultural and cultural institutional and institutional attitudes attitudes for to all. Community, cultural and institutional attitudes people with to people stigmatized with stigmatized conditions, conditions, along with along with for stigma science for stigma has science to be the has development to be the development and and for stigma science to beof the development implementation implementation ofhas scalable interventions scalable interventions that and address that address to people with to people stigmatized with stigmatized conditions, conditions, along with to people with stigmatized conditions, along with internalized internalized stigma that stigma an individual that an might individual feel, along might and with feel, and implementation implementation ofscalable scalable of interventions scalable interventions that address that “Not address implementation of interventions that address the intersectionality the intersectionality of stigma,” of said stigma,” Birbeck. said “Not Birbeck. internalized internalized stigma that stigma an individual that an might individual feel, might and feel, and internalized stigma that an discrimination individual might and the prejudice, the discrimination prejudice, and stereotyping andfeel, stereotyping they theythe intersectionality the intersectionality of stigma,” of said stigma,” Birbeck. said “Not Birbeck. “Not the intersectionality of this stigma,” Birbeck. “Not only wouldonly this would complement complement thesaid understanding the understanding that that the prejudice, discrimination prejudice, discrimination and stereotyping and stereotyping they they theface, prejudice, discrimination and stereotyping they must the face, be addressed must be addressed by research, byaccording research, to according the to only the wouldonly thiscomplement would complement this complement the understanding the understanding that that scientists scientists have already of the have causes, of the manifestations causes, manifestations only would already this the understanding that face, must face, be addressed must be addressed by research, by according research, to according the to the BMC collection, collection, which by wasresearch, which inspired was byinspired a 2017 to workshop bythe a 2017 workshop face, must beBMC addressed according scientists already scientists have already of the have causes, of the manifestations causes, manifestations and outcomes and of outcomes stigma, of it couldbut improve it could the improve health the health scientists already have of but thestigma, causes, manifestations BMC collection, BMC collection, which was which inspired was a 2017 workshop by a Health 2017 workshop convened by convened Fogarty’s byCenter Fogarty’s for Global Center Health for Global Studies. Studies. BMC collection, which was inspired byby ainspired 2017 workshop and outcomes and of outcomes stigma, but of stigma, it could couldbut improve it could the improve health of millions of worldwide.” millions worldwide.” and outcomes of stigma, but it improve the health the health convened by convened Fogarty’s by Center Fogarty’s for Global Center Health for Global Studies. Health Studies. convened by Fogarty’s Center for Global Health Studies. of millions of worldwide.” millions worldwide.” of millions worldwide.” During three During days three of meetings, days of U.S. meetings, and LMIC U.S. experts and LMIC experts During three During days three of meetings, days of U.S. meetings, and LMIC U.S. experts and LMIC experts RESOURCERESOURCE During three days of meetings, U.S. and LMIC experts 3 RESOURCERESOURCE 34 Delaware Journal of Public Health – June 2019 3 http://bit.ly/stigmaBIOMED RES OURCE http://bit.ly/stigmaBIOMED 3 http://bit.ly/stigmaBIOMED http://bit.ly/stigmaBIOMED

PPPRRROOO FFF III LLL EEE Fogarty Fellow fights Fogarty FogartyFellow Fellow fights fights cholera in Bangladesh cholera cholerain in Bangladesh Bangladesh By Karin Zeitvogel ByByKarin KarinZeitvogel Zeitvogel

Dr. Eric Nelson still vividly remembers the distraught Dr. Eric Nelson still vividly remembers the distraught Dr. Eric vividly remembers distraught father heNelson met instill Dhaka when he was a the Fogarty Fellow father hehemet ininDhaka when he was aa Fogarty Fellow father met Dhaka when he was Fogarty in 2005-06. “Holding his daughter in his arms, Fellow he inin2005-06. “Holding his in arms, he 2005-06. “Holding hisdaughter daughter in his his arms,three he gripped my arm and implored, ‘Doctor, I have gripped my arm and implored, ‘Doctor, I have three gripped my arm and implored, ‘Doctor, I have three children. Two died yesterday from cholera. Please save children. Two died children. Two diedyesterday yesterday fromcholera. cholera. Please Please save save this child,’” Nelson recalled. from this thischild,’” child,’”Nelson Nelsonrecalled. recalled.

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Nelson was paired with Dr. Ashraf Khan from Nelson waspaired paired with Dr.Ashraf Ashraf Khan from Nelson was with Dr. Khan from Bangladesh for the year-long Fogarty fellowship. After Bangladesh for the year-long Fogarty fellowship. After Bangladesh for theatyear-long fellowship. After training together NIH, the Fogarty two researched different training together at NIH, the two researched different training together at NIH, theNelson two researched different topics in Bangladesh, with focusing on cholera topics Bangladesh, withNelson Nelsonfocusing focusing on on cholera cholera topics ininBangladesh, transmission in mice.with transmission in mice. transmission in mice. Nelson’s days started before dawn, when he would Nelson’s daysfrom started beforepond dawn, when he would would pump water a Dhaka into a barrel on the Nelson’s days started before dawn, when he pump water from a Dhaka pond into a barrel on the the back water of a flatbed and then pump from arickshaw Dhaka pond into accompany a barrel on the back of a flatbed rickshaw and then accompany the rickshaw to the rickshaw hospital. Throughout the day, hethe would back of a flatbed and then accompany rickshaw to the hospital. Throughout the day,and he would run between the “mouse-house,” the hospital lab, rickshaw to the hospital. Throughout the day, he would run between thetime “mouse-house,” the hospital and lab, always making to study and analyze what was run between the “mouse-house,” the hospital and lab, always making time to study and analyze what was going making on around him. “As a Fellow, I learned how to be always time to study and analyze what was going on aroundand him.how “Asto a Fellow, I learned how to be a good observer act on those observations, going on around him. “As a Fellow, I learned how to be a goodasobserver and how to improve act on those observations, building tools that care observations, in challenging a such good observer and how to act on those such as building tools that improve care in challenging environments,” Nelson said. such as building tools that improve care in challenging environments,” Nelson said. environments,” Nelson said. As often happens in science, one project or idea led to As often happens in as science, one project or idea led to another. For weeks, he watched the Bangladeshi lab Asanother. often happens in science, one project or idea led to For weeks, as he watched the Bangladeshi lab technician who was studying samples under a darkfield another. For who weeks, as he watched the under Bangladeshi lab technician was studying samples a darkfield microscope to see which ones contained cholera and technician who waswhich studying under a darkfield microscope toNelson see onessamples contained and which didn’t, mentally calculated cholera that around microscope to see which ones contained cholera and which didn’t, Nelson mentally calculated that around half were autoclaved, meaning they were cholera-free. which didn’t, Nelson mentally calculated around half autoclaved, meaning were that cholera-free. Thatwere discovery eventually led tothey published papers in half were autoclaved, meaning they were cholera-free. That discovery eventually led to published papers which Nelson identified key factors that contributeinto That discovery ledfactors to published papers into which Nelson eventually identified key that contribute the understanding of cholera transmission. “One was which Nelson identified key factors that contribute to the understanding of cholera transmission. “One was starvation of Vibrio cholerae in nutrient-limited pond the understanding of cholera transmission. “One was starvation of Vibrio cholerae in nutrient-limited pond water, and the second was predation by little viruses starvation ofthe Vibrio cholerae inkill nutrient-limited pond water, and second was predation bycholerae,” little viruses called phages that infect and the V. water, and the second was predation by little viruses called phages that infect and kill the V. cholerae,” Nelson explained. “About half the samples that were called phages that infect and kill V. cholerae,” Nelson explained. “About half thethe samples that were autoclaved had these viral particles.” autoclaved had these viral particles.” Nelson explained. “About half the samples that were autoclaved had these viral particles.” As he continued his research, Nelson found antibiotics As he continued research, Nelson antibiotics in the majority ofhis cholera patients whofound insisted they in the majority of cholera patients who insisted they As he continued his research, Nelson found antibiotics 4 in the majority of cholera patients who insisted they

Fogarty Fellow: Fogarty Fellow: Fellow: Fogarty Fellowship at: Fellowship at: at: Fellowship U.S. partners: U.S. partners: partners: U.S.

2005-2006 2005-2006 2005-2006 Int’l Center for Diarrheal Disease Research, Bangladesh Int’lCenter Centerfor forDiarrheal DiarrhealDisease DiseaseResearch, Research, Bangladesh Int’l Bangladesh Massachusetts General Hospital, Harvard Medical School, MassachusettsGeneral General Hospital,Harvard Harvard Medical School, Massachusetts Medical School, Tufts University School ofHospital, Medicine TuftsUniversity UniversitySchool SchoolofofMedicine Medicine Tufts Research areas: Cholera transmission Research areas: areas: Cholera Choleratransmission transmission Research

hadn’t taken the drugs. What this said to Nelson was hadn’t taken drugs. What said was hadn’t taken the the drugs.cholera Whatthis this saidtotoNelson Nelson was that scientists studying transmission have to that scientists studying cholera transmission have toto that scientists studying transmission think not only about howcholera phage particles affect have cholera think not only about how phage particles affect cholera think not onlybut about phage particles affect cholera transmission also how about how antibiotics do. That transmission but also about do. transmission but also about how antibiotics do.That That finding, in turn, led Nelson tohow helpantibiotics create a tool, which finding, turn, led totohelp a atool, which finding, in turn,antibiotic ledNelson Nelson helpcreate create tool, which seeks to in change prescription habits among seeks change prescription habits among seeks to to Thirteen change antibiotic antibiotic prescription habits among doctors. years after the fellowship, Nelson and doctors. Thirteen years the fellowship, Nelson doctors. Thirteen yearsafter after the fellowship, Nelsonand and Khan officially conducted their first project together in Khan their Khan officially officially their firstproject projecttogether together 2018, running conducted aconducted clinical trial tofirst test whether this toolinin 2018, running aaclinical trial tototest whether this tool was more effective in paper form or as a mobile phone 2018, running clinical trial test whether this tool was more effective in paper form or as a mobile phone app changing thein behavior of doctors was at more effective paper form or as amanaging mobile phone app behavior diarrheal diseasethe in challenging environments. The trial, app at at changing changing the behaviorofofdoctors doctorsmanaging managing diarrheal disease in challenging environments. which looked at doctors’ decision-making processes diarrheal disease in challenging environments.The Thetrial, trial, which looked at doctors’ decision-making processes when fluid replacement and prescribing whichordering looked at doctors’ decision-making processes when ordering and prescribing antibiotics, notfluid only replacement achieved some significant outcomes when ordering fluid replacement and prescribing antibiotics, not only achieved some significant outcomes but also exemplified the “international collaboration that antibiotics, not only achieved some significant outcomes but also exemplified the “international collaboration that the NIH and Fogarty make possible, and the huge return but also exemplified the “international collaboration that the NIH and Fogarty make possible, and the huge return on that Fogarty whenand it supports earlytheinvestment NIH and Fogarty make gets possible, the huge return on investment that Fogarty gets when it supports earlycareer researchers,” Nelson said. on investment that Fogarty gets when it supports earlycareer researchers,” Nelson said. career researchers,” Nelson said. Nelson was recruited during his Fogarty fellowship by Nelson was recruited during his Fogarty by on then-director of icddr,b, Dr. David Sack, fellowship to collaborate Nelson was recruited during his Fogarty fellowship by then-director of icddr,b, Dr. David Sack, to collaborate a method to rapidly train personnel to manage cholera on then-director of icddr,b, Dr. David Sack, to collaborate a method to rapidly train personnel to manage cholera on and shigellosis outbreaks in resource-poor settings. a method to rapidly train in personnel to manage cholera and shigellosis outbreaks resource-poor settings. Called Cholera Outbreak Training and Shigellosis and shigellosis outbreaksTraining in resource-poor settings. Called Cholera Outbreak and Shigellosis (COTS), the method he helped to devise has since been Called Cholera Outbreak Training and Shigellosis (COTS), the method he helped to devise since been used globally. An updated version is parthas of an immersive (COTS), the method he helped to devise has since been used globally. An updated version is part of an immersive one-week outbreak response course Nelson leads in used globally. An updated version isNelson part ofleads an immersive one-week outbreak response course in Haiti. one-week outbreak response course Nelson leads in Haiti. Haiti. Nelson attributes the innovative projects he’s been Nelson thesupport innovative projects he’s been involvedattributes with to the he got from Fogarty and NIH Nelson attributes the innovative projects he’s involved with to the support he got from Fogarty and NIH as an early-career scientist. “Every aspect of mybeen research involved with to the support he got from Fogarty andare NIH as an early-career scientist. “Every aspect of my research has been positively impacted by Fogarty, in ways that as an early-career scientist. “Every aspect of my research has been positively impacted by Fogarty, in ways that are still declaring themselves,” he summarized. “Had Fogarty still declaring summarized. has put been impacted by Fogarty, in“Had waysFogarty that are not mepositively at themselves,” the bench forhe a year in Bangladesh, my not put me at the bench for a year in Bangladesh, still declaring he summarized. “Had my Fogarty portfolio wouldthemselves,” either be empty or filled by traditional portfolio would either be empty or filled by traditional not putscience.” me at the bench for a year in Bangladesh, my bench bench science.” portfolio would either be empty or filled by traditional bench science.” 35

Photo courtesy of Dr. Eric Nelson Photo Photo courtesy courtesy of Dr. of Dr. EricEric Nelson Nelson

“In 2005, no one should have been dying of cholera,” “In 2005, no have been dying “In 2005, noone oneshould should have been dying of of cholera,” cholera,” Nelson said. “To me, this simple meeting expressed Nelson said. “To me, this simple meeting expressed Nelson said. “To me, this simple meeting expressed failings at so many levels and crystallized my purpose failings many levels andcrystallized crystallized my my purpose purpose failings atatsosomany levels and as a researcher and clinician.” as a researcher and clinician.” as a researcher and clinician.”

Eric J. Nelson, M.D., Ph.D. Eric J. J. Nelson, Nelson, M.D., M.D.,Ph.D. Ph.D. Eric

Q&A

JON ATHAN S AMET, M.D., M.S.

Dr. Jonathan Samet has spent decades researching the health risks of inhaled pollutants, including secondhand smoke and particles in outdoor air such as those in vehicle exhaust. A longtime Fogarty and NIH grantee, he has conducted research around the world, including in China, Latin America and Africa. A pulmonary physician and epidemiologist, Samet was named dean of the Colorado School of Public Health in 2017. Previously, he was the director of the University of Southern California (USC) Institute for Global Health, and a professor and chair of the department of epidemiology at Johns Hopkins University’s Bloomberg School of Public Health.

What impact has your tobacco research had?

What has this research achieved so far?

The Fogarty-supported tobacco projects I’ve been involved with have seeded many important things. When I first went to China in 1995, for instance, there was one person doing tobacco control with a tiny budget. There were smoke-free zones in the airport and everyone would be smoking in them. That has changed, and work funded by Fogarty, the Bill & Melinda Gates Foundation and, more recently, the Bloomberg Initiative, has played a big role in bringing about those changes. Today, social norms around secondhand smoke have shifted, and an increasing number of Chinese cities, including Beijing and Shanghai, have restrictions on smoking in public places.

In Kampala and Addis Ababa, we’ve completed a complicated assessment of child respiratory health in relation to air pollution. After identifying schools with a range of air pollution levels, we put an air quality monitor in each of 10 schools in both cities. We’ve collected data about respiratory health and measured lung function in about 1,000 children—100 from each school. We’ve also installed centrally located monitors in each city.

Fogarty support also helped to start the tobacco control program at the National Institute for Public Health of Mexico, which has become a regional leader in tobacco research and training. But there’s still work to do because there’s always a new issue in tobacco control. Who was talking about vaping three years ago? That crept up on us, and today, it’s hugely popular among young people.

What is your current Fogarty project? As part of the GEOHealth Hubs program, supported by Fogarty, the National Institute of Environmental Health Sciences (NIEHS), CDC and Canada’s International Development Research Centre, we're putting in place monitors for airborne particles in the capital cities of Ethiopia, Kenya, Rwanda and Uganda, to try to understand what air pollution levels are. Our focus is on capacity building and helping to develop scientists in East Africa who do environmental health work and want to advance policy through research. Fogarty’s aim is to develop researchers who can generate the evidence needed to affect policy, and be willing to step in and talk with policymakers about what their evidence shows. We’re giving them the tools to do that. 36 Delaware Journal of Public Health – June 2019

What challenges have you faced? When we started this work five or six years ago, there were very limited monitoring data available in Africa, there were some people involved in air pollution research and control, but no real enforcement capacity. The sources of air pollution in major cities are themselves complicated—things like trash burning, factories spewing out smoke, diesel vehicles. A lot of the world’s older diesel vehicles—the ones that blast out black smoke when they go down the street—have ended up in Africa. There are the problems that arise from using fuels that pollute indoors and outdoors, whether it’s burning wood or biomass, charcoal or animal dung. While the problem is well recognized, what to do about it is a challenge. Communication of risk is another challenge. With air pollution, people know it’s bad when the levels are extraordinary. Your eyes burn, you can’t see, there’s no question that it’s harming you. But as levels go down, people learn to live with pollution.

What can the US learn from this research? Although the U.S. has made great progress in bringing down air pollution, it remains a global issue. The pollution generated in China, for example, circulates around the world. So when there’s control as a result of research in China or Africa, there are benefits to Americans. Steps that are taken to reduce air pollution locally also are expected to have benefits in terms of greenhouse gas emissions.

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Researchers Researchers have have examined examined NCDs NCDs across across the the was was emerging, emerging, Fogarty Fogarty launched launched adeveloping series a series of of programs programs articles. health health toResearchers to environmental environmental health, health, publishing publishing nearly nearly 1,000 1,000 municable municable diseases diseases (NCDs) (NCDs) inin the the world world articles. Researchers have have examined examined NCDs NCDs across across the the was was emerging, emerging, Fogarty Fogarty launched launched adeveloping series a series of of programs programs lifespan; lifespan; sought sought to to understand understand how how diseases diseases interact interact to prepare prepare local local scientists scientists to to address address the the looming looming crisis, crisis, lifespan; articles. articles. Researchers Researchers have have examined examined NCDs NCDs across across the the was was emerging, emerging, Fogarty Fogarty launched a the series a looming series of of programs programs lifespan; sought sought toto understand understand how how diseases diseases interact interact toto to prepare prepare local local scientists scientists tolaunched to address address the looming crisis, crisis, with with each each other; other; and and explored explored risk risk factors factors and and other other which which claims claims 32 32 million million lives lives each each year. year. Between Between 2001 2001 and andwith lifespan; lifespan; sought sought to to understand understand how how diseases diseases interact interact towhich to prepare prepare local local scientists scientists to to address address the the looming looming crisis, crisis, with each each other; other; and and explored explored risk risk factors factors and and other other which claims claims 3232 million million lives lives each each year. year. Between Between 2001 2001 and and cross-cutting cross-cutting issues. issues. In In addition addition to to research research and and training, training, 2017, 2017, Fogarty Fogarty and and its its NIH NIH partners partners invested invested nearly nearly $80 $80 with with each each other; other; and and explored risk risk factors factors and and other other which which claims claims 32 32 million million lives lives each each year. year. Between Between 2001 2001 and and cross-cutting cross-cutting issues. issues. Inexplored In addition addition toto research research and and training, training, 2017, 2017, Fogarty Fogarty and and itsits NIH NIH partners partners invested invested nearly nearly $80 $80 the the nearly nearly 80 80 funded funded projects projects spurred the the creation creation of of million million to to establish establish NCD NCD research research partnerships partnerships between between cross-cutting cross-cutting issues. issues. In In addition addition tospurred to research research and and training, training, 2017, 2017, Fogarty Fogarty and and its its NIH NIH partners partners invested invested nearly nearly $80 $80 the the nearly nearly 8080 funded funded projects projects spurred spurred the the creation creation of of million million to to establish establish NCD NCD research research partnerships partnerships between between curricula curricula and and degree degree programs, programs, and and new new health health practices U.S. U.S. and lowlowand and middle-income middle-income countries countries (LMICs) (LMICs) the the nearly nearly 80 80 funded funded projects projects spurred spurred the the creation creation ofpractices of million million toand to establish establish NCD NCD research research partnerships partnerships between between curricula curricula and and degree degree programs, programs, and and new new health health practices practices U.S. U.S. and and lowlowand and middle-income middle-income countries countries (LMICs) (LMICs) and and policies policies in in countries countries throughout throughout the the developing developing institutions, institutions, and and build build related related research research training training programs. programs.and curricula curricula and and degree programs, programs, and and new new health health practices practices U.S. U.S. and and lowlowand and middle-income middle-income countries countries (LMICs) (LMICs) and policies policies indegree in countries countries throughout throughout the the developing developing institutions, institutions, and and build build related related research research training training programs. programs. world. world. and and policies policies inin countries countries throughout throughout the the developing developing institutions, institutions, and and build build related related research research training training programs. programs. world. world. Under Under the the Fogarty Fogarty programs, programs, more more than than 600 600 investigators investigators world. world. Under Under the the Fogarty Fogarty programs, programs, more more than than 600 600 investigators investigators Noncommunicable Noncommunicable diseases diseases aa complex a complex problem, problem, have have received received long-term long-term NCD NCD research research training training and, and, along along Noncommunicable Under Under the the Fogarty Fogarty programs, programs, more more than than 600 600 investigators investigators Noncommunicable diseases diseases areare areaarecomplex complex problem, problem, have have received received long-term long-term NCD NCD research research training training and, and, along along Noncommunicablediseases diseasesarearea complex a complexproblem, problem, with with their their mentors, mentors, have have addressed addressed atraining variety atraining variety of of topics topics from from Noncommunicable have have received received long-term long-term NCD NCD research research and, and, along along with with their their mentors, mentors, have have addressed addressed a variety a variety of of topics topics from from and and research research and and training training needs needs continue continue toevolve. evolve. and and research research and and training training needs needs continue continue to to toevolve. evolve. with with their their mentors, mentors, have have addressed addressed a variety a variety of of topics topics from from

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Noncommunicable Noncommunicable diseases diseases (NCDs) (NCDs) claim claim 32 million million lives lives in in developing countries countries Noncommunicable Noncommunicable diseases diseases (NCDs) (NCDs) claim claim 3232 32 million million lives lives in developing in developing developing countries countries each each year. year. To help help address address the the epidemic, epidemic, Fogarty Fogarty has supported supported NCD NCD research research — —ROGER DR. ROGER ROGER I.I. GL I. ASS, GL FOGART ASS, FOGART FOGART YY DIRECTOR Y DIRECTOR each each year. year. To To To help help address address the the epidemic, epidemic, Fogarty hashas has supported supported NCD NCD research research Noncommunicable Noncommunicable diseases diseases (NCDs) (NCDs) claim claim 32Fogarty 32 million million lives lives in developing in developing countries countries — DR. — DR. DR. ROGER I. GL GL ASS, ASS, FOGART Y DIRECTOR DIRECTOR and training training programs programs since since 2001. 2001. andand and training training programs since since 2001. 2001. each each year. year. Toprograms To help help address address the the epidemic, epidemic, Fogarty Fogarty hashas supported supported NCD NCD research research — DR. — DR. ROGER ROGER I. GL I. GL ASS, ASS, FOGART FOGART Y DIRECTOR Y DIRECTOR andand training training programs programs since since 2001. 2001. Three Three of Fogarty’s Fogarty’s NCD NCD programs programs were were reviewed reviewed recently recently Three Three of of of Fogarty’s Fogarty’s NCD NCD programs programs were were reviewed reviewed recently recently

by by the the Center’s Center’s Division Division for for International International Science Science Policy, Policy, Three of of Fogarty’s Fogarty’s NCD NCD programs programs were were reviewed reviewed recently recently byThree by the the Center’s Center’s Division Division for for International International Science Science Policy, Policy, Planning Planning and and Evaluation Evaluation to to determine determine how how the the initiatives initiatives by by the the Center’s Center’s Division Division for for International International Science Science Policy, Policy, Planning Planning and and Evaluation Evaluation toto determine determine how how the the initiatives initiatives enhanced enhanced research research collaborations collaborations and and built built sustainable sustainable Planning Planning and and Evaluation Evaluation toto determine determine how how the the initiatives initiatives enhanced enhanced research research collaborations collaborations and and built built sustainable sustainable research research capacity capacity in in NCDs. NCDs. The The team team examined examined grant grant and and enhanced enhanced research research collaborations collaborations and and built built sustainable sustainable research research capacity capacity inin NCDs. NCDs. The The team team examined examined grant grant and and publications publications data, data, surveyed surveyed U.S. U.S. investigators investigators and and foreign foreign research research capacity capacity in in NCDs. NCDs. The The team team examined examined grant grant and and publications publications data, data, surveyed surveyed U.S. U.S. investigators investigators and and foreign foreign collaborators, collaborators, and and interviewed interviewed Fogarty Fogarty staff staff to determine determine publications publications data, data, surveyed surveyed U.S. U.S. investigators investigators and and foreign foreign collaborators, collaborators, and and interviewed interviewed Fogarty Fogarty staff staff toto to determine determine the the impact impact of of the the NCD NCD programs. programs. The The findings findings have have been been collaborators, collaborators, and and interviewed interviewed Fogarty Fogarty staff staff to to determine determine the the impact impact of of the the NCD NCD programs. programs. The The findings findings have have been been posted posted online online and and include include recommendations recommendations for for future future the the impact impact of of the the NCD NCD programs. programs. The The findings findings have have been been posted posted online online and and include include recommendations recommendations forfor future future priorities. priorities. posted posted online online and and include include recommendations recommendations forfor future future priorities. priorities. priorities. priorities. The The evaluation evaluation and and the the latest latest Fogarty Fogarty funding funding The The evaluation evaluation and and the the latest latest Fogarty Fogarty funding funding opportunities opportunities for for NCD NCD research research training training programs programs come come The The evaluation evaluation and and the the latest latest Fogarty Fogarty funding funding opportunities opportunities forfor NCD NCD research research training training programs programs come come at at a critical a critical time. time. Heart Heart disease, disease, cancer, cancer, diabetes diabetes and and opportunities opportunities for for NCD NCD research research training training programs programs come come atat a critical a critical time. time. Heart Heart disease, disease, cancer, cancer, diabetes diabetes and and other NCDs NCDs disproportionately disproportionately affect affect people people in poorer poorer at at a other critical a NCDs critical time. time. Heart Heart disease, disease, cancer, cancer, diabetes diabetes and and other other NCDs disproportionately disproportionately affect affect people people inin in poorer poorer countries. countries. More More than than three-quarters three-quarters of of all all NCD NCD deaths deaths other other NCDs NCDs disproportionately disproportionately affect affect people people in in poorer poorer countries. countries. More More than than three-quarters three-quarters of of allall NCD NCD deaths deaths globally globally occur occur in in LMICs, LMICs, according according to to the the WHO. WHO. Driven Driven countries. countries. More More than than three-quarters three-quarters of of all all NCD NCD deaths deaths globally globally occur occur inin LMICs, LMICs, according according toto the the WHO. WHO. Driven Driven by by an an aging aging population, population, rapid rapid urbanization, urbanization, unhealthy unhealthy globally globally occur occur in in LMICs, LMICs, according according to to the the WHO. WHO. Driven Driven byby anan aging aging population, population, rapid rapid urbanization, urbanization, unhealthy unhealthy lifestyles lifestyles and and other other forces, forces, the the burden burden of these these chronic chronic by by an an aging aging population, population, rapid rapid urbanization, urbanization, unhealthy unhealthy lifestyles lifestyles and and other other forces, forces, the the burden burden of of of these these chronic chronic diseases diseases is is expected expected to to increase increase further further unless unless proven proven lifestyles lifestyles and and other other forces, forces, the the burden burden of of these these chronic chronic diseases diseases is is expected expected toto increase increase further further unless unless proven proven interventions interventions are are implemented. implemented. Part Part of of that that challenge, challenge, diseases diseases is is expected expected to to increase increase further further unless unless proven proven interventions interventions are are implemented. implemented. Part Part of of that that challenge, challenge, asas asas noted noted in in a 2018 a 2018 WHO WHO report, report, is is that that many many countries countries lack lack interventions interventions are are implemented. implemented. Part Part of of that that challenge, challenge, as as noted noted inin a 2018 a 2018 WHO WHO report, report, is is that that many many countries countries lack lack research research capacity. capacity. noted noted in in a 2018 a 2018 WHO WHO report, report, is is that that many many countries countries lack lack research research capacity. capacity. research research capacity. capacity. “Noncommunicable “Noncommunicable diseases diseases are are a a complex problem, problem, “Noncommunicable “Noncommunicable diseases diseases are are a complex a complex complex problem, problem, and and research research and and training training needs needs continue continue to to evolve,” evolve,” “Noncommunicable “Noncommunicable diseases diseases are are a complex a complex problem, problem, and and research research and and training training needs needs continue continue toto evolve,” evolve,” said said Fogarty Fogarty Director Director Dr. Dr. Roger Roger I. Glass. I. Glass. “This “This evaluation evaluation and and research research and and training training needs needs continue continue to to evolve,” evolve,” said said Fogarty Fogarty Director Director Dr. Dr. Roger Roger I. I. Glass. Glass. “This “This evaluation evaluation shows shows the the substantial substantial progress progress we we have have made made but but also also said said Fogarty Fogarty Director Director Dr. Dr. Roger Roger I. I. Glass. Glass. “This “This evaluation evaluation shows shows the the substantial substantial progress progress wewe have have made made but but also also points points out out the the tremendous tremendous need need for for continued continued support.” support.” shows shows the the substantial substantial progress progress we we have have made made but but also also points points out out the the tremendous tremendous need need forfor continued continued support.” support.” points points out out the the tremendous tremendous need need forfor continued continued support.” support.”

Resources: Resources: http://bit.ly/NCDResearchEval http://bit.ly/NCDResearchEval Resources: Resources: http://bit.ly/NCDResearchEval http://bit.ly/NCDResearchEval Resources: Resources: http://bit.ly/NCDResearchEval http://bit.ly/NCDResearchEval

FOCUS ON NONCOMMUNICABLE DISEASES FOCUS ON NONCOMMUNICABLE DISEASES

Programs evolved to meet new challenges Programs evolved to meet new challenges Fogarty’s NCD research training programs began with

Fogarty’s NCD research training programs began with 14 grants awarded through the International Clinical, 14 grants awarded through the International Clinical, Operational and Health Services Research and Training Operational and Health Services Research and Training Award (ICOHRTA) in 2001. Several years later, after an Award (ICOHRTA) in 2001. Several years later, after an update to the Global Burden of Disease Study highlighted update to the Global Burden of Disease Study highlighted the NCDs with the highest burden in developing countries, the NCDs with the highest burden in developing countries, Fogarty launched another program focusing on cancer, Fogarty launched another program focusing on cancer, lung disease, diabetes and cardiovascular disease, known lung disease, diabetes and cardiovascular disease, known as the Noncommunicable Chronic Diseases Research as the Noncommunicable Chronic Diseases Research Training Program (NCoD). Those two programs were Training Program (NCoD). Those two programs were eventually consolidated into a new initiative when program eventually consolidated into a new initiative when program officer Dr. Kathleen Michels recognized the need for a officer Dr. Kathleen Michels recognized the need for a more holistic approach. The Chronic, Noncommunicable more holistic approach. The Chronic, Noncommunicable Diseases and Disorders Across the Lifespan Research Diseases and Disorders Across the Lifespan Research Training Program (NCD-Lifespan), which began in fiscal year Training Program (NCD-Lifespan), which began in fiscal year 2011 and continues today, emphasizes research across the 2011 and continues today, emphasizes research across the aging continuum and aims to support the science needed to aging continuum and aims to support the science needed to develop and implement evidence-based interventions. develop and implement evidence-based interventions. While not part of the evaluation, Fogarty has also seeded the While not part of the evaluation, Fogarty has also seeded the NCD researcher pipeline through other programs focused on NCD researcher pipeline through other programs focused on brain disorders, trauma and injury, and tobacco cessation. brain disorders, trauma and injury, and tobacco cessation. In addition, the Center has broadened the disciplines In addition, the Center has broadened the disciplines included in its Fellows and Scholars program to include included in its Fellows and Scholars program to include cardiology, diabetes, cancer, kidney disease and other NCD cardiology, diabetes, cancer, kidney disease and other NCD specialties. specialties.

NCD research training programs have impact NCD research training programs have impact The three NCD programs combined provided substantial The three NCD programs combined provided substantial training for 660 scientists. Those opportunities, which training for 660 scientists. Those opportunities, which lasted six months or more, included fellowships and lasted six months or more, included fellowships and certificate programs, master’s degrees, research and certificate programs, master’s degrees, research and professional doctorate degrees, and postdoc positions. professional doctorate degrees, and postdoc positions. Nearly half of the long-term participants were in nonNearly half of the long-term participants were in non-

degree programs. While long-term activities were the core degree programs. While long-term activities were the core of the programs, most grants also offered workshops of the programs, most grants also offered workshops and other short-term opportunities to enhance skills in and other short-term opportunities to enhance skills in specific areas such as lab techniques, grant writing and specific areas such as lab techniques, grant writing and research protocol development. research protocol development. As signs of success, trainees and grantees were able to As signs of success, trainees and grantees were able to leverage their experiences to obtain funding for further leverage their experiences to obtain funding for further research or research training projects. Half of the survey research or research training projects. Half of the survey respondents reported having at least one trainee who respondents reported having at least one trainee who

Top Categories of NCD Articles 2003-2015 Top Categories of NCD Articles 2003-2015

Note: Articles can focus on more than one research area. As such, a grant can be counted in more than one NCD category Note: Articles can focus on more than one research area. As such, a grant can be counted in more than one NCD category

NCD category NCD category

Mental Health/Behavioral Health Mental Health/Behavioral Health Risk Factors Risk Factors Diseases Cardiovascular Cardiovascular Diseases Substance Abuse/Addiciton Substance Abuse/Addiciton Cancers Cancers Metabolic/Gastro/Digestive Kidney Disorders Metabolic/Gastro/Digestive HIV/STIs/Infectious DiseasesKidney Disorders HIV/STIs/Infectious Diseases Trauma/Injury Trauma/Injury Neurological/Developmental Disorders Neurological/Developmental Disorders Maternal/Child Health Maternal/Child Reproductive Health Reproductive Environmental/Occupational Health Environmental/Occupational Health Bone Diseases BoneDiseases Diseases Eye Eye DiseasesDiseases Respiratory Respiratory Oral Health Diseases Oral AgingHealth Disorders Aging Disorders Grand Total Grand Total

2003 2004 2003 2004

1 1

1 1 1 1

2 2

38 Delaware Journal of Public Health – June 2019

1 1

2 2

2005 2005

2006 2006

2007 2007

2008 2008

4 14 12 22 22 23 3

3 3

2 21 1

5 5

7 7

21 21

4 4

5 5 3 13 1

16 16

2 2

3 13 31 33 3

15 15

12 124 4

1 81 83 23 22 2

2009 2009

13 136 26 26 61 21 62 56 25 2

2 2

2010 2010

10 108 18 17 107 10 4 44 42 2 2 2

1 1

1 12 12 1

1 1

38 38

47 47

49 49

2011 2011

10 10 11 116 66 68 18 14 64 36 13 11 21 21 1

2012 2012

15 15 17 17 14 14 13 13 11 116 26 72 67 62 22 21 21 2

2013 2013

2014 2014

3 23 21 1

1 1

9 9 25 25 15 15 11 11 13 13 11 11 6 66 96 9

2 21 1 60 60

101 101

20 20 27 27 16 168 87 107 10 12 125 55 52 12 1

1 1 111 111

1 1 116 116

Grand

2015 Grand 2015 Total Total 25 25 22 22 35 35 12 12 11 11 18 184 104 105 95 91 21 2 1 11 11 1 157 157

128 128 120 120 91 91 76 76 62 62 55 55 54 54 52 52 44 44 17 17 10 107 76 65 55 52 12 1 735 735

FOCUS ON ON NONCOMMUNICABLE NONCOMMUNICABLE DISEASES DISEASES

Case studies demonstrate demonstrate impact on NCD policy policy The evaluation evaluation contains contains several several cases cases studies studies representative representative of of how how findings findings from from NCD NCD research research projects have have influenced influenced health health policies policies and and programs programs in developing developing countries. countries. The The opioid opioid Tramadol Tramadol has has become become extremely extremely popular popular in in the the Middle Middle East, East, including including Egypt Egypt where where aa dangerously dangerously toxic toxic version version is is sold sold cheaply cheaply on on the the streets. streets. AA research research training collaboration between Cairo University training collaboration between Cairo University and and the the University University of of California, California, Los Los Angeles Angeles conducted conducted aa multi-country multi-country study study of of Tramadol Tramadol addiction. addiction. Evidence Evidence from this study and others helped from this study and others helped inform inform the the WHO, WHO, and and the the governments governments of of Egypt Egypt and and the the United United Arab Arab Emirates Emirates about about the the treatment treatment needs needs of of Tramadol Tramadol users users and and promoted promoted the the approval approval of of appropriate appropriate medications medications in in the the two two countries. countries. The The research research found found that that grand grand mal seizures occurred in 28.5 percent of study mal seizures occurred in 28.5 percent of study participants participants during during prior prior withdrawal withdrawal periods. periods. Because Because of that, treatment centers in Egypt and of that, treatment centers in Egypt and the the UAE UAE have have seizure seizure prevention prevention strategies strategies as as part part of of their their withdrawal withdrawal management management plans. plans.

Photocourtesy courtesy Bahr Weiss Photo of of Dr.Dr. Bahr Weiss

Findings Findings from from aa research research project project in in Vietnam Vietnam helped helped convince the Ministry of Health to make convince the Ministry of Health to make child child mental mental health health a a priority, priority, and and the the national national health health insurance insurance started started covering covering certain certain conditions. conditions. The The research research was the product of a collaboration between was the product of a collaboration between Vietnam Vietnam National University and Vanderbilt University in the National University and Vanderbilt University in the U.S. Investigators conducted Vietnam’s first nationally U.S. Investigators conducted Vietnam’s first nationally representative child mental health epidemiology survey. representative child mental health epidemiology survey. Among its findings, significant behavioral mental Among its findings, significant behavioral mental health problems were associated with an approximately health problems were associated with an approximately 350 percent increase for risk of academic functional 350 percent increase for risk of academic functional impairment. impairment. This 5-year-old Vietnamese girl was a participant in a study that This 5-year-old Vietnamese girl was a participant in a study that increased her country’s interest in child mental health services. increased her country’s interest in child mental health services.

successfully successfullyobtained obtainedadditional additionalfunding. funding.Many Manyformer former trainees traineesnow nowhave havepositions positionsininacademia academiawhere, where,as as the evaluation confirmed, their roles may range from the evaluation confirmed, their roles may range from “instructing “instructingthe thenext nextgeneration generationofofresearchers, researchers,totoleading leading clinical rounds at a university hospital, clinical rounds at a university hospital,totoconducting conducting research researchin inaalab.” lab.”Other Otheralumni alumnihave haveassumed assumedroles roles within the government or with not-for-profit within the government or with not-for-profitorganizations. organizations. Building Buildinginstitutional institutionalcapacity—creating capacity—creatingaastrong strong research environment—is research environment—isanother anotherarea areawhere whereFogarty’s Fogarty’s NCD NCDprograms programshave havemade madean animpact. impact.Grantees Granteesand and collaborators collaboratorsfrom fromaround aroundthe theworld worldprovided provideddozens dozensofof examples examplesofofhow howtheir theirawards awardshelped helpedcreate createcourses coursesoror certificate and degree programs in topics that certificate and degree programs in topics thatinclude include cancer cancerepidemiology, epidemiology,environmental environmentalsciences, sciences,nutrition, nutrition, mental mentalhealth, health,maternal maternaland andchild childhealth, health,and andthe theethics ethics of clinical trials. Respondents also reported they of clinical trials. Respondents also reported theyhad had produced producedtraining trainingmaterials materialsand andsecured securedLMIC LMICgovernment government commitments to increase staffing. The award, commitments to increase staffing. The award,many manysaid, said, enabled enabledinstitutions institutionstotorecruit recruitor orretain retainfaculty facultyinterested interested in inNCD NCDresearch. research.

Outcomes Outcomesinclude includepapers, papers,protocols protocolsand andproducts products Fogarty’s Fogarty’sprograms programshave haveadded addedtotothe thebody bodyofofknowledge knowledge related to NCDs. The review found that related to NCDs. The review found that982 982scientific scientific publications publicationsciting citingan anNCD NCDgrant grantwere wereproduced producedbetween between 2003 and 2017. The three most common 2003 and 2017. The three most commontopics topicswere were mental mentalhealth, health,risk riskfactors factorssuch suchas asobesity obesityand andnutrition, nutrition, and cardiovascular diseases. and cardiovascular diseases.

AAbibliometric bibliometricanalysis analysisexamined, examined,among amongother otherthings, things, citation impact and collaborations. A key finding citation impact and collaborations. A key findingwas wasthat that 69 percent of alumni grantees published at least three 69 percent of alumni grantees published at least three or more articles with an LMIC colleague after their NCD or more articles with an LMIC colleague after their NCD grant ended, signaling they had kept up the scientific grant ended, signaling they had kept up the scientific relationship that was formed because of the program. relationship that was formed because of the program.

NCD NCD Publications Publicationsand andImpact Impact

Bibliometric indicator Bibliometric indicator

Number of citations (times cited) Number of citations (times cited) Mean citation count Mean citation count Median citation count Median citation count

Value Value

7,761 7,761 13.13 13.13 7 7

Bibliometric indicators for NCD articles supported by Fogarty programs, Bibliometric indicators for NCD articles supported by Fogarty programs, 2003-2015 2003-2015 “Overall the results of the bibliometric analysis and co“Overall the results of the bibliometric analysis and coauthorship network suggest that grantees and alumni are authorship network suggest that grantees and alumni are producing high quality scientific articles, continuing to producing high quality scientific articles, continuing to foster collaborations between U.S. and foreign scientists, foster collaborations between U.S. and foreign scientists, and have contributed to important empirical evidence to and have contributed to important empirical evidence to combat NCDs in LMICs,” as noted in the assessment. combat NCDs in LMICs,” as noted in the assessment. Grantees and their collaborators have made other Grantees and their collaborators have made other contributions to science. When asked what their project contributions to science. When asked what their project produced, 19 investigators—nearly half of those who produced, 19 investigators—nearly half of those who responded—reported developing clinical protocols for use responded—reported developing clinical protocols for use

in LMICs. They include a clinical trial of a therapy targeting breast cancer and a protocol to manage sickle cell disease. Seventeen grantees reported building patient registries and databases; 11 created software and analytic tools; and four produced devices or prototypes.

Challenges and unmet needs

represented in research training such as metabolic disorders, hearing issues and chronic kidney diseases. Additionally, investigators may want to consider requiring each trainee to write and submit a grant proposal, because the process and feedback could help them take a critical step toward becoming an independent investigator.

While progress has been made, tackling NCDs will require many more well-qualified researchers and mentors, according to the evaluation. Grantees and collaborators who were surveyed named a range of research topics that still require attention. “Adding to this need, the diversity of NCDs that make up the epidemic adds complexity to the process of building capacity. For example, a country may have built a critical mass of researchers in cardiovascular disease, but there remains a lack of experts that can manage the growing diabetes, trauma/injury or hypertension issues in the country,” the review stated.

Some of the evaluation’s findings have been incorporated into the newest funding opportunity announcements, which have deadlines in November 2019 and 2020. In a further effort to build institutional capacity, renewal applications funded solely by Fogarty must come from the foreign site. The move away from U.S.-led projects is intended to bolster LMIC institutions’ capacity to secure their own funding. New applications are expected to propose collaborations with a single LMIC institution as the major partner, thereby concentrating resources and training opportunities at one institution so a strong foundation is built.

Many grantees pointed to implementation science research as an area for growth, given its value in developing health policy guidelines and determining how to adapt or scale up interventions. Funding was an issue, with many grantees noting that even though LMIC governments may recognize the benefit of NCD research, their national budgets are too strained to support it. Creating protected time for research was also identified as an ongoing challenge, given that faculty at LMIC institutions often have competing interests.

Fogarty has additional funding opportunities to help NCD training program alumni and other early-career researchers make the transition to independent investigator. The Emerging Global Leader Award gives junior faculty at LMIC institutions financial support and protected time for research. And the Global Noncommunicable Diseases and Injury Across the Lifespan: Exploratory Research program gives LMIC investigators the opportunity to jumpstart research programs related to NCDs, trauma and injury.

When asked about hurdles they faced in building capacity, some grantees said that five years of funding, which is typical for the research training grant mechanism (known as D43), was not long enough to effect change in some countries. The biggest obstacles within the research infrastructure at LMICs were related to grant management and accounting, and institutional review boards that were either lacking or slow to give approval.

“These programs can prime the NCD research pipeline in LMICs by giving younger scientists additional opportunities to develop their research skills,” said Fogarty’s Dr. Glass. “It’s our hope these experiences will propel them toward becoming the scientific leaders in their countries who will in turn prepare future generations of researchers.” Strong NIH support for Fogarty’s NCD programs The NCD research programs have enjoyed broad

Recommendations and next steps

support across NIH. Over time, Fogarty has had a

Recognizing that LMICs are facing the dual burden of NCDs and infectious diseases, the evaluation recommended collaboration between those scientific communities and suggested that future iterations of the NCD program consider how to prioritize the nexus between NCDs and infectious diseases. Encouraging such comorbidity research, the review noted, will help build a highly skilled and nimble research workforce.

dozen partners: the National Cancer Institute (NCI),

Priority also should be given to research topics that cut across diseases, including prevention and implementation science, common risk factors, developmental origins, maternal and child health, and stigma. An emphasis also should be placed on research areas that so far have been under40 Delaware Journal of Public Health – June 2019

National Center for Complementary and Integrative Health (NCCIH), National Institute on Aging (NIA), National Institute on Alcohol Abuse and Alcoholism (NIAAA), Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institute on Drug Abuse (NIDA), National Institute of Dental and Craniofacial Research (NIDCR), National Institute of Environmental Health Sciences (NIEHS), National Institute of Mental Health (NIMH), National Institute of Neurological Disorders and Stroke NINDS), National Institute of Nursing Research (NINR), and the Office of Dietary Supplements (ODS).

OPINION OPINION OPINION

ByBy Dr.Dr. Roger Roger I. Glass, I. Glass, Director, Director, Fogarty Fogarty International International Center Center By Dr. Roger I. Glass, Director, Fogarty International Center

New New energy for global health blossoming across NIH Newenergy energyfor forglobal globalhealth healthisis isblossoming blossomingacross acrossNIH NIH There’s There’s a new a new wave wave of of enthusiasm enthusiasm a new wave of enthusiasm forThere’s for global global health health sweeping sweeping across across for global health sweeping across NIH. NIH. In In addition addition to to the the continuing continuing NIH. In addition to the continuing strong strong support support from from NIH NIH Director Director support from I’m NIH Director Dr.strong Dr. Francis Francis S.S. Collins, Collins, I’m pleased pleased Dr. Francis S. Collins, I’m to to have have three three new new institute institutepleased to have on three new institute directors directors on campus campus who who share share directors on campus who share our our passion passion to to build build research research our passion tofund build research capacity capacity and and fund studies studies to to capacity and fund studies to improve improve the the health health of of the the world’s world’s improve the health of the world’s least least fortunate. fortunate. I was I was delighted delighted fortunate. I was delighted to least to bebe joined joined in in Kenya Kenya recently recently byby to be joined in Kenya recently by the the relatively relatively new new directors directors of of the the institutes institutes concerned concerned with with the relatively new directors of the institutes concerned with mental mental and and child child health health research. research. There, There, they they were were able able to to mental and the child healththeir research. There, they were able to see see firsthand firsthand the impact impact their programs programs are are having having onon the the see firsthand the impact their programs are having on the ground. ground. ground. AA visit visit to to anan innovative innovative project project in in rural, rural, western western Kenya Kenya A visit to an innovative projectInstitute inInstitute rural, of western Kenya particularly particularly impressed impressed National National of Mental Mental Health Health particularly impressed National Institute of Mental Health (NIMH) (NIMH) Director Director Dr.Dr. Josh Josh Gordon. Gordon. ByBy enhancing enhancing irrigation irrigation (NIMH) Director Dr. Josh Gordon. By enhancing irrigation and and improving improving productivity productivity of of farmers farmers living living with with HIV, HIV, and improving productivity of farmers living will with HIV, researchers researchers found found it’sit’s more more likely likely the the farmers farmers will adhere adhere researchers found it’s more likely the farmers will adhere to to their their antiviral antiviral medication medication regimens regimens and and keep keep their their to their antiviral medication regimens and keep their clinic clinic appointments. appointments. AA few few hours’ hours’ drive drive away away in in Eldoret, Eldoret, clinic appointments. A few hours’ drive away in Eldoret, Kenyan Kenyan and and U.S. U.S. researchers researchers are are studying studying how how to to keep keep Kenyan and U.S. researchers are studying how to keep adolescents adolescents with with HIV HIV onon treatment treatment using using peer peer advisors advisors adolescents with HIV on treatment using peer advisors and and group group therapy. therapy. They’re They’re also also investigating investigating how how to to treat treat and groupand therapy. They’re also investigating how to treat depression depression and trauma trauma to to improve improve control control of of HIV HIV infection, infection, depression and trauma tosymptoms. improve control of HIV you infection, and and alleviate alleviate mental mental health health symptoms. I encourage I encourage you to to and alleviate mental health symptoms. I encourage you to read read Dr.Dr. Gordon’s Gordon’s full full blog blog post post about about hishis travels, travels, which which Dr. full blog post about his travels, which heread he sums sums upGordon’s up with with this this observation, observation, “Through “Through cutting-edge cutting-edge he sums up with this observation, “Through cutting-edge research research around around the the world, world, global global efforts efforts yield yield truly truly global global research impacts.” impacts.”around the world, global efforts yield truly global impacts.”

She She reported reported being being moved moved byby her her interactions interactions with with children children She reported being moved by her interactions with and and families families who who are are living living with with HIV/AIDS. HIV/AIDS. She She also alsochildren and families who areby living with HIV/AIDS. She alsoto to said said she she was was inspired inspired by many many of of the the women women working working said she was inspired by many of the women working to reduce reduce HIV HIV infections infections among among adolescent adolescent girls girls and and young young reduce HIV infections among adolescent girls and young women women through through the the program program called called DREAMS DREAMS (Determined, (Determined, women through the program called DREAMS (Determined, Resilient, Resilient, Empowered, Empowered, AIDS-free, AIDS-free, Mentored, Mentored, and and Safe Safe Resilient, Empowered, AIDS-free, Mentored, and Safe women). women). Administered Administered byby the the President’s President’s Emergency Emergency women). Administered by the President’s Emergency Plan Plan forfor AIDS AIDS Relief Relief (PEPFAR), (PEPFAR), the the DREAMS DREAMS partnership partnership Plan forthe AIDS Relief (PEPFAR), the DREAMS and partnership includes includes the Bill Bill && Melinda Melinda Gates Gates Foundation Foundation and other other includes the Bill & Melinda Gates Foundation and other private private organizations. organizations. private organizations. Overall, Overall, the the trip trip was was a powerful a powerful demonstration demonstration of of the the Overall, the and trip was a powerful demonstration of impact impact NIMH NIMH and NICHD NICHD investments investments have have made made inthe in impact NIMH and NICHD investments have made in advancing advancing global global health health capacity capacity and and research, research, with with a a advancing global health capacity and research, with awork. reminder reminder that that real real people’s people’s lives lives depend depend onon this this vital vital work. reminder that real people’s lives depend on this vital work. Back Back home home in in Bethesda, Bethesda, I was I was pleased pleased to to have have Dr.Dr. Gordon Gordon Back home inNational Bethesda, I was to have Dr. Gordon and and the the new new National Institute Institute ofpleased of Biomedical Biomedical Imaging Imaging and the new National Institute of Biomedical Imaging and and Bioengineering Bioengineering (NIBIB) (NIBIB) Director Director Dr.Dr. Bruce Bruce Tromberg Tromberg and Bioengineering (NIBIB) Director Dr. Bruce Tromberg join join meme forfor a discussion a discussion with with Fogarty’s Fogarty’s advisory advisory board. board. join me for a discussion with Fogarty’s advisory board. Both Both gave gave usus valuable valuable insights insights into into how how wewe might might spur spur Both gave us valuable insights into how we might spur innovation innovation in in global global health health and and build build LMIC LMIC capacity capacity in in innovation in global health and build LMIC capacity in bioengineering bioengineering and and other other related related fields. fields. bioengineering and other related fields.

Arriving Arriving at at NIH NIH from from the the University University of of California, California, Irvine, Irvine, at NIH from the University ofschools California, Irvine, Dr.Arriving Dr. Tromberg Tromberg said said many many engineering engineering schools now now have have Dr. Tromberg said many engineering schools now have improving improving human human health health asas their their top top goal. goal. Engineering Engineering is is improving human health as their top goal. Engineering even even being being combined combined with with medicine medicine asas a new a new discipline. discipline.is even being combined with medicine as a Pettigrew, new discipline. For For instance, instance, hishis predecessor, predecessor, Dr.Dr. Roderic Roderic Pettigrew, is is now now For instance, his predecessor, Dr. Roderic Pettigrew, isat now building building the the first first such such fully fully integrated integrated national national program program at building the first such fully integrated national program Texas Texas A&M A&M University. University. I was I was also also excited excited to to hear hear that that Dr.Dr.at Texas A&M I was also excited to hear that Dr. Tromberg Tromberg is is a University. proponent a proponent of of engineering engineering capacity capacity building, building, Tromberg is a proponent of engineering capacity building, having having ledled a two-week a two-week workshop workshop in in Côte Côte d’Ivoire d’Ivoire to to teach teach having led a two-week workshoptoin Côte d’Ivoire to teach entrepreneurship entrepreneurship and and innovation innovation to African African scientists. scientists. entrepreneurship and innovation to African scientists. Indeed, Indeed, hehe said said the the experience experience changed changed hishis life. life. Now Now that that MyMy colleague colleague Dr.Dr. Diana Diana Bianchi, Bianchi, director director of of the the Eunice Eunice Indeed, he said the experience changed his life. Now that My colleague Dr. Diana Bianchi, director of the Eunice sensors sensors and and other other components components are are inexpensive inexpensive and and more more Kennedy Kennedy Shriver Shriver National National Institute Institute of of Child Child Health Health and and sensors and other components are inexpensive and more Kennedy Shriver National Institute of Child Health and easily accessible accessible in in LMICs, LMICs, technologies technologies forfor health health can can bebe Human Human Development Development (NICHD), (NICHD), said said it was it was “an “an unforgettable unforgettable easily easily accessible inneeds, LMICs, technologies for tools health can Human Development (NICHD), said “an unforgettable adapted adapted to to suit suit local local needs, he he said. said. Portable Portable tools can can bebe be experience.” experience.” Her Her visit visit included included time time at it at a was busy a busy public public adapted to suit local needs, he said. Portable tools can be experience.” Her visit included time at a busy public developed to to reduce reduce barriers barriers to to care, care, improve improve access access and and hospital hospital in in Nairobi, Nairobi, asas well well asas rural rural sites sites in in western western Kenya. Kenya. developed developed to reduce barriers to care, improve access and hospital in Nairobi, as well as rural sites in western Kenya. democratize democratize human human health. health. She She reported reported being being very very impressed impressed byby the the fact fact that that postpostdemocratize human health. She reported being very impressed byin the fact thatfor postpartum partum mothers mothers are are housed housed and and fedfed in the the hospital hospital for partum mothers are housed and fed the hospital for With this this wonderful wonderful energy energy and and enthusiasm enthusiasm from from mymy new new weeks weeks and and months months after after delivery delivery of of a premature a in premature baby, baby, and and With With this I’m wonderful energy and enthusiasm from my new weeks and months after delivery of a premature baby, and colleagues, colleagues, I’m more more optimistic optimistic than than ever ever that that by by working working are are incorporated incorporated into into the the daily daily nursery nursery routine routine byby providing providing colleagues, I’m moreNIH, optimistic than ever that by to working are incorporated into the daily nursery routine by providing collaboratively collaboratively across across NIH, wewe can can speed speed advances advances to expressed expressed breast breast milk milk and and changing changing their their babies’ babies’ diapers. diapers. collaboratively across NIH, we can speed advances to expressed breast milk and changing their babies’ diapers. improve improve the the health health of of allall people. people. She She was was also also struck struck at at how how clinical clinical and and implementation implementation improve the health of all people. She was also struck at how clinical and implementation research research is is embedded embedded in in the the overall overall culture culture and and operations operations is embedded inmore the culture and operations at research at Moi Moi University, University, even even more sooverall so than than in in many many American American RESOURCES RESOURCES at Moi University, even more so than in many American academic academic medical medical centers. centers. RESOURCES http://bit.ly/NIHglobalhealth http://bit.ly/NIHglobalhealth academic medical centers. http://bit.ly/NIHglobalhealth

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PEOPLE PEOPLE PEOPLE PEOPLE PEOPLE

Bridbord, Bridbord,Holmes Holmeslauded laudedasasglobal globalhealth healthleaders leaders Bridbord, Bridbord, Holmes Holmes lauded lauded as asglobal global health healthleaders leaders Drs. Drs. Ken Ken Bridbord Bridbord and and King King Holmes Holmes are are co-recipients co-recipients of of the the

Drs. Drs. Ken Ken Bridbord Bridbord and and King King Holmes Holmes are are co-recipients co-recipients of of the the Consortium Consortium of of Universities Universities for for Global Global Health Health 2019 2019 Distinguished Distinguished Bridbord, Holmes lauded as global health leaders Consortium Consortium of of Universities Universities for for Global Global Health Health 2019 2019 Distinguished Distinguished Leadership Leadership Award, Award, the the organization’s organization’s highest highest honor. honor. AsAs longtime longtime Drs. Ken Bridbord and King Holmeshighest are co-recipients oflongtime the Leadership Leadership Award, Award, the the organization’s organization’s highest honor. honor. Ascreated As longtime director director of of Fogarty’s Fogarty’s extramural extramural programs, programs, Bridbord Bridbord created Consortium of Universities for programs, Global Health 2019 created Distinguished director director of of Fogarty’s Fogarty’s extramural extramural programs, Bridbord Bridbord created initiatives initiatives that that provided provided research research training training forfor 6,000 6,000 scientists scientists Leadership Award, theresearch organization’s highest honor. As longtime initiatives that that provided provided research training training for for 6,000 6,000 scientists scientists in initiatives in lowlowand and middle-income middle-income countries. countries. Now Now retired, retired, Bridbord Bridbord is is a a director ofmiddle-income Fogarty’s extramural programs, Bridbord created in in lowlowand and middle-income countries. countries. Now Now retired, retired, Bridbord Bridbord is is a a Fogarty Fogarty senior senior scientist scientist emeritus. emeritus. initiatives that provided research training for 6,000 scientists Fogarty Fogarty senior senior scientist scientist emeritus. emeritus. in low-aand middle-income countries. Now retired, Bridbord Holmes, Holmes, Fogarty a Fogarty advisory advisory board board member member and and grantee, grantee, is is is a Holmes, Holmes, Fogarty aand Fogarty advisory advisory board board member and and grantee, grantee, is is Fogartyaand senior scientist emeritus. professor professor founding founding director director of member of the the Department Department of of Global Global professor professor and and founding founding director director of of the the Department Department of of Global Global Health Health (DGH) (DGH) at at the the University University of of Washington. Washington. InIn hishis more more Holmes, a Fogarty advisory board member and grantee, is Health Health (DGH) at the the University University ofresearch of Washington. Washington. InIn hishis more more than than 50(DGH) 50 years years ofat of global global health health research and and training, training, Holmes Holmes professor and founding director of theand Department of Global than than 50 50 years years of of global global health health research research and training, training, Holmes Holmes has has collaborated collaborated with with over over 170 170 trainees trainees and and mentees, mentees, and and has has Health (DGH) atwith the University of Washington. In hisand more has has collaborated collaborated with over over 170 170 trainees trainees and and mentees, mentees, and has has produced produced some some 800 800 publications. publications. than 50 some years of800 global health research and training, Holmes produced produced some 800 publications. publications. hascancer collaborated with over 170 trainees and NIH NIH cancerdirector director Sharpless Sharpless moves moves tomentees, toFDA FDA and has produced some 800 publications. NIH NIH cancer cancer director director Sharpless Sharpless moves moves to to FDA FDA Dr.Dr. Norman Norman E.E. "Ned" "Ned" Sharpless, Sharpless, director director of of NIH’s NIH’s National National Cancer Cancer Dr. Dr. Norman Norman E. E. "Ned" "Ned" Sharpless, Sharpless, director director of of NIH’s NIH’s National National Cancer Cancer Institute Institute since since 2017, 2017, has has been been tapped tapped to to become become acting acting FDA FDA NIH cancer director Sharpless moves to FDA Institute Institute since since 2017, 2017, has has been been tapped tapped to to become become acting acting FDA FDA commissioner commissioner in in April. April. Previously, Previously, Sharpless Sharpless directed directed the the Lineberger Lineberger Dr. Norman E. "Ned" Sharpless, director of directed NIH’s National Cancer commissioner commissioner inCancer in April. April. Previously, Previously, Sharpless Sharpless directed the the Lineberger Lineberger Comprehensive Comprehensive Cancer Center Center at at the the University University of of North North Carolina. Carolina. Institute since 2017, has been tapped to become acting FDA Comprehensive Comprehensive Cancer Cancer Center Center at at the the University University of of North North Carolina. Carolina. Sharpless Sharpless treated treated leukemia leukemia patients patients and and conducted conducted research research onon commissioner inleukemia April. Previously, Sharpless directed the Lineberger Sharpless Sharpless treated treated leukemia patients patients and and conducted conducted research research onon cancer cancer and and aging. aging. Comprehensive Cancer Center at the University of North Carolina. cancer cancer and and aging. aging. Sharpless treated leukemia patients andscientist conducted Swaminathan Swaminathan named named WHO’s WHO’s chief chief scientist research on cancer and aging. Swaminathan Swaminathan named named WHO’s WHO’s chief chief scientist scientist Dr.Dr. Soumya Soumya Swaminathan, Swaminathan, a former a former Fogarty Fogarty trainee, trainee, has has been been Dr. Dr. Soumya Soumya Swaminathan, Swaminathan, a former a former Fogarty Fogarty trainee, trainee, has has been been appointed appointed to to a newly a newly created created WHO WHO position, position, Chief Chief Scientist, Scientist, Swaminathan named WHO’s chief scientist appointed appointed to to a newly a newly created created WHO WHO position, position, Chief Chief Scientist, Scientist, charged charged with with strengthening strengthening the the organization’s organization’s core core scientific scientific work. work. Dr. Soumya Swaminathan, athe former Fogarty core trainee, has been charged charged with with strengthening strengthening the organization’s organization’s core scientific work. work. She She had had been been deputy deputy director-general director-general forfor programs. programs. Ascientific pediatrician A pediatrician appointed todeputy adeputy newlydirector-general created WHO position, Chief Scientist, She She had had been been director-general for for programs. programs. A pediatrician A pediatrician and and clinical clinical researcher, researcher, Swaminathan Swaminathan was was director director general general of of the the charged with strengthening the organization’s core scientific work. and and clinical clinical researcher, researcher, Swaminathan Swaminathan was was director director general general of of the the Indian Indian Council Council of of Medical Medical Research Research before before joining joining WHO. WHO. She had beenofdeputy director-general forjoining programs. A pediatrician Indian Indian Council Council of Medical Medical Research Research before before joining WHO. WHO. and clinical researcher, Swaminathan was director general Richards-Kortum Richards-Kortum added added totoInventors Inventors Hall HallofofFame Fame of the Richards-Kortum Richards-Kortum added added to to Inventors Inventors Hall Hall of of Fame Fame Indian Council of Medical Research before joining WHO. Former Former Fogarty Fogarty advisory advisory board board member member Dr.Dr. Rebecca Rebecca RichardsRichardsFormer Former Fogarty Fogarty advisory advisory board board member member Dr. Dr. Rebecca Rebecca RichardsRichardsKortum Kortum is is among among the the 2019 2019 inductees inductees into into the the National National Inventors Inventors Richards-Kortum added to Inventors Hall of Fame Kortum Kortum is is among among the the 2019 2019 inductees inductees into into the the National National Inventors Hall Hall of of Fame. Fame. A professor A professor of of bioengineering bioengineering and and director director ofInventors of the the Former Fogarty advisoryofboard member Dr. Rebecca RichardsHall Hall of of Fame. Fame. A professor A professor of bioengineering bioengineering and and director director ofRichardsof the the Rice Rice 360° 360° Institute Institute forfor Global Global Health Health at at Rice Rice University, University, RichardsKortum is Institute amongfor the 2019 inductees into the NationalRichardsInventors Rice Rice 360° 360° Institute for Global Global Health Health at at Rice Rice University, University, RichardsKortum Kortum develops develops medical medical devices devices forfor use use in in low-resource low-resource settings. settings. Hall ofdevelops Fame. Amedical professor of bioengineering and directorsettings. ofsettings. the Kortum Kortum develops medical devices devices forfor use use in in low-resource low-resource Rice 360° Institute for Global Health at Rice University, RichardsKortum develops medical devices for Clemens use in low-resource settings. Oral Oral cholera cholera vaccine vaccine developer developer Clemens honored honored

Oral cholera cholera vaccine vaccine developer developer Clemens Clemens honored honored Dr.Oral Dr. John John D.D. Clemens, Clemens, executive executive director director of of Fogarty Fogarty grantee grantee

Dr. Dr. John John D.the D. Clemens, Clemens, executive executive director director ofDiarrhoeal of Fogarty Fogarty grantee grantee institution institution the International International Centre Centre forfor Diarrhoeal Disease Disease Oral cholera vaccine developer Clemens honored institution institution the the International International Centre forfor Diarrhoeal Disease Disease Research, Research, Bangladesh, Bangladesh, is is a co-recipient aCentre co-recipient ofDiarrhoeal of Thailand’s Thailand’s Prince Prince Dr. JohnBangladesh, D. Clemens,isexecutive director of Thailand’s Fogarty grantee Research, Research, Bangladesh, is a and co-recipient a co-recipient ofcollaborator of Thailand’s Prince Prince Mahidol Mahidol Award. Award. Clemens Clemens and longtime longtime collaborator Dr. Dr. Jan Jan institution theClemens International Centre for DiarrhoealDr. Disease Mahidol Mahidol Award. Award. Clemens and and longtime longtime collaborator collaborator Dr. Jan Jan R. R. Holmgren Holmgren of of Sweden Sweden were were recognized recognized for for developing developing an an oral oral Bangladesh, is a recognized co-recipient of Thailand’s Prince R.Research, R. Holmgren Holmgren of of Sweden Sweden were were recognized for for developing developing oral oral cholera cholera vaccine vaccine that that has has protected protected millions millions of of people. people.anan Mahidol Award. Clemens and longtime collaborator Dr. Jan cholera cholera vaccine vaccine that that has has protected protected millions millions of of people. people. R. Holmgren of awarded Sweden were recognized for developing an oral Abdool Abdool Karim Karim awarded byby Kuwait Kuwaitfor forHIV HIVresearch research cholera vaccine that has protected millions of people. Abdool Abdool Karim Karim awarded awarded by by Kuwait Kuwait for for HIV HIV research research Longtime Longtime Fogarty Fogarty grantee grantee Dr.Dr. Salim Salim Abdool Abdool Karim Karim shares shares Longtime Longtime Fogarty Fogarty grantee grantee Dr. Dr. Salim Salim Abdool Abdool shares shares Kuwait’s Kuwait’s 2018 2018 Al-Sumait Al-Sumait Prize Prize for for Health, Health, a Karim Kuwaiti a Karim Kuwaiti award award Abdool Karim awarded by Kuwait for HIV research Kuwait’s Kuwait’s 2018 2018 Al-Sumait Al-Sumait Prize Prize for for Health, Health, a Kuwaiti a Kuwaiti award award honoring honoring people people and and organizations organizations that that address address challenges challenges Longtime Fogarty grantee Dr. Salim Abdool Karim shares honoring honoring people people and and organizations organizations that that address address challenges challenges in in Africa. Africa. Abdool Abdool Karim, Karim, director director of of the the Centre Centre forfor the the AIDS AIDS Kuwait’s 2018 Al-Sumait Prize of forof Health, a Kuwaiti award in in Africa. Africa. Abdool Abdool Karim, Karim, director director the the Centre Centre for for the the AIDS AIDS Programme Programme of of Research Research in in South South Africa, Africa, was was recognized recognized forfor hishis honoring people and organizations thatwas address challenges Programme Programme of of Research Research in in South South Africa, Africa, was recognized recognized hishis contributions contributions to to HIV/AIDS HIV/AIDS treatment treatment and and prevention. prevention. forfor in Africa. Abdool Karim, director of the Centre for the AIDS contributions contributions to to HIV/AIDS HIV/AIDS treatment treatment and and prevention. prevention. Programme of Research in South Africa, was recognized for his 42 Delaware Journal contributions of Public Health to – June 2019 HIV/AIDS treatment and prevention.

Global Global Global Global HEALTH HEALTH Briefs Global Briefs HEALTH HEALTH Briefs Briefs HEALTH Briefs

NIH NIH releases releases plan plan forfor women’s women’s health health NIH releases releases plan plan for women’s women’s health NIHNIH NIH has has developed developed a strategic afor strategic plan plan to advance tohealth advance

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Supplement Supplement improves improves infant infant outcomes outcomes Full report: http://bit.ly/NIHwomen Supplement improves infant infant outcomes outcomes ForSupplement For women women in resource-poor inimproves resource-poor settings, settings, taking taking For For women women in resource-poor in resource-poor settings, settings, taking taking a certain a certain daily daily nutritional nutritional supplement supplement before before Supplement improves infant outcomes aconception certain aconception certain daily daily nutritional nutritional supplement supplement before before or in or early in early pregnancy pregnancy may may improve improve For women in early resource-poor settings, taking conception conception or in or in early pregnancy pregnancy may may improve improve growth growth of the of the fetus, fetus, according according to an to an NIH-funded NIH-funded a certain daily nutritional supplement before growth growth ofThe the of the fetus, fetus, according according to an towith an NIH-funded NIH-funded study. study. The supplement supplement is fortified is fortified with vitamins vitamins andand conception or in earlyispregnancy may improve study. study. The The supplement supplement fortified is fortified with with vitamins andand minerals, minerals, andand provides provides protein protein andand fat.fat.vitamins growth and of and the fetus, according toand an fat. NIH-funded minerals, minerals, provides provides protein protein and fat. Journal Journal article: article: http://bit.ly/NutritionForMoms http://bit.ly/NutritionForMoms study.article: The supplement is fortified with vitamins and Journal Journal article: http://bit.ly/NutritionForMoms http://bit.ly/NutritionForMoms minerals, and provides protein and fat. 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WHO WHO posts posts R&D R&D spending spending byby country country Full posts report: http://bit.ly/WHO_malaria WHO WHO posts R&D R&D spending spending byby country country New New analysis analysis from from the the WHO WHO Global Global Observatory Observatory on on New New analysis analysis from from the the WHO WHO Global Global Observatory on on Health Health R&D R&D shows shows thatthat only only 41% 41% of 75 of Observatory 75 countries countries WHO posts R&D spending by75 country Health Health R&D R&D shows shows that that only only 41% 41% of of 75 countries countries analyzed analyzed metmet their their health health R&D R&D spending spending targets targets New analysis from the WHO Global Observatory on analyzed analyzed met met their their health health R&D R&D spending spending targets targets using using thethe most most recent recent data data available. available. Some Some lowlowHealth R&D shows that only 41% ofSome 75Some countries using using the the most most recent recent data data available. available. lowlowincome income countries countries allocated allocated a higher a higher percentage percentage of of analyzed met their healtha R&D spending targets income income countries countries allocated allocated higher a higher percentage percentage of of their their GDP GDP on on health health than than high-income high-income countries. countries. using the most recent data available.countries. Some lowtheir their GDP GDP on on health health than than high-income high-income countries. Website: Website: http://bit.ly/WHO_benchmark http://bit.ly/WHO_benchmark incomehttp://bit.ly/WHO_benchmark countries allocated a higher percentage of Website: Website: http://bit.ly/WHO_benchmark their GDP on health than high-income countries. NIH, NIH, FDA FDA host host treatment treatment collaboration collaboration tool tool Website: http://bit.ly/WHO_benchmark NIH, NIH, FDA FDA host host treatment treatment collaboration collaboration tool tool To encourage To encourage information information sharing sharing of treatment of treatment To encourage To encourage information information sharing sharing of treatment of treatment practices practices forfor neglected neglected diseases diseases andand emerging emerging or or NIH, FDA host treatment collaboration practices practices forfor neglected neglected diseases diseases and and emerging emerging ortool or drug-resistant drug-resistant infections, infections, the the NIHNIH and and FDA FDA have have To encourage information sharing ofFDA treatment drug-resistant drug-resistant infections, infections, the the NIH NIH and and FDA have have built built a tool a tool called called Collaborative Collaborative UseUse Repurposing Repurposing practices forcalled neglected diseases and emerging or built built a tool a tool called Collaborative UseUse Repurposing Repurposing Engine Engine (CURE). (CURE). TheCollaborative The aim aim is to is capture to capture and and centralize centralize drug-resistant infections, the NIH and FDA have Engine Engine (CURE). (CURE). The The aim aim is to is capture to capture and centralize centralize thethe global global experience experience of new of new uses uses of approved ofand approved built a tool called Collaborative Use Repurposing the the global global experience experience of new of new uses uses of approved of approved medical medical products products −both −both positive positive andand negative. negative. Engineproducts (CURE). The aim ispositive to capture and centralize medical medical products −both −both positive andand negative. negative. Website: Website: https://cure.ncats.io https://cure.ncats.io the global experience of new uses of approved Website: Website: https://cure.ncats.io https://cure.ncats.io medical products−both positive and negative. PAHO PAHO studies studies youth youth health health in in Americas Americas Website: https://cure.ncats.io PAHO PAHO studies studies youth health health ininin Americas Half Half of all of all deaths deaths ofyouth young of young people people the inAmericas the Americas Americas Half ofdue all oftoall deaths of young of young people people inasthe inas the Americas Americas areHalf are due preventable to deaths preventable causes causes such such homicide, homicide, PAHO studies youth health in Americas are are due due to preventable to preventable causes causes such such as as homicide, homicide, traffic traffic fatalities fatalities andand suicide, suicide, according according to atonew a new Halffatalities of all deaths of suicide, youngaccording people intothe traffic traffic and and suicide, according atonew aAmericas new report report byfatalities by thethe Pan Pan American American Health Health Organization Organization are due tothe preventable causes such as homicide, report report by by the Pan Pan American American Health Health Organization Organization (PAHO). (PAHO). TheThe study study examines examines various various health health aspects aspects trafficThe fatalities and suicide, according to aspects a new (PAHO). (PAHO). The study study examines examines various various health health aspects of the of the region’s region’s 237 237 million million young young people people andand report by the237 Pan American Health Organization of the of the region’s region’s 237 million million young young people people and and provides provides recommendations recommendations forfor improvement. improvement. (PAHO).recommendations The study examines various health aspects provides recommendations forfor improvement. improvement. Fullprovides Full report: report: http://bit.ly/PAHO_youth http://bit.ly/PAHO_youth ofreport: the region’s 237 million young people and FullFull report: http://bit.ly/PAHO_youth http://bit.ly/PAHO_youth provides recommendations for improvement. Full report: http://bit.ly/PAHO_youth

MARCH/APRIL 2019

Funding Opportunity Announcement

Details

Deadline

Global Infectious Disease (GID) Research Training Program (D71) (D43) Clinical Trial Optional

http://bit.ly/IDtraining

July 25, 2019

Global Brain and Nervous System Disorders Research Across the Lifespan (R21) Clinical Trial Optional (R01) Clinical Trial Optional

http://bit.ly/NIHGlobalBrain

Nov 7, 2019

Emerging Global Leader Award (K43) Independent Clinical Trial Required (K43) Independent Clinical Trial Not Allowed

http://bit.ly/NIHGlobalLeader

Nov 7, 2019

Noncommunicable Diseases and Disorders Research Training Programs in LMICs (D43) Clinical Trial Optional

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Nov 12, 2019

Ecology and Evolution of Infectious Diseases Initiative (EEID) (R01)

http://bit.ly/EEIDNIH

Nov 20, 2019

For more information, visit www.fic.nih.gov/funding

Global Health Matters Volume 18, No. 2 ISSN: 1938-5935 Fogarty International Center National Institutes of Health Department of Health and Human Services Managing editor: Ann Puderbaugh Ann.Puderbaugh@nih.gov Writer/editor: Shana Potash Shana.Potash@nih.gov Writer/editor: Karin Zeitvogel Karin.Zeitvogel@nih.gov Web manager: Anna Pruett Ellis Anna.Ellis@nih.gov Designer: Carla Conway All text produced in Global Health Matters is in the public domain and may be reprinted. Please credit Fogarty International Center. Images must be cleared for use with the individual source, as indicated.

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March/April 2019

Poor quality drugs pose “health emergency,” study says More than a quarter of a million children die each year due to poor quality and fake medicines, according to a study published in March in the American Journal of Tropical Medicine and Hygiene. The assessment by a team of experts from the public and private sector concludes that a “pandemic” of falsified and substandard drugs for treating malaria, pneumonia, hypertension and other diseases has become a “public health emergency,” especially in low- and middleincome countries. It cites evidence that up to 155,000 children die Poor quality and fake medicines (top photo) every year due to fake malaria are an urgent threat. drugs alone, and that a similar number die from low-quality or counterfeit antimicrobial drugs prescribed to treat pneumonia. Other common fake drugs include prescription opioids and medicines for heart disease, erectile dysfunction and cancer. Fogarty senior scientist emeritus Dr. Joel Breman, a co-author on the study, said that fake drugs are often peddled over the internet and sometimes linked to organized crime and terrorist groups. Poor quality drugs cost the global economy an estimated $200 billion per year, Breman said, and contribute to the growing problem of antimicrobial resistance.

R E SOURCE Journal article: http://bit.ly/ASTMH_fakedrugs 43

Wellness and Prevention Digest Pain in the Nation Issue Brief:

Alcohol and Drug Misuse and Suicide and the Millennial Generation a Devastating Impact This issue brief, focused on the Millennial Generation, is a continuation of Trust for America’s Health (TFAH) and Well Being Trust’s Pain in the Nation: The Drug, Alcohol and Suicide Crises series. The Pain in the Nation series helps inform and create a comprehensive National Resilience Strategy. This brief is focused on Millennials for numerous reasons: Millennials are dying due to alcohol and drug misuse and suicide in record numbers. Millennials are more than one-third of the workforce, they are the largest proportion of Americans serving in the military. About a quarter lack health insurance, many are burden by education debt, and, many are or will be parents responsible for the well-being of young children. LISTEN TO THE PODCAST

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44 Delaware Journal of Public Health – June 2019

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Caring for the LGBTQ Community with Pride For eight consecutive years and counting, Christiana Hospital and Wilmington Hospital have earned the Leader in LGBTQ Healthcare Equality designation â&#x20AC;&#x201D; the highest recognition â&#x20AC;&#x201D; from the Healthcare Equality Index of the Human Rights Campaign Foundation. We are honored to be named among the most equitable, inclusive health care providers and employers in the country. As a leader in LGBTQ health care equality we are dedicated to serving the unique health needs of lesbian, gay, bisexual, transgender and queer people in our community. #worldpride

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Building Resilience, Reducing Risk: Four Pillars to Creating Safer, More Supportive Schools for LGBTQ+ Youth Rev. Karla Fleshman, L.C.S.W., M.Div.; Transitions Delaware llc

ABSTRACT In 2017 Delaware, LGBTQ+ Youth reported that almost 1 out of 3 were bullied on school grounds. Additionally, over 50% reported feeling sad/hopeless; and almost as many seriously considered suicide as an option, while 32% planned for suicide with almost 1 in 4 reporting having acted on their suicide plan at least once. Of all the students who reported a suicide attempt, 10% required medical treatment as a result of their attempt.1 The Delaware Department of Education does not have comprehensive statewide protections in place to support some of our most vulnerable youth, yet school districts can make a positive difference in implementing policy/practices to build resilience and reduce risk. This article will focus on four key areas where schools and school districts may implement changes toward creating safer, more supportive schools: (1) policy/procedures that protect LGBTQ+ students at the administrative level; (2) comprehensive cultural sensitivity training for serving LGBTQ+ students and their families; (3) incorporating inclusive curriculum on LGBTQ+ history into the classroom; (4) and creating, supporting, and sustaining gender sexuality alliances in both the middle and high schools.

BACKGROUND TW…“TW” is short-hand for “trigger warning” and is used to warn the audi-

shares with them other ways to express themselves that build up, rather than tear down others. An LGBTQ+ youth observes this public support and feels affirmed. (Incident Occurred in a Delaware High School)

Every day in our schools, LGBTQ+ youth experience unkind words, hurtful actions, and harmful policies that put their lives at risk, yet it doesn’t have to be that way.

The Delaware Youth Risk Behavioral Survey (DEYRBS) is conducted every other year in select classes within Delaware public high schools. The most recent data is from 2017, and for the first-time included questions asking about gender identity and gender expression (See Table 1).

ence/listener that what is about to be shared may be triggering as it involves trauma in some form or fashion.

WHAT DO DELAWARE LGBTQ+ YOUTH SAY? TW…“That’s Sooooooo GAY! What fa**ots!” Two students are loudly

discussing a recent event in the hallway as a teacher walks up to them and takes the time to explain to them how their words hurt. The teacher then

Youth today identify across a much broader spectrum of options including pansexual, asexual, bisexual, agender, non-binary, as well as transgender. The option “unsure” may be interpreted two different ways: (1) the young person completing the survey is still engaged in age appropriate identity formation and is, therefore,

Table 1. Delaware 2017 Youth Risk Behavior Survey Questions

On Gender Identity

Question: Some people describe themselves as transgender when their sex at birth does not match the way they think or feel about their gender. Are you transgender?

Yes

Unsure

Not Sure What Question is Asking

1.4

95.7

1.0

1.8

On Gender Expression Question: A person's appearance, style, dress, or the way they walk or talk may affect how people describe them. How do you think other people at school would describe you? Response Options

Male

Very Feminine

1.1

25.6

Mostly Feminine

1.3

38.0

Somewhat Feminine

Female

2.3

16.2

Equally Feminine & Masculine

10.6

16.7

Somewhat Masculine

12.4

2.4

Mostly Masculine

37.9

0.6

Very Masculine

34.3

0.5

46 Delaware Journal of Public Health – June 2019

unsure of their own identity at time of completing the survey; or (2) the youth does not see an option that represents how they self-identify and so choose “unsure” as the closest option to their self-identity. By accessing www.KidsCount.org figures for 2017 in conjunction with DEYRBS 2017, we can calculate that there are approximately 986 (2.4%) Transgender/Non-Binary Youth and 4,824 (13.7%) Gay, Lesbian, Bisexual, Pansexual Youth in our High Schools. These same youth responded to the following questions on school safety (see Table 2).2

The historical ten identified “adverse childhood experiences” (ACE’s) outlined in the original study from 1995-975 were not explicit to LGBTQ+ experiences yet illustrate a road map toward understanding the adverse impact of trauma on LGBTQ+ adolescents and adults (see Figure 1).

We find that Delaware LGBTQ+ Youth are twice as likely to be

Table 2. Delaware 2017 Youth Risk Behavior Survey Question on Sexual Orientation

Question: Which of the following best describes you? Choices Heterosexual

Total 86.3

Gay or Lesbian

3.3

Bisexual

7.5

Not Sure

2.9

threatened or injured with a weapon on school property, bullied on school property, or felt so unsafe they didn’t go to school at least once in the last 30 days compared to heterosexual youth (See Table 3). This unsafe environment leads to an accumulation of stressors over time creating a stress proliferation in LGBTQ+ youth that can exacerbate mental health problems and decrease an ability to cope.3 The Human Rights Campaign Report Growing UP LGBTQ in America surveyed over 10,000 students age 13-17 and national trends substantiate and affirm the challenges of Delaware LGBTQ+ Youth. Twice as likely as their peers to say they have been physically assaulted, kicked or shoved, 92% of LGBTQ+ youth also report they hear negative messages about being LGBTQ+. The top sources of this negative messaging are the school, their peers, and social media. The biggest problems our LGBTQ+ youth face in Middle School and High School is parents/family are not accepting (26%) and trouble at school/ bullying (21%).4

THE EFFECTS OF TRAUMA TW…“What’s in your pants!” A teenager shouts this across the room at a

transgender student. The aggressor continues to shout while moving toward the student when another classmate steps in between to intervene. The substitute teacher either didn’t notice or didn’t know how to intervene so they remained at the desk looking at papers. (Incident Occurred in a Delaware Middle School)

Figure 1. LGBTQ+ Adverse Experiences

Research on the impact of microaggressions [4/sidebar] toward LGBTQ+ adults6 and adolescents7 who recall school victimization highlight heightened psychological distress, higher substance abuse use, higher risk of depression, social anxiety, suicidality8; and may suffer long-term negative effects which can contribute to increased rates of PTSD within the LGBTQ+ community.9,10 Further exploration of the long-term outcomes on LGBTQ+ adults appear to show even higher levels of distress when race/ethnicity and/or transgender/non-binary are factored in to identify the compounded adverse impact often felt with intersectional minority identities.11–13 “Actions which promote invisibility and deny a young person’s right to exist as their authentic self is trauma” - author By reviewing the DEYRBS 2017 data we can hear directly from our LGBTQ+ youth; and the findings are startling and disturbing. LGBTQ+ Youth are twice as likely to feel sad or hopeless compared to heterosexual youth. These same youth are 3-4 times as likely to consider suicide and make a suicide plan. Most unsettling is that 1 in 5 report attempting suicide with almost 10% of those youth requiring medical intervention (see Table 4).

Table 3. School Safety Delaware High Schools

Questions

Heterosexual

Gay / Lesbian

Bisexual

Not Sure

Were threatened or injured with a weapon on school property?

5.4

9.0

9.5

11.1

Were in a physical fight on school property?

8.3

9.9

9.5

11.8

Were electronically bullied?

13.3

18.4

29.6

22.0

Were bullied on school property?

17.1

28.0

34.4

24.3

Did not go to school because they felt unsafe at school or on their way to or from school?

6.1

10.3

9.9

10.7

Were ever physically forced to have sexual intercourse?

5.4

21.2

22.1

13.1 47

Table 4. Effects of ACEs on High School Youth in Delaware

Question

Heterosexual

Gay / Lesbian

Bisexual

Not Sure

Felt Sad or Hopeless

27.5

53.1

66.0

46.4

Seriously considered attempting suicide

13.3

4.4

49.6

31.8

Made a plan about how they would attempt suicide

10.4

33.2

39.4

25.6

Attempted Suicide

5.4

18.6

24.2

14.3

Suicide attempt resulted in an injury, poisoning, or overdose that had to be treated by a doctor or nurse

1.7

9.6

6.9

5.6

Additionally, when homes are not safe and when schools are not safe, the research reflects higher rates of homelessness, higher rates of Juvenile Justice System use, higher rates in the Foster Care System, increased dropout rates, and increased high risk behaviors (including self-harm, drugs, alcohol abuse, and un-safe sexual activity.11,14,15 Our LGBTQ+ young people deserve better in our schools. We owe it to our children to have an affirming launch into adulthood. How might we begin to create safer, more supportive schools? How might we build resilience while reducing risk for our LGBTQ+ youth?

MICROAGGRESSIONS • Microassaults are small behaviors that are intentional and purposefully hurtful (e.g., using the wrong name or pronouns, name calling, making derogatory statements or threatening gestures). • Microinsults are rude statements that are usually unintentional or unconscious that indicate ignorance or bias (e.g., asking inappropriate questions, redirecting someone to another bathroom, or facial expressions that reveal confusion or disgust). • Microinvalidations are statements or actions that are usually unintentional or unconscious that ignore, minimize, or nullify a person’s identity (e.g., having only two options for sex/gender on forms, classroom illustrations of famous people in history who are all white, all straight, and all cisgender). • Intersectional Microaggressions are microaggressions (of all types) that are connected to multiple parts of a person’s identity (such as race and gender or religion and ethnicity) • Systematic Microaggressions & Discrimination are institutionally based microaggressions that cannot be attributed to one specific person but that affect many or most members of a group. Green, E.R. & Maurer, L.M (2015). The Teaching Transgender Toolkit: A Facilitator’s Guide to Increasing Knowledge, Decreasing Prejudice & Building Skills. Ithaca NY: Planned Parenthood of The Southern Finger Lakes: Out for Health.

48 Delaware Journal of Public Health – June 2019

WHAT WE CAN DO TO MAKE A DIFFERENCE I propose there are four key areas in which both immediate and lasting change can occur to improve the safety and support for all children. These four pillars are: (1) policy/procedures that protect LGBTQ+ students at the administrative level; (2) comprehensive cultural sensitivity training for faculty/staff serving LGBTQ+ students and their families; (3) incorporating inclusive curriculum on LGBTQ+ history into the classroom; (4) and creating, supporting, and sustaining gender sexuality alliances at both the Middle and High Schools.

PILLAR ONE: SCHOOL ADMINISTRATION / SCHOOL DISTRICTS Currently there is no unequivocal policy through the Delaware Department of Education that protects all youth across the spectrum of Sexual Orientation, Gender Identity, and Gender Expression (SOGIE).16 Yet, there is evidence on the positive impact such policies have toward creating a safer environment for LGBTQ+ youth. When the highest leadership position in the school system makes it clear that LGBTQ+ students are protected the results are astounding!17,18 Resource: Model district anti-bullying and harassment policy by GLSEN (Gay, Lesbian, Straight Education Network) First and foremost, anti-bullying policies that are explicitly inclusive of SOGIE and enforced show a significant reduction in the risk of suicide attempts in LGBTQ+ youth in both Middle School and High School (see Figure 2). Additionally, LGBTQ+ youth who report a reduction in victimization at school more readily identify adult mentors/allies, which leads to LGBTQ+ youth being more likely to engage in school activities while reducing high risk behaviors.19,20 Hatzenbuehler and Keyes compared school district policies in Oregon based on inclusive to least inclusive policies and noted: (1) school districts that adapt inclusive anti-bullying policies see a decrease in rates of suicide attempts from previous years. The research noted: “Whereas 31% of lesbian and gay adolescents attempted suicide in counties where school districts were the least likely to adopt inclusive anti-bullying policies, only 17% attempted suicide in counties with the greatest proportion of school districts with inclusive policies.”21 This is corroborated by Saewyc, et al., whose study illustrated that schools with anti-bullying policies for three or more years showed greater gains in reduced risk and increased safety than schools for fewer years/no policy. Equally significant, the studies demonstrated reduced risk for suicide among both LGBTQ+ youth and heterosexual youth!22

Figure 2. Sexual Orientation Gender Identity/Expression Policies

Other Policy Suggestions: De-gender rites of passage in a school. Change Homecoming King & Queen to Homecoming Royalty. Eliminate gendered graduation robes.23

PILLAR TWO: CULTURAL SENSITIVITY TRAINING OF FACULTY AND STAFF A 2019 study entitled Supporting Safe and Healthy Schools for LGBTQ Students: A National Survey of School Counselors, Social Workers, and Psychologists reported the following findings: • 37% of school mental health professionals had never received any formal training on LGBTQ+ student issues during their career • 76% of school mental health professionals received little to no training on working with LGBTQ+ youth. 24 May I call you friend? A school administrator shared with me that school policy and parent demands prevented them calling the transgender student by their affirming name and pronouns. Each time the student was called their “dead name” and mis-gendered, the pain on their face was evident. The school administrator’s heart is about affirming each child’s inherent dignity and self-worth. Found between a proverbial rock and hard place they looked at the student and said, “May I call you friend?” The student smiled because in that moment they knew they were seen and affirmed. (This act of compassion and mentoring occurred in a Delaware School) Another study noted “teachers’ own prejudice against sexual minorities may prevent them from being positive role models for sexuality minority youth”25 When our school’s staff/faculty are ill-prepared and ill-trained to support LGBTQ+ youth, microaggressions go unaddressed and support for these same youth decrease. The most effective way to create culturally competent supportive staff/faculty is to require excellent professional development for all staff/faculty that: (1) centers on evidence-based research on challenges/opportunities of LGBTQ+ youth across the full SOGIE spectrum; (2) brings in the significance of intersectionality in relationship with ACE’s; and (3) through didactic exercises, trains staff to become aware of and know how to effectively intervene when microaggressions occur; (4) while providing insight on how to build resilience within these same youth.26

Transitions Delaware, llc has provided trainings to school administration and faculty ranging between sixty minutes to a full day based upon the identified needs and goals of the school or district. One of the frequent benefits noted by those who attend the trainings is the small group, didactic exercises that afford participants the opportunity to ask clarifying questions and practice affirmation exercises geared at building resilience in youth. The other benefit extolled by participants is having a greater understanding on the differences between sexual orientation and gender identity and gender expression in relation to greater insight on the ever-expanding vocabulary and pronoun usage of LGBTQ+ youth in their identity formation. It is advisable that consultation be provided by trainers to those requesting a training in advance to ensure the materials provided and delivered are relevant content to the school making the request. When comprehensive training is well delivered, research illuminates that staff/faculty become effective supporters of LGBTQ+ youth: (1) LGBTQ+ students with supportive school staff, were less likely to feel unsafe (40.6% vs. 78.7%); (2) were less likely to miss school because they felt unsafe or uncomfortable (16.9% vs. 47.2%); (3) had higher GPAs than other students (3.3 vs. 2.8); and (4) were less likely to say they might not graduate high school (1.7% vs. 9.5%).11

PILLAR THREE: INCLUSIVE CURRICULUM An inclusive curriculum validates LGBTQ+ youth. Hidden rainbows are as important as hidden figures!27 Visibility of LGBTQ+ historical figures from math/science, the arts, political/social justice, etc. provide the LGBTQ+ young person mentors and role models while also “normalizing” the value and importance of LGBTQ+ contributions to society to heterosexual and cisgender students.28–30 In one study it was noted that “by infusing relevant transgender content into lectures and reading materials, instructors contribute to normalizing transgender issues for an inclusive curriculum.”31 The Center for Disease and Control (CDC) reports LGBTQ+ youth are more likely to have poor health outcomes than their heterosexual (straight) peers.32 Yet, only 4% of LGBTQ+ students were taught positive information about LGBTQ+ people or issues in their health classes.18 Through direct interactions with LGBTQ+ youth in the Delaware public schools, there is a common refrain heard from the students who say sexuality education is “heteronormative and cisnormative.” The Delaware DHHS Division of Public Health identified in the Delaware Adolescent Sexual Health State Plan (January 2011) that …services must be strengthened to better serve sexual minority youth (i.e., students who either identified as gay, lesbian, bisexual, transgender or reported any same-sex sexual contact). And inclusive policies will strengthen the capacity of youth-serving organizations to prevent risk behaviors and improve health outcomes among Lesbian, Gay, Bisexual, Transgender and Questioning (LGBTQ) youth.33 49

Yet, upon informal interviews with parents, students, and health teachers, an inclusive health and sex education for Delaware LGBTQ+ youth does not appear to be evident despite there being the January 2011 Delaware Adolescent Sexual Health State Plan which states services must be strengthened to better serve sexual minority youth.

their emotional/mental health through both peer and adult mentoring. 38 Through peer mentoring, LGBTQ+ students are able to share experiences and stories of affirmation and support which displace and replace the negative messages encountered in homes or in hallways. When a GSA is scheduled on a day/ time that makes it difficult for LGBTQ+ youth to attend, the result is a poorly attended GSA that is often erroneously interpreted by faculty/administration as meaning there are no LGBTQ+ students in need of this support at that school. This is a false narrative. Equally important, if the GSA Adviser is not recognized by the LGBTQ+ youth as an ally, they will not attend. Trust is essential for youth to risk disclosing their identity to a representative of the school. Christian Rummel, of the American Institute for Research writes:

In February 2019, New Jersey became the second state to require that schools teach LGBTQ+ history.34 When LGBTQ+ students were interviewed on the value of inclusive curriculum, they shared:

In-person mentoring relationships may serve an important protective role for [LGBTQ+] youth, helping them to confront challenges…informal mentoring relationships with adults may promote positive educational outcomes…mentors appear well-positioned to offer ongoing support that can attune to the needs of youth as they navigate through phases of exploring, accepting, and sharing their identity with others.14

“learning about LGBTQ+ issues in my school helped stop bullying;” and “people in my class became more aware of things…were simply more educated afterwards, and had a little bit of an easier time talking about LGBTQ+ issues;” and another student explained “that when LGBTQ+ youth see themselves reflected in the curriculum they can feel hopeful about their own future.”35,36 From library books to lesson plans, it is important to incorporate LGBTQ+ into the curriculum because the visibility gives LGBTQ+ students hope while educating and fostering compassion among their peers. In fact, 75.2% of LGBTQ+ students in schools with an inclusive curriculum said their peers were accepting of LGBTQ+ people, compared to 39.6% of those without an inclusive.18

PILLAR FOUR: GENDER SEXUALITY ALLIANCES (GSAS) GSAs are one of the primary ways for middle and high school administration, faculty, and staff to offer safe, affirming space for LGBTQ+ youth. The interplay of the four pillars of support creates a school environment where a GSA moves from crisis management of daily microaggressions to affirming informal/ formal mentoring, as well as leadership development through a school sanctioned club. GSAs are in a key position to foster youth resiliency through mentoring. The historical three primary purposes of GSAs are social, support, and advocacy.37 GSA Advisers are often school teachers or counselors; and research supports that having “mentors—especially teacher-mentors—are positive forces in the educational resilience of sexual minority youth ... [and] provide the biggest boost to the chances that sexual minority youth will attend college.”24 When GSAs are active in the school, research has demonstrated time and again that there were fewer homophobic comments from peers, less victimization related to SOGIE, greater school connectedness, and more instances of teacher intervention in homo/transphobic harassment. Additionally, and as significantly important, youth who can be present in a GSA experience a more positive impact on 50 Delaware Journal of Public Health – June 2019

Big Brothers Big Sister of Delaware is the only formal mentoring program in state that has a targeted LGBTQ+ Mentoring Program for both Middle/High School GSAs, as well as traditional Big Brother/Sister/Sibling matches with Little Brother/Sister/Sibling matches. In summary, the positive outcomes of GSAs are a reclaimed sense of hope, a stronger sense of school connectedness, and an increased sense of well-being, educational attainment, and positive self-esteem. The positive impact of GSAs at both the middle & high schools translates into a reduction in high-risk behaviors and increase in resiliency in LGBTQ+ youth.

BUILDING RESILIENCE IN TODAY’S LGBTQ+ YOUTH "When all Americans are treated as equal, no matter who they are or whom they love, we are all more free."--Barack Obama In the note he left behind when Eric James Borges engaged in death by suicide, he said, “my pain is not caused because I am gay. My pain was caused by how I was treated because I am gay.”39 How best can we counter pain caused by a community that treats LGBTQ+ youth differently because they are LGBTQ+? The four pillars briefly highlighted in this article provide a road map toward changing the school culture by creating community of inclusion and cultivating mentoring relationships which can inspire LGBTQ+ youth to discover their dreams and live into their potential. By engaging the metaphor of four pillars in relation to a school building, if one pillar is missing, the structure will become unstable, and unstable buildings risk collapse, often resulting in injury or even death. In K. Asakura article entitled Paving Pathways Through the Pain: A Grounded Theory of Resilience Among Lesbian, Gay, Bisexual, Trans and Queer Youth, they write: “On the one hand, it courageous that these LGBTQ+ youth actively paved their own pathways to resilience. On the other hand, there are potential personal costs on youth when they individually assume and carry responsibilities to cope with external adversities put on them.”40

Today, as evidenced by the Delaware Youth Risk Behavioral Survey, many Delaware schools operate without any or with minimal efforts in helping LGBTQ+ youth pave a pathway to resilience. Shifting a school climate from exclusion to inclusion requires an intentional and transparent plan! The actionable steps for District School Boards, Superintendents, and School Administration require changing the policies and procedures to include SOGIE; and to allocate funds for training culturally competent and equipped faculty and staff to be better able to engage intersectional, appropriate formal and informal mentoring of LGBTQ+ youth in the classroom, on the stage, court, field, and through GSAs at the middle and high school.

REFERENCES 1. 2017 Delaware Youth Risk Behavior Survey (YRBS). Center for Drug and Health Studies, University of Delaware. Retrieved from https://www.cdhs.udel.edu/seow/school-surveys/youthrisk-behavior-survey-(yrbs) 2. 2019 Kids Count in Delaware Fact Book. (2019). Retrieved from http://udspace.udel.edu/handle/19716/24098 3. Nurius, P. S., Uehara, E., & Zatzick, D. F. (2013, April). Intersection of stress, social disadvantage, and life course processes: Reframing trauma and mental health. American Journal of Psychiatric Rehabilitation, 16(2), 91–114.PubMed https://doi.org/10.1080/15487768.2013.789688

The personal cost on LGBTQ+ youth cultivating their own resilience often involves the adverse effects of ACEs and longterm medical/mental health complications as outlined in the beginning of this article. Therefore, it is beholden upon school boards, superintendents, school administration, faculty and staff to “… have the responsibility to share the burden carried by these youth and envision and actualize the kind of social climates that pave smoother pathways on which LGBTQ+ youth can march on with less pain and more joy.”41

4. Growing Up, L. G. B. T. in America. Retrieved from https://www.hrc.org/youth-report/about-the-survey

SUMMARY

7. Mueller, A. S., James, W., Abrutyn, S., & Levin, M. L. (2015, May). Suicide ideation and bullying among US adolescents: Examining the intersections of sexual orientation, gender, and race/ethnicity. American Journal of Public Health, 105(5), 980–985. PubMed https://doi.org/10.2105/AJPH.2014.302391

Twenty years ago this year, I graduated from Columbia Theological Seminary (CTS) with a master’s in divinity. I was told during my entrance interview that I was the first LGBTQ+ person to openly apply to the seminary. I did not walk into a welcoming community, and my experience fluctuated from welcoming to tolerated to hostile. This was a difficult environment for my then 28-year-old self. I had access to family, friends, and community support as I walked through this stressful time. Sadly, we do not afford that same level of encouragement and support to children who come out as young as ten (and even younger).42 Through my own lived experience, I can “testify” on the importance of bringing LGBTQ+ curriculum into the classroom setting as a means for creating positive change. I can “preach” about the value of having faculty and administration engage in cultural sensitivity training. During my senior year, I preached a sermon entitled “Let the Little Children Come unto Me, Do Not Stop Them” referencing the words ascribed to Jesus in the Gospel of Mathew 19:14. My message was about creating safer, more supportive churches and schools for LGBTQ+ youth. The day after I talked about the risks LGBTQ+ youth face, the world learned about Mathew Shepperd; and a year after I graduated, the student body started a gender sexuality alliance called Imago Dei, which means ‘image of God’. This GSA remains active at CTS as a positive influence in the community, and the southern seminary now celebrates diversity across sexual orientation, gender identity, and gender expression. Meaningful and lasting change takes time. This kind of change calls forth leaders who are willing to risk public scrutiny and criticism. May you, the reader, be inspired and encouraged to be the change we need today in our Delaware schools. May we, together, create safer, more supportive schools for LGBTQ+ youth.

5. "The Adverse Childhood Experiences (ACE) Study". (2014, May). CDC.gov. Retrieved from https://www.cdc.gov/ violenceprevention/childabuseandneglect/acestudy/about.html 6. Greene, D. C., Britton, P. J., & Fitts, B. (2014). Long-term outcomes of lesbian, gay, bisexual, and transgender recalled school victimization. Journal of Counseling and Development, 92, 406–417. https://doi.org/10.1002/j.1556-6676.2014.00167.x

8. Russell, S. T., Ryan, C., Toomey, R. B., Diaz, R. M., & Sanchez, J. (2011, May). Lesbian, gay, bisexual, and transgender adolescent school victimization: Implications for young adult health and adjustment. The Journal of School Health, 81(5), 223–230. https://doi.org/10.1111/j.1746-1561.2011.00583.x 9. Rivers, I. (2004). Recollections of bullying at school and their long-term implications for lesbians, gay men, and bisexuals. Crisis, 25(4), 169–175. https://doi.org/10.1027/0227-5910.25.4.169 10. Roberts, A. L., Austin, S. B., Corliss, H. L., Vandermorris, A. K., & Koenen, K. C. (2010, December). Pervasive trauma exposure among US sexual orientation minority adults and risk of posttraumatic stress disorder. American Journal of Public Health, 100(12), 2433–2441. https://doi.org/10.2105/AJPH.2009.168971 11. Mustanski, B., Andrews, R., & Puckett, J. A. (2016) The effects of cumulative victimization on mental health among lesbian, gay, bisexual, and transgender adolescents and young adults. American Public Health Association, 106, 527-533 12. James, SE, Herman, J.L., Rankin, S., Keisling, M., Mottet, L., & Anafi, M. (2016, December). The Report of the 2015 US Transgender Survey. National Center for Transgender Equality. 13. Burdge, H., Hyemingway, Z. T., & Licona, A. C. (2014). Gender nonconforming youth: Discipline disparities, school push-out, and the school-to-prison pipeline. 14. Mallory, C., Sears, B., Hasenbush, A., & Susman, A. (2014) Ensuring access to mentoring program for LGBTQ youth. The Williams Institute. Retrieved from https://williamsinstitute.law. ucla.edu/wp-content/uploads/Access-to-Youth-MentoringPrograms.pdf 51

15. Rummel, C. L. (2016) Mentoring lesbian, gay, bisexual, transgender, questioning, intersex, and gender nonconforming youth. American Institutes of Research. Retrieved from http:// nationalmentoringresourcecenter.org/images/PDF/LGBTQ_ Population_Review.pdf 16. GLSEN.org. (2019). GLSEN Chapters create LGBTQ-inclusive schools. Retrieved from https://www.glsen.org/chapters 17. Asakura, K. (2017, September). Paving Pathways through the pain: A grounded theory of resilience among lesbian, gay, bisexual, trans, and queer youth. J Res Adolesc, 27(3), 521–536. https://doi.org/10.1111/jora.12291 18. Hatzenbuehler, M. L., Birkett, M., Van Wagenen, A., & Meyer, I. H. (2014, February). Protective school climates and reduced risk for suicide ideation in sexual minority youths. American Journal of Public Health, 104(2), 279–286. https://doi.org/10.2105/AJPH.2013.301508 19. Kosciw, J. G., Greytak, E. A., Giga, N. M., Villenas, C., & Danischewski, D. J. (2016). The 2015 National School Climate Survey: The experiences of lesbian, gay, bisexual, transgender, and queer youth in our nation’s schools. Retrieved from https:// www.glsen.org/sites/default/files/2015%20National%20 GLSEN%202015%20National%20School%20Climate%20 Survey%20%28NSCS%29%20-%20Full%20Report_0.pdf 20. Goodenow, C., Szalacha, L., & Westheimer, K. (2006). School support groups, other school factors, and the safety of sexual minority adolescents. Psychology in the Schools, 43, 573–589. https://doi.org/10.1002/pits.20173 21. Hatzenbuehler, M. L., & Keyes, K. M. (2013, July). Inclusive anti-bullying policies and reduced risk of suicide attempts in lesbian and gay youth. J Adolesc Health, 53(1, Suppl), S21–S26. https://doi.org/10.1016/j.jadohealth.2012.08.010 22. Saewyc, E. M., Konishi, C., Rose, H. A., & Homma, Y. (2014, January 1). School-based strategies to reduce suicidal ideation, suicide attempts, and discrimination among sexual minority and heterosexual adolescents in Western Canada. International Journal of Child, Youth & Family Studies : IJCYFS, 5(1), 89–112. https://doi.org/10.18357/ijcyfs.saewyce.512014 23. GLSEN. (2016) Transgender Model District Policy. Retrieved from https://www.glsen.org/article/transgender-model-districtpolicy 24. GLSEN. (2019). Supporting Safe and Health Schools. Retrieved from https://www.glsen.org/article/supporting-safe-andhealthy-schools-lgbtq-students 25. Gastic, B. & Johnson, D. (2009). Teachers-mentors and the educational resilience of sexual minority youth. Journal of Gay & Lesbian Social Services, 21, 219 – 231. https://doi.org/10.1080/10538720902772139 26. Transitions Delaware llc. (2019). Training Services. Retrieved from https://transitionsde.com/training-services/ 27. National Aeronautics and Space Administration. (2017) Website Educational Resource: From Hidden to Modern Figures. Modern Figures Education Resources Retrieved from https://www.nasa.gov/modernfigures/education-resources 28. Gowen, L. K., & Winges-Yanez, N. (2014). Lesbian, gay, bisexual, transgender, queer, and questioning youths’ perspectives of inclusive school-based sexuality education. Journal of Sex Research, 51(7), 788–800. https://doi.org/10.1080/00224499.2013.806648 52 Delaware Journal of Public Health – June 2019

29. Maguth, B. M., & Taylor, N. (2014). Bringing LGBTQ topics into the social studies classroom. Social Studies, 105, 23–28. https://doi.org/10.1080/00377996.2013.788471 30. Helmer, K. (2016). Reading queer counter-narrative in the high-school literature classroom: Possibilities and challenges. Discourse (Abingdon), 37(6), 902–916. https://doi.org/10.1080/01596306.2015.1120943 31. Case, K. A., Stewart, B., & Tittsworth, J. (2009). Transgender across the curriculum: A psychology for inclusion. Teaching of Psychology, 36, 117–121. https://doi.org/10.1080/00986280902739446 32. CDC. (2019) Protective factors for LGBT youth: Information for health and education professionals. Retrieved from https:// www.cdc.gov/healthyyouth/disparities/lgbtprotectivefactors. htm 33. Delaware DHHS Division of Public Health. (2011) Delaware Adolescent Sexual Health State Plan. Retrieved from https:// dhss.delaware.gov/dhss/dph/chca/files/deyouthshsp.pdf 34. Adely, H. (2019, Feb). New Jersey becomes second state in nation to require that schools teach LGBT history. North Jersey Record. Retrieved from https://www.northjersey.com/ story/news/2019/02/01/nj-schools-teach-lgbt-history-newlaw/2743028002/ 35. Snapp, S. D., Burdge, H., Licona, A. C., Moody, R. L., & Russell, S. T. (2015). Students’ perspectives on LGBTQ-inclusive curriculum. Equity & Excellence in Education, 48(2), 249–265. https://doi.org/10.1080/10665684.2015.1025614 36. Hanna, J. L. (2017). One student at a time: A reflection of support for a first-year GSA club and its impact on perceived acceptance for LGBTQ students. The Clearing House: A Journal of Educational Strategies, Issues and Ideas, 90(3), 98–102. https://doi.org/10.1080/00098655.2017.1301154 37. Network, G. S. A. (2019) What is a GSA club? Retrieved from https://gsanetwork.org/what-is-a-gsa/ 38. Poteat, V. P., Yoshikawa, H., Calzo, J. P., Gray, M. L., DiGiovanni, C. D., Lipkin, A., . . . Shaw, M. P. (2015, JanuaryFebruary). Contextualizing gay-straight alliances: Student, advisor, and structural factors related to positive youth development among members. Child Development, 86(1), 176–193. https://doi.org/10.1111/cdev.12289 39. Huffpost. (October, 2012) Eric James Borges’ Suicide Note, Memorial Service Sheds New Insight Into Bullied Gay Teen’s Life. Retrieved from https://www.huffpost.com/entry/ericjames-borges-gay-teen-filmmaker-suicide-note_n_1240101 40. Asakura, K. (2017, September). Paving pathways through the pain: A grounded theory of resilience among lesbian, gay, bisexual, trans, and queer youth. J Res Adolesc, 27(3), 521–536. https://doi.org/10.1111/jora.12291 41. Hawkins, L. (2018, Jan 16) When do children know their gender identity? Children’s Hospital of Philadelphia: Health Tip of the Week. Retrieved from https://www.chop.edu/news/health-tip/ when-do-children-develop-their-gender-identity 42. 2017 Delaware Youth Risk Behavior Survey (YRBS). Center for Drug and Health Studies, University of Delaware. Retrieved from https://www.cdhs.udel.edu/seow/school-surveys/youthrisk-behavior-survey-(yrbs)

Sincere thanks to the sponsors of our 89th Annual Meeting

Be a part of the Millennial Summit August 6-7, 2019 Chase Center on the Riverfront Wilmington, Delaware One of the Top 5 conferences in the country, the Millennial Summit will gather 1000+ young professionals, impact players, rising stars and innovators of all ages and backgrounds.

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54 Delaware Journal of Public Health â&#x20AC;&#x201C; June 2019

SAVE THE DATE ACCEL Community Research Exchange Monday, September 23, 2019 Co-Chairs: Omar Khan MD, Lee Pachter DO Conference Manager: Azarri Badawi MPH Location: University of Delaware, Clayton Hall Conference Center, Newark, DE Please join us as we look to the future of community engagement in research! We expect this to be a stimulating and productive event with expert keynote speakers, engaging panel discussions, your choice of interactive workshops, and networking opportunities. This event will help develop partnerships for research to improve key outcomes in health. Researchers, health care providers, community organizations, community members, and health care leaders are encouraged to attend.

Questions? Contact us at accelceo@de-ctr.org or 302-428-6581 Work supported by an Institutional Development Award (IDeA) from the National Institute of General Medical Sciences of the National Institutes of Health under grant number U54-GM104941 (PI: Binder-Macleod).

Part of the Solution to Address Sexual and Gender Minority Health and Health Care Disparities: Inclusive Professional Education Karla Bell, P.T., D.P.T. Thomas Jefferson University, College of Rehabilitation Science, Department of Physical Therapy

ABSTRACT Background and Purpose. The public health perspective regarding sexual and gender minority health has continued to expand beyond the hallmark AIDS crisis in the 1980s. Sexual and gender minorities experience various health and healthcare disparities for a variety of reasons. A 2017 national survey indicated that 8% of lesbian, gay, bisexual, and queer (LGBQ) respondents had been refused care by a health care provider in the last year because of their sexual orientation, and 29% of transgender identified individuals were refused care.1 Healthcare provider attitudes and behaviors contribute significantly to some of these disparities. This perspective piece provides a synopsis of the public health/population health challenge with health disparities in these populations and a call for action to have professional health education be more inclusive of content pertinent to the health and treatment of sexual and gender minorities. This perspective also provides a summary of educational recommendations and sample curricular objectives to assist ease of integration into health professional education, regardless of discipline. A framework of pedagogy and delivery of curricula is beyond the scope of this perspective piece. Position and Rationale. In seeking solutions to impactful ways of achieving health and healthcare equity in these communities, one solution has to be on the educational and academic side of health professions. In its broadest sense, the literature suggests a strong positive association between education and health from a socio-ecological model perspective. This perspective piece speaks directly to the subset of how education can have a direct impact on health disparities through the health care provider’s interpretation and use of information learned/not learned. Discussion and Conclusion. Based on pedagogical principles in education and literature suggesting positive associations between impact on health disparities and health professional education,2 it is concluded that health professional education - regardless of discipline - should be inclusive of sexual and gender minority content to address this significant gap in knowledge, awareness, and skill in health delivery for these populations.

INTRODUCTION From an educational and population health perspective, the foundation of health care professional education has been non-inclusive of health care discussions regarding sexual and gender minorities (SGM) and the health disparities that exist within these populations.3–6 In fact, the inclusion of this content has not been included or studied in all health disciplines, but where it has, it reveals a significant gap.7–9 In the last decade, the medical literature has started to unravel and discover the very real health care needs that go along with these identities. Since sexual and/or gender identities are not a required demographic data point to collect, data and research in healthcare regarding discrimination and health disparities is markedly limited. From the latest demographic statistics that we do have, conservative estimates put the collective populations within these spectrums at ~ 4.1% of the U.S. population; however it’s important to note this number is not inclusive of all identities within these populations.10 The data around health disparities/ equity that we do have indicates pervasive and statistically significant numbers of both discrimination and health disparities among these populations.11,12 56 Delaware Journal of Public Health – June 2019

The literature also supports the very real correlate of healthcare provider discrimination and bias to perpetuation of health disparities in these populations, specifically in delaying health care or not seeking health care altogether.13–16 While the educational research is mixed on the impact of cultural competency education in translating to improved healthcare delivery, it does indicate a positive association in acquiring new knowledge, improved attitudes and skills, and enhanced patient experience.17,18 We also have limited to no data regarding sexual and gender minority inclusive cultural competency education for health care professional education and its impact.17 Cohen and Syme advocated for more research exploring to what extent educational interventions can address health inequities, noting that this is an area of infancy in the research realm.19 Alcaraz and colleagues go further in describing a framework to help advance research and interventions focused on health equity, inclusive of sexual and gender minority health.20 Cameron et al., also take a deeper dive into structural competency and delivery of educational curricula in a context that hopes to expand identitybased health needs in a meaningful and truly impactful way.21 Throughout the professional educational curricula in healthcare (physical therapy, medical, nursing, occupational therapy, speech,

chiropractic, etc.) there is limited to no time dedicated to learning about cultural competency or health disparities regarding these populations.22 That has to change. Some programs dedicate numerous hours and lectures to rare diseases and conditions; the likelihood of encountering one of these in one’s professional career are minimal. However, healthcare professionals will all treat patients with identities in sexual and gender minorities. Most professionals likely won’t be comfortable doing so and may identify a lack of preparation in the professional curriculum as one reason. Implicit and explicit bias has also been identified in the literature as a contributor to discriminatory practice among healthcare providers.14,16,23 When looking at these gaps in curricula for our healthcare professionals, one can argue that the approach to fill them should be multi-faceted, and at minimum start with requiring professional education to be inclusive of these populations’ health needs and characteristics. The American Association of Medical Colleges (AAMC) has published a monograph with sexual and gender minority competencies for medical professional curricula, which this author summarizes for generalization to all disciplines.14 This commentary establishes the necessity of healthcare professional education to be inclusive of sexual and gender minority content to specifically address the healthcare disparities that providers directly contribute to: implicit/explicit bias, discrimination, and cultural incompetence.

THE LITERATURE AND SGM HEALTH DISPARITIES Operationally, this author speaks to lesbian, gay, bisexual, and transgender (LGBT) health disparities because some of the identities included in the inclusive terms “sexual and gender minorities” have not been studied to date. The literature specifically speaks to the following identities in health disparity research: LGBT. It is purported that LGBT health disparities stem from a sociocultural environment that devalues these minority identities.24 Meyer and Frost apply the minority stress model to health outcomes: minority stress is based on the premise that prejudice and stigma directed toward sexual and gender minorities brings about unique stressors and these cause adverse health outcomes manifested as health disparities.25 This commentary speaks specifically to education being a public health answer to having an impact on these disparities, primarily because provider behaviors and attitudes have a direct correlation on disparities in these communities.1 As we gain more insight into the health of these populations, we continue to note drastic and significant health disparities across the spectrums of these communities. Of note, there is strong literature looking into resilience factors as attributes of positive contributors to health in these communities.26–30 Table 1 provides a summary of some key health and health care disparities, which this author has adapted from the AAMC publication.14 See Table 1

THE LITERATURE AND SGM CONTENT IN HEALTH PROFESSIONAL EDUCATION Two recent systematic reviews of sexual and gender minority inclusive education in the health professions reinforce the conclusions that education and training of healthcare providers and students will improve skills and ultimately may lead to

improved quality of healthcare for sexual and gender minorities.6,7 These systematic reviews also concluded that our professional education curricula have a long way to go to be inclusive of this content, consistent with delivery of this content in all disciplines, and establishing a conceptual model for best practice of curricula implementation. In the AAMC monograph, the authors discuss numerous challenges and advancements to education reform in this area. Of note in the barriers and challenges is that they are multi-factorial, and combine both lack of mentoring/modeling in clinical practice with absence of faculty willing and able to teach relevant content in the didactic curriculum.14 There is no current requirement of this content in health professional literature as a stand-out component, rather, it is often implied as covered under other areas, such as cultural competency or domains of competency for history taking, etc. The literature suggests is that this is not nearly comprehensive enough to address the core knowledge and skills needed to provide patient-centered care for these populations. Most of the literature supporting the necessity and preliminary effectiveness of sexual and gender minority inclusive curricula has been done in the medical community. All health disciplines need to follow suit in opening their curricula and their research to supporting these communities in their health. Given the direct and significant contribution to health disparities by provider discrimination and bias, health professional education can serve to increase awareness and knowledge of these communities to help inform best practices in health delivery and help foster a more affirming climate and approach in training and delivery. The author fully acknowledges the complexity and numerous other aspects around culture and climate that also need to be addressed when making curricular shifts. This commentary is meant to be a succinct snapshot of advocating for educational interventions to be one of the public health answers to health disparities in SGM communities, fully recognizing the many layers of implementation challenges from societal to individual level barriers. It is beyond the scope of this commentary to discuss delivery recommendations, curricular models, pedagogical influences to delivery. This commentary aims to provide a summary of recommendations for content and scope only. There is no best-practice model validated to date regarding curricula integration. One of the most comprehensive models/guides to date is AAMC’s 2014 publication utilizing competency domains for medical education. That publication is the foundation for the summary below, given that it extensively synthesized the available literature and utilized a broad panel of experts. Table 2 provides a summary of recommendations for health professional educational curricular threads, regardless of discipline. This content crosses all health disciplines, and can be individualized and contextualized discipline-specific, however, the curricular threads noted in this summary are considered integral to all disciplines. See Table 2

CONCLUSION The cultural shift in education is great, however, the alternative to this cultural shift is not acceptable. Romanelli provides a candid summary: “the root causes of system-level barriers were all attributed to social-structural factors that worked to exclude and erase LGBT people from the institutions that shape the health and mental health systems55.” This commentary establishes the 57

Table 1: Overview of Health and Health Care Disparities in Sexual and Gender Minority Populations (Adapted and Modified from AAMC, 2014) Health Disparity

Prevalence/Statistic

Populations Affected

Obesity

2x risk compared with heterosexual women31

Lesbian and bisexual women

Asthma

1.5 times the risk compared to heterosexual counterparts

LGB adults

Cardiovascular disease

>2 times the risk compared to heterosexual counterparts

LGB adults

Significant elevations in biomarkers of cardiovascular disease compared to heterosexual men

Young GB men

>2 times the risk compared to heterosexual counterparts33

Bisexual individuals

Higher prevalence versus population as whole32

LGBT population

Increased likelihood at younger age than heterosexual counterparts34

LGB individuals

2x the risk compared to heterosexual women

Lesbian women

3x the risk compared to heterosexual men and women

Bisexual men and women

HIV/AIDS and other STIs

Elevated risk for HIV/AIDs and other STIs

Gay men and transgender women

Cancer

Increased anal cancer rates primarily due to increased risk for HPV36

Gay and bisexual men and men who have sex with men

Increased breast cancer; increased fatal breast cancer

Lesbian and bisexual women

Cervical cancer primarily due to elevated risk for HPV

Lesbian and bisexual women

Colon and rectal cancer primarily due to elevated risk factors

Lesbian and bisexual women

Lung cancer; further research needed as to reason

LGBTQ individuals

Smoking

Physical disability

Prostate cancer; further research needed as to reason

Men who have sex with men

Lifetime risk of violent victimization and maltreatment; Lifetime exposure to traumatic experiences

Higher risk than heterosexual and cisgender individuals

Substance use/abuse

>2x more likely to have used any illicit drug in past year41

Lesbian, gay, bisexual individuals

Increased binge-drinking41

Adult LGBT individuals

90% more likely to use substances than heterosexual adolescents42,43

LGB adolescents

Less likely to practice safer sex than heterosexual counterparts44

Young gay men

>4x incidence of risky sexual practices/unsafe practices compared to white peers45

Lesbian and bisexual youth who identify as “mixed” race/ethnicity

>1/3 prevalence in hazardous weight control behaviors46

LGB youth

Less engagement in moderate/vigorous physical activity or participation in sports than non-LGBT counterparts47

LGBT youth

Significantly increased risk than non-LGB counterparts48

GB adult men and LGB youth

~4x risk of depression

Non-treated transgender individuals

Risk behavior likelihood

Depression, anxiety

Suicide ideation / attempts

Healthcare discrimination and mistreatment

37–40

LGBTQ individuals

2-4x risk of suicide ideation compared with heterosexual men50

GB men

2x more likely to have suicide ideation and 4x more likely to make serious suicide attempts requiring medical attention than heterosexual counterparts51

LGB youth

14% prior suicide attempt; 50.8% transgender male suicide attempts; 41.8% nonbinary individuals; 29.9% transgender females; 27.9% questioning individuals; 17.6% females; 9.8% males52

LGBTQ youth

33% of transgender respondents experienced a negative interaction with a healthcare provider53

Transgender individuals

Refusal of Care: 8% LGB respondents experienced refusal of care; 29% of transgender respondents experienced refusal of care54

LGBT individuals

58 Delaware Journal of Public Health – June 2019

Table 2. Summary of Recommendations for Health Professional Education Curricular Threads (Expanded Upon from AAMC, 2014) Area of Domain of Practice

Recommendations for Content

Sample Objectives for Outcomes of Education

Patient Care

Include terminology and practices specific to SGM populations

Develop effective rapport with all patients utilizing inclusive language and practices that avoid assumption-based terminology.

Teach health disparities and health equity specific to SGM populations Knowledge for Practice

Practice-Based Learning and Improvement

Interpersonal and Communication Skills

Apply biophysical scientific principles fundamental to health

“Define and describe the differences among: sex and gender; gender expression and gender identity; gender nonconformity, and gender dysphoria; and sexual orientation, sexual identity, and sexual behavior.”14

Apply principles of social-behavioral sciences to principles of patient care

“Understand and describe historical, political, institutional, and sociocultural factors that may underlie health care disparities experienced by SGM populations.”14

Teach investigatory and analytic approach to clinical situations inclusive of sexual and gender minorities

“Recognize the gaps in scientific knowledge and identify various harmful practices that perpetuate the health disparities for patients in the SGM populations.”14

Teach self-awareness and reflection to identify strengths, deficiencies and limits in one’s knowledge and expertise

“Demonstrate the ability to elicit feedback from individuals who identify within SGM populations about their health experiences and identify opportunities for change to improve care (e.g. inclusive language on intake forms).”14

Teach critical appraisal and application of evidence related to patient health

Include important clinical questions pertinent to SGM populations as they emerge when seeking the literature to inform clinical decisions.

Cultural humility and competency content inclusive of these populations

Demonstrate knowledge of current terminology respectful of SGM populations when describing patient care or establishing rapport with patients.

Teach trauma-informed care and practices Skill based content on demonstrating insight and understanding about emotions and human responses to emotions that allow self-development in interpersonal interactions

“Understand that implicit bias and assumptions about sexuality, gender, and sex anatomy may adversely affect verbal, nonverbal, and/or written communication strategies involved in patient care, and engage in effective corrective self-reflection processes to mitigate those effects.”14

Cultural humility and competency content and behaviors inclusive of these populations.

Recognize and sensitively address all patients’ and families’ health traditions and beliefs, and understand the possible effect on diverse forms of sexuality and gender/gender identity.

Confidentiality and patient privacy with circumstances unique to these populations

Recognize and follow the unique aspects of confidentiality with SGM populations and utilize appropriate consent practices.

Ethics and accountability to patients, society, and the profession

“Accept shared responsibility for eliminating disparities, overt bias, and develop policies and procedures that respect all patients’ rights to self-determination.”14

Teach advocacy for quality patient care and patient care systems

Demonstrate knowledge about legal and systemic barriers to health and resultant discriminatory practices that inhibit optimal health outcomes for SGM populations.

Teach the coordination of patient care to specifically target disparity impact

“Identify and partner with community resources that provide support to SGM populations to help eliminate bias from health care and address community needs.”14

Teach practices to effect change on behalf of SGM populations on a systems level

“Explain how homophobia, transphobia, heterosexism, and sexism affect health care inequalities, costs, and outcomes.”14

Interprofessional Collaboration

IPE cultural competency practices relative to establishing and maintaining respectful climates/cultures, dignity, diversity, and ethical integrity

Utilize interprofessional communication and collaboration in providing culturally competent, patient-centered care to the SGM populations and participate effectively as a member of an interdisciplinary health care team.

Personal and Professional Development

Self-reflection content thread regarding personal and professional development goals

“Critically recognize, assess, and develop strategies to mitigate one’s own implicit biases in providing care to SGM individuals and recognize the contribution of bias to increased iatrogenic risk and health disparities.”14

Professionalism

Systems-Based Practice

necessity for all health professional discipline education to be inclusive of a sexual and gender minority thread throughout all content domains, however, assessment of that learning and direct impact to patient care is not necessarily addressed here. There is a paucity of literature on true assessment and direct patient impact of cultural competency education, and essentially no literature on the impact of sexual and gender minority inclusive education. Ethics are not optional when you are a healthcare provider, and it is long past due that we include all patient populations in the education and training of health care professionals. The four principles of health care ethics - autonomy, beneficence, nonmaleficence, and justice - do not stop short of inclusion of sexual and gender minority patients. There is no doubt, we have to do better in every aspect of health with these populations, and one public health answer is to ensure that our professional education curricula are inclusive and outcome based for patient-centered care with these populations.

8. Obedin-Maliver, J., Goldsmith, E. S., Stewart, L., White, W., Tran, E., Brenman, S., . . . Lunn, M. R. (2011, September 7). Lesbian, gay, bisexual, and transgender-related content in undergraduate medical education. JAMA, 306(9), 971–977. https://doi.org/10.1001/jama.2011.1255

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HIGHLIGHTS FROM

The

NATION’S HEALTH A P U B L I C AT I O N O F T H E A M E R I C A N P U B L I C H E A LT H A S S O C I AT I O N

June 2019 The Nation’s Health headlines Online-only news from The Nation’s Health newspaper Stories of note include: • Colorado county named healthiest US community: Report scores 3,000 communities on healthrelated issues Read full story >> • Thousands of children, teens killed by guns annually in US Read full story >> • National Public Health Week 2019 events showcase creativity: Events share science, promote action Read the story >> • Workers using Healthy People goals to improve local health: Objectives guide work in communities Read full story>> • Happiness can be good for your health Read full story >> • Public health extras: New competencies available, HUD inspections lacking, opioid addiction recommendations released by IHS Read full story >> • Newsmakers Read full story >> • Resources Read full story >>

Why Count and Measure? Justin Glasgow, M.D.; Medical Director, Quality, Hospital Medicine, UAB Medicine

INTRODUCTION The first recorded sign of counting in early humans is attributed to a collection of tally marks found on a baboon fibula in the Congo region of Africa, which dates to approximately 40,000 years ago. While it is unknown what was recorded (or if counting was the true intention), the recovered segment of bone has 29 tally marks, leading to a hypothesis that people were tracking the lunar phase. A health related hypothesis is that women were tracking menstrual cycles. The process of counting advances with time, and clearly is in use in 4,000 BC, with development of urban cities in Sumeria. Cities bring together a collection of people and resources in close proximity, necessitating a process to track and monitor people and resources. The Egyptians in 3,000 BC expanded on counting and developed measuring, which supports the ability to build pyramids and temples. The next major development, to the bane of many teenagers and perhaps their parents, was the Greeks development of more advanced mathematics, building the base for Algebra and Trigonometry. In healthcare, perhaps the most famous early story of counting and measuring is that of John Snow, commonly considered a founding father of Epidemiology. His story is notable for the thoroughness with which he counts and tracks cases of cholera in an outbreak, and is able to show how they congregate around specific water pumps in London. Not only did this introduce the concept of epidemiologic case tracing, but perhaps also established the basis for studying how social determinants created health disparities.

COUNTING IN MODERN HEALTHCARE Modern healthcare seems to have an endless array of counts and measures. From the standard Complete Blood Count (CBC) to complex National Surgical Quality Improvement Program (NSQIP), healthcare providers and healthcare systems collect innumerable measures of health and healthcare. While the field strives to understand outcomes, it often has a limited or superficial understanding of the patients receiving care. With the Centers of Medicare and Medicaid Services (CMS) promoting electronic health records through the meaningful use (MU) incentives program, there has been some standardization of information collection. The 2014 Edition of the Stage 1 MU program incentivized the systematic collection of a patient’s preferred language, gender, race, ethnicity and date of birth. This program has explicit definitions for race and ethnicity categories, but does not define expectations on gender collection. In fact, a summary document from CMS uses gender and sex interchangeably. The development of the MU program precedes current recognition about risk of privacy invasion with data collection of large internet and social media companies, but within that context it is critical to ask whether it is necessary for healthcare systems and providers to collect this data. The stated purpose within MU is that the systematic collection of data elements will serve as a platform for understanding health disparities and driving efforts to improve quality, safety, and efficiency. This noble pursuit to understand and reduce health disparities is indeed 64 Delaware Journal of Public Health – June 2019

necessary if we are going to continue to effectively improve the quality of health in our own neighborhoods and across the nation.

HEALTH DISPARITIES – WHY DOES COUNTING MATTER? Health disparities are any measure of higher burdens of illness, injury, disability or mortality experienced by one group compared to another. Health disparities exist in most everywhere that they have been explored. Amongst those who identify as a gender or sexual minority (GSM), disparities have been identified in a number of arenas. As a population, there are higher rates of tobacco, alcohol, and illicit substance use. Studies have also identified higher rates of many chronic conditions such as asthma, ischemic heart disease, hypertension, obesity, depression, and anxiety. And perhaps most unfortunate (but not uncommon): in settings where health disparities exist, GSM populations also have lower rates of seeking healthcare services. Talking about health disparities in GSM populations as a single monolithic population ignores disparities that exist between various groups within the populations. Individuals identifying as transgender have starkly worse health behaviors and health outcomes than those who identify as a sexual minority. Due to the recent growth in recognition of individuals who identify as non-binary, there is little understanding of what specific health disparities they face, or how those differ from disparities previously identified among individuals identifying as transgender. Among those who identify as a sexual minority, when analyzed separately, individuals identifying as bisexual have greater health disparity than those who identify as the same gender but only identify as having same sex attraction (i.e. gay men have elevated rates of heavy drinking, but bisexual men have even higher rates of drinking). Given good recognition regarding the existence of health disparities, is there truly a need to further collect data to assess health disparities? Answering this question requires some consideration of the scientific field that serves as the basis for studies on health disparities: epidemiology. Epidemiology is classically defined as the study of the diseases that affect a population. As the field has evolved, it more broadly examines how different factors impact the health of populations. Those trained in epidemiology build a strong foundation in study design and statistical analysis, which includes a particular emphasis on understanding the strengths and weaknesses of different study designs and analytic techniques. The popular media can make jokes about how one study says coffee will help you live longer while the next says coffee will kill you, but to an epidemiologist who has reviewed the research, they can often identify how different decisions in a study design can lead to these disparate findings. This is, of course, assuming that the splashy headline also doesn’t just reflect an over simplification of the research study conclusions promoted to garner attention and drive views.

EPIDEMIOLOGY AND COUNTING There are many considerations epidemiologists use when evaluating research, here we will discuss two that can help us

understand the importance of collecting structured data to help better analyze and understand health disparities. The concepts of internal validity and external validity are critical to understanding why GSM individuals (and quite frankly, anyone) should want to be accurately counted and should want to ensure that their health care organizations are consistently and systematically capturing appropriate demographic information. Internal validity addresses how well a study measures the relationship of interest and whether it appropriately accounts for how other variables (called confounders) impact that relationship. For example, a study may wish to examine the relationship between GSM identity and utilization of emergency departments (ED) for care that can more effectively and efficiently be provided in a primary care office (also called ambulatory care sensitive conditions). If a study only measured an individualâ&#x20AC;&#x2122;s GSM identity and their rates of ED and primary care office utilization over a specific time frame, it would miss other critical confounders that impact why individuals choose to use one health care setting over another. A common confounder here is insurance status: GSM populations generally have higher rates of being uninsured, and being uninsured increases the likelihood of utilizing an ED for care over a primary care setting (as uninsured individuals generally do not have a longitudinal primary care relationship). So if a study finds an association between GSM identity and excess ED utilization, but does not account for differential rates of insurance, we cannot safely conclude that study found a true relationship: it would be considered to have weak internal validity. The role of unmeasured confounders is a common cause for why nutrition studies (i.e. what is the impact of coffee or chocolate) will sometimes show health benefits and other times health hazards. In contrast, external validity addresses how well a sample of patients within a study represents the greater population at large. Issues with external validity are commonly found in many clinical drug trials. Given the high expense involved in clinical drug trials, these studies are designed to have high internal validity and promote the ability to find a benefit of the drug in question if it exists. However, this leads to excluding patients from the study population who may receive the drug once it becomes available widely in clinical practice. An easy example is that clinical trials rarely include pregnant women, so little is known about the effectiveness of many drugs in pregnant women. In many instances, the only information about risks of fetal teratogenicity is based on animal studies or several post-market birth defect registries. While the story of thalidomide occurred before (and is a primary driver for) the current paradigm of drug testing and approval, it demonstrates how external validity impacts study findings. Initial studies on thalidomide focused on the drug as a sedative, and found that it was essentially impossible to overdose on the medication. This led to its approval, and in some countries the medication was even sold without a prescription. However, those studies did not include many populations, particularly pregnant women. As its clinical use expanded from a sedative to being used to treat nausea (specifically morning sickness in pregnancy), this meant the early studies did not have sufficient external validity to address the safety of the medication. It was recognized that thalidomide was a fetal teratogen, and resulted in unknown numbers of miscarriages, as well as numerous birth defects, limb defects being the most famously linked. In general, studies examining health disparities in GSM populations often suffer from major risks to both their internal

and external validity. Internal validity is often weak because studies try to draw a simple line between GSM identity and either a health behavior or health outcome. For example, a study documenting increased rates of alcohol use among gay and bisexual identified men compared to heterosexual identified men also found higher reported rates of severe psychological distress among gay and bisexual identified men. This easily raises the question of how does severe psychological distress and alcohol consumption interact, and might that relationship confound the independent relationship with sexual identity (internal validity). It is certainly reasonable to hypothesize that psychological distress can lead to alcohol use as an (ineffective) attempt at coping, but similarly, alcohol is a depressant and could impact how individuals perceive their psychological distress. It is likely that alcohol and psychological distress confound the relationship of the other with sexual identity, however without a sufficient population size (external validity), the study could not statistically account for this possibility, leaving an open question for further studies. The previous study data came from the National Health Interview Survey (NHIS), which suggests the study sample is representative of the large population (supporting generalizability), but that sort of study sample is rare in the literature evaluating health disparities in GSM populations. Frequently, studies utilize a sample of convenience, which helps develop preliminary findings, but limits how broadly findings should be applied. Common settings for identifying a large enough cohort of GSM identified individuals to participate in a study frequently means working in an urban setting and recruiting from settings that cater to the population, such as a gay bar or a community free clinic for sexual health services. It doesnâ&#x20AC;&#x2122;t require much creative thinking to recognize that, when a study recruits from a bar, rates of alcohol and tobacco consumption (in the times when you could still smoke indoors) in that group may not reflect the behaviors of the greater GSM population. Similarly, those receiving care in an urban free clinic likely have a different healthcare experience than their urban compatriots with health insurance, whose healthcare experience may also be dramatically different from GSM individuals residing in a rural environment which may not have easy access to the same level of public health resources.

THE IMPORTANCE OF COUNTING AND MEASURING GSM POPULATIONS In the context of healthcare, and more importantly public health, why should we want to count and measure GSM populations accurately? In 2017, healthcare spending accounted for 17.9% of the Gross Domestic Product (GDP) or about $3.5 trillion annually. Disparities in health will either directly or indirectly cost the country more over time than if we were providing everyone with the best high value care. The challenge is that if we have not accurately measured and assessed the health disparities, then our attempts to develop and implement interventions to reduce disparities are likely to fall woefully short of their aims. If we look back to the example of the relationship between GSM identity, psychological distress, and alcohol consumption, a poor understanding of this relationship is likely to lead to an ineffective intervention. An intervention focused only on achieving alcohol sobriety is unlikely to be successful if it does not address the underlying psychological distress that may be driving alcohol consumption. The intervention may achieve a brief period of sobriety in individuals, but since a key driver of 65

alcohol consumption might not have been addressed, later events that increase stress will place an individual that lacks the adequate coping skills to address this driver at a higher risk of relapse. Unfortunately, in many concepts of public health, the causal relationship between an individualâ&#x20AC;&#x2122;s demographics and health outcomes are too complex for a simple survey to assess with sufficient internal or external validity. Simply put, a survey of 700 gay men (with an appropriate heterosexual comparison group) cannot sufficiently help us understand the complex relationship between sexual identity, psychological distress and substance use. Without large datasets that allow for careful and systematic study of complex relationships, there will be a persistent high risk of drawing the wrong conclusions about health disparities faced by minority populations.

HOW CAN YOU BE COUNTED? There are opportunities beyond collecting data during routine medical care that can also contribute to our efforts to understand and alleviate health disparities. For GSM populations, the PRIDE study (pridestudy.org) is the first long-term national health study of LGBTQ people with periodic surveys to assess physical, mental and social health. Additionally, the National Institutes of Health is supporting the All of Us study (allofus.nih.gov, Joinallofus. org) which represents an effort to gather data from one million or more people, with the goal of collecting data from a broad representative sample of all individuals living in the United States. These programs represent opportunities to contribute to the health and wellbeing of all. So why, as a GSM individual, should you want to share your identity with a healthcare provider or system? In a world of

explicit discrimination and unconscious bias, there are countless barriers to wanting to share information with a provider. Long term, helping a medical provider understand the whole of your physical, mental and social health will support a strong patient provider relationship and drive effective diagnosis and management. In many instances, your identity (whether related to race, ethnicity, gender identity, or sexual identify) is unlikely to change the medical care you receive. Yet, as I think about common diagnoses, I have a hard time identifying a single diagnosis where a sexual or gender identity wouldnâ&#x20AC;&#x2122;t ever potentially contribute to helping a provider develop an appropriate treatment plan. Common causes of symptoms may not be related to GSM identities, but if those are ruled out, knowledge about GSM identity may help formulate questions to better understand potential for more rare causes of symptoms.

CONCLUSION To summarize, counting and measuring were established early in civilization as a way to help distill complex systems into an understandable process. The expansion of electronic health records provides an opportunity for well-structured interventions to address quality in healthcare and, more importantly, disparities in health. However, our current understanding of health disparities may be superficial, as it is often built on studies with significant limitations from an epidemiologic perspective when it comes to internal and external validity. In order to support improvements in public health (and consequently, help address unsustainable healthcare spending) there should be broad support for collecting data to help understand populations, such as gender and sexual minority patients, whether as part of routine healthcare or as participants in national studies.

NEW MPH IN EPIDEMIOLOGY The University of Delaware now offers a master of public health in epidemiology - the only program in the region focusing on applied epidemiology. Graduates will be experts in using data to prepare and prevent health impacts of natural disasters and disease outbreaks on communities locally, nationally and globally.

udel.edu/mph-epi 66 Delaware Journal of Public Health â&#x20AC;&#x201C; June 2019

Delaware Day

Healthcare Job Fair

WHO:

Residents in any specialty, especially at Delaware’s health systems; DIMER Students in residencies anywhere in the United States; previous DE Academy of Medicine loan recipients; NPs and PAs interested in Delaware practice

WHERE:

Del-One Conference Center Delaware Technical Community College, Terry Campus

WHEN:

Saturday, July 13, 2019 9:00 am – 12:00 pm

WHY:

Network with recruiters from all of Delaware’s Hospitals/Health Systems to discuss available job opportunities!

The Religious Landscape for LGBTQ+ Persons The Rev. Dr. Douglas D. Gerdts, D.Min. Pastor/Head of Staff, First & Central Presbyterian Church, Wilmington, DE

ABSTRACT Navigating the world of organized religion is difficult under the best of circumstances given the wide array of expressions, interpretations, ideology, tolerance, and willingness to include all persons. For a member of the LGBTQ+ community, a negative experience can range from merely uncomfortable to intensely and emotionally damaging. To mitigate the negative and increase propensity for a positive experience, markers as to a faith community’s degree of openness and inclusion not only exist, but are clear, identifiable, and to a large degree, dependable. This brief review of the major religions and faith traditions in Delaware provides some of those markers along with guidelines for understanding. The focus of this review is based on demographic data from the 2014 Religious Landscape Study conducted by the Pew Research Center’s Religion and Public Life Section.

THE RELIGIOUS LANDSCAPE FOR LGBTQ+ PERSONS “Landscape” is an apt word for what members of the LGBTQ+ communities will find as they explore the often-unpredictable terrain of religious and spiritual waystations. Some byways will be rolling, halcyon vistas replete with faith-based institutions extending an extravagant welcome. They’ll meet follow travelers who have been in the trenches of equality and nondiscrimination fights (and victories) for a generation. Visitors will be considered immediate family and welcomed around a table set with diversity, inclusion, and abundance – all viewed with gratitude. Other routes will be cluttered with twists and turns and unmarked forks, with hills that hide the path beyond the ridge or curves that disguise hazards. The “all are welcome” banner looks worn, tattered, and neglected. How is one to know what to believe or trust? The national organization may decree a restrictive stance while the local congregation balks and chooses a more progressive and inclusive posture. Sure, you’re welcome to come inside, sit quietly, conform, and never disclose much about yourself. Know your place in the pew-lined closet and everything will be fine. Lastly are the dead ends. The message is clear: you’re not wanted, you’re “less than” and have no place or purpose here. The only good thing? No time or energy is wasted. Thank you for your candor! The survey undertaken for this essay has sorted and sifted the various faith communities in Delaware into the above groups of “Welcoming Waystations,” “Middle of the Road,” and the “Dead Ends.” From there, further exploration of the “Waystations” group narrows the focus in an effort to provide greater propensity for a positive experience. The Pew Research Center remarks, “the 2014 U.S. Religious Landscape Study is based on telephone interviews with more than 35,000 Americans from all 50 states. This is the second time the Pew Research Center has conducted a Religious Landscape Study.” The first study was conducted in 2007.1 68 Delaware Journal of Public Health – June 2019

For the purposes of this survey, only religious communities which garnered at least 1% of the Delaware population were surveyed, hence groups such as New Age, Pagan, Wiccan, or Native American were omitted due to a quantitative limit, and not because of any bias or prejudice on the part of the author (see Table 1). From the list, the following were investigated as their stance on three basic areas: attitude toward homosexuality, support for or against marriage equality, and ordination, if appropriate (see Table 2).2 As this initial survey was undertaken, one key indicator became clearly evident, and that is a denomination’s or tradition’s public and system-wide stand on marriage equality for same-gender couples. All other indicators followed suit regardless if the position was affirming or condemning. The “gray area” arose when either there was no centralized message or individual communities dissented from the prescribed position. Therefore, if a denomination supports and practices samegender marriage equality, one can safely assume that its congregations are welcoming and affirming, and that LGBTQ+ persons are eligible for ordination. Hence, if an LGBTQ+ person were to seek a community of faith in which to explore membership or alliance, one should start with the following organizations: • Conservative Jewish Movement • Episcopal Church • Evangelical Lutheran Church in America • Presbyterian Church (USA) • Reconstructionist Judaism • Reform Jewish Movement • Society of Friends (Quakers) • Unitarian Universalist Association of Churches • United Church of Christ

Table 1. Religious Denominations of Survey Population Grouping

Denomination

Percentage of DE Population (%)

Evangelical Protestant Southern Baptist Convention

Independent Baptist

“Other” Baptist

Assemblies of God

Church of Christ

Mainline Protestant American Baptist

United Methodist Church (UMC)

Evangelical Lutheran Church in America (ECLA)

Presbyterian Church (USA)

“Other” Presbyterian

Episcopal Church

“Other” Episcopal

Historically Black Churches Independent Baptist

African Methodist Episcopal Church (AME)

AME Zion Church

Roman Catholic

Orthodox Christian

Jewish

Muslim

Hindu

Unitarian

Table 2. Religious Groups’ Stance on Homosexuality, Marriage, and Ordination Denomination

Homosexuality

Marriage

Ordination

Welcoming Waystations ELCA

This is the most welcoming of the three leading Lutheran denominations. LGBTQ+ folks are “welcome to participate fully in the life of the congregation

Ministers and congregations have autonomy as to marriage and many will perform same-gender ceremonies.

LGBTQ+ people are eligible for ordination.

Episcopal

LGBTQ+ people are entitled to the “full and equal claim on love, acceptance, and the care of the church.”

Marriage equality is supported and practiced.

Ordination is open to all persons.

Judaism – Conservative

Some congregations are affirming – others are not. Denomination has taken strong stand in favor of inclusion.

Supports and practices marriage equality.

LGBTQ+ persons are eligible for ordination.

Judaism – Reconstructionist

Most consistently welcoming and affirming of Jewish denominations.

Affirms and practices samegender marriage.

All persons are eligible for ordination. Discrimination is prohibited.

Judaism – Reform

Most congregations are fully welcoming, inclusive, and affirming.

Affirms same-gender marriage. “Relationship of Jewish, samegender couple is worthy of affirmation through appropriate Jewish ritual.”

All persons are eligible for ordination.

Presbyterian Church (USA)

LGBTQ+ people are fully integrated in the life of the church. The denomination is entirely welcoming although there are degrees within congregations.

Marriage equality is fully supported and the standard marriage ceremony is now gender-inclusive.

LGBTQ+ candidates are eligible for ordination.

Religious Society of Friends (Quakers)

Meetings are autonomous and LGBTQ+ folks are welcome.

Will perform same-gender weddings.

No ordination standards.

Unitarian

Not only do Unitarians open their doors to all persons, but “value diversity of sexuality and gender and see it as a spiritual gift.”

Unitarians have been at the forefront of the struggles and victories for marriage equality.

Ordination is open to all.

United Church of Christ (UCC)

“Extravagantly welcome!”

Affirms equal rights for all persons including marriage.

Yes – all persons are eligible for ordination.

Denomination

Homosexuality

Marriage

Ordination

Middle of the Road Buddhism

No central teaching or government. Wide array on all topics.

Hindu

There is no central authority in the denomination and “given the inherent spiritual equality, Hindus should not ostracize but accept LBGT persons as fellow sojourners.” Kama Sutra celebrated same-sex activity.

Some communities will affirm same-gender marriage. Varies.

Yes, all men and women are eligible for ordination but are expected to maintain a vow of celibacy.

Muslim – Sunni and Shi’a

“It is rare that an openly LGBTQ+ Muslim feels welcome at a mainstream mosque in the United States.”

Same-gender marriage is normally not affirmed, although some imams will perform.

There is no formal process for ordination.

United Methodist Church (UMC)

Recently affirmed the “Traditional Plan” which prohibits homosexuality in the church

One man and one woman. In addition, clergy can be punished for performing or participating in a same-gender wedding.

Will not ordain.

70 Delaware Journal of Public Health – June 2019

Denomination

Homosexuality

Marriage

Ordination

The Dead Ends AME

Church condemns same-sex relationship.

Does not support marriage equality.

Denomination is not in favor of ordination of openly gay persons to the ranks of clergy.

American Baptist

Homosexuality is incompatible with Christianity

One man and one woman

Will not ordain.

Church of Jesus Christ Homosexual attraction is not a sin, of Latter-day Saints but action on it is. No longer offers (Mormons) conversion therapy.

Same-gender marriage is seen as apostasy.

Ordination is open to men only and no LGBT.

Eastern Orthodox

Homosexuality is immoral and inappropriate forms of behavior and attacks the institutions of marriage and family.

Marriage is reserved for one man and one woman. It is a sacred institution reserved for monogamous heterosexuals.

LGBTQ+ persons and women are not eligible.

Judaism – Orthodox

Homosexuality is prohibited – although there are small signs of welcome.

Forbids and condemns samegender marriage

Does not ordain LGBTQ+ or women.

National Baptist Convention

Homosexuality is incompatible with Christianity.

One man and one woman

Strongly independent congregations hence ordination stands may vary, but rarely do.

Marriage is one man and one woman.

LGBTQ+ people and women are not eligible for ordination.

Presbyterian Church in “Homosexual practice is sin.” Churches America (PCA) seek to “transform the lifestyle” with conversion programs designed for people to “leave behind the gay lifestyle.” “Gender distortions” are considered sin. Roman Catholic

“Homosexual acts are intrinsically Does not support marriage immoral and contrary to natural law. equality. Homosexual tendencies are “objectively disordered.”

Ordination is possible due to celibacy vow.

Southern Baptist Convention

Homosexuality is always considered One man and one woman sinful and impure. Classified with adultery and pornography. It should be opposed. “Love the sinner, hate the sin.”

Will not ordain a person who is homosexual regardless of activity.

The following graphic produced by the Pew Research Center provides a more in-depth review (see Figure 1).3 Although the scope of possibilities has been drastically reduced, sadly, the work does not end there. Within those listed on the above graphic as “Sanctions Same-Sex Marriage,” the demeanor of individual faith communities and churches may vary drastically. The denomination with which I am most familiar is the Presbyterian Church (USA) wherein I serve as a pastor for one of the most liberal, progressive, and accepting congregations – not just in Delaware – but in the entire denomination. Yet, within two miles is another congregation of the PCUSA in which an openly gay, lesbian, or trans person may not (read: “probably won’t”) feel welcome and included despite “all are welcome” signage. What follows are six tips for determining the degree of welcome, comfort, and safety one may or may not discover when walking through the doors: 1. Google “gay friendly (name of denomination/tradition) church/faith community in (city or town).” Save considerable time and frustration and search only the denominations or faith traditions in the far-left column of Figure 1.

Figure 1. Where Major Religons Stand on Same-Sex Marriage (Pew Research Center)

2. Scan websites – but first, don’t read a word, just look at pictures. A community that’s intentional about its welcome will make that clear with the people they place on their homepage. Are there any photos of people appear to be 71

part of the LGBTQ+ communities? Are there any samegender couples? 3. Read the opening statement of the home page – does it go beyond “all are welcome”? Most every congregation or group considers itself “welcoming” and so one must dig a little deeper. Does the statement mention any advocacy or social groups specific to LGBTQ+ people? Scan a few recent sermons, talks, newsletters, announcements, or bulletins and watch for language that is either radically welcoming or appears to support more traditional and heteronormative persons and family configurations. 4. Find a policy on marriage. Again, communities that are gay-friendly and perform marriages will make that clear in their language about weddings. This is, as discussed above, the “litmus” test for both denominations and for individual faith communities. 5. If the website promotes phrases such as “family values,” “Bible-based preaching,” or anything “traditional” – this is likely not a community that values the diversity that LGBTQ+ folks bring. 6. Larger is often safer – but not always. Downtown, citycentered is often a better bet than suburban or rural – but not always! Much of the above emanates from the experiences of openly gay and lesbian persons, yet the same indicators of welcome and inclusion should hopefully hold for transgender or gender nonconforming people. Faith communities may not have as much direct experience or well-developed relationships with trans persons, but a community committed to diversity and inclusion has a higher likelihood of welcoming all.

The religious landscape for LGBTQ+ persons can be treacherous and difficult to navigate, yet by restricting oneself to those communities that support and practice same-gender marriage and following the six tips listed, one can quickly minimize hazardous conditions! The journey is worth it. Finding a faith-based community with which to practice, grow, nurture, question, and even challenge one’s spirituality adds a dimension to life that adds nearly immeasurable meaning, joy, and purpose. Knowing that one is “home”, that one is “family,” when for so many of the LGBTQ+ community neither of those may have been positive experiences, is a degree of acceptance and celebration not often found in secular society. Lastly, there are many factors unrelated to sexuality that converge to determine whether or not a faith community is a good “fit.” If one doesn’t feel right – keep moving. Trust always that there is a community that is just as anxious to greet you as you are to find it – and that makes the world a better place for us all!

REFERENCES 1. Pew Research Center. (2014). Religious Landscape Study: Adults in Delaware. Retrieved from https://www.pewforum. org/religious-landscape-study/state/delaware/ 2. Campaign, H. R. (n.d.) Faith Positions. Retrieved from https:// www.hrc.org/resources/faith-positions 3. Pew Research Center. (2015, December 21) Where Christian churches, other religions stand on gay marriage. Retrieved from https://www.pewresearch.org/fact-tank/2015/12/21/wherechristian-churches-stand-on-gay-marriage/

D E L AWA R E B I O . O R G I N F O @ D E L AWA R E B I O . O R G

72 Delaware Journal of Public Health – June 2019

CAMP Rehoboth 37 Baltimore Avenue Rehoboth Beach, DE 19971 302-227-5620 info@camprehoboth.com

CAMP Rehoboth Mission CAMP Rehoboth is a 501(c)(3) nonprofit community service organization dedicated to creating a positive environment inclusive of all sexual orientations and gender identities in Rehoboth Beach and its related communities. We seek to promote cooperation and understanding among all people as we work to build a safer community with room for all. CAMP Rehoboth Purpose We seek to promote community well-being on all levels; to foster the development of community groups; to develop community space; to promote human and civil rights; to work against prejudice and discrimination; to lessen tensions among the community at large; and to help foster the economic growth of the area. We work toward these ends through activities such as the following: •

• • • •

Fundraising for other non-profit organizations, such as AIDS service organizations, gay, lesbian, bisexual and transgender community organizations, recycling programs, environmental projects, literacy training, and other ventures for the general betterment of the community. Networking resources and information by publishing a newsletter, and functioning as an alternative tourist bureau and information center. Promoting artistic expressions and creative thinking, and giving aid to artists and craftspeople with an emphasis on the works of lesbians and gay men. Education and outreach to the larger community, including sensitivity training seminars, and printed materials to promote positive images of gay and lesbian people and others. Promoting political awareness to build a safe and inclusive community through voter information, education, and registration; and analysis of issues and candidates.

CAMP Rehoboth Vision We create proud and safe communities where gender identity and sexual orientation are respected.

LGBTQ+ – LEXICON OF TERMS Adverse Childhood Experiences (ACEs) Traditionally 10 types of childhood trauma that can go on to affect a person’s health: physical abuse, verbal abuse, sexual abuse, physical neglect, emotional neglect, a parent with alcoholism, a mother who is a victim of domestic violence, a family member in jail, a family member diagnosed with mental illness, and the disappearance of a parent (through divorce, death, or abandonment).

Agender A person who does not identify themselves as having a particular gender.

Asexual A person without sexual feelings or associations.

Assigned at Birth Gender given at birth (i.e. “it’s a girl!” “it’s a boy!”)

Binary Male- or female-identified

Bisexual Sexually attracted not exclusively to one particular gender; attracted to both men and women.

Cisgender A person whose sense of personal identity and gender corresponds with their gender assigned at birth.

Cisnormative The assumption that all humans are cisgender.

Coming Out A person’s disclosure of their sexual orientation or gender identity to others (also: coming out of the closet).

74 Delaware Journal of Public Health – June 2019

Dead-Name The birth name of someone who has changed their name. In the case of transgendered persons somewhere along the transitioning process, deadnaming is referring to that person by the name they used before they transitioned.

Dissociation The separation of normally related mental processes.

Gender Dysphoria Distress caused by the misalignment of one’s sex assigned at birth and their gender identity.

Gender Expansive An adjective describing misidentification with traditional gender roles based on sex assigned at birth. This term encompasses those who are binary, nonbinary, transgender, genderqueer, agender, Two Spirit, and myriad genders other than cisgender

Gender Expression The way in which a person expresses their gender identity, typically through appearance, dress, and behavior.

Gender Identity A person’s perception of having a particular gender, which may or may not correlate with the gender assigned at birth.

Genderqueer Denotes a person who does not subscribe to conventional gender distinctions, but identifies with neither, both, or a combination of male and female genders.

Heteronormative A worldview that promotes heterosexuality as the normal or preferred sexual orientation.

Heterosexual A person sexually attracted to people of the opposite sex.

Homophobic Having or showing a dislike or prejudice against homosexual persons.

Homosexual A person sexually attracted to people of the same sex.

LGBTQ Stands for Lesbian, Gay, Bisexual, Transgender, Queer and/or Questioning.

Microaggressions A statement, action, or incident regarded as an instance of indirect, subtle, or unintentional discrimination against members of a marginalized group such as a racial or ethnic minority.

Misgendering To refer to someone (especially a transgender person) using a word, pronoun, or form of address, that does not correctly reflect the gender with which they identify (i.e. calling a transgender male “miss” or “she”).

Non-binary People who identify as neither ‘male’ nor ‘female.’

Pansexual Not limited in sexual choice with regard to biological sex, gender, or gender identity.

PTSD Post-Traumatic Stress Disorder.

Resilience The capacity to cope adaptively with the effects of risk factors or adverse experiences.

Sexual Orientation A person’s sexual identity in relation to the gender to which they are attracted (i.e. homosexual, heterosexual, pansexual, bisexual, etc.).

Telehealth Technologically mediated health services that allow users to interact with various health care providers via computer or smartphone.

Transgender A person whose sense of personal identity and gender does not correspond to that assigned at birth.

Transgender Man Aka trans man. A man who was assigned female at birth.

Transgender Woman Aka trans-woman. A woman who was assigned male at birth.

Transitioning The process some gender expansive people may undergo in order to align themselves with their gender identity through social and/or medical interventions.

Transphobia Dislike or prejudice against transsexual or transgender people.

Trigger A term used to describe sensations, images, or experiences that trigger a traumatic memory.

Two Spirit An umbrella term used by some indigenous North Americans to describe Native people in their communities who fulfill a traditional thirdgender (or other gender-variant) ceremonial role in their cultures.

LGBTQ+ – RESOURCES If you or someone you know is considering suicide, please call: • National Suicide Hotline: 800-273-8255 • Trans Lifeline: 877-565-8860 • The Trevor Project: 866-488-7386

Federal: Centers for Disease Control and Prevention - https://www.cdc.gov/lgbthealth/ U.S. Department of Health and Human Services - https://www.hhs.gov/ Healthy People 2020 - https://www.healthypeople.gov/ National Institutes of Health - https://www.nih.gov/

Delaware: AIDS Delaware - http://aidsdelaware.org/ Bayhealth LGBTQ Equality for Patients - https://www.bayhealth.org/lgbtq Beautiful Gate Outreach Center - https://www.bgate.org/ Big Brothers Big Sisters of Delaware - http://bbbsde.org/ Brandywine Counseling & Community Services - http://www.brandywinecounseling.org/ CAMP Rehoboth Resource Guide - https://www.camprehoboth.com/lgbt-resource-guide Children & Families First - https://www.cffde.org/supporting-teens Christiana Care LGBTQ Health Initiatives - https://christianacare.org/services/lgbtqhealth/ Delaware DHSS, Division of Public Health, Bureau of Health Equity https://www.dhss.delaware.gov/dhss/dph/mh/healthequity.html Delaware Department of Services for Children, Youth and their Families, Prevention and Behavioral Health Sciences - http://kids.delaware.gov/pbhs/pbhs.shtml Delaware PrEP - https://www.delawarehiv.org/delaware-prep/ Delaware PRIDE - http://www.delawarepride.org/resources/ Delaware Renaissance http://www.delren.org Equality Delaware - www.equalitydelaware.org Help is Here Delaware - http://www.helpisherede.com/ Henrietta Johnson Medical Center - https://www.hjmc.org/ HIV Consortium https://www.delawarehiv.org/ La Red Health Center - http://www.laredhealthcenter.org

LGBT Health Clinic Resources in Delaware Multiple Locations: • AIDS Delaware External • Chase Braxton Health Care External Wilmington • Christiana Care External 76 Delaware Journal of Public Health – June 2019

Nemours Children’s Health System: Gender Wellness Program https://www.nemours.org/services/gender-wellness.html PFLAG, Wilmington, DE - https://www.pflagwilmde.org/Resource-Guide The Rainbow Chorale of Delaware - https://therainbowchorale.org/rcd-links SAGE: Advocacy and Services for LGBT Eldershttps://www.sageusa.org/ United Way of Delaware – http://www.uwde.org United Way of DE PRIDE Council http://uwde.org/how-we-work/affinity-groups/pride-council/ Westside Family Healthcare - https://www.westsidehealth.org/ Information from GLMA: Health Professionals Advancing LGBTQ Equality (http://glma.org)

• |Top 10 Things Lesbians Should Discuss with their Healthcare Provider http://www.glma.org/index.cfm?fuseaction=Page.viewPage&pageID=691

• Top 10 Things Gay Men Should Discuss with their Healthcare Provider http://glma.org/index.cfm?fuseaction=Page.viewPage&pageID=690

• Top 10 Things Bisexuals Should Discuss with their Healthcare Provider http://glma.org/index.cfm?fuseaction=Page.ViewPage&PageID=1026

• Top 10 Things Transgender Persons Should Discuss with their Healthcare Provider http://www.glma.org/ index.cfm?fuseaction=Page.viewPage&pageID=692

• Transgender Health Resources http://www.glma.org/index.cfm?fuseaction=Page.viewPage&pageId=948&grandparentID=534&parentID=938&nodeID=1

Education All of Us Study – www.allofus.nih.gov PRIDE Study – www.pridestudy.org Public School-Based Services - http://kids.delaware.gov/pbhs/pbhs.shtml Safe Zone Project - https://thesafezoneproject.com/

Social Support Delaware LGBTQ+ Social Group on Facebook - https://www.facebook.com/delgbtq/ PFLAG (Parents and Friends of Lesbians and Gays) - http://community.pflag.org/ PTK Delaware - Parents of Transgender Kids Support Group - PTKDelaware@gmail.com

LGBT Hotlines • GLBT National Help Center External • GLBT National Youth Talkline External • GLBTQ Domestic Violence Project External • Trevor Helpline / Trevor Project (Crisis Intervention / Suicide Prevention for LGBT Youth) External – 1-866-488-7386

Referral Services • Association of Gay and Lesbian Psychiatrists Online Referral System External • GLMA Provider Directory External 77

Delaware Journal of

Public Health

Submission Guidelines

updated October 16, 2018

About the Journal Established in 2015, The Delaware Journal of Public Health is a bi-monthly, peer-reviewed electronic publication, created by the Delaware Academy of Medicine/Delaware Public Health Association. The publication acts as a repository of news for the medical, dental, and public health communities, and is comprised of upcoming event announcements, past conference synopses, local resources, peer-reviewed content ranging from manuscripts and research papers to opinion editorials and personal interest pieces, relating to the public health sector. Each issue is largely devoted to an overarching theme or current issue in public health. The content in the Journal is informed by the interest of our readers and contributors. If you have an event coming up, would like to contribute an Op-Ed, would like to share a job posting, or have a topic in public health you would like to see covered in an upcoming issue, please let us know. If you are interested in submitting an article to the Delaware Journal of Public Health, or have any additional inquiries regarding the publication, please contact DJPH Deputy Editor Elizabeth Healy at ehealy@delamed.org, or the Executive Director of The Delaware Academy of Medicine and Delaware Public Health Association, Timothy Gibbs, at tgibbs@delamed.org

Information for Authors Submission Requirements The DJPH accepts a wide variety of submission formats including brief essays, opinion editorials pieces, research articles and findings, analytic essays, news pieces, historical pieces, images, advertisements pertaining to relevant, upcoming public health events, and presentation reviews. If there is an additional type of submission not previously mentioned that you would like to submit, please contact a staff member. Submissions should be completed under general APA guidelines for formatting and citations. Articles should be written in Microsoft Word format, in a clear, easily readable font with 1.5-inch to 2-inch spacing, and 1-inch margins. The suggested font is 12 point Times New Roman. Once completed, articles should be submitted via email to ehealy@delamed.org as an attachment. Graphics, images, info-graphics, tables, and charts, are welcome and encouraged to be included in articles. Please ensure that all pieces are in their final format, and all edits and track changes have been implemented prior to submission. 78 Delaware Journal of Public Health â&#x20AC;&#x201C; June 2019

Submission Length While there is no prescribed word length, full articles will generally be in the 2500-4000-word range, and editorials or brief reports will be in the 1500-2500-word range. If you have any questions regarding the length of a submission, or APA guidelines, please contact a staff member. Copyright Opinions expressed by contributors and authors do not necessarily reflect the opinions of the DJPH or affiliated institutions of authors. Copying for uses other than personal reference or interest without the consent of the DJPH is prohibited. All material submitted alongside written work, including graphics, charts, tables, diagrams, etc., must be referenced properly in accordance with APA formatting. Conflicts of Interest Any conflicts of interest, including political, financial, personal, or academic conflicts, must be declared prior to the submission of the article, or in conjunction with a submission. Conflicts of interest are any competing interests that may leave readers feeling misled or

deceived, and/or alter their perception of subject matter. Declared conflicts of interest may be published alongside articles in the final electronic publication.

Abstracts

Nondiscriminatory Language

The word limit is 200 words, including headings. A title page should be submitted with this abstract as well.

Use of nondiscriminatory language is required in all DJPH submissions. The DJPH reserves the right to reject any submission found to be using sexist, racist, or heterosexist language, as well as unethical or defamatory statements. Additional Documents and Information for Authors Please Note: All authors and contributors are asked to submit a brief personal biography (3 sentences maximum) and a headshot along submissions. These will be published alongside final submissions in the final electronic publication. For pieces with multiple authors, these additional documents are requested for all contributors.

Authors must submit a structured or unstructured abstract along with their article.

Structured abstracts should employ 4-5 headings: Objectives (begins with “To…”) Methods Results Conclusions A fifth heading, Policy Implications, may be used if relevant to the article. Trial Registration information is required for clinical trials and must be included in the final version abstract All abstracts should provide the dates(s) and location(s) of the study is applicable. Note: There is no Background heading.

Example of Information in Abstract Objective: State the objective or study question starting with “To …” (e.g., “To determine whether…”). Methods: Provide the basic design, place, year(s), setting, and number of participants of the study. If applicable, include the name of the study, the duration of follow-up. Indicate exposure and outcomes. Results: Include quantitative results. Conclusions: Provide only conclusions of the study that are directly supported by the results, whether positive or negative. Policy implications: Provide a statement of relevance indicating implications for health policy, avoiding speculation and overgeneralization. Trial Registration: For clinical trials, the name of the trial registry, registration number, and URL of the registry must be included in the cover letter ONLY and in the manuscript only after it is officially accepted. Relevant Abbreviations should be mentioned here and will not be counted in the word limit.

Index of Advertisers APHA’s 2019 Annual Meeting and Expo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 American Public Health Association The DPH Bulletin June 2019 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Division of Public Health, Department of Health and Social Services DHSS Press Release . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Division of Public Health, Department of Health and Social Services Health Science Career Panel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Wilmington Friends School Save the Date - John Scholz Stroke Education Conference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 John H. Ammon Medical Education Center Christiana Hospital HPV Vaccination Rates in Delaware . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Quality Insights AAHD Call To Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 American Association on Health and Disability Wellness and Prevention Digest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 Trust for America's Health Caring for the LGBTQ Community with Pride . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Christiana Care Health Systems Thanks to our Sponsor - The 89th Annual Meeting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Delaware Journal of Pubic Health Save the Date - Millennial Summit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 Millennial Summit Save the Date - ACCEL Community Research Exchange . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 ACCEL The Nation's Health - June 2019 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 American Public Health Association New MPH in Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 University of Delaware Health Sciences Delware Day Healthcare Job Fair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Delaware Health Sciences Alliance DelawareBio . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 DelawareBio CAMP Rehoboth Community Center. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 CAMP Rehoboth DJPH Submission Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 Delaware Journal of Public Health 80 Delaware Journal of Public Health – June 2019

Delaware Academy of Medicine / DPHA 4765 Ogletown-Stanton Road Suite L10 Newark, DE 19713

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The Delaware Academy of Medicine is a private, nonprofit organization founded in 1930. Our mission is to enhance the well being of our community through medical education and the promotion ofpublic health. Our educational initiatives span the spectrum from consumer health education tocontinuing medical education conferences and symposia. The Delaware Public Health Association was officially reborn at the 141st Annual Meeting of the American Public Health Association (AHPA) held in Boston, MA in November, 2013. At this meeting, affiliation of the DPHA was transferred to the Delaware Academy of Medicine officially on November 5, 2013 by action of the APHA Governing Council. The Delaware Academy of Medi-cine, who’s mission statement is “to promote the well-being of our community through education and the promotion of public health,” is honored to take on this responsibility in the First State.

ISSN 2639-6378