DJPH - Minority Health - from Disparities to Equity

Journal of

Public Health

Delaware Academy of Medicine

OFFICERS

S. John Swanson, M.D. President Killingsworth Lynn Jones, FACHE President-Elect

Professor Rita Landgraf (Co-Chair) Vice President

Jeffrey M. Cole, D.D.S., M.B.A. Treasurer

Stephen C. Eppes, M.D. Secretary

Omar A. Khan, M.D., M.H.S. (Co-Chair) Immediate Past President

Timothy E. Gibbs, M.P.H. Executive Director, Ex-officio

DIRECTORS

David M. Bercaw, M.D. Lee P. Dresser, M.D. Eric T. Johnson, M.D. Erin M. Kavanaugh, M.D. Joseph Kelly, D.D.S. Joseph F. Kestner, Jr., M.D. Brian W. Little, M.D., Ph.D. Arun V. Malhotra, M.D.

Daniel J. Meara, M.D., D.M.D. Ann Painter, M.S.N., R.N. John P. Piper, M.D. Charmaine Wright, M.D., M.S.H.P.

EMERITUS

Robert B. Flinn, M.D. Barry S. Kayne, D.D.S.

Delaware Public Health Association Advisory Council:

Omar Khan, M.D., M.H.S. Chair

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

Louis E. Bartoshesky, M.D., M.P.H. Gerard Gallucci, M.D., M.H.S. Melissa K. Melby, Ph.D. Mia A. Papas, Ph.D. 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

Marshala Lee, M.D., M.P.H.

Editor

Liz Healy, M.P.H.

Editor

Kate Smith, M.D., M.P.H.

Editor

Fields

Director

Public Health

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

3 | In This Issue

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

Timothy E. Gibbs, M.P.H.

4 | Guest Editor

Marshala Lee, M.D., M.P.H.

6 | HIV Prevention Programs for Racial and Ethnic Minority Communities Do The Right Thing 4LIFE: An African American Prevention/ Outreach Program Utilizing Barbershops and Beauty Salons

Frank Hawkins, M.S.

Derrick Reed

8

| Peer Mediated Groups: Nonpharmacologic Management of Pain for and By Those with Sickle Cell Disease

Stephanie Guarino, M.D., M.S.H.P.

Charmaine S. Wright, M.D., M.S.H.P.

Lee M. Pachter, D.O.

Sophie M. Lanzkron, M.D., M.H.S.

16 | The Fight to Dismantle Systemic Racism and for Racial Justice in Delaware As Seen Through the Eyes of the Delaware Racial Justice Collaborative

Emily Kauffman

Raina Allen

20 | The Migrant Crisis and Access to Health Care

Fabricio J. Alarcon, M.D., F.A.C.P.

26

| Evaluating Characteristics in Lung Cancer Screening Program Participants and Non-Small Cell Lung Cancer (NSCLC) Patient Populations

Iftekhar Khan, M.D.

Rishi Sawhney, M.D.

Stephanie McClellan, M.B.A., M.S.N., R.N., C.M.S.R.N., N.E.-B.C. Kathrina Chua, M.D.

Abeer Alfaraj, M.D.

John Shevock, F.A.C.H.E., F.A.C.M.P.E. Dain Chun, M.S.

COVER

The data show that racial and ethnic minority groups, throughout the United States, experience higher rates of illness and death across a wide range of health conditions, including diabetes, hypertension, obesity, asthma, and heart disease, when compared to their White counterparts. (CDC.gov)

30

| Delaware Mombinus Addresses Health Inequities in Vulnerable Communities

Melissa Minor-Brown Marie Pinkney

32 | Global Health Matters July/August 2022

Fogarty International Center

44 | It Takes ALL of US: Promoting Preconception Health in Delaware

LaToya Brathwaite, M.S.N., R.N.-F.N.P.

48

| Developing a Storytelling Study for African Americans with Hypertension: A Study Protocol

Yendelela L. Cuffee, Ph.D., M.P.H. Natasha Renee Burse, Dr.P.H.

Rachel Jaffe

J. Lee Hargraves, Ph.D.

60 | COVID-19 Pandemic Experience: A Collaborative Approach to Eliminate Health Disparities

Eunice Gwanmesia, Ph.D., M.S.N., M.S.H.C.A., R.N. Alicia Clark

62 | Firearm Violence in Wilmington, DE: An Update on 2020

David D. Chen, M.D., M.P.H. Toba Bolaji, D.O.

70 | Racism in Medicine: Targeting Microaggressions in Delaware Healthcare (TMDH)

Nicole Sabine

78 | Lexicon & Resources

82 | Edgewood: The Black Sanitorium for the White Plague

Sharon Folkenroth Hess, M.A.

84 | Index of Advertisers

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).

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

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 © 2022 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

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.

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

IN THIS ISSUE

Minority Health

Across the country and here in Delaware, people in racial and ethnic minority groups experience higher rates of poor health and disease for a range of health conditions, including asthma, cancer, diabetes, heart disease, hypertension, obesity, and preterm birth. According to the Kaiser Family Foundation: “Black, Hispanic, and AIAN people fare worse than White people across the majority of examined measures ... This pattern is consistent across measures related to health coverage, access, and use; health status, outcomes, and behaviors; and social determinants of health. Notably, these groups do not fare better than their White counterparts for any examined measures of social determinants of health. Black people do have better experiences than White people for some cancer screening and cancer incidence measures, although they have higher rates of cancer mortality. Hispanic people fare better than White people across some health outcome measures, including life expectancy, some chronic diseases, and most measures of cancer incidence and mortality.”1

These health disparities are preventable, and can affect many other populations of people (i.e. those with disabilities, women, the LGBTQI+, people for whom English is not their primary language, and recent immigrants). By increasing awareness of these disparities and creating interventions to address them, we can improve health equity. The CDC defines health equity as “the state in which everyone has a fair and just opportunity to attain their highest level of health.”2

This issue includes articles on HIV Prevention in Minority Communities, Dismantling Systemic Racism and Racial Justice, COVID-19 Pandemic Experience, Firearm Violence, Racism in Delaware Healthcare, and many more. As always, we welcome your feedback, and ask you to take a look at page 46 where we have listed the topic areas for 2023. Please consider a submission in any of these areas, or pass along to colleagues who might be interested. The Journal is Delaware’s publication, first and foremost – and we want to hear from you!

REFRENCES

1. Hill, L., Artiga, S., & Haldar, S. (2022, Jan). Key facts on health and health care by race and ethnicity. Keiser Family Foundation. https://www.kff.org/racial-equity-and-health-policy/report/key-facts-on-health-and-health-care-by-race-and-ethnicity/

2. Centers for Disease Control and Prevention. (n.d.). What is health equity? https://www.cdc.gov/healthequity/whatis/index.html

A Call to Action: Achieving Health Equity in the First State

On March 26, 1966, during a press conference prior to his speech at the Medical Committee for Human Rights’ annual meeting, Dr. Martin Luther King Jr. proclaimed that “We are concerned about the constant use of federal funds to support this most notorious expression of segregation. Of all the forms of inequality, injustice in health is the most shocking and the most inhuman because it often results in physical death. I see no alternative to direct action and creative nonviolence to raise the conscience of the nation.”1,2 Fifty-six years later, we are still sounding the alarm in efforts to raise the conscience of the nation and remedy the health effects of systemic racism and social inequities in our society.

Across the United States, African Americans, Latinos, Native Americans and many other racial and ethnic minority communities continue to be disproportionately affected by COVID-19.3 Despite our tireless efforts to escape the pandemic, reports show that long-standing systemic health and social inequities largely resulting from structural racism continue to place racial and ethnic minority groups at an increased risk of getting sick and dying from COVID-19 and many other preventable illnesses.4,5 Pre-pandemic disparities allowed the COVID-19 pandemic to produce drastically disproportionate health impacts from community to community.

Health inequities literally span from the cradle to the grave, in the form of higher rates of infant mortality, maternal mortality, chronic and infectious diseases, disability, and premature mortality among many racial and ethnic minority groups relative to national averages.6–8 The pervasiveness of health inequalities has caused untold and unnecessary suffering in many communities of color, and this suffering alone should prompt urgent, comprehensive efforts to rectify these disparities. Additionally, health inequities are costly and affect us all.9 Among countries with high GDP (gross domestic product) per capita, the United States spends the most towards healthcare, yet we rank last in overall life expectancy.10 This abysmal ranking is largely attributable to the life expectancy gaps that exist for racial and ethnic minority groups that have widened even further as a result of the COVID-19 pandemic.11 Health disparities and lower life expectancy pose a significant economic burden for the nation, given the costs associated with treating preventable illnesses and the economic losses associated with poor health among some of the fastest-growing populations.

The COVID-19 pandemic has given us a new call to action. This call to action to overcome health inequities must not be ignored and is as much needed today as the call to action that occurred during the civil rights movement. Today it’s COVID-19, but the next pandemic is right around the corner. This special issue highlights data, policies, and interventions geared towards eradicating health disparities. It is my sincere hope that this issue will serve as a call to action for galvanizing resources and efforts towards achieving health equity in the First State.

REFERENCES

1. Dittmer, J. (2009). The good doctors: the Medical Committee for Human Rights and the struggle for social justice in health care. Bloomsbury Publishing USA.

2. Byrd, W. M., & Clayton, L. A. (2012). An American health dilemma: a medical history of African Americans and the problem of race: beginnings to 1900. Routledge.

3. Dalsania, A. K., Fastiggi, M. J., Kahlam, A., Shah, R., Patel, K., Shiau, S., . . . DallaPiazza, M. (2022, February). The relationship between social determinants of health and racial disparities in COVID-19 mortality. Journal of Racial and Ethnic Health Disparities, 9(1), 288–295. https://doi.org/10.1007/s40615-020-00952-y

4. Tan, S. B., deSouza, P., & Raifman, M. (2022, February). Structural racism and COVID-19 in the USA: A countylevel empirical analysis. Journal of Racial and Ethnic Health Disparities, 9(1), 236–246. https://doi.org/10.1007/s40615-020-00948-8

5. Siegel, M., Critchfield-Jain, I., Boykin, M., & Owens, A. (2022, June). Actual racial/ethnic disparities in COVID-19 mortality for the Non-Hispanic Black compared to Non-Hispanic White population in 35 US States and their association with structural racism. Journal of Racial and Ethnic Health Disparities, 9(3), 886–898. https://doi.org/10.1007/s40615-021-01028-1

6. Baciu, A., Negussie, Y., Geller, A., Weinstein, J. N., & National Academies of Sciences, Engineering, and Medicine. (2017). The state of health disparities in the United States. In Communities in action: Pathways to health equity. National Academies Press (US).

7. LaVeist, T. A. (2011). Minority populations and health: An introduction to health disparities in the United States. John Wiley & Sons.

8. Louis, J. M., Menard, M. K., & Gee, R. E. (2015, March). Racial and ethnic disparities in maternal morbidity and mortality. Obstetrics and Gynecology, 125(3), 690–694 https://doi.org/10.1097/AOG.0000000000000704

9. LaVeist, T. A., Gaskin, D., & Richard, P. (2011). Estimating the economic burden of racial health inequalities in the United States. Int J Health Serv, 41(2), 231–238. https://doi.org/10.2190/HS.41.2.c

10. Emanuel, E. J. (2018, March 13). The real cost of the US health care system. JAMA, 319(10), 983–985. https://doi.org/10.1001/jama.2018.1151

11. Andrasfay, T., & Goldman, N. (2021, February 2). Reductions in 2020 US life expectancy due to COVID-19 and the disproportionate impact on the Black and Latino populations. Proceedings of the National Academy of Sciences of the United States of America, 118(5), e2014746118.

https://doi.org/10.1073/pnas.2014746118

Online-only news from The Nation’s Health newspaper

Public health workers fine-tune messaging on monkeypox: Lessons from COVID-pandemic shape engagement

Kim Krisberg

Now hiring: 3,000 people sought to shore up local public health, build career skills: Q&A with Public Health AmeriCorps’ Pearlman Eeshika Dadheech

Community teams support healthy eating, access to care through Healthiest Cities & Counties Challenge Teddi Nicolaus

Put vaccinations on your family back-to-school list Teddi Nicolaus

U.S. cities launch equity-based resilience programs in face of growing heat Mark Barna

Freight routes harm health of nearby residents: People of color, low incomes disproportionately harmed Mark Barna

JEDI principles offer playbook to improve climate readiness Kim Krisberg

Environmental justice hub creates connections Mark Barna

Editorial: Building support for advocacy on climate can boost community health Chris Kabel and Kimberly Lyle

HIV Prevention Programs for Racial and Ethnic Minority Communities

Do The Right Thing 4LIFE: An African American Prevention/Outreach Program Utilizing Barbershops and Beauty Salons

ABSTRACT

Using the Popular Opinion Leader Model to develop and implement new creative, innovative, and effective programs reaching the African American community.

STATEMENT OF NEED

According to the Delaware HIV Surveillance Report for cases diagnosed through December 2019, a total of 3,483 Delawareans were known to be living with Human Immunodeficiency Virus (HIV) and of those, 2,020 had progressed to stage 3 HIV, also known as Acquired Immune Deficiency Syndrome (AIDS).1 The cumulative number of HIV/stage 3 (AIDS) cases ever diagnosed in Delaware reached 6,210 that same year.1 As noted in the Centers for Disease Control and Prevention’s (CDC) HIV Surveillance Report of 2019, Delaware’s HIV incidence rate for 2018 (11.2 per 100,000 persons) was the 16th highest in the United States.2

African Americans are disproportionately affected by the HIV/stage 3 HIV (AIDS) burden. While 22% of Delaware’s total population is African American, this group accounts for 65% of all HIV/stage 3 HIV (AIDS) cases ever diagnosed in the state.1 This racial disparity is more pronounced in Delaware compared to the general U.S. population and persists. Of all persons living with a diagnosed HIV infection, African Americans account for 41% in the U.S. and 58% in Delaware.1,2

COVID

When the coronavirus hit the world in March 2020 it was clear that messaging needed to be disseminated to the African American with urgency. Research indicates that social determinants of health such as the places individuals live and work, their access to quality health care, and the resources to lead a healthy lifestyle play a major role in determining health status and health outcomes. It was imperative that the information come from respected leaders from the community. As a result, barbershop and beauty salon owners were summoned to assist with spreading the word about COVID testing, masking, and other precautions.

AIDS DELAWARE’S RESPONSE: DO THE RIGHT THING 4LIFE (DTRT4L)

In response to the apparent need for services and programs that specifically target African Americans in high-risk areas in Delaware, AIDS Delaware developed Do The Right Thing 4LIFE (DTRT4L) in 2000. DTRT4L is an innovative, culturally sensitive non-traditional outreach program designed to educate African Americans about HIV/AIDS and its prevention methods.

STRATEGIC APPROACH: THE POPULAR OPINION LEADER MODEL

The DTRT4L program utilizes the Popular Opinion Leader (POL) model, designed by the Centers for Disease Control and Prevention, a community level peer-based outreach strategy.3 POLs deliver education and prevention messages to community members who they encounter daily through their everyday jobs. POLs in the DTRT4L program are owners of the barbershops and beauty salons that serve as venues for the program’s activities and services. These venues are culturally specific depending on the population being targeted and are selected for their ability to attract large numbers of community members daily. POLs provide informal, one-on-one HIV prevention messages to others in their salon/community. Education messages include endorsing healthy behaviors, dispelling myths, and discussion of risk reduction methods. A key component of the DTRT4L program is “educational parties.” POLs invite their consumers to attend these events, hosted at the salons, where AIDS DE staff facilitates educational presentations in a fun and culturally sensitive manner.

Some of the shops that have assisted and supported AIDS Delaware are: HIS IMAGE, Infinity Hair Design, and Salon Ollae, along with many others.

RESULTS

African Americans consistently need to hear and see messages about safer sex and abstinence. Due to the creativeness with the DTRT4L program, we can reach individuals that may not ordinarily attend conferences, workshops, or seminars. By providing the community with information in a way they can easily understand, their fears and misconceptions around HIV/ AIDS can be dispelled.

The program has reached over 6,000 individuals. When the program began there were only five salons involved. Currently there are 32 salons involved in the program. As a result of the messages given by POLs, AIDS Delaware has seen a dramatic increase in HIV testing numbers. Through the DTRT4L program 1, 124 people have been tested. To date there have been no positive results at our testing sites.

PROGRAMMATIC CHALLENGES

Chief among the challenges AIDS Delaware has encountered in implementing the DTRT4L program is the inability of community members to attend the educational parties or workshops. Too often, individuals have conflicts around work, childcare, or other obligations that prevent them from participating in the program. The program’s target constituency, African Americans, is seldom able to afford or secure reliable sources for childcare, making it difficult for them to attend DTRT4L program events regularly.

AIDS Delaware has sought to make the DTRT4L program easily accessible to the target population. As the program’s POLs are themselves community members and interact daily with program participants, they can monitor barriers individuals may encounter in participating in the DTRT4L program. AIDS DE will also work to locate or refer individuals to childcare providers and assist program participants in locating transportation and covering costs.

LESSONS LEARNED

Through this program we have learned that a program must consider all the needs of its target population. POLs or members of a specific community are sometimes more qualified to reach the intended audience. African Americans have their own therapeutic advisors, barbers, or beauty salon stylist.

NEW HORIZONS

Health Havens: Historically barbershops and beauty salons have been a hub for people to congregate to discuss various topics and—many years ago—receive minor medical treatment. The barber pole was a symbol that the barber-surgeon could perform a minor procedure and the pole was given to the person to squeeze to allow the vein to pop up. Studies highlight the effectiveness of utilizing models of barbershop-based health services, interventions, and education programs. With adequate training and support, barbers and stylist can serve as effective frontline public health workers whereby their trusting relationships enable them to serve as a liaison between health/social services and the community to facilitate access to services and improve the quality and cultural awareness of health care.

RECOMMENDATIONS

Public health research shows that in comparison to their counterparts, African Americans are more likely to be uninsured or underinsured and as a result have lower access to quality healthcare and tend to receive lower quality healthcare. Due to many social and economic factors, African Americans are disproportionately affected by several conditions such asthma, diabetes, serious heart conditions, chronic kidney disease and severe obesity.

To proactively assist individuals with engaging in responsible healthcare, training barbershops and beauty salon owners as health professionals serves a conduit towards receiving proper healthcare treatment and finding a health home. For this model to be effective, funding must be allocated for:

• Training

• Community nurses

• Space in shop

• Medical equipment i.e., blood pressure cuffs etc.

Mr. Hawkins may be contacted at hawkins@aidsdelaware.org.

REFERENCES

1. Delaware Health and Social Services. (2021, Jan). Delaware HIV surveillance report for cases diagnosed through December 2019. Retrieved from: https://www.dhss.delaware.gov/dhss/dph/epi/files/2020hivepiprofile.pdf

2. Centers for Disease Control and Prevention. (2021, May).

HIV surveillance report, 2019. Vol 32. Retrieved from https://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hivsurveillance-report-2018-updated-vol-32.pdf

3. Centers for Disease Control and Prevention. (2020, Jan). Popular opinion leader (POL). Retrieved from: https://www.cdc.gov/hiv/pdf/research/interventionresearch/ compendium/rr/cdc-hiv-intervention-rr-good-pol.pdf

Peer Mediated Groups: Nonpharmacologic Management of Pain for and By Those with Sickle Cell Disease

Stephanie Guarino, M.D., M.S.H.P.

Internal Medicine and Pediatric Hematology/Oncology Physician, Nemours Children’s Health; Director, Adult Sickle Cell Program, Center for Health Care Needs and Institute for Research on Equity & Community Health (iREACH), ChristianaCare Charmaine S. Wright, M.D., M.S.H.P. Medical Director, Center for Special Health Care Needs, ChristianaCare

Lee M. Pachter, D.O.

Institute for Research on Equity & Community Health (iREACH), ChristianaCare; Professor, Pediatrics & Population Health, Thomas Jefferson University Sophie M. Lanzkron, M.D., M.H.S. Johns Hopkins University

BACKGROUND

Sickle cell disease (SCD) is a genetic disorder that causes red blood cells to become misshapen and break down. Affecting 90,000 Black and Brown people in the US, the disease causes decreased blood flow resulting in pain, fatigue, and infection. SCD causes significant morbidity across the lifespan, affecting all aspects of patients’ daily functioning. Finding ways to manage the most common and debilitating complications, including chronic pain, is of utmost importance to restoring quality of life and decreasing health care utilization in this population. Several studies have estimated that chronic daily pain affects 30-50% of adult patients with SCD.1,2 Furthermore, in both pediatric and adult patients with SCD, those with more frequent chronic pain report more frequent depressive symptoms, more frequent hospital admission, and more significant functional disability.2,3 Those patients on chronic opioid therapy report poorer health-related quality of life (HRQL) outcomes as well as higher symptom burden and more somatic symptoms including depression and anxiety.4,5 Racism and stigma provide further barriers in the appropriate management of sickle cell disease.

RACIAL DISPARITIES

Racial disparities in pain care appear to stem, in part, from a perceptual source. Previous psychological research in this domain has focused on high-level social cognitive processes. For example, volunteer adult participants, registered nurses, and nursing students attribute higher thresholds for pain to Blacks vs. Whites6,7 as a function of stereotypes regarding social status8 and false beliefs about racial biological differences.9 Beyond these factors, other work links reduced care for racial minorities’ pain to implicit racial bias10 and beliefs regarding substance abuse.11 Notably, studies of experimental pain suggest that Black participants exhibit lower pain tolerance and thresholds for pain12,13 stemming from cultural and neurobiological differences in pain beliefs, experiences, and coping.14 However, other work demonstrates a separate, potentially more tractable source of disparities in pain care: Biases in the visual perception of painful facial expressions. Specifically, White perceivers consistently demonstrate more conservative thresholds for seeing pain on Black (vs. White) faces.15 This perceptual bias stems from disruptions in configural processing: racial bias in pain perception was intact for upright faces, but significantly reduced when faces were inverted. Critically, racial bias in pain perception was still

present when equating stimuli on skin tone, luminance, contrast, structure, and expression, and this bias in pain perception positively predicted racial bias in treatment independent of explicit prejudice and stereotypes. In sum, we suggest that disparities in pain care stem, in part, from a perceptual source. Disrupted configural processing of Black faces yields more stringent thresholds for the interpretation of perceived pain in Black patients, triggering a cascade of biased processing and behavior fueling societal-level racial inequity in care.

It is unclear how experiences of bias and discrimination affect health outcomes such as SCD pain. Discrimination is associated with decreased self-efficacy and poor mental health outcomes (see Figure 1). The Improving Patient Outcomes with Respect and Trust (IMPORT) study demonstrates that patients with SCD report higher rates of race-based discrimination compared to other Black patients.16 Disease-based discrimination was associated with more significant self-reported pain. Previous research has shown that patients with SCD report experiences of poorer interpersonal care when hospitalized than other patient groups (9). Furthermore, these patients report poor communication with medical personnel, which has been associated with lower trust and higher rates of discharge against medical advice (10). Because virtually all patients with SCD identify as Black or other racial and ethnic minorities, it is important to understand how experiences of racism and stigma interact to affect a patient’s health and functioning. It is unclear how physical, psychosocial, and other drivers influence pain, selfefficacy at managing SCD and care utilization in patients with SCD and chronic pain.

THE IMPORT STUDY

The IMPORT study demonstrated important relationships between experiences of SCD-related stigma and increased acute care utilization.6 The IMPORT study was an NHLBIfunded observational cohort study of SCD patient experiences with health care. Participants were recruited at two academic medical centers in the Baltimore/Washington, DC Metro area. To be eligible for participation, clinic attendees needed to be over 15 years of age, with HbSS, HbSC, Hb SB-thalassemia, or Hb SS/α-thalassemia and no plans to move within three years. Participants completed a battery of surveys including the SelfCare Self-Efficacy Scale (SCSES) upon enrollment and every six months across three years. A total of 291 subjects were enrolled.

DOI: 10.32481/djph.2022.10.004

Red boxes: outcomes of interest

Blue boxes: physical drivers

Green boxes: psychosocial drivers

Black boxes: additional drivers

Dr. Lanzkron is a co-investigator on this project and maintains IRB approval for the study at Johns Hopkins (IRB00234974). Patients with SCD report greater burden of disease-based discrimination that is associated with higher self-reported pain measures.7,16 Racism can be experienced at many levels; health care settings are certainly not immune and have been sources of some of the most egregious examples in our history. Since SCD is predominantly seen in Black patients, experiences of racism are a key contributor to their health.12–14

EXPERIENCES OF RACISM

Experiences of racism have negative effects on chronic pain and depressive symptoms in SCD. Previous research noted that higher levels of perceived racism predicted more depressive symptoms in adolescents with SCD.15 An additional study found that in adolescent patients with SCD, greater experiences of racism were associated with greater pain burden and greater perceived health-related stigma was associated with lower health-related quality of life.17 Although a systematic review demonstrated an association between pain and depressive or anxiety symptoms in pediatric SCD, they noted the need for ongoing research to better understand the relationship and to extend the research to adult patients.18 Furthermore, ways to intervene to moderate these effects have not yet been studied.

SELF-MANAGEMENT PROGRAMS

Self-management programs may be efficacious for treatment of chronic pain. Though not yet tested for patients with SCD, peer-led self-management groups as an alternative to those facilitated by experts have been trialed in other patient populations with positive results. For example, in other chronic diseases such as diabetes and HIV, selfmanagement programs have been shown to improve health outcomes and patient self-efficacy.5,8 Research has shown feasibility and effectiveness in pain management for elderly nursing home patients and women living with HIV/AIDS.9,10

In these studies, there was a significant reduction in daily pain scores as well as an improvement in patient-reported mood measures; sample sizes were small and did not include SCD patients. Our preliminary data also showed that most respondents felt that peers or people living with SCD should be involved in leading the groups. This finding reinforces the importance of using a community-engaged research (CEnR) approach to developing such a programmatic intervention. Additionally, mental health literature demonstrates that group interventions can be used to decrease disease-specific stigma; this has not yet been studied in SCD.19

SICKLE

PROGRAMS IN DELAWARE

ChristianaCare’s Sickle Cell Program cares for almost half of the 400 adult patients with SCD who reside in Delaware. In a pilot funded by the Delaware Center for Translational Research ACCEL program, we are adapting the general curriculum of a peer-mediated pain group specifically for use in SCD using key informant interviews with patients with SCD and family members. The general six-week curriculum for a peer mediated group intervention helps patients with a range of chronic illnesses decrease pain levels and develop coping skills. Patientreported outcomes are measured and monitored via PROMIS-29 scale at the beginning and end of the program, as well as through the Global Impression Scale at the end and the PHQ9 and GAD7, measures of depression and anxiety, throughout. This program provides a supportive platform for patients to share their narrative and struggles. During individual meetings prior to group sessions, the patient and physician identify challenges and begin to work on solving problems. The course teaches skills that help manage pain through relaxation, visualization, and guided imagery exercises. Participants set realistic goals that are congruent with their morals and values and create a paced, modified, or replacement approach to accomplish those goals. Adding the perspective and curricular items important to those patients with SCD, specifically addressing racism and stigma, we hypothesize will enhance the effectiveness of the intervention.

The next steps in this work are funded through a COBRE grant supporting the Delaware Comprehensive Sickle Cell Research Network of which ChristianaCare is a member. We plan to examine the complex interplay between experiences of racism at many levels, disease-related stigma, and racial identity on chronic pain. First, we will analyze the landmark IMPORT dataset to evaluate the relationship between SCDrelated stigma and self-efficacy in the management of SCD. Next, we will explore the themes of racism in a medical setting, SCD-related stigma, and self-efficacy in disease management in order to incorporate them into the curriculum. Finally, we will demonstrate feasibility of the SCD-specific chronic pain curriculum we have created through extensive community engagement. While group interventions have demonstrated effectiveness in improving outcomes for other chronic diseases, they have not yet been studied in SCD. The use of peermediators is also novel in SCD. Once these relationships are better understood and the curriculum has been proven feasible, we can pilot the intervention and evaluate its impact on the experience of chronic pain and effective self-management of disease in adult patients with SCD.

INNOVATION

Previous research has begun to evaluate the relationship between experiences of racism, stigma, and chronic pain in SCD, yet significant gaps in our understanding of these interactions remain. Furthermore, the way that patients’ selfperception of race influences these experiences is also unclear. As the mental health literature demonstrates, one way to effectively fight stigma is through group interventions.

This evaluation of the IMPORT dataset will be the first analysis of the associations between experiences of stigma and self-efficacy at managing SCD. These data were collected from a large group of adult patients with SCD in a longitudinal cohort at two major institutions and demonstrate important interactions between SCD-related stigma, worsening pain, trust, and communication in healthcare.6 This innovative study was the first to specifically examine these factors in SCD and demonstrated a greater burden of race-based discrimination than was previously reported in other Black cohorts, indicating the unique barriers faced by patients with SCD. Additionally, the study validated a SCD-specific tool to evaluate stigma and collected data on ratings of self-efficacy. However, the relationship between these two factors has not yet been explored.

This project will be the first to look at how racial identity relates to experiences of stigma and discrimination and ratings of self-efficacy at managing SCD. The interaction between these factors have not been explored, particularly through a qualitative methodology. An improved understanding of these relationships, particularly in adult patients with SCD, will better inform our intervention to address the drivers of chronic pain and acute care utilization. Patients with SCD may experience both race-based discrimination and SCD-related stigma, both of which are influenced by a patient’s own racial identity. This will be the first peer-mediated intervention that specifically targets chronic pain in SCD. Group programs have documented efficacy in general chronic pain management, but this will be the first study to examine peer-led groups to improve self-efficacy in SCD. Ultimately, having an effective non-pharmacologic approach to chronic pain would be a ground-breaking intervention that addresses an outcome that patients have expressed is important to them. The intervention will be developed based on specific needs identified by the community of patients with SCD. Any treatment modality must address not only the physical manifestations and chronic pain, but also the patients’ psychosocial experiences of racism and stigma. Our proposed project is driven by strong interest from our patients with SCD based on preliminary data. We will build on the work accomplished during the first year of our CTR Pilot Project into this COBRE2 target project, to adapt the current chronic pain curriculum for use in SCD. The intervention will be led by peer leaders with SCD in collaboration with clinicians, representing a paradigm-shift in the approach to patient education and care delivery. By involving patients with SCD in community-engaged research to evaluate and adapt materials, the curriculum and peer leaders produced by this project will be unique. We will be the first research group to create an intervention that addresses how bias and discrimination affect health outcomes in SCD pain, led by the very patients who experience it. The relationship of these drivers, especially as they relate to chronic pain in SCD, will give patients a nonpharmacological treatment option and a new approach to hopeful self-care.

Dr. Guarino may be contacted at: stephanie.guarino@christianacare.org

Research reported in this publication was supported by the National Institute of General Medical Sciences of the National Institutes of Health under Award Number 5P20GM109022-07. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

REFERENCES

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2 Sil, S., Cohen, L. L., & Dampier, C. (2016, June). Psychosocial and functional outcomes in youth with chronic sickle cell pain. The Clinical Journal of Pain, 32(6), 527 533 https://doi.org/10.1097/AJP.0000000000000289

3. Lee, S., Vania, D. K., Bhor, M., Revicki, D., Abogunrin, S., & Sarri, G. (2020, July 7). Patient-reported outcomes and economic burden of adults with sickle cell disease in the United States: A systematic review. International Journal of General Medicine, 13, 361 377. https://doi.org/10.2147/IJGM.S257340

4 Adam, S. S., Telen, M. J., Jonassaint, C. R., de Castro, L. M., & Jonassaint, J. C. (2010, July). The relationship of opioid analgesia to quality of life in an adult sickle cell population. Health Outcomes Research in Medicine, 1(1), e29 e37. https://doi.org/10.1016/j.ehrm.2010.04.002

5 Sogutlu, A., Levenson, J. L., McClish, D. K., Rosef, S. D., & Smith, W. R. (2011, May-June). Somatic symptom burden in adults with sickle cell disease predicts pain, depression, anxiety, health care utilization, and quality of life: The PiSCES project. Psychosomatics, 52(3), 272 279 https://doi.org/10.1016/j.psym.2011.01.010

6. Bediako, S. M., Lanzkron, S., Diener-West, M., Onojobi, G., Beach, M. C., & Haywood, C., Jr. (2016, May). The measure of sickle cell stigma: Initial findings from the Improving Patient Outcomes through Respect and Trust study. Journal of Health Psychology, 21(5), 808 820. https://doi.org/10.1177/1359105314539530

7 Haywood, C., Lanzkron, S., Bediako, S., Strouse, J.J., Haythornthwaite, J., Carroll, C.P., …, & Beach, M.C. (2014, Dec). Perceived discrimination, patient trust, and adherence to medical recommendations among persons with sickle cell disease. J Gen Intern Med, 29(12) 1657-1662. doi: https://doi.org/10.1007/s11606-014-2986-7

8. Trawalter, S., Hoffman, K. M., & Waytz, A. (2012). Racial bias in perceptions of others’ pain. PLoS One, 7(11), e48546 https://doi.org/10.1371/journal.pone.0048546

9. Hoffman, K. M., Trawalter, S., Axt, J. R., & Oliver, M. N. (2016, April 19). Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proceedings of the National Academy of Sciences of the United States of America, 113(16), 4296 4301

https://doi.org/10.1073/pnas.1516047113

10 Sabin, J. A., & Greenwald, A. G. (2012, May). The influence of implicit bias on treatment recommendations for 4 common pediatric conditions: Pain, urinary tract infection, attention deficit hyperactivity disorder, and asthma. American Journal of Public Health, 102(5), 988 995. https://doi.org/10.2105/AJPH.2011.300621

11 Hausmann, L. R. M., Gao, S., Lee, E. S., & Kwoh, K. C. (2013, January). Racial disparities in the monitoring of patients on chronic opioid therapy. Pain, 154(1), 46 52 https://doi.org/10.1016/j.pain.2012.07.034

12. Bailey, Z. D., Krieger, N., Agénor, M., Graves, J., Linos, N., & Bassett, M. T. (2017, April 8). Structural racism and health inequities in the USA: Evidence and interventions. Lancet, 389(10077), 1453 1463 https://doi.org/10.1016/S0140-6736(17)30569-X

13. Trent, M., Dooley, D. G., Dougé, J., Cavanaugh, R. M., Lacroix, A. E., Fanburg, J., Wallace, S. B., (2019, August). The impact of racism on child and adolescent health. Pediatrics, 144(2), e20191765 https://doi.org/10.1542/peds.2019-1765

14. Power-Hays, A., & McGann, P. T. (2020, November 12). When actions speak louder than words – racism and sickle cell disease. The New England Journal of Medicine, 383(20), 1902 1903 https://doi.org/10.1056/NEJMp2022125

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16. Haywood, C., Jr., Diener-West, M., Strouse, J., Carroll, C. P., Bediako, S., Lanzkron, S., Beach, M. C., & the IMPORT Investigators, & the IMPORT Investigators. (2014, November). Perceived discrimination in health care is associated with a greater burden of pain in sickle cell disease. Journal of Pain and Symptom Management, 48(5), 934 943 https://doi.org/10.1016/j.jpainsymman.2014.02.002

17. Wakefield, E. O., Popp, J. M., Dale, L. P., Santanelli, J. P., Pantaleao, A., & Zempsky, W. T. (2017, February/March). Perceived racial bias and health-related stigma among youth with sickle cell disease. J Dev Behav Pediatr, 38(2), 129 134 https://doi.org/10.1097/DBP.0000000000000381

18. Reader, S. K., Rockman, L. M., Okonak, K. M., Ruppe, N. M., Keeler, C. N., & Kazak, A. E. (2020, June). Systematic review: Pain and emotional functioning in pediatric sickle cell disease. Journal of Clinical Psychology in Medical Settings, 27(2), 343 365. https://doi.org/10.1007/s10880-019-09647-x

19 Schomerus, G., Angermeyer, M. C., Baumeister, S. E., Stolzenburg, S., Link, B. G., & Phelan, J. C. (2016, February). An online intervention using information on the mental health-mental illness continuum to reduce stigma. Eur Psychiatry, 32, 21 27 https://doi.org/10.1016/j.eurpsy.2015.11.006

The DPH Bulletin

From the Delaware Division of Public Health

Public Health Alert Web portal provides COVID-19, monkeypox, and flu updates

To provide information about current public health issues of elevated concern, the Division of Public Health (DPH) launched a Public Health Alert web portal, de.gov/PublicHealthAlerts, on September 1.

The user-friendly central landing page provides access to the COVID-19, monkeypox, and flu web pages. COVID 19 information can still be found at de.gov/coronavirus, monkeypox information can still be found at de.gov/monkeypox, and flu information can still be found at flu.delaware.gov.

A new webpage to provide information about monkeypox was also unveiled at the same time. As of September 13, 34 cases of monkeypox were reported to DPH. The cases are among 33 men and one woman and range in age from 18 to 64 The Centers for Disease Control and Prevention reported 21,985 monkeypox cases in the U.S. as of September 12, with Maryland, Pennsylvania, New Jersey, and Washington, D.C. each having between 457 and 649 cases.

The JYENNOS vaccine, approved by the Food & Drug Administration for use against smallpox, is authorized for use with monkeypox in high risk and immunocompromised individuals. Nearly 1,000 individuals in Delaware had received one dose of the two-dose series as of September 13. Vaccine appointments can be scheduled at NewarkUrgentCare.org and beebehealthcare.org/online-scheduling. To schedule a vaccine appointment at a DPH clinic, call the monkeypox hotline at 866 408 1899. A screening evaluation will be conducted first.

Visit de.gov/monkeypox for vaccine eligibility requirements, vaccine clinic locations, a medical providers section, and flyers in English and Spanish.

For more information, call the monkeypox hotline at 866 408 1899 Monday through Friday from 8:30 a.m. to 4:30 p.m. or email questions to DPHCall@delaware.gov.

202

Bivalent COVID-19 booster vaccine now available in Delaware

Updated COVID 19 vaccine booster doses, called bivalent boosters, are now available to individuals who completed their primary vaccination series (two doses of Pfizer, Moderna or Novovax, or one dose of Johnson & Johnson) two months earlier. The Moderna and Pfizer bivalent boosters target two strains of COVID 19 the original strain of the virus and two of the Omicron variants (BA.4 and BA.5), the current most widespread variants in the world.

Individuals may choose either the Pfizer or Moderna bivalent booster, regardless of which primary series vaccine or original booster dose they had previously. The Pfizer bivalent booster is currently authorized for ages 12 and older; while Moderna’s is currently authorized for 18 years of age and older. With back to school and other group activities now occurring, DPH asks parents of children under age 12 to have their children complete the primary COVID 19 vaccine series and get the original monovalent booster to protect them. At a minimum, completing a child’s primary series now will make children eligible for the bivalent booster when it is approved for younger children

Since the Omicron variants are widely circulating, DPH encourages eligible Delawareans to get the bivalent boosters to protect against severe illness, hospitalization, and death.

Bivalent boosters are currently available at DPH clinics. Visit de.gov/getmyvaccine or vaccines.gov for other locations.

For more information, visit de.gov/boosters, email questions to DPHCall@delaware.gov, or call 866 408 1899 Monday through Friday from 8:30 a.m. to 4:30 p.m. Those who are deaf, hard of hearing, Deaf Blind or speech disabled can contact DPH by dialing 711 first using specialized devices (i.e. TTY, TeleBraille, voice devices).

DPH re-accredited as nationally accredited public health agency

The Division of Public Health (DPH) is among only 22 percent of the accredited public health departments in the country to earn continued accreditation this year. The national Public Health Accreditation Board (PHAB) reaccredited DPH on August 18. To maintain its accreditation status, DPH demonstrated that it meets PHAB’s quality standards and measures. The Centers for Disease Control and Prevention identifies accreditation as a critical strategy for strengthening public health infrastructure.

“After 2½ years of the COVID 19 pandemic, Delawareans have learned how important it is to have a strong public health response in our state,” said Delaware Department of Health and Social Services (DHSS) Secretary Molly Magarik. “I am grateful to the Public Health Accreditation Board for this re accreditation, but I am especially grateful to the employees of the Division of Public Health for the work they have done and continue to do during the pandemic, and the work they do every day to evolve, improve and advance the health of Delawareans. This is another way we are building a healthier and stronger Delaware.”

DPH Interim Director Dr. Rick Hong expressed gratitude to outgoing Associate Deputy Director Cassandra Codes Johnson and Office of Performance Management Director Matthew Whitman for their dedication and tireless work in spearheading the re-accreditation process. Additionally, he recognized the work of former DPH Director Dr. Karyl Rattay in building a strong foundation within the Division which led to DPH’s initial accreditation in June 2016. For more information, read the press release at https://www.dhss.delaware.gov/dhss/pressreleases/ 2016/dphaccreditation 060816.html

Refresh household emergency kits

Household emergency kits should be refreshed once or twice per year. Fall is a good time to undertake that task, beginning with canned goods.

PrepareDE.org recommends that kits have at least a three day supply of non perishable food and a can opener. As temperatures cool, stores typically offer sales on canned soup, tomato sauce, and canned meats. Pre Thanksgiving sales feature canned vegetables and evaporated and condensed milk. Every week, buy a few extra cans, reaching to the back of the store shelf for cans with the longest expiration dates. Pop top cans do not require a can opener. Put those cans aside, using a dedicated indoor shelf. Place items with the nearest expiration date at the front and use them first.

Begin your household emergency kit with the following items:

• One gallon of drinking water per person per day

• Food non perishable, three day supply

• Can opener, mess kits, paper cups, plates, paper towels, plastic utensils, and garbage bags

• Battery powered or hand crank radio, flashlight, battery powered lantern, extra batteries, heavy work gloves, and a whistle

• First aid kit and personal items, such as medications, glasses, dentures and cleaner, and hearing aids.

• Toilet paper, feminine supplies, and diapers

• Disinfecting wipes and disposable face masks

• Soap, shampoo, hand sanitizer, moist towelettes, toothbrush and toothpaste

• Cash because ATM machines may not work

• Cell phone power bank or car charger

• Copy of important documents in waterproof portable container or sealed Ziploc bags

• Recent photos of family members in waterproof portable container or sealed Ziploc bags

• For each person, a seasonally appropriate change of clothing and rain gear

• Fire extinguisher. Read the complete checklist at https://www.preparede.org/make a kit/

The Angle Measuring Tool uses visual, sound, and vibration cues to set an extension ladder at the proper angle. For the free app, visit the App Store, Google Play, or www.cdc.gov/niosh/topics/falls/mobileapp.html.

Preventing falls eliminates traumatic injuries, lost work, and health care costs

Falls can result in broken bones, head injuries, and temporary or permanent disabilities leading to major life changes for the individual and their families.

Governor John Carney and Lieutenant Governor Bethany Hall-Long have proclaimed September 18 24, 2022, as Falls Prevention Awareness Week

Falls are the leading cause of trauma related hospitalizations in U.S. adults aged 65 and older, with one in four in that age group falling every year, according to the Centers for Disease Control and Prevention (CDC). In 2021, 1,833 seniors over the age of 64 fell and were seen at a Delaware trauma center, according to the Delaware Trauma Registry.

The Delaware Coalition for Injury Prevention’s (DCIP) Falls Prevention Team recommends older adults reduce their risk of falling by engaging in consistent physical activity and balance exercises, getting regular hearing and vision exams, receiving appropriate nutrition and sleep, having medication reviews with their doctor or pharmacist, and keeping homes and yards clutter free, well lit, and modified as needed. In the community, ramps and walkways should be maintained and well-lit.

To improve coordination and balance, older Delawareans can enroll in A Matter of Balance© classes. For a schedule, call Volunteer Delaware 50+ at 302 515 3020. To schedule the fall prevention programs BingoCize and ThinkFirst to Prevent Falls©, send an email to Christiana Care at injuryprevention@christianacare.org For free family and provider resources, visit the CDC at https://www.cdc.gov/steadi/index.html

Household upgrades can reduce falls

Making small household upgrades can benefit all household members, especially seniors and those at risk of falling. Use these suggestions:

• Change faucets and doorknobs to levers, which individuals with arthritis or less dexterity can grasp more easily.

• Make flooring transitions seamless by eliminating door thresholds. Flush entryways accommodate those with mobility challenges.

• Remove unnecessary furniture, rugs, and clutter to widen walkable corridors and lessen the risk of falling.

• Install grab rails and supports in showers, near toilets, and close to kitchen seating. Hire a professional to install grab bars properly.

• Use smart lighting that is activated by motion or darkness. Rocker light switches are easier to push than smaller toggle switches.

• Install a stair lift for individuals with fall risks who are advised not to use stairs.

Falls Prevention Team hosts free movie and health fair September 20

On September 20, the Falls Prevention Team and the Modern Maturity Center (MMC) will show the movie “Denying Gravity.” The movie highlights in a relatable, good humored approach the benefits of fall prevention activities for seniors. A small health fair with information on preventing falls precedes the movie.

The entire event is free and open to the public and runs from 11:00 a.m. to 1:00 p.m. at the MMC, located at 1121 Forrest Avenue in Dover, Delaware. Registration is not required. Should movie goers choose to stay for lunch in the Longwood Dining Room, the cost is $6 for ages 60+ and $9 for ages 59 and younger. Visit www.modern maturity.org for more information.

From the Delaware Division of Public Health

It’s time to get your 2022 flu vaccine

The 2022-23 influenza season begins October 3, 2022. The Division of Public Health (DPH) reminds Delawareans 6 months of age and older to get their annual flu vaccine for protection against flu illness, hospitalization, and death. Being vaccinated protects you and those at risk of flu complications

Those at higher risk of becoming ill from the flu should closely manage their health Individuals at higher risk are children younger than 5 years old (especially children younger than 2 years), adults 65 years and older, pregnant people, and those with chronic underlying medical conditions. Chronic conditions include asthma, Chronic Obstructive Pulmonary Disease and other lung diseases, heart disease, diabetes, neurologic conditions, blood disorders, obesity, and weakened immune systems

DPH urges flu vaccinations for those who live or work with infants under 6 months of age and those who live or work in congregant settings such as long term care and correctional facilities.

For more information about flu, visit flu.delaware.gov and cdc.gov/flu, or call 1-800-282-8672 for the difference between cold and flu.

Get your flu vaccine every year.

• Avoid close contact with sick people.

• Cover coughs and sneezes with a tissue, or cough or sneeze into your inner elbow.

• Wash hands often with soap and water for 20 seconds or use hand sanitizer.

• Do not touch your eyes, nose, and mouth.

• Clean and disinfect frequently touched surfaces.

• If sick with flu like illness, stay home for 24 hours until fever free (temperature less than 100 degrees Fahrenheit) without fever reducing medication If symptoms worsen, call your doctor.

Stay well to help our health care system

Delawareans who are vaccinated against the flu reduce the burden of flu illness on health care providers, emergency departments, and hospitals. They avoid unnecessary sick visits to providers, trips to the emergency department, and hospitalizations due to flu. Providers can concentrate on assisting the sick and keeping healthy individuals well. Hospitals beds can be for those needing them most.

Flu vaccines are available to the public from health care provider offices, pharmacies (including grocery store pharmacies), DPH clinics, health centers, urgent care clinics, and community vaccination events Many employers and schools offer the flu vaccine on site. Visit flu delaware.gov for locations.

The flu vaccine is free to most Delawareans, even if you do not have insurance. Individuals without insurance or covered by Medicaid or Medicare may receive vaccines for flu and COVID 19 at Public Health clinics and community vaccination events. Flu vaccines may be given at the same time as other vaccines, including the COVID 19 and monkeypox vaccines. Discuss concerns with your health care provider. For more information about flu vaccines in Delaware, visit flu.delaware.gov or call 1-800-282-8672.

Visit the CDC at www.vaccines.gov/

The Centers for Disease Control and Prevention now recommend that adults 65 years and older get higher dose or adjuvanted flu vaccines over standard dose unadjuvanted flu vaccines. Visit https://www.cdc.gov/flu/highrisk/65over.htm.

The Fight to Dismantle Systemic Racism and for Racial Justice in Delaware As Seen Through the Eyes of the Delaware Racial Justice Collaborative

ABSTRACT

George Floyd’s May 2020 murder ignited a racial reckoning and social justice movement nationally and locally. Awareness of present-day racism increased even as racial disparities widened across health, wealth, education, and other social determinants. The Delaware Racial Justice Collaborative (DRJC) responded to the moment as membership surged and antiracist efforts expanded. The DRJC, powered by the United Way of Delaware, is committed to addressing structural racism by organizing volunteers across seven impact areas. Health Equity is one of the seven established committees and focuses on health inequities in Delaware. The DRJC has also supported the creation of the Equity Counts Data Center in partnership with the Delaware Division of Public Health. The fight for racial justice continues two and a half years after George Floyd’s life was taken, and we need you to #JoinTheMovement.

During the evening of May 25, 2020, a father of five purchased cigarettes from a local convenience store. The store clerk suspected a counterfeit bill was used in the transaction and called the police, who quickly responded. What happened next captured the attention of Americans across the country and insighted rage and a reckoning on race. This outpouring of emotion sparked what was arguably the largest protest movement in United States history.

George Floyd was immobilized by a Minneapolis police officer who held his knee on Floyd’s neck for more than nine minutes, completely blocking his ability to breathe. Following Floyd’s death, millions of Americans in shock and anguish mobilized to join the fight for racial justice. Across the country and in Delaware, people gathered in the streets of their local communities. They protested police violence and the unequal treatment of Black people chanting Black Lives Matter! - a seemingly simple and obvious statement with profound political significance. That movement in 2020 awakened those who thought racism was dead, didn’t believe it existed, or had been willing to ignore it. The movement was a strong demonstration of Americans’ willingness to reckon with systemic and institutional racism.

The reckoning for which many Americans had protested did not seem to translate into tangible changes for people of color. According to a Pew Research Center survey conducted in October 2021, 65% of the almost 4,000 Black Americans surveyed said the increased national attention on racial inequality did not lead to changes that improved their lives.1 Additionally, almost 70% said discrimination was the main reason many Black people cannot get ahead.1 Amidst a backlash against racial progress,2,3 there is still a great amount of work to be done to move the needle around racial justice.

Further compounding barriers for Blacks in America was the experience of the recent health crisis. The COVID-19 pandemic disproportionately affected Black households.4 Job losses were greater,5 education gaps widened,6 and life expectancy decreased.7 A disproportionate number of Black Americans were “essential workers,” and were at higher risk to contract the disease while working longer, in-person hours in lower wage jobs.8 Black Americans saw a 3-year decline in life expectancy from 2019 to 2020 resulting in a life expectancy gap between White and Black populations that hasn’t been as large since 1999.7 These setbacks for African American households have hindered the march toward racial equity.

Dismantling institutional and systemic racism is a laborious and unrelenting process that requires time and attention. Great national public awareness, education, and debates are all necessary in advancing the cause but are not sufficient. What happens in the streets with a loud microphone and on social media needs to be matched behind the scenes with dedicated people focused on identifying the policies and procedures that inhibit people of color and replacing them with those that are more equitable.

In Dr. Ibram X. Kendi’s, “How to be an Antiracist,” he argues that racism is not a fixed part of a person’s identity.9 Further, he asserts that “a racist policy is any measure that produces or sustains racial inequity between racial groups.”9 An antiracist works to locate the roots of problems in power and policies,9 according to Kendi. It is within this antiracist framework that the Delaware Racial Justice Collaborative (DRJC) provides a safe space and platform for communities throughout Delaware to dissect and redress institutional policies and procedures related to racial justice.

The DRJC has been engaged in this fight since its inception in 2015. In its early days, this small but mighty collection of civic

leaders and volunteers kept a laser-like focus on diversity, equity, and inclusion in State government employment. On the heels of the national racial reckoning and Black Lives Matter movement, the DRJC received requests from hundreds of new volunteers to join. People from across the state wanted to actively engage in the fight against racism in Delaware.

The groundswell of new members led the United Way of Delaware to fully embrace the DRJC. It has been, since 2020, officially powered by the United Way of Delaware, providing administrative support to expand its capacity. Today, the DRJC is comprised of more than 200 individuals and organizations working in committees to uncover, repeal, and restructure policies and practices that negatively impact people of color. The work is organized around seven impact areas: health equity, wealth creation, public policy, education, criminal justice, youth advancement, and Diversity, Equity & Inclusion (DEI). They function in teams where “agents of change” from the grassroots to the grasstops join forces and work together to drive change.

The DRJC is proud of recent policy victories that chip away at inequities in Delaware and contribute to progress. Through its Public Policy committee, the DRJC successfully advocated alongside other community groups and advocates for legislative remedies to several racial inequities. In the last two years, the DRJC has successfully advocated for HB 195 (signed 7/21/21), requiring body worn cameras for police and other law enforcement officials. HB 198 (signed 6/17/2021), requires K-12 public and charter schools to incorporate Black history and the Black experience into K-12 curricula. HB 375 (signed 8/30/22), creates the Delaware Racial Equity Consortium. The Consortium, housed at Delaware State University, brings the African American task force into Delaware Code with the power and governing authority needed to act on the task force recommendations. It also guarantees a longer-term investment by the State of Delaware to remedy the systemic injustice that African Americans have experienced. The DRJC is actively tracking the implementation of these bills.

The DRJC’s Health Equity committee is also gaining traction. It is comprised of providers, health professionals working in the field, advocates, and other interested parties. The committee meets monthly to discuss myriad factors contributing to inequities in health care, including access to medical care, the social determinants of health, and the structural features of the health system in Delaware. Inequities in health care create unequal health outcomes. To illustrate, infant mortality in Delaware is higher than the national average, and black infant mortality rate is more than two and a half times as high as the white rate of infant deaths.10 The Delaware Department of Health and Social Services (DHSS) acknowledges that “growing research points to intentional work addressing institutional and structural racism policies as the way to close the mortality gap in African American babies and moms and change the trajectory for future generations.”10

The Health Equity committee is working to address the lack of awareness of medical professionals of color and attracting and retaining doctors of color to Delaware. The need for culturally competent care was demonstrated in a Pew Research Center survey.11 It found, “when asked to consider potential factors

responsible for differences in health outcomes for Black people, 63% of Black adults view less access to quality medical care in the area they live to be a major reason why Black people in the U.S. generally have worse health outcomes than other adults.”11 To this end, the DRJC and the National Medical Association, First State Society, partnered to create a new online Black Doctors in Delaware directory to be launched in October 2022. To follow in the longer term are Delaware directories for Black Mental Health Professionals, Latino/Hispanic Doctors, and for other Doctors of Color (other races and ethnicities).

The Health Equity committee has also recently been using its advocacy voice. During the Delaware General Assembly’s most recent session, a DRJC member and practicing physician offered public comment in support of increased funding for the State Division of Public Health’s (DPH) Bureau on Health Equity during the Joint Finance (JF) Committee’s FY 2023 hearing. The State’s annual budget for the Bureau is $45,000, making Delaware the smallest state-based health equity team of surrounding states including Pennsylvania, Maryland, New Jersey, New York, and Rhode Island. This committee recommended a significant increase in funds to support community driven initiatives to address the social determinants of health10 with the understanding that the funding was necessary but not sufficient and more investment is needed to have a systemic impact.

Further demonstrating its commitment to eliminate racial disparities and health inequities, the DRJC and the Delaware Division of Public Health (DPH), have created the new Equity Counts Data Center (ECDC). Located on DPH’s “My Healthy Community” platform, Equity Counts is designed to provide access to data and resources that acknowledge structural racism as a root cause of inequities. According to Boston University’s Antiracism center, “[t]he study of data concerning inequities and disparities allow us to better understand experiences of racism and to see more clearly how and where racism manifests.”12 By understanding where racism is occurring and how it manifests, “we can then identify racist policies so that we can craft antiracist policies.”12 The ECDC displays data across Delaware by Zip-code, race, ethnicity, and age based on the DRJC inspired “equity pillars” of health, criminal justice, wealth creation, and education.

It is vital to acknowledge and measure the disparities that exist. Data are required. Groups passionate about change are encouraged to better utilize data to measure, analyze and remedy the disparities and inequities across our society. Those who would like to learn more about Equity Counts and how to power up their work at the intersections of equity and data are asked to contact Emily Kauffman, Equity Counts manager, at ekauffman@uwde.org

The DRJC is committed to the fight for racial justice and is grateful for wide-ranging community support. Throughout U.S. history, many of those who fought for freedom and equality were not able to enjoy the fruits of their labor during their lifetimes. We celebrate that some progress has been made, but the work is far from complete. Achieving a fully free and emancipated society is achieved through hard work each day by everyday citizens. The DRJC urges you to join us. Visit uwde.org/drjc to learn more and join the movement!

1. Cox, K., & Edwards, K. (2022, Aug 30). Black Americans have a clear vision for reducing racism, but little hope it will happen. Pew Research Center Race & Ethnicity. https://www.pewresearch.org/race-ethnicity/2022/08/30/blackamericans-have- a-clear-vision-for-reducing-racism-but-little-hope-itwill-happen/

2. Glickman, L. (2020, May 22). How white backlash controls American progress. The Atlantic. https://www.theatlantic.com/ideas/archive/2020/05/white-backlashnothing- new/611914/

3. Jefferson, H., & Ray, V. (2022, Jan 6). White backlash is a type of racial reckoning, too. FiveThirtyEight. https://fivethirtyeight.com/features/white-backlash-is-a-type-of- racialreckoning-too/

4. Monte, L. M., & Perez-Lopez, D. J. (2022, Apr 12). How the pandemic affected black and white households. Census.gov https://www.census.gov/library/stories/2021/07/how- pandemicaffected-black-and-white-households.html

5. Groeger, L. V. (2020, Jul 20). What coronavirus job losses reveal about racism in America. ProPublica. https://projects.propublica.org/coronavirus-unemployment/

6. Goldhaber, D., Kane, T., McEachin, A., Morton, E., Patterson, T., & Staiger, D. (2022). The consequences of remote and hybrid instruction during the pandemic. National Bureau of Economic Research. https://doi.org/10.3386/w30010

7 Arias, E., Tejada-Vera, B., Ahmad, F., & Kochanek, K. D. (2021, Jul). Vital statistics rapid release - provisional life expectancy estimates for 2020. National Vital Statistics System (NVSS). https://www.cdc.gov/nchs/data/vsrr/vsrr015-508.pdf

8. Gould, E., & Shierholz, H. (2020, Mar 19). Not everybody can work from home: black and hispanic workers are much less likely to be able to telework. Economic Policy Institute. https://www.epi.org/blog/black-and-hispanic-workers-are-much-lesslikely-to- be-able-to-work-from-home/

9 Kendi, I. X. (2019). How to Be an Antiracist. One World.

10. Rattay, K. T. (2022, Feb 22). Fiscal year (FY) 2023 Governor’s recommended budget [Lecture notes]. Delaware Health and Social Services.

https://www.dhss.delaware.gov/dhss/files/dphremarks2023.pdf

11 Funk, C. (2022, Aug 24). Black Americans’ views of and engagement with science. Pew Research Center Science & Society.

https://www.pewresearch.org/science/2022/04/07/black-americansviews-of-and- engagement-with-science/

12. Center for Antiracist Research. (2022, Jun). Toward evidencebased antiracist policymaking: problems and proposals for better racial data collection and reporting.

https://www.bu.edu/antiracism-center/policy/policy-reports/towardevidence-based- antiracist-policymaking/

The Migrant Crisis and Access to Health Care

However, there is no internationally accepted legal definition of a migrant. Most agencies and organizations define migrants as people staying outside their country of origin, who are not asylum-seekers or refugees.

Most people in the world have had to leave the place where they were born or grew up. Some people move as far as the next town or city. Other people will need to leave for more pressing reasons–sometimes for a short time, but sometimes permanently. More often than what we know, millions of people make one of the most difficult decisions in their lives: to leave their homes and loved ones looking for a better life, to seek a new job, higher wages or seek better education. Unfortunately, many people are forced to flee their country to escape prosecution or human rights violations such as torture. Other people are forced to leave their hometowns because they no longer feel safe, for being targeted because of who they are, personal choices, or different beliefs (ethnicity, religion, sexuality and/or political opinions, etc.).

However, these journeys in hope for a better life are not always safe, and can be full of traumatizing experiences, danger and fear. Some people risk falling prey to some form of exploitation, such as human and drug trafficking.

In the event they legally settle in their new community, many migrants face challenges of being accepted by new host communities, disrupting communal integration, and harmonious living. They face barriers based upon their cultural practices, religious beliefs, language, discrimination and racism.

As a result of their migration, people lose their support networks. Like an invisible “force field,” support networks are the people who surround and share your life—that you can turn to for encouragement, support and personal growth. Having a good support network is a vital tool in maintaining wellbeing—and most times something that we are so used to that we take them for granted. Losing this network can lead to people ending up feeling alone and isolated, or victims of depression, anxiety and substance abuse.

ARE ALL IMMIGRANTS THE SAME?

The terms migrant, refugee, and asylum seeker are often used interchangeably, but it is important to distinguish between them as there is a legal difference.

Migrants can return home if they wish, unlike refugees or asylum seekers who cannot safely return home. This distinction is important for governments, since countries handle migrants under their own immigration laws and processes.

The main difference is choice. Simply speaking, a migrant is someone who chooses to move, and a refugee or an asylum seeker is someone who has been forced from their home.

Some migrants leave their country because they want to work, seek better wages, study or join family, for example. Others feel they must leave because of poverty, natural disasters, political unrest, gang violence or other serious circumstances that exist in their home country.

Refugees are people who have fled war, violence, conflict, or persecution and have crossed an international border to find safety in another country. The risks to their safety and life were so great that they felt they had no choice but to leave and seek safety outside their country because their own government cannot or will not protect them from those dangers. Refugees have a right to international protection.

An asylum-seeker is a person who has fled their home in search of safety and protection in another country. Because he or she cannot obtain protection in their home country, they seek it elsewhere. Asylum seekers have left their country and are seeking protection from persecution and serious human rights violations. They have not yet been legally recognized as a refugee and are waiting to receive a decision on their asylum claim. Seeking asylum is a human right. Therefore, anyone is allowed to enter another country to seek asylum.

Many of those crossing the U.S. border from Central American countries—El Salvador, Guatemala and Honduras—are in fact asylum seekers, not migrants. They have a well-founded fear of persecution if they were to return home.

It is important to understand that just because migrants do not flee persecution, they are still entitled to have all their human rights protected and respected, regardless of the status they have in the country they moved to. Governments must protect all migrants from racist and xenophobic violence, exploitation and forced labor. Migrants cannot be detained or forced to return to their countries without a legitimate reason.

Refugees and asylum seekers are employment eligible and are authorized to work indefinitely because their immigration status does not expire.

The other important category refers to undocumented immigrants, who are foreign-born individuals residing in the U.S. without authorization. This group includes individuals who entered the country without authorization and individuals who entered the country lawfully and stayed after their visa or status expired.

The United States government processes migrants through the United States’ Customs and Border Protection (CBP) agency.1

Founded on May 28, 1924, the United States Border Patrol is a federal law enforcement agency under the United States’ Customs and Border Protection and is responsible for securing the borders of the United States.

DOI: 10.32481/djph.2022.10.006

“It is a great satisfaction to do something for ourselves, but it is a privilege, an honor and a much greater satisfaction to do something meaningful for someone else in need”

In the last year, U.S. Customs and Border Protection logged more than 2.3 million illegal border crossings. This has led to not only a humanitarian crisis, but also a dire security breakdown. We have our border patrol agents spending most of their time processing and helping immigrants settle instead of patrolling the border. This creates a gateway for dangerous drugs and criminals to enter our country: in the past year, CBP has seized more than 645,000 pounds of illegal drugs, including nearly 13,600 pounds of the deadly synthetic opioid fentanyl.1

ACCESS TO HEALTH CARE IS NOT A PRIVILEGE BUT A HUMAN RIGHT

Like any US citizen, migrants will require access to health care. The countries most current migrants come from, along with the living circumstances they were facing in their home country, puts them at a higher risk of a suboptimal health status. Chronic conditions like diabetes, high blood pressure, heart disease, and malnutrition are prevalent among migrants. In addition, their current situation puts them at higher risk of mental health illnesses, such as depression, anxiety, post-traumatic stress disorder and substance abuse.

Undocumented immigrants are not eligible for federally funded public health insurance programs, including Medicare, Medicaid and the Children’s Health Insurance Program (CHIP).

To care for the lower income residents, including undocumented immigrants, the U.S. relies on a patchwork system of safety-net providers, including public and not-for-profit hospitals, federally qualified community health centers (FQHCs), and migrant health centers.

The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (“PRWORA”) states that only “qualified aliens” are allowed access to federal and state public benefits, including Medicaid. A qualified alien is one who falls into one of the following categories2:

• Lawful permanent resident (LPR or green card holder);

• Refugee;

• Asylee;

• Cuban/Haitian entrant;

• Paroled into the U.S. for at least one year;

• Conditional entrant granted before 1980;

• Granted withholding of deportation;

• Battered noncitizen, spouse, child, or parent;

• Victims of trafficking and his/her spouse, child, sibling, or parent or individuals with pending application for a victim of trafficking visa;

• Member of a federally recognized Indian tribe or American Indian born in Canada; and

• Citizens of the Marshall Islands, Micronesia, and Palau who are living in one of the U.S. states or territories (referred to as Compact of Free Association or COFA migrants).

Effective December 27, 2020, COFA migrants are considered “qualified noncitizens” and are eligible for Medicaid, if they meet all of the eligibility criteria for their state.

Other lawfully Present Immigrants:

• Granted Withholding of Deportation or Withholding of Removal, under the immigration laws or under the Convention against Torture (CAT);

• Individual with Non-Immigrant Status, includes worker visas, student visas, U-visa, and other visas, and citizens of Micronesia, the Marshall Islands, and Palau;

• Temporary Protected Status (TPS);

• Deferred Enforced Departure (DED);

• Deferred Action Status, except for Deferred Action for Childhood Arrivals (DACA) who are not eligible for health insurance options;

• Lawful Temporary Resident;

• Administrative order staying removal issued by the Department of Homeland Security;

• Resident of American Samoa;

• Applicants for certain statuses; and

• People with certain statuses who have employment authorization.

Undocumented immigrants are considered “non-qualified aliens,” and therefore can only receive limited federal and state public benefits. Undocumented immigrants may be eligible for “Emergency Medicaid” benefits for services needed for the treatment of an emergency medical condition (excluding organ transplants). They still need to meet all other general Medicaid requirements except those related to immigration status.

An emergency medical condition is defined at §1903(v)(3) of the Social Security Act (“SSA”)3 as a medical condition (including emergency labor and delivery) manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in:

• (1) placing the patient’s health in serious jeopardy,

• (2) serious impairment to bodily functions, or

• (3) serious dysfunction of any bodily organ or part. Although the PRWORA severely limits what public benefits a state can provide to non-qualified aliens, it allows states to provide additional state funded benefits if state laws enacted after August 22, 1996 affirmatively provide for such eligibility.

There is also a federal rule requiring that the condition must have had a “sudden onset,” however, the Medicaid Act does not contain this language. There is no definitive rule on when an emergency condition ends for the purposes of cutting off emergency Medicaid. In addition, what defines “acute” or “sudden onset” can be misleading as well. A person can have a chronic condition, but in the absence of treatment can result in either placing the patient’s health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of a bodily organ or part.

In addition, in 1986 the Congress enacted the Emergency Medical Treatment and Active Labor Act (EMTALA) as part of the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) (Pub. L. 99-272).4 This law prevents hospitals that participate in the Medicare program from denying care to

unstable patients that could not afford to pay for their care. It requires hospitals covered by the law to provide patients with an emergency medical condition with “an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition (EMC) exists.”

In Delaware, neither legally residing noncitizens nor illegally/ undocumented residing immigrants are eligible for full Medicaid coverage, but remain eligible for emergency services and labor and delivery only.5

To be eligible for Emergency Medicaid, the individual must meet all eligibility requirements for a specific Medicaid eligibility group. The individual does NOT have to meet the requirement concerning a declaration of satisfactory immigration status and verification of that status.6

Delaware Medical Assistance Program (DMAP) defines an emergency as:

• a sudden serious medical situation that is life threatening; OR

• a severe acute illness or accidental injury that demands immediate medical attention or surgical attention; AND

• without the treatment a person’s life could be threatened or the person could suffer serious longlasting disability.7

Medically necessary physician (surgeon, pathologist, anesthesiologist, emergency room physician, internist, etc.) or midwife services rendered during an emergency service that meets the above criteria are covered. Ancillary services (laboratory, x-rays, pharmacy, etc.) rendered during an emergency service that meets the above criteria are also covered. Emergency ambulance services to transport these individuals to and from the services defined above are also covered.

The following services are not covered8:

• Any service delivered in a setting other than an acute care hospital emergency room or an acute care inpatient hospital. The only exception is that labor and delivery services may be rendered in a birthing center.

• Any service (such as pharmacy, transportation, office visit, lab or x-ray, home health) that precedes or is subsequent to a covered emergency service. The only exception is that ambulance transportation that is directly related to the emergency is covered

• Organ transplants

• Long term care or rehabilitation

• Routine prenatal and post-partum care Unfortunately, many lawfully present immigrants who are eligible for coverage remain uninsured because immigrant families face a range of enrollment barriers, including fear, confusion about eligibility policies, difficulty navigating the enrollment process, and language and literacy challenges.

In addition to their own health risks, migrants are at risk of:

• Health disparities: this can lead to suboptimal care and poorer health outcomes, when compared to the medical care other groups in the same community receive.

• Inequities: refers to differences which are unnecessary, avoidable and are considered unfair and unjust. Health equity is the absence of systematic disparities in health between groups with different levels of underlying social advantage/disadvantage, related to economic status, positions of power or prestige.

• Different Social Determinants of Health (SDOH): refer to environmental conditions where people live, study, work, worship that affect a wide range of health conditions, care for the conditions and outcomes.

HOW IS HEALTH EQUITY ACHIEVED?

According to the CDC, Health equity is achieved when every person has the opportunity to “attain his or her full health potential” and no one is “disadvantaged from achieving this potential because of social position or other socially determined circumstances.”9

The COVID-19 pandemic has contributed to increased health, social and financial needs and declines in health coverage among the immigrant population. Immigrants’ work (such as crowded spaces), living (such as sharing housing), and transportation situations put them at increased risk for potential exposure to coronavirus. Noncitizen immigrants also faced risk of financial difficulties due to the pandemic, as many work in service industries, such as restaurants, poultry farms and food services, that suffered cutbacks during the early phases of the pandemic. At the same time, immigrants have had more limited access to COVID-19 financial relief. Immigration-related fears may have contributed to reluctance accessing COVID-19 vaccines.

HOW IS THE GOVERNMENT ADDRESSING THIS PROBLEM?

Recent federal and state activity has focused on expanding access to health care for immigrants. At the federal level, legislation has been proposed that would expand eligibility for health coverage for immigrants.

Some states take up federal options to expand Medicaid and CHIP coverage for lawfully present immigrant children and pregnant women. In addition, several states have recently proposed or taken action to expand state-funded coverage to low-income people regardless of immigration status.

The Biden-Harris Administration has proposed new public rules in an attempt to help reduce fears among immigrants and encourage them to participate in non-cash assistance programs, including health coverage. Funding for Navigator programs has been increased, which provides enrollment assistance to individuals. However, even with these actions, it will likely take time and sustained efforts to rebuild trust and reduce fears about the use of services among immigrant families.

The Administration has also increased funding for outreach and enrollment assistance, which may help eligible immigrant families enroll and stay enrolled in coverage, including

awarding CMS $80 million in funding for 60 Navigator programs in 30 states with Federally-Facilitated Marketplaces for the 2022 plan year.

Navigator programs must provide information that is culturally and linguistically appropriate, and can assist individuals with renewing Medicaid coverage and help those who are no longer eligible for Medicaid transition to coverage through the marketplaces. This assistance may be particularly important for helping immigrant families enroll in and maintain coverage given the complex eligibility requirements for immigrants and potential linguistic barriers and fears of negative immigration consequences.

In 2021, the Health Equity and Access Under the Law (HEAL) Act10 and Lifting Immigrant Families Through Benefits Access Restoration Act (LIFT the BAR) Act11 were introduced into Congress. The intention is to remove the five-year waiting period for health coverage and other assistance programs that currently apply to many lawfully present immigrants under the 1996 PRORWA rules. These acts would expand the definition of lawfully present immigrants to include Deferred Action for Childhood Arrivals (DACA) recipients and certain other immigrants who are authorized to be in the U.S., so that they could qualify for federally funded health care programs. In addition, the HEAL Act would allow undocumented immigrants to access health insurance coverage through the ACA Marketplaces and to be eligible for subsidies to offset the cost of this coverage. Both acts also would ensure that lawfully present immigrants with incomes below 100% Federal Poverty Level (FPL) may receive subsidies if they are ineligible for Medicaid based on immigration status if they live in a state that has not expanded Medicaid.

Several states have proposed or taken action to expand coverage for immigrant children and pregnant individuals. Currently, six states (California, Washington, DC, New York, Oregon and Washington state) provide comprehensive statefunded coverage to all income-eligible children, regardless of immigration status.

The American Rescue Plan Act12 gives states the option to extend Medicaid postpartum coverage from 60 days to 12 months beginning in April 2022. Five states—California, Connecticut, Massachusetts, Minnesota, and Washington—that are planning to take up this option will also extend the coverage to postpartum individuals who are not eligible due to immigration status. California13 and Illinois14 recently implemented 12 months postpartum coverage regardless of immigration status through CHIP Health Services Initiatives amendments.

Some states are also taking action to expand fully state-funded coverage to adult immigrants. California Governor Gavin Newsom’s 2022-2023 proposed budget would provide fully state-funded Medicaid coverage to all income-eligible adults, ages 26 to 49, regardless of immigration status, no sooner than January 1, 2024. The state previously extended state-funded Medicaid coverage to young adults ages 19-26 regardless of immigration status, and adults ages 50 and older will become eligible on May 1, 2022.

As of July 1st, 2022, In Oregon, the Cover All People Act (now known as “Healthier Oregon”), extends state-funded coverage to all low-income adults who are not eligible due

to immigration status.15 Prior to this recent state activity, only the District of Columbia’s locally-funded Healthcare Alliance program, created in 1999, provided health coverage to low-income residents regardless of immigration status.16 States can also provide state-funded premium subsidies to immigrants who are ineligible for federal premium subsidies in the Marketplace due to their immigration status. In Colorado, beginning in 2023, state residents with income up to 300% FPL who do not qualify for health insurance under the Affordable Care Act or other public programs because of their immigration status will be eligible for state-funded premium subsidies to assist them in purchasing individual coverage.17

The Biden-Harris Administration has proposed changes to public charge policies that are intended to reduce fears of enrolling in health coverage and accessing care. As noted, after taking office, the Administration reversed public charge policies implemented by the Trump Administration that had made some immigrant families more reluctant to access health coverage and care for themselves and their children.

The Biden-Harris Administration’s changes to public charge policy and increased funding for outreach and enrollment assistance may help increase access to health coverage for immigrant families. However, no matter what the government efforts are, they will not reach maximum success unless we put efforts to rebuild trust and reduce fears in the migrant community.

IS THERE A SOLUTION ON THE HORIZON?

The short-term solution to the migrant crisis and access to health care will entirely rest on the hands of the federal and local governments. The immigrant people are not the problem. Rather, the causes that drive families and individuals to cross borders and the short-sighted and unrealistic ways that politicians respond to them are the problem. The crisis situation is not the number of migrants seeking protection, but the government system’s failure to respond in an orderly way.

The cost of not providing health care to immigrants is big, but not as bad as many think. A study by Fernando A. Wilson et al in 2020 showed that the annual expenditures per person were $1629 for unauthorized immigrants and $3795 for authorized immigrants compared with $6088 for US-born individuals.18

In a recent publication by Steven A. Camarota et al on October 10, 2019, it was estimated that allowing uninsured, low-income illegal immigrants access to Federally funded programs would likely cost taxpayers around $10 billion per year, assuming many chose not to enroll, with costs potentially rising as high as $23 billion.19

As of today, the majority of the healthcare to be provided to migrants will rest on the hands of safety-net providers, including public and not-for-profit hospitals, federally qualified community health centers (FQHCs), and migrant health centers.

Federally Qualified Health Centers (FQHCs)

FQHCs play a pivotal role in the short-term solution.

Jack Geiger and Count D. Gibson Jr. pioneered the founding of the first two health centers in the nation at Columbia Point, Dorchester MA, and Mound Bayou, Mississippi, launching a movement in urban and rural areas across the country in 1965.

Delaware’s three health centers—La Red Health Center (mostly serving Sussex County), Henrietta Johnson Health Center and Westside Health Center (both serving mostly New Castle county)—operate 14 sites across the state and provide care for vulnerable patient populations, many of whom have no other options for care. Community Health Centers provide comprehensive services including primary care, dental services, behavioral health care, prenatal services, substance abuse treatment, STD counseling and education and pharmacy.

Since its inception over twenty years ago, La Red Health Center has served an estimated 20,000 unduplicated Hispanic patients. The Center currently provides prenatal services to over 500 Hispanic women every year. La Red Health Center has implemented the nationally recognized evidence-based Navigator outreach program, “The Promotoras,” that has built a defacto support network and through culturally sensitive outreach services, has earned the trust of the local immigrant population. All these efforts are some unique examples of what FQHCs can do to improve the health of an underserved population.

By mission and design, FQHCs exist to serve those who have limited access to healthcare, although all are welcome. We take pride on serving populations that may otherwise find barriers to healthcare in other medical practices.

FQHCs help improve the quality of life for millions of their underserved patients, including immigrants. Their preventative care is cost efficient and allows many patients to have access to affordable immunizations, mammograms, Pap smears, health education, and other preventative services.

FQHCs deliver culturally competent, comprehensive primary care. Thanks to Federal financial support, FQHCs have the ability to provide additional supportive services such as health education, case management, translation, and transportation that promote access to care and break barriers migrants face, that otherwise would result in poor health outcomes.

This makes immigrants a logical population to be served by FQHCs. There are several challenges that FQHCs might face when delivering charitable healthcare to immigrant populations. Some examples of these challenges include sensitivity to cultural norms, trouble securing financial support, promoting a safe environment, community and patient rejection and lack of financial resources to address more expensive medically necessary procedures or invasive interventions, such as surgeries, dialysis, organ transplants, etc.

Staff members that work in a FQHC are, by the nature of their daily job and training, culturally sensitive and trained to interact in the world of cultural diversity. Therefore, FQHCs are more open to accommodate and understand different cultural norms pertinent to their immigrant population.

People in the community might have different levels of acceptance to the FQHCs attending to the needs of migrants. FQHCs must be prepared to be celebrated or rejected because of this service.

During times of heightened political sensitivity around immigration issues, a FQHC must create an environment that is “safe” for those whose immigration status is questionable. FQHCs must be diligent in reassuring patients and immigrant communities that they will be safe in seeking service from their facilities. Any FQHC that serves an immigrant population should have protocols in place on how to respond should immigration official appear at the clinic to check credentials. Remember – it is difficult to build trust, but very easy to lose it.

Culturally sensitive health care will help bring about positive health outcomes for diverse populations. It can help narrow the gap in health care outcomes and promotes health equity, which must remain as the ultimate goal of our efforts. We must always remember that dignity and quality of health care are rights of all and not the privileges of a few.

LONG-TERM SOLUTIONS

The long-term solution lies far beyond the efforts of local FQHCs, hospitals and migrant health centers. Powerful and financially strong nations must put pressure on foreign governments to honor their responsibility to protect every single person’s rights. They must make sure that refugees, asylum-seekers and migrants are safe, and are not tortured, discriminated against or left living in poverty.

Migration is often driven by the search for better livelihoods and new opportunities. Indeed, global and regional social and economic inequalities are expressed most powerfully through the figure of the migrant, as one who crosses borders in search of work, education and new horizons.

Highly developed nations should help less fortunate countries stop conflicts, increase average wealth levels, improve education opportunities, improve social security and health insurance, fight extreme poverty, stop discrimination, among other actions to encourage their citizens to remain in their land and be part of future progress.

In order to mitigate the migration issue, it is crucial to stop conflicts and wars so that people are not forced to leave their homes. Governments of developed countries all over the world should work together and should implement financial sanctions to countries which engage in conflicts.

It is imperative that the financial stability in poor countries improves so that people have an incentive to stay home rather than to migrate to other countries in search for better wages and financial opportunities. Rich developed countries should provide not only financial assistance to less fortunate countries but also scientific support so that poor countries can progress and develop by increasing their knowledge, which in turn should translate to progress, better financial stability and higher living standards.

Education is indirectly proportional to level of poverty and it is directly connected to job opportunities. Low levels of education often lead to higher levels of unemployment and poverty.

It is equally important that poor countries have enough government support in case their citizens urgently need it.

We need to guide our efforts to eradicate extreme hunger and poverty. Poverty is the principal cause of global hunger. Many people migrate to a wealthier country just because they are no longer able to survive in their home countries due to extreme poverty.

People all over the world have to become more tolerant towards minorities and have to accept their lifestyles, gender, race and literacy. Discrimination is one of the leading causes of migration.

If we increase overall living conditions in poorly developed countries, people would be less likely to migrate. This includes better access to better wages, health insurance, better access to education, better social security support and overall safer conditions.

Dr. Alarcon may be contacted at alarconf111@gmail.com

1. US Customs and Border Protection Agency. (n.d.).

https://www.cbp.gov/

2. Healthcare.gov. (n.d.). Coverage for lawfully present immigrants.

https://www.healthcare.gov/immigrants/lawfully-present-immigrants/

3. Social Security Act. 42 U.S.C. §1396b(v)(3)

4. Emergency Medical Treatment and Active Labor Act. 42 C.F.R 489.24(a)(1)(i)

5. State Funded Benefits 16 DE Reg 14360

6. Declaration of U.S. Citizenship and Satisfactory Immigration Status DE Reg 14380

7. Delaware Medicaid. (n.d.). https://www.benefits.gov/benefit/1623

8. Coverage of Emergency Services and Labor and Delivery Only. 16 DE Reg 14370

9. Centers for Disease Control and Prevention. (2022, Mar). Health equity.

https://www.cdc.gov/chronicdisease/healthequity/index.htm

10. Res, S. 1660, 117th Cong. (2021).

https://www.congress.gov/bill/117th-congress/senate-bill/1660/text

11. Res, H. R. 5227, 117th Cong. (2021).

https://www.govtrack.us/congress/bills/117/hr5227/text

12. Res, H. R. 1319, 117th Cong., (2021).

https://www.congress.gov/bill/117th-congress/house-bill/1319/text

13. State of California. (2021, Sep 14). Children’s health insurance program state plan amendment, California.

https://www.medicaid.gov/CHIP/Downloads/CA/CA-21-0032.pdf

14. State of Illinois. (2021, Sep 15). Children’s health insurance program state plan amendment, Illinois.

https://www.medicaid.gov/CHIP/Downloads/IL/IL-21-0014.pdf

15. OR H.B. 3352, 81st Assembly. (2021).

https://olis.oregonlegislature.gov/liz/2021R1/Downloads/ MeasureDocument/HB3352/Enrolled

16. Washington, D. C. (2022). Health care alliance. Retrieved from https://dhcf.dc.gov/service/health-care-alliance

17. CO S.B. 20-2015, 73rd Assembly. (2020). https://leg.colorado.gov/bills/sb20-215

18. Wilson, F. A., Zallman, L., Pagán, J. A., Ortega, A. N., Wang, Y., Tatar, M., & Stimpson, J. P. (2020, December 1).

Comparison of use of health care services and spending for unauthorized immigrants vs authorized immigrants or US citizens using a machine learning model. JAMA Network Open, 3(12), e2029230.

https://doi.org/10.1001/jamanetworkopen.2020.29230

19 Camarota, S. A., Zeigler, K., & Richwine, J. (2019, Oct 10).

How much would it cost to provide health insurance to illegal immigrants? Center for Immigration Studies.

https://cis.org/Report/Cost-of-Health-Insurance-for-Illegal-Immigrants

Evaluating Characteristics in Lung Cancer Screening Program Participants and Non-Small Cell Lung Cancer (NSCLC) Patient Populations

Iftekhar Khan, M.D.

Chief, Oncology Services; Medical Director, Medical Oncology; Bayhealth Cancer Center; Sub-Speciality Education Coordinator & Faculty, Hematology, Bayhealth Rishi Sawhney, M.D.

Medical Director, Bayhealth Cancer Institute; Sub-Specialty Education Coordinator, Oncology, Bayhealth

Stephanie McClellan, M.B.A., M.S.N., R.N., C.M.S.R.N., N.E.-B.C. Cancer Institute Manager, Bayhealth

Kathrina Chua, M.D.

Medical Oncologist, Bayhealth Cancer Center

Abeer Alfaraj, M.D.

Medical Oncologist, Bayhealth Cancer Center

John Shevock, F.A.C.H.E., F.A.C.M.P.E. Senior Director of Operations, Oncology Service Line, Bayhealth Cancer Center

Dain Chun, M.S.

Statistician, Ph.D. Student, University of Florida

ABSTRACT

Objective. To assess and compare specific characteristics and identify any differences, gaps, and/or disparities among two population groups; Bayhealth Lung screening program participants and newly diagnosed nonsmall cell lung cancer patients. Methods. This study was conducted with 2019 data from the American College of Radiology (ACR) registry, 1st time Low Dose CT screenings (Group 1) and the Bayhealth Cancer registry, newly diagnosed non-small cell lung cancer patients (Group 2). Results. Group 1 has 615 participants and Group 2 has 140 participants. The groups are separated based upon who is a first-time participant in the Bayhealth Lung Screening program in 2019 compared to patients who were newly diagnosed with Non-small Cell Lung Cancer at Bayhealth Medical Center-Cancer Center in 2019. Groups 1 and 2 had a statistical difference in the number of packs per year of cigarettes smoked. In group 2 there is no association between smoking status and clinical stage of diagnosis. There is however an association between smoking experience and pathological stage. Conclusion. Smoking continues to be the main contributing factor in patients diagnosed with non-small cell lung cancer. In addition to prevention efforts, early detection through Lung Cancer screenings is vital to identify early stage cancer.

INTRODUCTION

Lung cancer is the most prevalent cause of cancer-related deaths in the United States.1 The highest risk factor for developing lung cancer is cigarette smoking.1 The National Lung Screening Trial (NLST) found that lung cancer detected at an early-stage (using low-dose computed tomography, or LDCT), when most treatable, can decrease mortality rates by 20 percent.2 The American College of Chest Physicians (ACCP)3 recommends annual LDCT for adults age 55-77 years (the U.S. Preventive Services Task Force (USPSTF) age range recommendation is 55-80 years based on study models4) who are asymptomatic and have smoked at least 30 pack years (or more) and continue to smoke or have quit smoking within the last 15 years.3,4

Although cancer incidence, mortality, and smoking rates have declined overall in the United States, cancer health disparities continue to exist among certain population groups.4–6 Cancer health disparities are differences in cancer measurements and outcomes among certain population groups.6 Cancer measurement examples include cancer incidence, survivorship, mortality, morbidity, and screening rates.6 Population group examples include; race/ethnicity, gender, socioeconomic status (SES), and geographic location.6 Cancer health disparities have many contributing factors. For example, studies have shown

that certain SES risk factors, such as income, education level, occupation and geographic location, can affect an individual’s cancer risk behavior, such as tobacco use and cancer screening participation.6,7 Certain population groups are more at risk for cancer health disparities than others. For example, minority ethnic/racial groups are more likely to have higher poverty rates and less access to health care.6 In addition, lung cancer rates are higher among Black and American Indian/Alaska Native men compared to other race/ethnicity groups.5 Overall, African Americans have higher cancer mortality rates compared to other race/ethnicity groups.6 SES factors play a major role in healthcare access and education.6,7 For example, studies have found that SES has more of an impact than race/ethnicity when predicting access to education and health care services.6,7 A study by Singh and Jemal5 analyzed census-based cancer data in the United States and found that men with less education and income had higher lung cancer mortality rates. Similarly, income and education levels inversely affected lung cancer mortality rates among females.5 In addition, studies have found that medically underserved individuals in poverty, regardless of race/ethnicity, are less likely to participate in cancer screenings.5 It is a national goal to assess, address, and decrease health disparities in cancer screening and outcomes.7

DOI: 10.32481/djph.2022.10.007

The Low Dose Lung CT Screening program was initiated at Bayhealth Medical Center in 2015. The initiation of this program was in response to the Centers for Medicare and Medicaid Services (CMS) determination that national coverage on screening for lung cancer was an appropriate preventative service benefit and eligibility criteria had been established.8 The initial roll out of Low Dose Lung CT’s required shared decision making and lung cancer screening counseling. At the time of study, the referral source was primary care physicians and pulmonologist in Kent and Sussex Counties.

In 2018, the Bayhealth Cancer Institute initiated a Lung Cancer Screening Navigator to provide Lung Cancer Screening education, facilitate community-initiated screenings, and remove barriers so that individuals are able to complete lung screening based on recommendations by the US Preventive Services Task Force. Focused navigation and education across the community allowed for an increase in lung screening services over the course of 2018.

METHODS

For this study the American College of Radiology Lung Cancer Screening Registry and the Bayhealth Cancer Center Oncology Cancer Registry was used for patient identification. Two groups were identified as meeting study qualifications.

Group 1: Individuals who are first time participants in the Bayhealth Lung Screening Program in 2019.

Group 2: Patients who are newly diagnosed with NSCLC at Bayhealth Medical Center, Cancer Centers (Kent and Sussex campuses) in 2019.

For Group 1 the following information was collected (see Table 1):

• Age participated in the Bayhealth Lung Screening Program in 2019

• Gender

• Race

• Ethnicity

• Smoking Status

Number of packs-years of smoking

Number of year(s) since quitting

• Postal code (geographic location)

For Group 2 the following information was collected (see Table 1):

• NSCLC Stage

• Age newly diagnosed with NSCLC in 2019

• Gender

• Race

• Ethnicity

• Smoking Status

Number of pack(s)-year(s) of smoking

Number of year(s) since quit

• Postal code (geographic location)

G1 (n=615)

(n=140)

Sex

Male Female 338 (55.0) 277 (45.0) 72 (51.4) 68 (48.6) 0.51

Primary Race/Ethnicity (G1_Q002)

White 1 Asian 2 Black/African American 3 Hispanic/Latin 4 Native American 5 Other 6 Non-response NA 9

Hispanic ethnicity

Yes No Other (included decline to answer)

Age 50-54 1 55-59 2 60-64 3 65-69 4 70-74 5 75-79 6 80 and up 7

498 (81.0) 5 (0.8) 89 (14.5) 0 (0.0) 1 (0.2) 9 (1.5) 1 (0.2)

11 524 80

0 (0.0) 137 (22.3) 176 (28.6) 141 (22.9) 117 (19.0) 44 (7.2) 0 (0.0)

Number of packs per year

Less than 30 PYH 1 30-34 PYH 2 35-39 PYH 3 40-44 PYH 4 45-49 PYH 5 50-54 PYH 6 55-59 PYH 7 60-64 PYH 8 65-69 PYH 9 70-74 PYH 10 75-79 PYH 11 80-84 PYH 12 85-89 PYH 13 90-94 PYH 14 95-99 PYH 15 > 100 PYH 16

28 (4.6) 165 (26.8) 47 (7.6) 154 (25.0) 55 (8.9) 57 (9.3) 8 (1.3) 32 (5.2) 5 (0.8) 3 (0.5) 11 (1.8) 16 (2.6) 4 (0.7) 4 (0.7) 3 (0.5) 23 (3.7)

116 (82.9) 5 (3.6) 18 (12.9) 0 (0.0) 0 (0.0) 1 (0.7) 0 (0.0)

0.12

3 137 0 <0.0001

10 (7.1) 17 (12.1) 21 (15.0) 35 (25.0) 17 (12.1) 18 (12.9) 22 (15.7)

42 (30.0) 5 (3.6) 7 (5.0) 8 (5.7) 6 (4.3)

(4.3) 5 (3.6) 1 (0.7)

(0.7) 0 (0.0)

(1.4)

(5.0) 0 (0.0)

(7.1)

(0.0)

(28.6)

Number of packs per year (Categorized differently)

Less than 30 PYH 1 30-59 PYH 2 60-89 PYH 3 > 90 PYH 4

year history

28 (4.6) 486 (79.0) 71 (11.5) 30 (4.9)

(30)

(26.4)

(7.9)

(35.7)

<0.0001

RESULTS

Group 1 yielded six hundred fifteen (615) participants. Group 2 yielded one hundred forty (140) participants. Of the participants from Group 1 and Group 2, there was no statistical significance for sex or primary race reported. The Fisher Test indicated a statistical significance for age in comparison to number of packs per year smoked. Packs per year were consolidated to demonstrate the statistical difference with an increase in the amount of tobacco consumed.

In the study of Group 2, there is no relationship found between smoking status and clinical stage. Fisher Exact Test was used for this analysis. There is however an association between smoking and pathological stage. The Fisher Exact Test was used, and the clinical significance was 0.04. Based on this information, patients who reported they are active smokers with greater than 30 pack per year smoking history all had confirmed Non-small cell lung cancer diagnosis.

The Group 2 study continued with an assessment of the relationship between age and clinical versus pathological stage. The Kendall Tau rank coefficient was used. The correlation coefficient tau between Age and clinical stage among smoking population is -0.12, showing low association. The correlation coefficient tau between Age and pathological stage among smoking population is -0.06, showing low association. While age remains a minimal factor in the equation, the data continues to determine continued smoking over time produces a lung cancer diagnosis. In the case for Group 2 the diagnosis was NonSmall Cell Lung Cancer. Group 2 findings also support the updated recommendation by the US Preventive Task Force, for adults who have a 20 pack-year smoking history to start annual screening for lung cancer with low-dose CT.9

CONCLUSION

There is a growing body of evidence supporting current and former smokers to participate in low-dose CT lung screening programs. Low-dose CT’s are proven to increase the number of early stage lung cancer diagnosis, motivate smoking cessation, and thereby reduce mortality from late stage lung cancer diagnosis.10 While identifying disparities in the patient population studied, it was discovered that no patients in Group 2 participated in the low-dose CT lung screening program. This points to a gap in access to screening. Additionally, key stakeholder education is needed across the community of primary care physicians, pulmonary physicians, and in the general patient population to help increase awareness of the benefits of low-dose CT lung screening programs. In addition to education, removing the stigma of a lung cancer diagnosis through early education and smoking cessation programs stand to benefits long term patient outcomes across the community and increase trust in the healthcare system. Future research should focus on patient barriers to access lung cancer screening programs and the utilization of smoking cessation programs.

Dr. Khan may be contacted at Iftekhar_khan@bayhealth.org

REFERENCES

1. Centers for Disease Control and Prevention. (2022). Basic information about lung cancer. https://www.cdc.gov/cancer/lung/basic_info/

2. Aberle, D. R., Adams, A. M., Berg, C. D., Black, W. C., Clapp, J. D., Fagerstrom, R. M., . . . Sicks, J. D., & the National Lung Screening Trial Research Team. (2011, August 4). Reduced lung-cancer mortality with low-dose computed tomographic screening. The New England Journal of Medicine, 365(5), 395–409. https://doi.org/10.1056/NEJMoa1102873

3 Mazzone, P. J., Silvestri, G. A., Patel, S., Kanne, J. P., Kinsinger, L. S., Wiener, R. S., . . . Detterbeck, F. C. (2018, April). Screening for lung cancer; CHEST guideline and expert panel report. Chest, 153(4), 954 985 https://doi.org/10.1016/j.chest.2018.01.016

4. Krist, A. H., Davidson, K. W., Mangione, C. M., Barry, M. J., Cabana, M., Caughey, A. B., Wong, J. B., & the US Preventive Services Task Force. (2021, March 9). Screening for lung cancer: U.S. Preventive Services Task Force recommendation statement. JAMA, 325(10), 962 970. https://doi.org/10.1001/jama.2021.1117

5. Singh, G. K., & Jemal, A. (2017). Socioeconomic and racial/ethnic disparities in cancer mortality, incidence, and survival in the United States, 1950-2014: Over six decades of changing patterns and widening inequalities. Journal of Environmental and Public Health, 2017, 2819372 https://doi.org/10.1155/2017/2819372

6 National Cancer Institute. (2022) Cancer disparities. https://www.cancer.gov/about-cancer/understanding/disparities

7 Office of Disease Prevention and Health Promotion. (2020). Cancer-topics and overviews. https://www.healthypeople.gov/2020/topics-objectives/topic/cancer

8 Centers for Medicare and Medicaid Services (2015). Screening for lung cancer with low dose computed tomography (LDCT)-Decision summary.

Dear Public Health Partners,

The Mid-Atlantic Public Health Partnership is proud to bring its third annual and very first in-per son conference to public health communities across Pennsylvania, Delaware, and Maryland. Extreme weather events in recent weeks are a reminder that climate change and public health are inextrica bly connected. Adapting public health policy to address the climate crisis is key to protecting and strengthening our communities.

The Delaware Academy of Medicine/Delaware Public Health Association (Academy/DPHA), Maryland Public Health Association (MdPHA), and Pennsylvania Public Health Association (PPHA) are bringing together regional experts through a two-day conference focused on the theme, “Public Health and Climate Change: Response, Policy and Implementation.”

Date: March 16 & 17, 2023

Location: The Sciences & Engineering Center and The Commons – West Chester University 155 University Ave, West Chester, PA 19383

Registration details to follow. Here is the link to the call for abstracts. Abstracts must be received by 5:00 p.m. on December 31, 2022.

This conference will provide public health students, professionals, and partners across our region with the opportunity to learn about and engage in conversations about innovative strategies to address climate issues in the region.

We look forward to an in-person exciting conference this time!

Sincerely, Delaware Public Health Association Maryland Public Health Association Pennsylvania Public Health Association

Delaware Mombinus Addresses Health Inequities in Vulnerable Communities

DELAWARE GENERAL ASSEMBLY

STATE OF DELAWARE

LEGISLATIVE HALL DOVER, DELAWARE 19901

In 2020, Delaware like many other states witnessed firsthand how the COVID-19 pandemic exacerbated health inequities in vulnerable communities, especially among minority groups and seniors.

We are very much aware of how health problems are traditionally linked to genetics and the environment. However, as legislators, we also understand how policy action and inaction can negatively influence the health of residents, as well.

One issue that hits close to home is Black maternal health. It’s alarming that Black women in the United States are more likely to die from pregnancy or childbirth than women in any other race group, including Delaware. Unfortunately, the heightened risk of pregnancy-related death for Black women spans income and education levels.

We have witnessed this firsthand and have experienced less than adequate treatment.

Another sad reality is Delaware is also ranked 28th in the nation for infant mortality, with the Black babies dying at a rate three times higher than White babies. To address this crisis affecting both Black mothers and their children, we drafted and sponsored the 2022 Delaware Momnibus, a series of six bills designed to support mothers throughout their pregnancies and post-partum.

The first step is through HB 344, which develops bias and competency training for healthcare workers and requires the Delaware Perinatal Quality Collaborative to create training guidelines for health professionals.

Two bills, HB 343 and HB 234, expand Medicaid access to include doula services, and extend Medicaid coverage throughout the first year of postpartum, improving the well-being of mothers and infants in need of consistent care.

The Delaware Momnibus also provides care for incarcerated women through two bills. One is HB 342, which prohibits the use of restraints on women in their second and third trimester, and in the 13-week immediate postpartum period. The second, HB 345, provides access to doula services for pregnant and postpartum women in custody.

Finally, one bill requires the Child and Maternal Death Review Commission, formerly known as the Child Death Review Commission, to take a closer look and present recommendations to improve maternal and infant mortality, health problems that result from being pregnant and giving birth, as well as racial disparities. Legislators, healthcare professionals, and community members can all play a part in bringing about positive change. Some of the things we can all do to implement change:

• Public policy and connecting with legislators through letters or phone calls.

• Organize events and drives to reach vulnerable communities.

• Advocate and educate people about social determinants.

We are committed to addressing healthcare inequities and eliminating discrimination in all forms. Although there is a great deal of work to be done, we are taking steps in the right direction.

We must continue to prioritize policies and continue to confront Black maternal health disparities in order to eliminate all forms of discrimination in healthcare. Too many lives are at stake -- and we cannot afford to rest.

AFREHealth focuses on decolonization & disparities

The fifth annual AFREHealth Symposium, held in Harare, Zimbabwe, this past August, offered in-person attendance and presentations for the first time in two years. While the official theme was “COVID-19 pandemic and post-pandemic issues for health education, research, and service delivery,” the topic of decolonization ran through many sessions, especially in view of the ongoing disparities brought into sharper focus by the pandemic.

Established through a Fogarty grant in 2018, the African Forum for Research and Education in Health (AFREHealth) is an interdisciplinary professional society that seeks to improve the quality of health care in Africa through research, education, and capacity building.

Three Fogarty grantees gave plenary talks, Dr. Francis Omaswa, chancellor of Soroti University, Dr. Damalie Nakanjako, professor of medicine at Makerere University, and Dr. Catherine Kyobutungi, executive director of the African Population and Health Research Center. Dr. Ndola Prata of the University of California Global Health Institute, a consortium in Fogarty’s Global Fellows and Scholars/ LAUNCH program, also presented.

“COVID should become an opportunity,” to prioritize the health care workforce in Africa, said Omaswa during his talk on human resource challenges post pandemic. “Health care HR on the continent has been too focused on administrative tasks; managers don’t understand the skills of their staff,” he added. He stressed how the COVID-19 pandemic exacerbated worker shortages in all countries, but especially in lower income ones as higher-income countries could recruit from abroad to deal with the patient influx.

“If Africa doesn’t employ our own healthcare workers they will be ‘taken’ by the Global North,” Omaswa warned. His recommendations included African nations investing in their health workforce; development and support of national health resource plans; coordination between government, academia, and the private sector; and standardizing competencies for health care workers to bring about clinical excellence.

In her talk, Kyobutungi focused on reframing global health from a paradigm that sees part of the world (usually the Global South) as having problems and the other part (the Global North) as having solutions to one in which both problems and solutions are defined collaboratively. This was echoed by Ndola Prata who championed transitioning from “capacity-building” to “capacity-bridging”–acknowledging the capacity that exists within Africa.

This was also the first in-person conference since the loss of two AFREHealth leaders—Drs. James Hakim and David Olaleye. Both died from COVID-19 in 2021. Hakim was a member of the AFREHealth governing council and Olaleye oversaw AFREHealth's symposium in 2019. Both were involved in the Medical Education Partnership Initiative (MEPI) program, one of the progenitors of AFREHealth. Fogarty Director Roger I. Glass paid tribute to both men in his remarks during the opening plenary session: “James and David were both profoundly important leaders in advancing medical research and education in Africa. My hope is that their work will inspire a new generation to dedicate themselves to improving health on the continent.”

Webinar series highlights food insecurity

Fogarty’s Center for Global Health Studies is hosting a three-part webinar series on Global Food and Nutrition Insecurity.

The series will highlight innovative research projects on nutrition, food insecurity, and health outcomes as well as opportunities for adaption in the U.S.

All times Eastern Time

• Nov. 3 at 10 a.m. – Overview of Global Food and Nutrition Insecurity

• Nov. 10 at 10:30 a.m. – Leveraging Food Environment for Food and Nutrition Security

• Nov. 21 at 3 p.m. – Using Implementation Science to Address Food and Nutrition Insecurity

Improving the oral health of Kenyan teens living with HIV

Improving the oral health of Kenyan teens living with HIV

People living with HIV/AIDS often experience oral health issues, including tooth decay, painful sores and blisters, and periodontitis (bone loss around the teeth). Antiretroviral therapy (ART), a form of HIV treatment, has made these problems less common yet the medications themselves sometimes cause dental side effects. The Children’s HIV Oral Manifestations Project (CHOMP) is examining the relationship between oral disease, saliva, blood levels of vitamin D, and a patient’s overall quality of life.

People living with HIV/AIDS often experience oral health issues, including tooth decay, painful sores and blisters, and periodontitis (bone loss around the teeth). Antiretroviral therapy (ART), a form of HIV treatment, has made these problems less common yet the medications themselves sometimes cause dental side effects. The Children’s HIV Oral Manifestations Project (CHOMP) is examining the relationship between oral disease, saliva, blood levels of vitamin D, and a patient’s overall quality of life.

Ashley Karczewski joined CHOMP to better understand these complex oral dynamics in teens affected by HIV in Kenya, home to approximately 150,000 children living with HIV/AIDS. “Oral manifestations of HIV can greatly impact quality of life for these children. If they have tooth pain, they miss school. Sometimes malnutrition results if they lose teeth or have trouble chewing,” said Karczewski. For her Fogarty project, she focused on levels of antimicrobial peptides (AMPs) found in saliva that are protective of oral health.

Ashley Karczewski joined CHOMP to better understand these complex oral dynamics in teens affected by HIV in Kenya, home to approximately 150,000 children living with HIV/AIDS. “Oral manifestations of HIV can greatly impact quality of life for these children. If they have tooth pain, they miss school. Sometimes malnutrition results if they lose teeth or have trouble chewing,” said Karczewski. For her Fogarty project, she focused on levels of antimicrobial peptides (AMPs) found in saliva that are protective of oral health.

Microbes in our mouths

Microbes in our mouths

Our mouths are home to between 300 and 700 different bacterial species and our saliva contains AMPs that modulate this thriving community of organisms. AMPs benefit our health by boosting immunity and helping to prevent oral disease.

Our mouths are home to between 300 and 700 different bacterial species and our saliva contains AMPs that modulate this thriving community of organisms. AMPs benefit our health by boosting immunity and helping to prevent oral disease.

“What we found was that there was a correlation between the vitamin D status of the children and the salivary AMP cathelicidin LL-37—but it was the opposite of what we’d anticipated,” said Karczewski. Children with adequate vitamin D status had less, not more LL-37. The team’s theory is that vitamin D is a precursor to LL-37. So children with more LL-37 may have expended more vitamin D to produce their high levels of the beneficial AMP. “We also found a correlation to the ART regimen,” said Karczewski. “Children who began receiving ART earlier in life had higher levels of LL-37 and another AMP. So that means ART was likely helpful in boosting their immune systems.”

“What we found was that there was a correlation between the vitamin D status of the children and the salivary AMP cathelicidin LL-37—but it was the opposite of what we’d anticipated,” said Karczewski. Children with adequate vitamin D status had less, not more LL-37. The team’s theory is that vitamin D is a precursor to LL-37. So children with more LL-37 may have expended more vitamin D to produce their high levels of the beneficial AMP. “We also found a correlation to the ART regimen,” said Karczewski. “Children who began receiving ART earlier in life had higher levels of LL-37 and another AMP. So that means ART was likely helpful in boosting their immune systems.”

CHOMP, a collaboration that began four years ago between the University of Washington and the University of Nairobi, continues working towards its aims.

CHOMP, a collaboration that began four years ago between the University of Washington and the University of Nairobi, continues working towards its aims.

Ashley Karczewski, DDS

Ashley Karczewski, DDS

Fogarty Fellow:

U.S. institution:

Foreign institution: University of Nairobi School of Dental Sciences,

Research topic:

health in

living

“The goal is to gather data and then do a big clinical trial, where we provide vitamin D supplementation as a way of boosting the innate immunity of children living with HIV.”

The trial should begin in about two to three years and, if the results are beneficial, a similar cost-effective vitamin D supplementation plan “can be applied in other nations, whether low, middle or high income,” said Karczewski.

“The goal is to gather data and then do a big clinical trial, where we provide vitamin D supplementation as a way of boosting the innate immunity of children living with HIV.” The trial should begin in about two to three years and, if the results are beneficial, a similar cost-effective vitamin D supplementation plan “can be applied in other nations, whether low, middle or high income,” said Karczewski.

“Because cancer, diabetes, hypertension and other health issues create a compromised oral environment, vitamin D supplementation would be helpful to many people.”

“Because cancer, diabetes, hypertension and other health issues create a compromised oral environment, vitamin D supplementation would be helpful to many people.”

Currently, the CHOMP team is preparing to publish a series of papers analyzing their results.

Currently, the CHOMP team is preparing to publish a series of papers analyzing their results.

Karczewski received instruction on research methodology, grant and paper writing, and Institutional Review Boards (IRBs) through her fellowship. “One positive of the pandemic is it allowed me to focus on writing and career development,” she said. “We had bi-weekly consortium calls to discuss different topics and to hold workshops on grant and paper writing. Previously I’d done only bench research so this was like a PhD-lite year for me.”

Karczewski received instruction on research methodology, grant and paper writing, and Institutional Review Boards (IRBs) through her fellowship. “One positive of the pandemic is it allowed me to focus on writing and career development,” she said. “We had bi-weekly consortium calls to discuss different topics and to hold workshops on grant and paper writing. Previously I’d done only bench research so this was like a PhD-lite year for me.”

The disruption caused by SARS-CoV-2 also taught her “resiliency in the face of dealing with the limitations of a global pandemic. I was working with a huge team and coordinating between all these different people and moving parts.” Her Kenyan and U.S. mentors provided much-needed guidance.

The disruption caused by SARS-CoV-2 also taught her “resiliency in the face of dealing with the limitations of a global pandemic. I was working with a huge team and coordinating between all these different people and moving parts.” Her Kenyan and U.S. mentors provided much-needed guidance.

Since her Fogarty Fellowship, Karczewski has finished dentistry school and begun a residency in a cancer center. “What I learned in Nairobi helped me with all my patient interactions and also with my focus on medically compromised people.” Karczewski credits Fogarty with guiding her towards a career in hospital dentistry and clinical research. “I’m focused on cancer in my residency so I’m hoping that becomes my research niche— dentistry for cancer patients in a global health setting.”

Since her Fogarty Fellowship, Karczewski has finished dentistry school and begun a residency in a cancer center. “What I learned in Nairobi helped me with all my patient interactions and also with my focus on medically compromised people.” Karczewski credits Fogarty with guiding her towards a career in hospital dentistry and clinical research. “I’m focused on cancer in my residency so I’m hoping that becomes my research niche— dentistry for cancer patients in a global health setting.”

Dr. Jennifer Webster-Cyriaque, deputy director of the National Institute of Dental and Craniofacial Research (NIDCR), earned her DDS from SUNY Buffalo and her Ph.D. in microbiology/immunology

from the University of North Carolina (UNC)-Chapel Hill. She served on the faculty at the UNC schools of dentistry and medicine for more than two decades. Her research has explored causes for salivary gland disease in patients living with HIV and evaluated the oral microbiome’s impact on cancer-causing viruses and HIV outcomes. Since 2004, she’s led the UNC-Malawi project, which helped establish that nation’s first dental school in 2019.

Dr. Jennifer Webster-Cyriaque, deputy director of the National Institute of Dental and Craniofacial Research (NIDCR), earned her DDS from SUNY Buffalo and her Ph.D. in microbiology/immunology from the University of North Carolina (UNC)-Chapel Hill. She served on the faculty at the UNC schools of dentistry and medicine for more than two decades. Her research has explored causes for salivary gland disease in patients living with HIV and evaluated the oral microbiome’s impact on cancer-causing viruses and HIV outcomes. Since 2004, she’s led the UNC-Malawi project, which helped establish that nation’s first dental school in 2019.

What inspired you to become a scientist?

What inspired you to become a scientist?

As a child, I was always a very curious person, but I never entertained being a scientist because I didn't really have an example. The one person I was aware of was George Washington Carver, and then my older sister became a nurse, so I decided I would do something health related.

As a child, I was always a very curious person, but I never entertained being a scientist because I didn't really have an example. The one person I was aware of was George Washington Carver, and then my older sister became a nurse, so I decided I would do something health related.

what you show the world is important, but there's so much more there, right? Oral health is a barometer for what's happening elsewhere in your body. If you take saliva, you can measure many diseases at distant sites. Who wouldn't want to give spit instead of getting a needle? It’s easier and safer.

what you show the world is important, but there's so much more there, right? Oral health is a barometer for what's happening elsewhere in your body. If you take saliva, you can measure many diseases at distant sites. Who wouldn't want to give spit instead of getting a needle? It’s easier and safer.

At college, I focused on becoming a doctor but then I read “The Unkindest Cut” by Marcia Millman and I recognized I would not be a good person to tell someone their loved one is dying or “we don’t know what to do.” So, I started to look for other professions and did a lot of volunteering and work study. One job, cleaning dishes in the laboratory, included some science project work during the summer and a volunteer position with a dentist in Buffalo led to a dental assistant’s job. That’s when I discovered that I really liked dentistry.

At college, I focused on becoming a doctor but then I read “The Unkindest Cut” by Marcia Millman and I recognized I would not be a good person to tell someone their loved one is dying or “we don’t know what to do.” So, I started to look for other professions and did a lot of volunteering and work study. One job, cleaning dishes in the laboratory, included some science project work during the summer and a volunteer position with a dentist in Buffalo led to a dental assistant’s job. That’s when I discovered that I really liked dentistry.

What do you enjoy most about your work?

What do you enjoy most about your work?

I enjoy seeing patients. It's like Christmas when you deliver new dentures to someone or when you relieve their pain. There’s a win in that. But at the same time there’s huge gratification in what you learn at the bench and take back to a patient—this is why my career has progressed on parallel tracks.

I enjoy seeing patients. It's like Christmas when you deliver new dentures to someone or when you relieve their pain. There’s a win in that. But at the same time there’s huge gratification in what you learn at the bench and take back to a patient—this is why my career has progressed on parallel tracks.

For me, science is a tool. I used to believe that scientists were these [she gestures indicating a person standing on a pedestal]. But now I realize that everybody who asks a question is a scientist—a scientist is somebody who really wants to know the answer.

For me, science is a tool. I used to believe that scientists were these [she gestures indicating a person standing on a pedestal]. But now I realize that everybody who asks a question is a scientist—a scientist is somebody who really wants to know the answer.

What should we know about oral health?

What should we know about oral health?

Oral health is essential and can be the genesis of other health problems, yet it has been overlooked. Think about it: your communication, your nutrition, your portal to every other organ is your mouth, yet oral health has mainly been touted as white teeth. They are pretty and

Oral health is essential and can be the genesis of other health problems, yet it has been overlooked. Think about it: your communication, your nutrition, your portal to every other organ is your mouth, yet oral health has mainly been touted as white teeth. They are pretty and

Oral cancers are a major problem. Virus-associated cancers cause more than 70% of head and neck cancers in the U.S., which is more than tobacco- or alcoholrelated cancers. One challenge for our field—and this is something we're working on—is building the evidence base with large enough studies to be able to demonstrate linkages to various diseases. I think as those studies grow, we will be able to see many direct connections, just as we’ve seen between oral health and cardiovascular disease.

Oral cancers are a major problem. Virus-associated cancers cause more than 70% of head and neck cancers in the U.S., which is more than tobacco- or alcoholrelated cancers. One challenge for our field—and this is something we're working on—is building the evidence base with large enough studies to be able to demonstrate linkages to various diseases. I think as those studies grow, we will be able to see many direct connections, just as we’ve seen between oral health and cardiovascular disease.

What do you hope to accomplish at NIH?

What do you hope to accomplish at NIH?

The most common disease in the whole world is tooth decay (dental caries), which is preventable. This past December, the Oral Health in America report clearly showed that disparities remain a major issue, despite technological advances. So, I would like to address disparities nationally and globally. Part of that is getting prevention messaging out there and helping to build capacity.

The most common disease in the whole world is tooth decay (dental caries), which is preventable. This past December, the Oral Health in America report clearly showed that disparities remain a major issue, despite technological advances. So, I would like to address disparities nationally and globally. Part of that is getting prevention messaging out there and helping to build capacity.

We need to integrate oral and general health; we need to diversify the workforce so that dentists look like the populations they treat; and we need to translate and implement what we’ve learned through research, because so much of what we know has never made it to the patient. As NIDCR’s deputy director, my potential impact is much larger now. Beyond a single patient or small group, I will be able to make programmatic changes, promote other people’s science, and help build training programs across the nation. Alongside Fogarty, I hope to make a difference globally as well.

We need to integrate oral and general health; we need to diversify the workforce so that dentists look like the populations they treat; and we need to translate and implement what we’ve learned through research, because so much of what we know has never made it to the patient. As NIDCR’s deputy director, my potential impact is much larger now. Beyond a single patient or small group, I will be able to make programmatic changes, promote other people’s science, and help build training programs across the nation. Alongside Fogarty, I hope to make a difference globally as well.

has been amputated. And that will affect the whole family and possibly an entire community.”

Hundreds of snakes are responsible for bites with up to 200 that can “really do damage,” said Wibmer. Each snake acts on its prey in a different way so different venoms have unique components; this also means patients must correctly identify a snake to receive the correct antivenom. For example, the venom of certain vipers or adders common to South and Central Americas and Central Africa affects how blood clots, leading to bleeding from the eyes. Other venoms can spur a blood clot leading to a heart attack or an embolism.

“Then the neurotoxic snakes, like cobras and mambas, can shoot venom into your eyes, where it goes straight to the nervous system, slowing down breathing and heart rate.”

“ ”

We can make something that's pure, so you can avoid anaphylactic shock. We might even be able to make compounds that can be given in the field instead of rushing someone to a hospital to give antivenom by IV.

Years of experience in virology showed Wibmer how antivenom can be transformed. Next-generation antivenoms need to be “high-affinity products that are long-lasting in the body, which is what we engineer into current therapeutics for other diseases,” he said.

Wibmer is pursuing two different approaches to achieve these goals. “One is the antibody isolation approach— trying to get antibodies from immunized animals and then making them in a lab, so that they can be 100% pure, engineered to stay in the body for a month, and effective in a small enough dose to be given in the field,” he said. A second approach is based on structural biology methodologies: Identify proteins that resemble the targets of venom (such as blood clotting cascades) and then enhance them through engineering.

Wibmer uses both approaches in his efforts to synthesize a broadly reactive therapeutic for various snake species native to both Africa and Asia. He has expressed snake toxins from each of the major toxin classes and characterized them using x-ray protein crystallography.

The next step in his project is to use structure-guided protein design to improve the binding regions of his lead protein candidates. So far he’s built “a solid foundation” for continued work, despite disruptions caused by SARSCoV-2. “Africa has huge shipping issues, which the pandemic exacerbated. I am now receiving things that I ordered in 2020!”

Wibmer remains hopeful of a good result because venom is unlike his former research focus, HIV, which is a “moving target” that evolves in millions of people every year. “Snakes evolved venom for their prey—they do not care about humans—so it’s the same toxin honed for the same rodents and birds. Even though venoms are diverse, it is easier to design interventions for them, because they’re a stable target.” Still he does not underestimate the challenges he faces, such as disseminating new medicines to LMICs and getting interest from Western pharmaceutical companies or investment for local drug development and manufacturing.

“A lot of people in LMICs don’t think highly of their own science. They think science is not important unless it comes from one of the big Western countries. When you look at the big labs doing work in India, in Africa, in Brazil, the people are comparable but getting them to believe that they are just as good as ‘big name so and so’ presenting at the conference—this is something we need to address. Because that confidence helps drive the passion and inspires people to produce good science.”

Public domain

Engineering a new molecule to neutralize venoms

Engineering a new molecule to neutralize venoms

Claire Komives, a professor of chemical engineering at San Jose State University, California, also works to modernize antivenom, yet her approach is unlike that of Constantinos Kurt Wibmer (see story, page 6). She entered this field after reading a news article around the time she was taking a sabbatical year at the Indian Institute of Technology, Delhi. The article falsely claimed that a particular opossum peptide could neutralize venom from several different snakes. “The data was terrible, still it got me thinking.” After all, she knew that when an American rattlesnake bites an opossum, the animal simply licks its wounds and moves on.

Claire Komives, a professor of chemical engineering at San Jose State University, California, also works to modernize antivenom, yet her approach is unlike that of Constantinos Kurt Wibmer (see story, page 6). She entered this field after reading a news article around the time she was taking a sabbatical year at the Indian Institute of Technology, Delhi. The article falsely claimed that a particular opossum peptide could neutralize venom from several different snakes. “The data was terrible, still it got me thinking.” After all, she knew that when an American rattlesnake bites an opossum, the animal simply licks its wounds and moves on.

Engineering a new molecule to neutralize venoms

Claire Komives, a professor of chemical engineering at San Jose State University, California, also works to modernize antivenom, yet her approach is unlike that of Constantinos Kurt Wibmer (see story, page 6). She entered this field after reading a news article around the time she was taking a sabbatical year at the Indian Institute of Technology, Delhi. The article falsely claimed that a particular opossum peptide could neutralize venom from several different snakes. “The data was terrible, still it got me thinking.” After all, she knew that when an American rattlesnake bites an opossum, the animal simply licks its wounds and moves on.

“Just for the heck of it, I purchased some synthesized opossum peptide and sent it to the National Natural Toxins Research Center at Texas A&M University in Kingsville, and they tested it and found that it indeed neutralized a lethal dose of rattlesnake venom.”

“Just for the heck of it, I purchased some synthesized opossum peptide and sent it to the National Natural Toxins Research Center at Texas A&M University in Kingsville, and they tested it and found that it indeed neutralized a lethal dose of rattlesnake venom.”

Excited, Komives began to compose her wish list for a next generation antivenom: heat resistant, shelf stable, available as a either pill, liquid, or inhalable mist, and, of course, “super inexpensive.”

“Just for the heck of it, I purchased some synthesized opossum peptide and sent it to the National Natural Toxins Research Center at Texas A&M University in Kingsville, and they tested it and found that it indeed neutralized a lethal dose of rattlesnake venom.” Excited, Komives began to compose her wish list for a next generation antivenom: heat resistant, shelf stable, available as a either pill, liquid, or inhalable mist, and, of course, “super inexpensive.”

Excited, Komives began to compose her wish list for a next generation antivenom: heat resistant, shelf stable, available as a either pill, liquid, or inhalable mist, and, of course, “super inexpensive.”

The team on her project in India, funded by the National Institute of Biomedical Imaging and Bioengineering, ran experiments "to determine whether the peptide, in its native form, could actually serve as an antivenom— meaning you inject it and it'll work.” The tests showed the molecule, in itself, did not work as antivenom, yet she had gained knowledge about its characteristics, including how it binds to other molecules. Seeing an active site, Komives decided to “try to display the peptide the way the serum protein in the opossum does.” She attached the peptide to a camelid nanobody, a technique increasingly used in pharmacology, and now it can be expressed in E. coli.

The team on her project in India, funded by the National Institute of Biomedical Imaging and Bioengineering, ran experiments "to determine whether the peptide, in its native form, could actually serve as an antivenom— meaning you inject it and it'll work.” The tests showed the molecule, in itself, did not work as antivenom, yet she had gained knowledge about its characteristics, including how it binds to other molecules. Seeing an active site, Komives decided to “try to display the peptide the way the serum protein in the opossum does.” She attached the peptide to a camelid nanobody, a technique increasingly used in pharmacology, and now it can be expressed in E. coli.

The team on her project in India, funded by the National Institute of Biomedical Imaging and Bioengineering, ran experiments "to determine whether the peptide, in its native form, could actually serve as an antivenom— meaning you inject it and it'll work.” The tests showed the molecule, in itself, did not work as antivenom, yet she had gained knowledge about its characteristics, including how it binds to other molecules. Seeing an active site, Komives decided to “try to display the peptide the way the serum protein in the opossum does.” She attached the peptide to a camelid nanobody, a technique increasingly used in pharmacology, and now it can be expressed in E. coli.

India is thought to have the highest loss of life due to snakebites in the world. A 2020 study estimated 58,000 deaths each year in the country.

India is thought to have the highest loss of life due to snakebites in the world. A 2020 study estimated 58,000 deaths each year in the country.

India is thought to have the highest loss of life due to snakebites in the world. A 2020 study estimated 58,000 deaths each year in the country.

Working with India and Nigeria India is thought to have the highest loss of life due to snakebites in the world. A 2020 study estimated 58,000 deaths each year in the country. Komives estimates that areas of Nigeria likely “have equal snakebite prevalence as India,” while the WHO recorded 6,687 people treated for snakebite envenoming in a single Nigerian hospital over a three-year period. Her research has led her to work in both countries.

Working with India and Nigeria India is thought to have the highest loss of life due to snakebites in the world. A 2020 study estimated 58,000 deaths each year in the country. Komives estimates that areas of Nigeria likely “have equal snakebite prevalence as India,” while the WHO recorded 6,687 people treated for snakebite envenoming in a single Nigerian hospital over a three-year period. Her research has led her to work in both countries.

Working with India and Nigeria India is thought to have the highest loss of life due to snakebites in the world. A 2020 study estimated 58,000 deaths each year in the country. Komives estimates that areas of Nigeria likely “have equal snakebite prevalence as India,” while the WHO recorded 6,687 people treated for snakebite envenoming in a single Nigerian hospital over a three-year period. Her research has led her to work in both countries.

The king cobra, the largest of venomous snakes, is found predominantly in forests from India through Southeast Asia. Their venom is neurotoxic.

Her rejiggered molecule works to neutralize venom “for almost all the Nigerian snakes and one Indian snake, the saw-scaled viper,” said Komives. Currently, she is working on creating a process to produce an active protein that scales in E. coli. “If it’s successful, then we’re talking about having a cheap, single molecule antivenom” that could undergo robust “lot by lot quality control,” she said.

Her rejiggered molecule works to neutralize venom “for almost all the Nigerian snakes and one Indian snake, the saw-scaled viper,” said Komives. Currently, she is working on creating a process to produce an active protein that scales in E. coli. “If it’s successful, then we’re talking about having a cheap, single molecule antivenom” that could undergo robust “lot by lot quality control,” she said.

Her rejiggered molecule works to neutralize venom “for almost all the Nigerian snakes and one Indian snake, the saw-scaled viper,” said Komives. Currently, she is working on creating a process to produce an active protein that scales in E. coli. “If it’s successful, then we’re talking about having a cheap, single molecule antivenom” that could undergo robust “lot by lot quality control,” she said.

Komives’s progress, like Wibmer’s, has been delayed by world events. “During the pandemic we weren’t allowed to come to the lab, and then it took six months to get a certain part for my bioreactor." Yet her efforts to design an antivenom continue.

Komives’s progress, like Wibmer’s, has been delayed by world events. “During the pandemic we weren’t allowed to come to the lab, and then it took six months to get a certain part for my bioreactor." Yet her efforts to design an antivenom continue.

Komives’s progress, like Wibmer’s, has been delayed by world events. “During the pandemic we weren’t allowed to come to the lab, and then it took six months to get a certain part for my bioreactor." Yet her efforts to design an antivenom continue.

Komives is currently working with the Ministry of Health in Nigeria to do “preliminary safety and efficacy tests, which would be the next step to making the peptide commercialize-able.” Her project has also found support in India, where current manufacturing methods (that use horses) are seen as unethical.

Komives is currently working with the Ministry of Health in Nigeria to do “preliminary safety and efficacy tests, which would be the next step to making the peptide commercialize-able.” Her project has also found support in India, where current manufacturing methods (that use horses) are seen as unethical.

Komives is currently working with the Ministry of Health in Nigeria to do “preliminary safety and efficacy tests, which would be the next step to making the peptide commercialize-able.” Her project has also found support in India, where current manufacturing methods (that use horses) are seen as unethical.

“The Nigerian hospital I’m working with sees 3,000 snakebite patients each year, mostly in the rainy season,” she said. Yet, the antivenoms available there are insufficient and cost $100 a dose. “These rural farmers in Nigeria, they simply don’t have the money. They are destroyed financially if somebody in the family gets bit.”

“The Nigerian hospital I’m working with sees 3,000 snakebite patients each year, mostly in the rainy season,” she said. Yet, the antivenoms available there are insufficient and cost $100 a dose. “These rural farmers in Nigeria, they simply don’t have the money. They are destroyed financially if somebody in the family gets bit.”

“The Nigerian hospital I’m working with sees 3,000 snakebite patients each year, mostly in the rainy season,” she said.

Yet, the antivenoms available there are insufficient and cost $100 a dose. “These rural farmers in Nigeria, they simply don’t have the money. They are destroyed financially if somebody in the family gets bit.”

Optimizing access to antivenom in the Amazon

The current generation of antivenoms may be imperfect, still they are an “efficacious and extremely safe” therapy for snakebite, said Dr. Charles Gerardo, a professor and emergency medicine specialist at Duke University. “Yet antivenoms are not getting into people—if no one ever sees antivenom in a timely fashion due to travel times, lack of infrastructure, lack of knowledge, then it does no good.” Gerardo has been conducting a study to improve antivenom access and distribution in Brazil, the results of which he hopes can be applied in other regions in the world.

Over the past five years, Brazil recorded roughly 140,000 cases of snakebite. Of these, about 70,000 resulted in death or illness. One aim of Gerardo’s project is to create a distribution model for antivenom, which is state produced at Instituto Butantan, using Brazil’s existing network of community health centers (CHCs) embedded within its nationalized health care system. Joao Ricardo Vissoci, coinvestigator and an assistant professor at Duke, explained, “The data showed a majority of snakebite events in the Amazon do receive antivenom, but a large proportion are delayed—meaning outside the six-hour window.” (There’s a greater likelihood of death or lasting effects when patients receive antivenom more than six hours after a bite.)

A crucial parameter in creating a distribution model, then, is the ability for most of the at-risk population to be able to travel to an antivenom site within six hours of a bite. Addressing this, the team, which includes Brazilian colleagues at the Tropical Medicine Center in Manaus, Amazonas, mixed “implementation science with data science,” said Vissoci.

Progressive methods to find solutions

Gerardo explained: “We took satellite imagery to find man-made structures and attributed populations to those areas. Then we had to determine travel times.” Given most people in the Amazon travel by river, the team created datasets of the entire river basin at two different times of the year—during the wet season and the “wetter” season.

“Once we modeled where the people are and how long it would take to get them to care,” said Gerardo, “then we could begin to generate location allocation plans—which CHCs do we (stock with antivenom) based on this data?”

Next, the team piloted a training process for teaching community health workers how to administer antivenom, including identifying types of snakebite, dealing with

allergic reactions, and when to transfer a patient to a higher level of care. The team also established clinical practice guidelines and minimum requirements for individual CHCs to qualify for administering antivenom. Finally, the team conducted various cost-effectiveness analyses, which showed that providing treatment at CHCs reduces hospital use and gets antivenom into patients faster.

Meeting the 2030 WHO goal

“If we continue on this path, we are on track to meet the 2030 WHO goal of reducing death and disability by snakebite in Brazil,” said Vissoci. Brazilian by birth, he said it is essential to build bridges across institutions and countries to contribute to global health. “We should be leveraging data better in the low-income world, because it takes a lot of work for people in these countries to generate that data. The computing capacity Duke has, including cloud computing data science techniques, means I can deploy artificial intelligence in the Amazon to understand how to distribute healthcare resources.”

While the global pandemic impacted the project, the team “navigated COVID pretty well,” said Gerardo, noting “a lot of this work involved advanced geospatial (analysis) and artificial intelligence and used existing data. We overcame challenges by being innovative.” The team remains on track and now most of the work is “in the manuscript or presentation phase, which is where we should be right now.”

Oral health researchers welcome here!

I was thrilled to give the keynote address at the annual meeting of the International Association for Dental Research. A renewed sense of urgency in global oral health is surfacing now and highlighted by two recent publications. One is the recent Lancet Commission on Oral Health, which brought together a collection of world-renowned experts to consider the opportunities and challenges ahead, primarily in the areas of global access to care and delivery. The second is the 2021 WHO Draft Global Strategy on Oral Health that has presented a fresh plan for tackling oral diseases. The WHO proposal includes a framework for tracking progress with measurable targets to be achieved by 2030.

There is a growing recognition that oral health has been left out of the agenda for universal health care (UHC). We all recognize that it’s impossible to exclude dental health from general health. It follows, then, that UHC can only be achieved when oral care is included in the commitment to “better health for all.”

I believe medical research and oral health research need not be conducted in silos. We at Fogarty welcome bright ideas from anyone from any discipline seeking to work on oral health issues. I see an abundance of opportunities spanning diverse medical and dental interests.

Though only a small percentage of NIH’s $45 billion dollar budget goes directly to Fogarty’s international agenda, all the institutes maintain global footprints, while more than half have joined us to fund global health projects.

Currently, the NIH has the good fortune of outstanding senior leadership with deep roots in oral health. Dr. Lawrence Tabak, is currently performing the duties of the NIH Director after previously holding the post of director of the National Institute of Dental and Cranial Research (NIDCR). Meanwhile, the NIDCR’s current director, Dr. Rena D’Souza, has strongly supported and promoted global oral health throughout her tenure.

The recent appointment of Dr. Jessica Webster-Cyriaque as NIDCR’s deputy director also speaks to an international

vision. Webster-Cyriaque helped found a training program in Malawi as well as that nation’s first dental school (see this issue’s Q&A on page 5).

Fogarty’s portfolio develops talent by sponsoring qualified, emerging investigators and giving them protected time to conduct research in LMICs. Individual research opportunities include one-year fellowships for students and postdocs from anywhere in the world. While still a dental student, Dr. Ashley Karczewski, helped conduct a survey of the provision of oral health care to teens living with HIV in Kenya as her Fogarty project. Past dental fellows include Dr. Lilliam Pinzon, who evaluated dental restorations in underserved HIV-positive children in Mexico.

Another Fogarty program, the International Research Scientist Development Award, provides five years of mentored support for U.S. postdoc scientists who wish to spend 50% of that time in an LMIC. Meanwhile, the Emerging Global Leader Award offers the same level of support for postdoc scientists from LMICs. Fogarty has supported Dr. Lord Gowans, who used genomic sequencing to elucidate the etiology of cleft palate in Ghana, and Dr. Dalton Wamalwa, who created an oral health training program called TABASAMU—a Swahili word meaning “smile”—for dentists wishing to work with HIV/AIDS patients in Kenya.

Two additional Fogarty programs, Data Science for Health Discovery and Innovation in Africa (DS-I Africa) and Mobile Health: Technology and Outcomes in Low and Middle Income Countries (mHealth) also welcome scientists with original oral health research projects.

Regarding mHealth, I wonder: What conditions could smart phone images help detect in the face, mouth, jaw, and gums? Could a mobile phone equipped with AI help diagnose patients who are supported by community health workers?

This is an extraordinary time to expand and articulate Fogarty’s global training and research agenda in the area of oral health. It will always be our mission to seek fresh scientific minds and projects committed to the goal of radical inclusion: better health, including oral health, for all.

Fauci to step down

After 54 years of public service at NIH, Dr. Anthony Fauci, Director of NIAID and Chief Medical Advisor to President Biden, announced he will be stepping down in December 2022. Fauci served as NIH’s face for many infectious disease threats during his decades-long career, including HIV/AIDS, West Nile virus, Ebola, Zika, and COVID-19.

Barbosa da Silva Jr. to lead PAHO

Dr. Barbosa da Silva Jr. was elected Director of the Pan American Health Organization (PAHO) during the 30th Pan American Sanitary Conference in September. Dr. Barbosa da Silva Jr. will begin his tenure in February. Currently the Assistant Director at PAHO, he was previously Brazil’s Secretary of Health Surveillance.

Nkengasong awarded Virchow Prize

PEPFAR Ambassador Dr. John Nkengasong has received the prestigious Virchow Prize for his long career of trailblazing contributions to global health. The prize recognizes the lifetime achievements of those dedicated to improving the health and well-being of the world’s most vulnerable and whose accomplishments align with the United Nations Sustainable Development Goals (UN SDGs).

Former Fogarty scientist heads Pasteur Network

The Pasteur Network has named Dr. Rebecca F. Grais, a former Fogarty scientist, Executive Director. The network brings together 33 institutions to improve human health through biomedical research, public health activities, training, and innovation. Grais has extensive experience in epidemiological research focused on underserved populations.

Fogarty-funded research receives AAAS award

An inexpensive paper microscope called the Foldscope received a 2022 Golden Goose award from the American Association for the Advancement of Science. Support from NIH was foundational to the early research that went into its creation. Co-creator Dr. Manu Prakash first conceived of a cheap microscope while studying malaria in Thailand.

Dr. Jim Cybulski was a student in Prakash’s lab at Stanford University when he started working with Dr. Prakash on the Foldscope. He also helped field test the microscope in Southeast Asia and Africa. The award recognizes federally funded science that has led to breakthroughs in biomedical research, medical treatments, and computing and communications technologies.

New guidance promotes equitable research partnerships

The ESSENCE on Health Research initiative & UK Collaborative on Development Research published a Good Practice document laying out four interconnected approaches to supporting equitable partnerships in global health research. Fogarty is a member of ESSENCE and contributed to the document which draws on the experience of funders, research organizations, and researchers in low-, middle- and high-income countries.

PIH establishes Farmer Scholarship Fund

Partners In Health announced a new $200 million scholarship fund named for the late humanitarian, physician, and global health advocate Paul E. Farmer. The fund will support medical students and global health delivery master’s degree candidates at the University of Global Health Equity (UGHE) in Rwanda for the next 25 years.

CUGH launches capacity platform

CUGH released its new Capacity Platform with the goal of connecting trainers with the training needs of institutions in low-income countries. It also allows institutions as well as affiliated individuals to post their training needs and training offerings, and users to search implementation science listings separately from general ones.

USAID announces TB elimination project

Supporting, Mobilizing, and Accelerating Research for Tuberculosis Elimination (SMART4TB) is a fiveyear initiative that will invest up to $200 million to identify more effective methods and tools for finding, treating, and preventing tuberculosis in 24 priority countries via an international consortium in the U.S., South Africa, India, Uganda, Kyrgyzstan, and Vietnam.

US and WHO hold Strategic Dialogue

HHS Secretary Xavier Becerra and WHO DirectorGeneral Dr. Tedros Adhanom Ghebreyesus, along with representatives, met in September to discuss priority global public health issues, areas of collaboration, efforts to develop a new pandemic instrument, and strengthening the International Health Regulations (IHR). The next Dialogue is slated for late 2023.

Global Health Matters

September/October 2022 Volume 21, No. 5 ISSN: 1938-5935

Fogarty International Center National Institutes of Health Department of Health and Human Services

Managing editor: Judy Coan-Stevens Judith.Coan-Stevens@nih.gov

Writer/editor: Mariah Felipe Mariah.Felipe@nih.gov

Writer/editor: Susan Scutti Susan.Scutti@nih.gov

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.

Tracking equity through authorship

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It matters—greatly—when a published study about sub-Saharan Africa credits scientists from the region as first or last authors. Authorship not only indicates leadership in conducting and sharing research, it also is an essential part of a researcher’s career. Good news: The number and percentage of Fogarty-funded publications about the region with subSaharan Africa (SSA)-affiliated first and last authors increased between the years 2008 and 2020, according to a new Fogarty-authored study published in BMJ Global Health.

“While SSA makes up 12.5% of the global population, only 1.1% of the world’s researchers are based in the region,” wrote Fogarty co-authors Ezinne Akudinobi and Deputy Director Dr. Peter Kilmarx. In addition to the total number of publications from the region rising, the percentage of those authors with an SSA affiliation rose as well – from 45% to 63% for first authors and 28% to 46% for last.

What’s needed is an investigation of impediments faced by SSA authors—

barriers, stringent authorship guidelines, and editorial bias, among them. “There is more at stake than publish or perish,” concluded Akudinobi and Kilmarx. “Ideally, African authorship will increasingly reflect Africans setting research agendas and writing about African issues for African

It Takes ALL of US: Promoting Preconception Health in Delaware

BACKGROUND

Chronic diseases and adverse health behavior known to affect pregnancy outcomes are prevalent among women of reproductive age (15–44 years). African-American and minority/Hispanic women are disproportionately affected by poor health with higher rates of comorbidities and chronic health conditions than White women.1

In Delaware, risk factors such as obesity, preeclampsia, and high blood pressure are on the rise in women of reproductive age. In addition, almost 40% of Black mothers experience a maternal mental health condition such as depression or anxiety. However, when compared to White women, Black women are half as likely to receive treatment.2 These health issues, coupled with a need for education in positive health practices and self-care, are all significant contributing factors to the widening disparity gap, and contributes to poor maternal and infant/child health outcomes.

These chronic health issues present unique reproductive challenges for women. A focus on preconception health results in improved reproductive outcomes. Life planning can be an effective tool to improve knowledge of preconception, contraception, and interconception health, which is especially helpful in women with chronic diseases and is helpful for maternal/child health outcomes in all women, regardless of health status.3

Additionally, issues such as lack of access to resources like health insurance, provider shortages, and difficulty accessing primary care and maternal health care in highrisk communities, as well as a lack of knowledge of the importance of preconception care, contributes to maintaining and perpetuating these disparities.

DELAWARE HEALTHY MOTHER AND INFANT CONSORTIUM/DPH INITIATIVE

The Delaware Healthy Mother and Infant Consortium (DHMIC), supported by the Delaware Division of Public Health’s (DPH) Family Systems, aims to address these health disparities by ensuring that all women are offered education and information during every health care visit in order to get and stay healthy BEFORE becoming pregnant. This is the primary goal of the “Every Woman Every Time” Well Woman Initiative for Delaware.

Another approach to reduce health disparities being utilized by the DHMIC/DPH is the implementation of placebased initiatives (PBIs). These initiatives address social determinants of health (SDOH) by providing preconception and maternal care services and support in high risk target areas through community mini-grant partners. In addition, community health workers are trained and deployed in high risk communities to meet the needs of women and provide

informal counseling, promote healthy behaviors, screen for SDOH, and refer to resources and services in Delaware.

DHMIC/DPH also disseminates information to the community through the use of the DE Thrives social media campaigns and provision of educational resources and materials such as life plans for women, men and teens; health information for women before, during and after pregnancy; community outreach; and Black maternal health awareness, including HerStory.com, which are available on the DE thrives website (https://dethrives.com/).

COMMUNITY PARTNERSHIPS TO ADDRESS SOCIAL DETERMINANTS OF HEALTH

Social determinants of health (SDOH) are defined as the circumstances where people are born, grow up, live, play, and work and have a significant role in shaping health outcomes.4 Women, infants, and young children in high-risk communities are exposed to unhealthy lifestyle/behavioral risk factors such as poor nutrition, physical inactivity, and smoking, as well psychosocial issues such as isolation and abuse.

These risk factors, as well as toxic stress, can result in life threatening conditions, poor maternal health conditions, and adverse pregnancy outcomes such as prematurity, low birth weight, and infant/child death. Research has shown that women, children and families do their best and have the ability to thrive when they are living in strong and supportive communities with access to the resources that they need.4

Through interviews conducted statewide in Delaware (available on dethrives.com/her-story), African American women have expressly stated that there is a need for support with obtaining mental health treatment; they feel unheard/ unseen by their health care providers; and that biases such as racism, social status, and lack of access to quality food, healthcare, and education are significant barriers to optimal health.

‘Healthy Women, Healthy Babies’ is a program designed for women who are at risk for poor birth outcomes in Delaware, and facilitates comprehensive preconception, prenatal, and interconception care to women, regardless of insurance status. The DHMIC/DPH supports seven healthcare partners throughout Delaware to provide this program. The program seeks to address health issues and SDOH by providing services and wraparound supports for women who want to live healthier lives, plan to become pregnant, or who are pregnant. The long-term goal of this program is to reduce disparate birth outcomes and save the lives of both babies and their mothers.

DOI: 10.32481/djph.2022.10.009

The ‘Healthy Women Healthy Baby Zones’ is a separate program that is a joint initiative of the DHMIC, DPH and the community as a part of the infant mortality reduction work in Delaware to address SDOH by implementing nonmedical community-based interventions through community partners to build state and local capacity.

Currently, the DHMIC/DPH has eight community-based organizations that have been awarded mini-grants anchored in best practice and promising approaches to implement small scale innovative strategies in the community targeted at the root causes of infant mortality in order to improve SDOH and equity in birth outcomes.

Mini-grantees are focused on specific areas of need such as:

• Resources for self-care and preventive physical health care;

• Stress, anxiety, and other mental health concerns;

• Need for pregnancy planning and reproductive health education;

• Isolation and disconnection; and

• Need for emergency financial support. The communities of primary focus are those with high risk factors such as high infant mortality, high premature birth rates, poverty and/or other societal/community risk factors. Through these community partnerships over 550 women have been served between the ages of 15-44 (primarily women of color). These partnerships have resulted in statistically significant reductions in stress—including increased feelings of hopefulness—and reductions in financial stress. It has also resulted in over a dozen trained doulas who are women of color, and increases in breastfeeding initiation and duration.5

LIFE PLANNING IN PRECONCEPTION HEALTH

Women of reproductive age are very diverse, with numerous health and psychosocial issues that can affect their reproductive health. In addition, there is a wide variety of healthcare delivery settings, making it difficult, if not impossible, to establish one ‘best’ standard model of preconception care for all women. Because of this, preconception care interventions must be uniquely tailored to women with regard to their specific circumstances, health needs, and personal desires.

A life plan (LP) is extremely useful in preconception healthcare, as well as interconception care, to ensure that health conditions and behaviors that may pose a risk to mothers and infants are identified and managed.1 A life plan is much more than just asking about pregnancy intention. If implemented and utilized to its full capacity, it is a costeffective preconception counseling tool that can be utilized in a variety of healthcare settings for women with chronic health diseases, as well as healthy women who may need guidance on maintaining their health and developing a plan for their healthcare future whether intending to become pregnant or not.

Use of a life plan has also been shown to be effective in managing the unique challenges that women with chronic health conditions experience during pregnancy. Preconception care targeted to African-American and minority women who may be at risk for poor birth outcomes has been shown to be effective when specific risk factors are identified and appropriate interventions are put into place. LPs are a useful tool to help identify women who are at risk and provide appropriate interventions and recommendations to resources based on the unique health care and personal needs of the woman.1

The DHMIC is a proponent of the life course model and the utilization of a life plan. The life course model is based on the understanding that an individual’s health status is a compilation of cumulative life conditions. Therefore, individual interventions should be tailored to account for the impact of social and environmental exposures on an individual’s health, both positive and negative.6 A life plan provides a way to tailor interventions most appropriate for the individual.

Through the DHMIC, the ‘My Life My Plan for Women’ located on the DE Thrives website (available in print and online at https://dethrives.com/mlmpw/overview) was created as an interactive way to help women think through their health goals, plan for the future (whether intending to become pregnant or not), and make healthy decisions. This provides an excellent opportunity for providers and community workers to educate and empower women to become involved in their own health future and advocate for their needs. The primary goal of the DHMIC in regards to life planning is to engage as many Delaware women as possible to utilize a life plan and think through their health behaviors, pregnancy intention, and health choices. Another DHMIC objective is to engage as many clinicians, educators, peer counselors, and other community workers in utilizing the life plan in their work with Delaware women, and sharing the life planning tools provided by the DHMIC.7

In addition to the provision of these resources and information, the DHMIC engages the community through the DE Thrives social media page, and provides education for providers and community health workers working with women of reproductive age that may be at risk.

SUMMARY

Life planning and the implementation of place-based initiatives to address SDOH in high risk communities are key strategies in Delaware promoted by the DHMIC/DPH to improve maternal/infant health outcomes and address health disparities. There has been progress in reducing maternal/ infant health disparities over time, however more work needs to be done to eliminate these disparities.

The use of a life plan for every woman and individual of reproductive age in Delaware could go a long way in helping to close that gap. Continued utilization of community partners through the mini grant program to deliver services and resources to high-risk communities is a place-based initiative that has also proved to be successful.

By continuing to provide education, resources, and promote community provider engagement, the DHMIC—in collaboration with DPH—helps to promote health equity by enabling ALL Delaware women to make a plan for their health future. Furthermore, it promotes and encourages women to manage chronic conditions before pregnancy, until ‘Every Woman Every Time’ receives the education and information needed to get and stay healthy BEFORE becoming pregnant.

As healthcare providers and community workers the potential positive impact of life planning in women of reproductive age cannot be overlooked. The challenge for HCPs and community workers is to consider how life planning can be incorporated into practice to start the conversation about preconception care. It is also important to consider how to partner with community organizations in high-risk areas to address the social determinants of health that can act as barriers to women achieving and maintaining optimal health.

Ms. Brathwaite may be contacted at LaToya_FNP@motherbabyandbeyond.com

REFERENCES

1. Biermann, J., Dunlop, A. L., Brady, C., Dubin, C., & Brann, A., Jr. (2006, September). Promising practices in preconception care for women at risk for poor health and pregnancy outcomes. Maternal and Child Health Journal, 10(S1, Suppl), 21–28. https://doi.org/10.1007/s10995-006-0097-8

2 Maternal Mental Health Leadership Alliance. (2021). Fact sheet “maternal mental health: black women & birthing people”. Retrieved from https://www.mmhla.org/wp-content/ uploads/2021/11/Black-Women-Birthing-People.pdf

3. Mittal, P., Dandekar, A., & Hessler, D. (2014, Spring). Use of a modified reproductive life plan to improve awareness of preconception health in women with chronic disease. The Permanente Journal, 18(2), 28 32 https://doi.org/10.7812/TPP/13-146

4 U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (n.d.) Social determinants of health-healthy people 2030. Retrieved from https://health.gov/healthypeople/objectives-and-data/socialdeterminants-health

5 Delaware Healthy Mother & Infant Consortium and Delaware Division of Public Health. (2022). Healthy women healthy baby zones mini-grants. Retrieved from https://dethrives.com/thriving-communities/healthy-womenhealthy-babies-zones-mini-grants

6. Jones, N. L., Gilman, S. E., Cheng, T. L., Drury, S. S., Hill, C. V., & Geronimus, A. T. (2019, January). Life course approaches to the causes of Health Disparities. American Journal of Public Health, 109(S1), S48 S55 https://doi.org/10.2105/AJPH.2018.304738

7 Delaware Healthy Mother & Infant Consortium and Delaware Division of Public Health. (2022). My life, my plan women. Retrieved from https://dethrives.com/dhmic/ strategic-initiatives/my-life-my-plan-women

Developing a Storytelling Study for African Americans with Hypertension: A Study Protocol

ABSTRACT

Objective. Storytelling is an engaging approach for promoting health and wellness among individuals with health conditions including type 2 diabetes (TTDM), breast cancer, and hypertension. Storytelling interventions are an evidence-based approach that has been effective in promoting behavioral change such as increasing physical activity, medication adherence, and making dietary changes. The use of storytelling to convey health information and promote behavior change is associated with increased engagement in self-management particularly in communities of color. The primary objective of this paper was to describe our process for developing the storytelling study; specifically, recruitment, screening, selecting storytellers, and developing a study-specific interactive website. The secondary objective was to describe the approach for conducting the feasibility study and conduct a 6-week web-based storytelling study. Methods. Between 2017 to 2020, we developed a storytelling study for African Americans with hypertension. During that period we recruited participants from a Federally Qualified Health Center, a local church, and at community events. We selected storytellers to share their experiences managing hypertension and filmed 10 storytellers. Presently, a feasibility and pilot study are underway, the goal of the feasibility study is to ascertain feedback about the stories and the study website from African American adults with hypertension. We will also conduct a 6-week pilot study with 30 African American adults to see if conducting a storytelling study online would be an effective approach for promoting behavioral change. Conclusions. We successfully recruited and filmed 10 storytellers and produced 9 stories about living with and managing hypertension. The feedback we received from participants in the feasibility and pilot study will be useful as we refine the design of the study to determine the potential for a future randomized controlled trial (RCT).

INTRODUCTION

Narrative communication is defined as nonverbal and verbal communication that is arranged in a logic manner to generate a meaning.1 Storytelling narratives typically portray cause-and-effect relationships that impact characters over a period. Previous studies have indicated that audiences find narratives easier to understand and more compelling than traditional forms of health communication.2 Narratives provide specific examples from which an individual can extrapolate more general truths via inductive reasoning. Storytelling is particularly effective in communities of color and in communities that have strong traditions of oral storytelling. Storytelling has been used to promote behavioral change, encourage self-efficacy, and break down resistance to healthrelated messages.3 Stories may encourage and motivate the participant to learn more or to take similar steps towards self-care as described within the stories. Stories elicit emotional responses and participants are able to empathize with the characters in the story, therefore, the participants may more easily remember the information contained in the story.4–7

Storytelling interventions are designed for promoting healthy lifestyles and delivering health information in the form of personal narratives from individuals with similar health conditions as well as social and cultural backgrounds. The stories convey health information in a way that goes beyond didactic teaching; it instead teaches the individual by allowing them to observe and connect with the actions taken by the storyteller.8 Storytelling interventions have demonstrated success in communities of color, and have been used to promote healthy behaviors such as dietary change, increased physical activity, and medication adherence for outcomes such as breast cancer, colorectal cancer, type 2 diabetes, and hypertension.5,9–12 Storytelling interventions are also an effective approach for health education and health promotion among individuals with limited health literacy, functional literacy, and those less likely to use technology to access health information.

Technology is an effective approach for delivering lifestyle and behavioral interventions. Web-based interventions are accessible using personal or public computers and mobile devices such as phones or tablets. A recent report from the Pew Institute indicated that approximately

DOI: 10.32481/djph.2022.10.010

95% of Americans own a cell phone and 77% are smart phone owners.13 The same report indicated that 45% of all Americans own a tablet (e.g., iPad, Galaxy Tablet, Nexus, or Kindle Fire). Due to the COVID-19 pandemic there has been a steady increase in the use of mobile technology, particularly among older adults. In 2021, over 90% of adults reported using the internet was essential and 40% reported using digital technology/internet in new ways due to the pandemic.14 Developing an intervention using an interactive video website may be an effective and engaging approach for delivering a behavioral health intervention, particularly in communities underrepresented and underrecruited for technologybased interventions, such as the African American community and individuals living in communities of low socioeconomic status. Using an interactive website may also be an effective approach for reaching individuals that are concerned about meeting in-person due to COVID-19 and those at increased risk of severe complications of COVID-19 like those managing chronic conditions (i.e., diabetes, hypertension).

The prevalence of controlled hypertension is low among all racial and ethnic groups, but is particularly low in the African American community.15 Approximately 20% of African Americans have controlled hypertension.16 African Americans also have the highest prevalence of hypertension in the United States, with 45% of African American men and 46% of African American women having the condition.17 Social and environmental factors—including access to care, family history, as well as psychosocial stressors—contribute to the increased prevalence of hypertension and uncontrolled hypertension, and are also associated with poorer health outcomes seen among African Americans with hypertension. Behavioral and lifestyle interventions designed to improve medication adherence, diet, and exercise among African Americans have demonstrated success in behavioral change,18,19 but African Americans still experience challenges in achieving controlled hypertension and long-term behavioral change.

There is a need to design engaging, effective, and impactful evidence-based studies and interventions to promote health and well-being among individuals with hypertension, and to make these studies available and accessible to African Americans living with and managing hypertension.

In response to this need, we developed the High Blood Pressure Stories (HBPStories), a storytelling study, with the goal of promoting lifestyle and behavioral change, and reducing systolic and diastolic blood pressure. In this paper, we describe the two phases of this study: development and feasibility. The primary objectives of the development phase were to recruit African American adults with hypertension to describe their experiences living with and managing hypertension and to develop a study specific website as a platform for sharing the stories. The objectives of the feasibility study were to elicit feedback about the stories and website, and to conduct a 6-week pilot study.

METHODS

Methodological Foundations

Our theoretical framework was developed based on an adapted version of the Slater Model of Narrative Communication Theory (see Figure 1).20 This theory has been used to inform the design of storytelling interventions such as the Culturally Sensitive Intervention: Birmingham Study, which informed the design of our study.7 The advantage of a narrative communication (storytelling) approach is that it appeals to populations with limited health literacy and breaks down resistance to health messaging. The Slater Model of Narrative Communication Theory posits that four constructs contribute to changes in attitudes, behavior, and motivation. We will briefly summarize the theory which has been described in detail in similar studies.3,21 First, the combination of the narrative content (storyline) and production quality leads the viewer to become transported by the story and absorbed into the storyline.7

Second, the persuasive subtext provides an underlying concept of behavioral change that motivates the individual to make lifestyle changes. Third, homophily and cultural relevance (e.g., similarity between characters and participants) allow viewers to self-identify with the individual telling the story. Observing their similarities with the storyteller, the viewer is better able to connect to the story and picture themselves making the changes described. The content and relatability of the illustrations, combined with an engaging literacy level of appropriate text, may allow the reader to become absorbed into the story. Lastly, the subtle behavioral change subtext and visual similarities between the viewer and the characters in the story may contribute to greater engagement in the story and ultimately promote behavior change.

Study Funding

The development phase of the HBPStories study was funded by the Penn State Clinical and Translational Science Institute KL2 program. The program provided three years of funding to conduct this study; this phase of the study was completed in September of 2020. The feasibility phase of the HBPStories study was funded by the University of Delaware COBRE Pilot Award, which provides one year of funding. The feasibility arm was awarded in December of 2021 and the study is ongoing.

Participating Sites

The development phase of the study was conducted at a Federally Qualified Health Center (FQHC) located in Harrisburg, PA, in a culturally and linguistically diverse area of the city. Many of the patients served by the FQHC were racial/ethnic minorities. The FQHC was an ideal location for recruitment, as over 5000 patients served by the clinic were receiving care and treatment for hypertension. The feasibility phase of the study is taking place at a Federally Qualified Health Center located in Wilmington, Delaware, which serves over 4,500 African Americans with hypertension.

Inclusion/Exclusion Criteria

The inclusion and exclusion criteria were the same for both the development and feasibility phases of the study. The inclusion criteria includes:

1) Diagnosis of hypertension;

2) Self-report being prescribed medication for the treatment of hypertension;

3) Age ≥ 18 years; and

4) Self-report being African American or Black.

The exclusion criteria includes:

1) Mental status precluding ability to provide informed consent;

2) Pregnancy; and

3) Unable to speak or read English.

DEVELOPMENT PHASE

Aims of the Development Phase

The development phase consisted of two objectives:

1) storyteller recruitment and filming and

2) website development.

Storyteller Recruitment and Filming. Semi-structured interviews were conducted with 15 African American adults to identify storytellers. Storytellers discussed the successes and difficulties in managing hypertension. Ten participants were selected to be filmed as storytellers; interviews were 18–20-minute stories that were edited to 2–3-minute stories.

Website Development. During the website development phase, we collaborated with Hayman studios to create the website as a platform for delivering the stories and health education information obtained from the American Heart Association. The study website is www.HBPStories.com. The website was designed so that participants could access the password protected website from a mobile device such as a phone, tablet, or a personal computer. The website contained three sections: personal stories, health education, and a section to request more information.

Recruitment and Consent

Study participants were recruited from various sites in Central Pennsylvania, an FQHC, and at community-based events hosted by Derry Street Methodist Church. Physicians, nurses, and staff at the FQHC supported the study by identifying individuals that met the inclusion/exclusion

criteria for the study and sharing the details of the study with the patients. The PI or a Research Assistant were onsite at the FQHC two days a week for on-site recruiting and conducting interviews. The FQHC hosted blood pressure screening and health education sessions twice a month during the Derry Street Methodist Church Food Pantry. Individuals interested in participating in the study were scheduled for a 30-minute screening interview and a semistructured interview to elicit stories. If the participants were unable to participate in the interview on the day of their visit to FQHC or at Derry Street Methodist Church, a phone interview was scheduled. Participants were consented during the phone interview or in-person. During the interview, the PI or study staff asked the participant questions from the Storytelling Project Script, to elicit their stories and to determine if the participant would be interested in engaging in the filming. The script encouraged storytellers to describe their experiences, particularly those related to the social determinants of health such as social support, accessing health care, transportation, and quality of care. Participants were encouraged to share their experiences, emotions, and concerns related to living with and managing hypertension. The script provided a framework for the storytellers to build upon. The PI reviewed the patient interviews and selected the participants who would have their stories filmed using the Storytelling Rating Form (Table 1). The selection criteria were based on the clarity of the story, how engaging the storyteller was, and the impact of the information shared in the story. If the participant was selected to be a storyteller, the study manager contacted the participant to schedule the 1.5-2hour filming session and to determine where the participant wanted to be filmed. Participants provided written consent before participating in the filming.

Questions from the Storytelling Filming Script

• Tell me the story of when you found out you had high blood pressure?

• Is there a person in your family or a friend that supports you in managing high blood pressure, please share a story of how they support you?

• After you found out you have high blood pressure, what did you do or where did you go to learn more about high blood pressure and your medication?

• What has been difficult or challenging about managing high blood pressure?

• What has made managing high blood pressure easier for you?

• Can you tell me a story about how you have made changes to manage high blood pressure?

• If you had a family member or friend that recently learned they had high blood pressure, what would you recommend they do?

• If they wanted more information about high blood pressure or places to get care, where would you recommend, they go?

• Please tell me why you decided to share your story about high blood pressure with others?

1. Storytelling Rating Form

How well did the storyteller do in explaining things in a way that is easy to understand?

Extremely Well

Very Well Somewhat Poorly Very Poorly

How well do the stories get across the message of taking care of yourself?

Extremely Well Very Well Somewhat Poorly Very Poorly

How well do stories provide specific examples of how to manage hypertension?

Extremely Well Very Well Somewhat Poorly Very Poorly

How well do the stories reflect a positive attitude towards high blood pressure?

Extremely Well

Very Well Somewhat Poorly Very Poorly

What was your overall impression of the videos?

Extremely Well

Very Well Somewhat Poorly Very Poorly

Study Design

Storyteller Recruitment and Filming. The storytellers engaged in a 18-20-minute interview to elicit personal narratives. The stories were focused on one or more of the social determinants of health (social support/social network, transportation, inability to afford medication, health literacy, housing instability, physical environment, locating healthy foods, and the patientphysician relationship). We recruited and interviewed 15 African Americans with hypertension. Participants reviewed a list of themes related to the social and behavioral determinants of health and used the themes as a guide when sharing their stories. Ten African Americans with hypertension were invited to share their stories of living with and managing hypertension. Ryan Hayman (videographer) filmed the storytellers in various locations in Harrisburg, Pennsylvania, including the FQHC, Broad Street Market, Midtown Bookstore, and the Susquehanna River Waterfront. Individuals selected for storytelling interviews received a $20 gift card for participating in the study. Individuals selected as storytellers and those who completed the filming sessions received an additional $40 gift card for a total of $60 for completing both parts of the study.

Website Development. Dr. Cuffee and Hayman Studios website development team collaborated to develop the study logo and website. In July of 2019, the Hayman Website Development Team submitted a proposal for three mood boards providing options for the appearance of the website and three logos, which displayed a variety of colors, images, and layout options for the website. The PI selected the final logo and website design for the HBPStories project. The website development team worked to create a mobile platform that would be accessible on a mobile device or a computer. For the health information section of the website, health information was obtained from the American Heart Association website and the American Heart Association of Central Pennsylvania. We selected six aspects of hypertension management (hypertension management, medication, healthy diet, active lifestyle, stress management, modifying behaviors) and provided brief educational information about each topic. The research team and PI collaborated with a peer-health coach, one of the storytelling participants, to review the materials and provide feedback on the topics that would be most helpful and informative to individuals managing hypertension. The peerhealth coach had a background in health, physical activity, and promotion of physical wellness, and an interest in supporting projects that promoted her values and interest.

Ethics

The development phase of the study was reviewed and approved by the Penn State Institutional Review Board (IRB). The FQHC in Harrisburg did not have an independent IRB, but provided a letter of support with the IRB submission.

FEASIBILITY PHASE

Aims of the Feasibility Phase

The feasibility phase has two objectives: 1) To obtain feedback from individuals viewing stories and 2) to conduct a six-week web-based demonstration.

Story and Website Viewing.

During the Story and Website Viewing phase of the study, 30 African American men and women with hypertension watched the stories filmed during the development phase and provide feedback on the effectiveness and engagement with the stories. They also shared personal preferences about the design features of the study that would be most useful for a lifestyle and behavioral storytelling intervention. The participants were surveyed using Research Electric Data Capture (REDCap) after watching each story and provided feedback on engagement, satisfaction, impact of the storyteller, and the usefulness of the story.

Pilot Study.

Thirty African Americans with hypertension will be recruited from a FQHC in Wilmington, Delaware to participate in a 6-week storytelling study. The 30 participants in the pilot study will not be the same participants in the Story and Website Viewing phase of the study. Each week, participants will watch one story, review one module of health information, and then complete a short survey in REDCap about their experience watching the story and reviewing the materials. The participants will engage in two study visits, one at baseline and a second at 6-weeks. Blood pressure will be measured during each visit and data on self-reported diet, exercise, medication adherence, and other behavioral measures will also be collected.

RECRUITMENT AND

For the Story and Website Viewing phase, we recruited participants from the FQHC in Wilmington, using flyers displayed at the University of Delaware, and at community events such as Newark Community Day. Participants were consented on-site for inperson visits and online using Adobe consent forms and using the signature function in HIPPA approved Zoom.

Study Design Feasibility Phase

Story and Website Viewing Phase.

During the baseline visit, the research team confirmed that potential participants met the inclusion/exclusion criteria, then had the study details explained and were consented for the study. Participants were scheduled for a one-hour study visit to view the stories and navigate the website. During the visit, self-reported demographic data including age, gender/gender-identity, income, and years of education were collected. All study data was collected in REDCap. Participants were instructed to watch the nine patient videos (each 2-3 minutes in length) and complete a short 3-5-minute REDCap survey after each video. The order of the survey completion in REDCAP was randomized to alternate the order in which participants watched the videos. After providing feedback on the individual stories, participants completed a 10-minute survey to gauge overall satisfaction with the stories, engagement, usefulness of the website, and potential uses for future studies. The feedback from the surveys will be used to rank which stories were most informative and engaging, and to select the top six for the pilot study phase of the study. Participants were also invited to participate in a 10-minute exit interview to discuss their decision and motivation for participation and if they would recommend the study to family or friends. The study visit took 1-1.5 hours to complete, and participants received $20 gift card upon completion of the surveys and an additional $10 gift card for participating in the exit interview.

Pilot Study.

Thirty participants will engage in a 6-week online storytelling study and provide feedback on the effectiveness, engagement, and recommendations for improving the design of the study for future interventions. During the baseline visit, the participants blood pressure will be measured to confirm they meet the inclusion criteria, the study details will be explained, and a research team member will consent the participant. Each participant will be invited to participate in a one-hour visit training session for using and accessing the study website. Each week participants will be instructed to watch one of the 2-3-minute stories and engage with one module of health information on the website by logging into the website with participant-specific log in credentials. After reviewing the materials and viewing the weekly story, participants will complete a 5-minute survey in REDCap. The participants will also review the health materials from the American Heart Association on the website covering topics such as using an electronic pill bottle to manage medication, exercising at home, and cooking healthy meals. Participants will be expected to spend 30-minutes to an hour each week viewing the stories and study material, and will be reimbursed with a free blood pressure monitor and $5 dollars each week for a total of $30 upon completion of the study survey. The study includes a pre- and post-study survey to assess changes in diet, physical activity, and medication adherence. The exit survey will collect data about engagement with the study, reasons for not participating/ dropping out, satisfaction with the study, and approaches for improving the study.

Ethics

The feasibility phase of the study was reviewed and approved by the University of Delaware IRB. The Federally Qualified Health Center in Wilmington does not have an independent IRB but has an internal review board that reviewed, provided feedback, and approval to conduct the study in conjunction with the Federally Qualified Health Center.

Planned Data Analysis

Qualitative data will be analyzed using NVIVO software. The study team will develop codes and conduct a thematic analysis, and two team members will analyze the data. For the Stories and Website Viewing phase we will apply a convergent mixed methods design. Specifically, the team will elicit common themes important for developing a behavioral storytelling intervention and descriptive statistics will be used to assess engagement of the storytellers and preferences for future interventions. The survey data and the quantitative data will be analyzed using STATA BE 17. We will collect quantitative data and conduct a baseline analysis of demographic variables using summary statistics, t-test, chi-square test and ANOVA. We will explore differences in engagement and preferences by gender, age, and income. For the pilot study we will analyze the data using qualitative research approaches. We will assess changes in blood pressure and selfreported changes in diet, physical activity, and medication adherence, using t-test, chi-square, and ANOVA, and adjust for age, gender, and literacy level.

DISCUSSION

Storytelling is an underutilized yet potentially powerful approach for promoting lifestyle and behavioral change for African Americans with hypertension. Adapting the delivery of a storytelling studies using a web-based platform may be a more engaging and accessible approach. We anticipate that this study will provide greater insights into the influence of storytelling on promoting lifestyle changes. The six-week study will provide insights into the engagement and satisfaction with a web-based storytelling study, and the potential for conducting an RCT. The development and feasibility phases of this study will lay the foundation for a future storytelling intervention that combines web-based storytelling and community-based storytelling to determine the most effective approach for conducting a storytelling intervention.

Limitations and Strengths

The development and feasibility studies are limited in that both recruited from Federally Qualified Health Centers in urban areas. The study participants are all African Americans; therefore the findings may not be generalizable to other racial and ethnic groups. However, the goal of this study is to provide a foundation for a future intervention for African Americans with hypertension. The study has a small sample size, but the objective of this study is to conduct a pilot and feasibility study, in preparation for an intervention with a larger sample size. Participants were recruited from FQHCs and community-events focused on health; therefore, the study participants may be more engaged in their medical care and management of hypertension than individuals that do not have access to or receive regular care from a health center. A strength of our study is that our study design applies mixed methods data collection to glean greater insights from participants about the effectiveness, engagement, and satisfaction with a storytelling study. The feedback from these participants will be helpful in designing and informing the design of a future storytelling interventions.

Developing and conducting a storytelling intervention will be most effective if participants are engaged in the development of the study and are invited to provide feedback about the study design. For the present study, we elicited feedback on the stories, website, and participant recommendations for the design of a future intervention. It is our hope that this feedback will provide important insights for designing an intervention that will be effective in promoting lifestyle and behavioral change but is also tailored to the needs of potential study participants. Our study findings will provide guidance and recommendations that might be useful for other researchers and providers interested in developing or conducting storytelling interventions for hypertension.

Funding: Dr. Cuffee was supported, in part by Grant 5 UL1 TR002014 and 5 KL2 TR002015 from the National Center for Advancing Translational Sciences (NCATS). Dr. Cuffee may be contacted at ylcuffee@udel.edu

REFERENCES

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5 Bollinger, S., & Kreuter, M. W. (2012, June). Real-time moment-to-moment emotional responses to narrative and informational breast cancer videos in African American women. Health Education Research, 27(3), 537 543. https://doi.org/10.1093/her/cys047

6 Dillard, J. P., & Peck, E. (2000). Affect and persuasion: Emotional responses to public service announcements. Communication Research, 27(4), 461 495 https://doi.org/10.1177/009365000027004003

7 Green, M. C., & Brock, T. C. (2000, November). The role of transportation in the persuasiveness of public narratives. Journal of Personality and Social Psychology, 79(5), 701 721 https://doi.org/10.1037/0022-3514.79.5.701

8. Hargraves, J. L., Bonollo, D., Person, S. D., & Ferguson, W. J. (2018, June). A randomized controlled trial of community health workers using patient stories to support hypertension management: Study protocol. Contemporary Clinical Trials, 69, 76 82. https://doi.org/10.1016/j.cct.2018.04.004

9 Green, M. (2006). Narratives and Cancer Communication. Journal of Communication, 56(Suppl 1).

10 Houston, T. K., Allison, J. J., Sussman, M., Horn, W., Holt, C. L., Trobaugh, J., . . . Hullett, S. (2011a, January 18). Culturally appropriate storytelling to improve blood pressure: A randomized trial. Annals of Internal Medicine, 154(2), 77 84 https://doi.org/10.7326/0003-4819-154-2-201101180-00004

11. Kreuter, M. W., Green, M. C., Cappella, J. N., Slater, M. D., Wise, M. E., Storey, D., Woolley, S. (2007, June). Narrative communication in cancer prevention and control: A framework to guide research and application. Ann Behav Med, 33(3), 221 235 https://doi.org/10.1007/BF02879904

12 Utz, S. W., Williams, I. C., Jones, R., Hinton, I., Alexander, G., Yan, G., Oliver, M. N. (2008, September-October). Culturally tailored intervention for rural African Americans with type 2 diabetes. The Diabetes Educator, 34(5), 854 865 https://doi.org/10.1177/0145721708323642

13 Anderson, M. (2015). Technology Device Ownership: 2015 Retrieved from http://www.pewinternet.org/2015/10/29/technologydevice-ownership-2015

14 McClain, C. V. E., Perrin A, Sechopoulos S, Raine L. (2021). The Internet and the Pandemic

15 Virani, S. S., Alonso, A., Benjamin, E. J., Bittencourt, M. S., Callaway, C. W., Carson, A. P., . . . Tsao, C. W., & the American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee (2020, March 3). Heart disease and stroke statistics-2020 update: A report from the American Heart Association. Circulation, 141(9), e139 e596. https://doi.org/10.1161/CIR.0000000000000757

16. Tsao, C. W., Aday, A. W., Almarzooq, Z. I., Alonso, A., Beaton, A. Z., Bittencourt, M. S., Martin, S. S. (2022, February 22). Heart disease and stroke statistics—2022 update: A report from the American Heart Association. Circulation, 145(8), e153 e639 https://doi.org/10.1161/CIR.0000000000001052

17 Mozaffarian, D., Benjamin, E. J., Go, A. S., Arnett, D. K., Blaha, M. J., Cushman, M., . . . Turner, M. B., & the Writing Group Members, & the American Heart Association Statistics Committee, & the Stroke Statistics Subcommittee. (2016, January 26). Heart disease and stroke statistics-2016 update: A report from the American Heart Association. Circulation, 133(4), e38 e360. https://doi.org/10.1161/CIR.0000000000000350

18 DeKoekkoek, T., Given, B., Given, C. W., Ridenour, K., Schueller, M., & Spoelstra, S. L. (2015, October). mHealth SMS text messaging interventions and to promote medication adherence: An integrative review. Journal of Clinical Nursing, 24(19-20), 2722 2735 https://doi.org/10.1111/jocn.12918

19. Ogedegbe, G. O., Boutin-Foster, C., Wells, M. T., Allegrante, J. P., Isen, A. M., Jobe, J. B., & Charlson, M. E. (2012, February 27). A randomized controlled trial of positive-affect intervention and medication adherence in hypertensive African Americans. Archives of Internal Medicine, 172(4), 322 326. https://doi.org/10.1001/archinternmed.2011.1307

20. Slater, M. D., & Rouner, D. (2002). Entertainment—education and elaboration likelihood: Understanding the processing of narrative persuasion. Communication Theory, 12(2), 173 191

21 Lee, H., Fawcett, J., & DeMarco, R. (2016, May). Storytelling/ narrative theory to address health communication with minority populations. Appl Nurs Res, 30, 58 60 https://doi.org/10.1016/j.apnr.2015.09.004

O. Y. Warren, MD

Seminar Virtual

Course Description

The Robert O. Y. Warren, MD Memorial Seminar was established in honor of Dr. Robert Warren, an outstanding Wilmington pediatrician. Dr. Warren practiced from 1932 until his death in 1968 and was instrumental in forming both the Child Guidance Center and the Child Diagnostic and Development Center, of which he was president. As the physician for Tower Hill School and a member of the Wilmington Public School Board of Education, Dr. Warren was also very active in children’s education.

The Delaware Chapter of the American Academy of Pediatrics, Delaware Academy of Medicine and Nemours Children’s Hospital, Delaware co-sponsor this annual continuing education program in order to perpetuate Dr. Warren’s memory. Dr. Warren left us with a legacy of devotion to the health and wellbeing of children which we strive to convey through this seminar.

The Robert O. Y. Warren, MD Memorial Seminar is designed to provide primary care providers with information on pediatric medicine that can be used to improve their clinical practice.

Learning Objectives

At the conclusion of this program, participants should be able to:

• Evaluate new onset hair loss in the child through building one’s dermatologic eye.

• Develop a treatment plan for common hair loss disorders.

• Employ under-utilized treatments for common dermatologic disorders such as atopic dermatitis.

• Incorporate novel treatments for pediatric dermatologic conditions that have been recently discovered.

• Discuss common injuries for youth athletes in various sports.

• Identify valuable evaluation treatment techniques for these injuries.

• List the causes of premature coronary artery disease presenting during childhood.

• Outline screening recommendations for premature coronary artery disease risk factors beginning in youth.

• Diagnose some common pediatric conditions and identify appropriate times to refer for a cardiology consult.

• Recognize thyroid disorders presenting with cardiac problems.

• Observe and assess “less-common” presentations of common anxiety disorders in children and adolescents.

• Explain the rationale for evidence-based exposure therapy for anxiety disorders in children and adolescents.

• Identify different exceptionalities that can present as attention difficulty.

• List the essential components to a useful evaluation.

• Determine when it is best to refer to ENT and what they can do to best prepare the patient for the visit.

• Communicate the advice that ENTs give their patients so that you may be able to avoid referrals.

• Identify patients needing to consult hematology.

• Describe the counseling suggested for abnormal hemoglobin newborn screens.

• Discuss the caries process, including etiology and transmission risk factors and patterns of decay.

• Illustrate risk factors and patterns of tooth decay.

Program Director

Robert S. Walter, MD, FAAP

Pediatrician

Brandywine Pediatrics

Clinical Associate Professor of Pediatrics Sidney Kimmel Medical College at Thomas Jefferson University

Keynote Speaker

Vikash S. Oza, MD

Director of Pediatric Dermatology

Associate Director of Dermatology Residency Program

Pediatric Dermatology Fellowship Director NYU Langone Hospitals

Associate Professor of Dermatology and Pediatrics

The Ronald O. Perelman Department of Dermatology at NYU Grossman School of Medicine

Faculty

Susan Anderer, PsyD

Licensed Psychologist

Certified School Psychologist

Private Practice

Carissa Baker-Smith, MD, MPH, MS

Director Pediatric Preventive Cardiology General Pediatric and Transplant Cardiologist

Nemours Children’s Hospital, Delaware

Associate Professor of Pediatrics Sidney Kimmel Medical College at Thomas Jefferson University

Jenna Briddell, MD

Attending Physician

Department of Otolaryngology Nemours Children’s Hospital, Delaware

Assistant Professor of Head and Neck Surgery - Otolaryngology and Pediatrics Sidney Kimmel Medical College at Thomas Jefferson University

Rachel Maher, DMD

Attending Dentist

Dentistry for Children Christiana Care Health System

Kathy Rupertus, PsyD

Licensed Psychologist

Clinical Director

The Anxiety and OCD Treatment Center, LLC

Corinna Schultz, MD, MSHP

Director of Hematology

Nemours Center for Cancer and Blood Disorders

Nemours Children’s Hospital, Delaware

Associate Professor of Pediatrics Sidney Kimmel Medical College at Thomas Jefferson University

Deepika Thacker, MD Medical Director, Cardiac Inpatient Unit Division of Cardiology Nemours Children’s Hospital, Delaware

Associate Professor of Pediatric Cardiology Sidney Kimmel Medical College at Thomas Jefferson University

Matthew Voltz, DO, ACT, CSCS

Attending Physician

Christiana Care Health System

Primary Care Sports Medicine Physician Delaware Orthopaedic Specialists, PA

General Information

Site: Due to ongoing COVID-19 concerns, this year’s conference will be VIRTUAL. This conference is only available as a live stream. A recorded version will NOT be available.

IMPORTANT NOTE: A link to join the conference will be emailed to you the week prior to the conference. It is very important that you register using an email address that you use frequently and will remember!

Accreditation: This activity has been planned and implemented in accordance with the accreditation requirements and policies of the ACCME through the joint providership of Nemours Children’s, the Delaware Chapter of the American Academy of Pediatrics and the Delaware Academy of Medicine. Nemours Children’s is accredited by the ACCME to provide CME for physicians.

This live activity is designated for a maximum of 6.00 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in this activity.

A certificate of participation will be provided to other health care professionals requesting credits. Participants should ensure in advance that their credentialing or licensing organization accepts AMA PRA Category 1 Credits™.

Americans With Disabilities Act: In accordance with the Americans With Disabilities Act, we will provide modifications in teaching methodologies to accommodate individual needs. To request disability accommodations, contact the Office of Continuing Medical Education at least 15 days in advance of the program at 302.651.6750.

Commercial Support: This program may be supported in part by unrestricted educational grants in accordance with ACCME standards. At the time of this printing, a list of commercial supporters was not available. Appropriate acknowledgement will be given to all exhibitors and supporters in conference materials at the time of the meeting.

Course Registration

Registration Fee: $70

Advance registration is required and should be received by October 26, 2022. All registrations received by this date will be confirmed in writing. Registration is limited and will be honored in the order of the date received.

Register online at PedsUniversity.org.

REGISTRATION DEADLINE: OCTOBER 26, 2022

We will not be accepting mail-in registrations/checks.

Cancellation Policy: A full refund will be given for WRITTEN cancellations received before October 26, 2022. No refunds will be given after this date.

Disclosure Policy: As a provider accredited by the Accreditation Council for Continuing Medical Education (ACCME), we must ensure balance, independence, objectivity and scientific rigor in all educational activities. In accordance with the Standards for Integrity and Independence in Accredited Continuing Education, all planners, teachers and authors involved in the development of CME content are required to disclose their relevant financial relationships that might be germane to the content of the activity. An individual has a relevant financial relationship if they have a financial relationship in any amount occurring in the last 24 months with an ineligible company whose products or services are discussed in the CME activity content over which the individual has control. We have policies/processes in place to mitigate relevant financial relationships. All relevant relationships will be mitigated.

Questions: Contact Betsy Lee at 302.559.4229 or betsy.lee@nemours.org

Register online at PedsUniversity.org or scan the QR code.

COVID-19 Pandemic Experience: A Collaborative Approach to Eliminate Health Disparities

Since the onset of the global COVID-19 pandemic, there have been 609,247,113 confirmed cases globally as of September 2022. The USA has registered 94,237,260 confirmed cases.1 Delaware has registered a total of 306,264 confirmed cases of COVID-19, with 3,086 deaths reported.2 According to 2019 data, Delaware has a population of 957,249 people, of which about 22% are Blacks who form part of medically underserved communities.2 Medically underserved communities that include African Americans have been worst hit by the COVID-19 pandemic in terms of morbidity and mortality, socioeconomic impact, and limited vaccine uptake. The onset and course of the COVID-19 pandemic revealed an underlying disparity in health when it comes to the underserved populations. Is this a new development? Or simply an unmasking of underlying issues that have always faced people in the underserved communities? For instance, the latest data from the Centers for Disease Control and Prevention (CDC) on the risk for COVID-19 infection, hospitalization, and death are, respectively, 1.1, 2.3 and 1.7 times higher among African American nonHispanic persons compared to the White population.3

The CDC also postulates that ethnicity is a risk factor for the social determinants of health that impact an exposure to the COVID-19 virus. The social determinants of health refer to the conditions in which people are born, grow, live, work and age.4 The determinants include race, ethnicity, social class, immigrant status, employment status or level of education.

There have been great challenges in building and maintaining trust with the Black, indigenous and people of color (BIPOC) populations when it comes to combating COVID-19, especially through vaccination. Vaccine hesitancy has been a major drawback among these communities, either as a result of distrust of the vaccine or sheer reluctance. The distrust could be due to historic systemic maltreatment and racism by governments and the health sector in delivery of healthcare, and in previous vaccine trials as well.5 This racial discrimination when seeking healthcare still persists to present day.6

Historically, the majority of the work within these communities is not done in collaboration with the local community leaders and trusted healthcare partners. There is a need to involve the local champions during the planning and development stages of strategies to distribute more vaccines to these populations. It is not merely about availability of COVID-19 vaccines that matters, but the actual number of people vaccinated.

Several approaches can be used to address the challenges and build on collaboration with the communities. These include active collaboration with trusted partners within the community. Health inequities result from generational burdens of structural and systemic disparities. To address social and economic barriers requires a comprehensive and holistic plan of action. In our case, our approach has been unique, purposeful, and very intentional working in the community, establishing relationships that are built on trust and listening to the people living in these communities, and engaging the community leaders who understand the community’s needs and are willing to roll up their sleeves. We provide a network of support (human and financial) to facilitate community stewardship. Through collaboration, we have partnered intentionally with trusted diverse, minority and Black owned agencies and practitioners to build a team of dedicated healthcare professionals drawn from these communities. This team promotes practical and acceptable ways of health education, disease screening, and vaccine accessibility, and assists in the creation of comprehensive health communication campaigns. We are engaging the community in meaningful ways – vaccine access, immunization education, nutrition and exercise, medication management, and mental health—mind, body and spirit —it all counts! Based on our collaboration and partnership, we conducted 70 health education sessions, over 150 vaccines, and connected community partners to three primary care healthcare providers in New Castle and Sussex Counties between March and August 2022.

We are also keeping in mind that developing and designing protocols has to be sensitive to the communities’ ways of life—taking into the account the legacy and history of medical treatment in Black and Brown communities while recognizing contemporary challenges. This process is very organic and not a one-size-fits-all because of the diversity within the communities and in the environment, hence the processes need to be fluid, using a cultural competence lens in which services are effectively delivered in a manner that is responsive to the unique cultural needs of a specific population. We confront the challenges with a problemsolving mindset. There is power in the community voice that must be acknowledged. COVID-19 prevention and vaccine education messages should be culturally appropriate and in acceptable language within the culture. The messengers should be entrusted with the responsibility of managing community projects and they must be properly resourced.

To effectively address the gap in healthcare disparities among the underserved populations, we need to make deliberate efforts in establishing active collaboration with the local leaders within these communities. These local leaders should be at the forefront during planning, designing, communication, community education, service delivery, and receiving feedback. This will enhance trust in the process, build capacity and improve on the uptake of these services by these communities. The active involvement of locals will also enhance independence of operations and sustainability once the supporting organizations stop being actively involved.

For these collaborative works to be sustainable, the issue of equitable distribution of—and access to—resources must also be addressed, since the small grants that the small agencies get are insufficient to sustain and expand the initiatives. By sharing this experience during COVID-19 pandemic, it is our hope that policy makers and institutional agencies will understand the significance of engaging traditional and non-traditional practitioners with a proven track record of results. We should allow initiatives time to take root. The greatest lessons are learned when we stumble and sometimes have to restart. Sustained support is critical to this process and collaboration is vital to our mutual success. Let’s place the financial investment in the hands of those trusted health professionals, institutional partners, and subject matter experts who have the knowledge and expertise to build healthy families, healthy communities, institutional and human capacity—we will eliminate the health disparities. It can be done!

Dr. Gwanmesia may be contacted at eunitysolutions@gmail.com

REFERENCES

1. World Health Organization. (2022). WHO Coronavirus (COVID-19) Dashboard. https://covid19.who.int/

2. Delaware Health and Social Services. (2022). Coronavirus (COVID-19) Data Dashboard. https://myhealthycommunity.dhss.delaware.gov/locations/state

3. Centers for Disease Control and Prevention. (2020). COVID-19 Hospitalization and Death by Race/Ethnicity, Updated November 30, 2020.

https://www.cdc.gov/coronavirus/2019-ncov/covid-data/investigationsdiscovery/hospitalization-death-by-race-ethnicity.html

4. World Health Organization. (2016). Social Determinants of Health http://www.who.int/social_determinants/en

5. Chastain, D. B., Osae, S. P., Henao-Martínez, A. F., FrancoParedes, C., Chastain, J. S., & Young, H. N. (2020, August 27). Racial disproportionality in Covid clinical trials. The New England Journal of Medicine, 383(9), e59. https://doi.org/10.1056/NEJMp2021971

6 NPR. Robert Wood Johnson Foundation & Harvard T.H. Chan School of Public Health. (2018). Discrimination in America: Final summary.

https://cdn1.sph.harvard.edu/wp-content/uploads/sites/94/2018/01/NPRRWJF-HSPH-Discrimination-Final-Summary.pdf

Firearm Violence in Wilmington, DE: An Update on 2020

ABSTRACT

Firearm violence within Delaware has been concentrated in the City of Wilmington and rates disproportionately affect populations, with the highest disparity and inequity in mortality among young Black men. This commentary provides an update to a prior review from 2018 with an analysis of the factors contributing to a surge in 2020 and the years beyond.

INTRODUCTION

Firearm violence and structural violence cannot be separated. While the former clearly propagates from person to person, the latter is by nature an indirect injury. Johan Galtung, who first characterized structural violence in 1969, describes it this way:

The violence is built into the structure and shows up as unequal power and consequently as unequal life chances. Resources are unevenly distributed, as when income distributions are heavily skewed, literacy/education unevenly distributed, medical services existent in some districts and for some groups only, and so on. Above all the power to decide over the distribution of resources is unevenly distributed (p. 171).1

There are few health disparities in which the inequity in outcomes is as stark as that for bullet wounds. A recently published report in the Centers for Disease Control and Prevention (CDC) Morbidity and Mortality Weekly Report describes that from 2019 – 2020, the firearm homicide rate increased by 34.6% across all age groups, reaching the highest levels since 1994.2 The rise was highest for young Black men: for those ages 10-24, this rate was between 54.9 – 77.3 deaths per 100,000 persons, which is 20.6 times higher than the rate for young White men in 2019, and within these subsets, the greatest rise was among those with the highest poverty levels. How might we estimate this relative impact on the life expectancy of Black men? By historic contrast, a decline in violent deaths for Black men between 1991 to 2012 was an improvement significant enough to be “roughly equivalent to the impact of eliminating obesity altogether (p.69).”3 The threat of losing such progress will be staggering, yet we already know that in 2020, firearm-related injuries have been the number one cause of death among persons 1-19 years of age.4

As an extension of a 2018 summary of firearm violence in Wilmington published here, this commentary describes context for understanding interval developments with a focus on these changes in 2020 and beyond.5

HISTORY OF FIREARM VIOLENCE AND PRACTICE IMPLEMENTATION

The epidemic of firearm violence is a complex problem deeply rooted in the fabric of American culture and the socioeconomic climate. Academic and policy perspectives span many disciplines including medicine, politics, economics, sociology, and criminology. Though the United States has seen many public health successes in the prevention and management of chronic, metabolic, and infectious diseases over the last half century, the framing of violence as a public health crisis has seen more variable progress. In 1979, violence was identified as one of the 15 priority areas in the The Surgeon General’s Report on Health Promotion and Disease Prevention6 and in the 1980s, urban communities with predominantly young African American male communities saw alarming increases in the incidence of gun violence.7 By 1983, the CDC established the violence epidemiology branch to focus study and resources on the issues of violence8 and published The Prevention of Youth Violence: A Framework for Community Action in 1992 outlining a public health approach to violence prevention.9

Yet the cause of the subsequent decline in violence following the 1990s is not clearly or purely attributable to healthcare interventions alone. Sharkey argues in his book, Uneasy Peace:

After decades in which urban communities were mostly left on their own to deal with the problem of rising crime, the most fundamental change that has taken place since the 1990s is that a wide range of different people and institutions began to take over urban spaces. The most visible and most controversial of these urban guardians, then and now, are the police (pp. 44-45).3

FIREARM VIOLENCE IN DELAWARE

In Delaware, firearm violence has been concentrated in the city of Wilmington. With a modest population of just over 70,000, the rate experienced in the city has been such an outlier among cities in the United States that the CDC performed an epidemiologic investigation in 2014.10

DOI: 10.32481/djph.2022.10.012

Through the early to mid-2010s, shooting incidents rose rapidly and 2013 saw a 45% increase in shooting incidents from the preceding years. The growth of Delaware’s homicide rates per capita grew at a faster rate than any other state and with a rate ranked as 4th highest for a city of comparable size. The report called for a collaborative arena for data sharing between Delaware social agencies to identify and support high risk individuals such as through the establishment of a local advisory committee for the evaluation of wraparound services/programs.

In the years since, the state of Delaware found that all forms of serious crime declined from 2016 – 2020 except for firearmrelated offenses 11 Firearm-related assaults increased by 31% over those years (pp. 3-7) and while this trend began prior to the onset of the COVID-19 pandemic, the rise in the year 2020 was especially sharp.

Even so, interpretation of local firearm violence trends from year to year are challenging and controversial. For example, 2017, 2020, and 2021 represent the three highest years on record for number of firearm victims as tabulated by the Delaware News Journal; a current year-to-date tally of victims for October 3, 2022 would appear lower compared to one, two, and five years prior yet is simultaneously higher than a year-to-date sample from 2018

or 2019 (see Figure 1).12 Do trends in 2022 represent a regression to mean, and is that is the consequence of local interventions or would they have occurred regardless? Are the factors that contributed to the rise in 2020 rooted in the same as those in 2017? Gross statistical observations alone, especially percentage changes and point estimates, lack context for judging intervention effectiveness; more intermediate and proximal factors are needed to infer causality.

FRAMEWORKS

Myriad models have been developed for identifying and modifying the primary factors influencing firearm violence, but there are two especially notable frameworks from the past five years. One is classically public health oriented with the most modern description emerging from a large summit in 2019 convened by 44 medical and injury prevention organizations.13 This framework uses a simple set of matrices to organize and classify evidence-based interventions, depicting a grid in which three prevention approaches (pre-injury/primary, injury/ secondary, and post-injury/tertiary) are each “crossed” with four opportunities (host factors, agent factors, the physical environment, and the social environment).

The other framework, proposed by Thomas Abt in 2017, begins with the public health prevention model, though with modifications to explicitly include evidence-based law enforcement strategies: in addition to primary, secondary, and tertiary prevention are the categories suppression (i.e. policing) and rehabilitation (i.e. justice system involvement).14 These are also crossed with interventions for the highest risk places, people, and behaviors

The strength of frameworks, though simple, is profound in being able to leverage structure and classification in organizing public discourse and consequently the associated mechanisms of research, implementation, and funding. Specifically, it encourages the articulation of proportion, focus, and temporality (i.e. causality) in interventions, which are critical tools in assessing effectiveness or lack thereof. In its best application, the relative and independent contributions and distinctions by different programs can be recognized without false dichotomization, fostering collective efficacy instead of competition.

The weakness of frameworks populated with a heavy emphasis on evidence is that they favor the institutions capable of producing such evidence in the first place. When these are framed as an exclusionary list of interventions, it can reinforce structural inequity. As Abt describes it in his book, Bleeding Out:

Programs are embedded within institutions, and institutions are embedded within systems. Programs operating in and among weak institutions and systems can make a temporary difference, but for more sustainable change, there must be deeper and broader change in the institutions themselves (p. 228).15

LEGITIMACY

With so many different interventions available, why did firearm violence rise so profoundly in 2020? In addition to an historic surge in new firearm purchases16 and a catastrophic pandemic, there was the death of George Floyd and precipitated protests and property destruction, which within the City of Wilmington was immediately evocative of similar events in 1968 following the assassination of Martin Luther King, Jr.17 While no firearm violence was involved, concurrent nationwide protests and responses by law enforcement prompted this statement by the National Network for Safe Communities (NNSC):

Police legitimacy – the community’s trust, or lack thereof in the police – is central to our work. As an organization focused on violence prevention, it is everything. Research – and our decades of experience on the ground – show clearly that as police legitimacy in a community goes up, violence in that community goes down. In this country, and especially in communities of color, there’s a huge legitimacy gap. Even in communities that experience the most violence, people respect the law, want to be safe, and want to work with the police. But they don’t trust the police or expect them to do the right thing.18

The public’s guarded response to public health interventions for COVID-19, such as masking mandates and vaccination campaigns, marks a parallel crisis in the “legitimacy” of medicine and medical institutions in caring for community health.19 In the medical literature, “mistrust” and “unmet need” are analogous to legitimacy even as they extend beyond those directly injured. A qualitative study on patients with chronic health conditions found they may view medical providers’ response to community violence as misdirected, disconnected, or ineffective.20 A study of survey data by Alang et al. found that “perceived police brutality is associated with greater likelihood of not getting needed medical care” and that “one of the ways by which perceived police brutality affects unmet need is by increasing medical mistrust (p. 4)”21

These observations begin to illustrate how, in communities disproportionately affected by firearm violence, there is a creeping collective failure in confidence in institutions to maintain health and safety. In other words, if Sharkey’s observation that the violent crime decline following the 1990s was a function of progressive institutional occupancy of urban public spaces, it may be that the shocks and erosion of their capacity, legitimacy, and perceived trustworthiness in 2020 resulted in its return.

CHANGES TO THE LOCAL LANDSCAPE

Since 2018, the largest of local institutions have launched violence intervention programs that 1) focus on those at highest risk of victimization (and within policing programs, perpetration), 2) incorporate high-quality, intensive wraparound-style social service programming and case management, and 3) engage with “credible messengers.”7 These are operationalized as: Group Violence Intervention, a Hospital-based Violence Intervention Program; and the Center for Structural Equity (using a violence interruption model similar to Cure Violence); as well as the continuation of the Youth Advocate Program which focuses on justiceinvolved adolescents. In 2022, a public safety consultant group, the Community-Based Public Safety Collective, conducted a landscape analysis of firearm violence in Wilmington, reviewing these programs and making a variety of recommendations for expansion and additions of services if given funding opportunities.22

And such funding is coming: $8 million in American Rescue Plan Act (ARPA) dollars will be for the City of Wilmington’s use for violence prevention and intervention programs23 and an additional $1.9 million from Congressional funds for programs statewide.24 Our hope is this unprecedented amount and work sets the precedent for measurable and enduring change.

Dr. Chen may be contacted at dchen@christianacare.org

1. Galtung, J. (1969). Violence, peace, and peace research. Journal of Peace Research, 6(3), 167–191. https://doi.org/10.1177/002234336900600301

2. Kegler, S. R., Simon, T. R., Zwald, M. L., Chen, M. S., Mercy, J. A., Jones, C. M., Dills, J. (2022, May 13). Vital signs: Changes in firearm homicide and suicide rates — United States, 2019–2020. MMWR. Morbidity and Mortality Weekly Report, 71(19), 656 663. “ https://doi.org/10.15585/mmwr.mm7119e1

3 Sharkey, P. (2018). Uneasy Peace: The Great Crime Decline, the Renewal of City Life, and the Next War on Violence. W. W. Norton & Company.

4. Goldstick, J. E., Cunningham, R. M., & Carter, P. M. (2022, May 19). Current causes of death in children and adolescents in the United States. The New England Journal of Medicine, 386(20), 1955 1956 https://doi.org/10.1056/NEJMc2201761

5 Chen, D. (2018, November 8). Firearm Violence in Wilmington. Dela J Public Health, 4(5), 14 21 https://doi.org/10.32481/djph.2018.11.004

6. Healthy People: The Surgeon General’s Report on Health Promotion and Disease Prevention (Chapter 1). (n.d.). Reports of the Surgeon General - Profiles in Science. Retrieved October 3, 2022, from https://profiles.nlm.nih.gov/spotlight/nn/catalog/nlm:nlmuid-101584932X94-doc

7. Centers for Disease Control and Prevention (CDC). (1994, October 14). Homicides among 15-19-year-old males—United States, 1963-1991. MMWR. Morbidity and Mortality Weekly Report, 43(40), 725 727 https://pubmed.ncbi.nlm.nih.gov/7935300

8 Institute of Medicine (US) and National Research Council. (US) Committee on Trauma Research. (1985). Injury in America: A Continuing Public Health Problem. National Academies Press (US). http://www.ncbi.nlm.nih.gov/books/NBK217490/

9. Fenley, M. A., Gaiter, J. L., Hammett, M., Liburd, L. C., Mercy, J. A., O’Carroll, P. W., . . . Thornton, T. N. (1993). The Prevention of youth violence: A framework for community action (cdc:27385). https://stacks.cdc.gov/view/cdc/27385

10 Sumner, S. A., Maenner, M. J., Socias, C. M., Mercy, J. A., Silverman, P., Medinilla, S. P., Hillis, S. D. (2016, November). Sentinel events preceding youth firearm violence: An investigation of administrative data in Delaware. American Journal of Preventive Medicine, 51(5), 647 655. https://doi.org/10.1016/j.amepre.2016.08.002

11. Price, S. (2021). Crime in Delaware: 2016 – 2020 Executive Brief. Statistical Analysis Center: Crime in Delaware, 16. https://sac.delaware.gov/wp-content/uploads/sites/64/2021/11/Crimein-DE-2020-Executive-Brief.pdf

12. Delaware News Journal. (n.d). Tracking gun violence in Delaware. Delaware Online. Retrieved from https://www.delawareonline.com/in-depth/news/2021/08/16/delawaregun-violence-database/5518513001/

13 Bulger, E. M , Kuhls, D. A., Campbell, B. T., Bonne, S., Cunningham, R. M., Betz, M., . . . Stewart, R. M. (2019, October). Proceedings from the medical summit on firearm injury prevention: A public health approach to reduce death and disability in the US. Journal of the American College of Surgeons, 229(4), 415 430.e12. https://doi.org/10.1016/j.jamcollsurg.2019.05.018

14 Abt, T. P. (2017, Mar). Towards a framework for preventing community violence among youth. Psychol Health Med, 22(sup1), 266–285. https://doi.org/10.1080/13548506.2016.1257815

15 Abt, T. (2019). Bleeding out: The devastating consequences of urban violence--and a bold new plan for peace in the streets. Hachette UK.

16. Miller, M., Zhang, W., & Azrael, D. (2022, February). Firearm purchasing during the COVID-19 pandemic: Results from the 2021 National Firearms Survey. Annals of Internal Medicine, 175(2), 219 225. https://doi.org/10.7326/M21-3423

17. Hughes, I., Kuang, J., Newman, M., & Gamard, S. (n.d.). Wilmington protest for Floyd turns violent; police order people off the streets. The News Journal. Retrieved from https://www.delawareonline.com/story/news/2020/05/30/wilmingtonprotests-george-floyd-turn-violent-night/5295496002/

18. Statement on the death of George Floyd. (n.d.). National Network for Safe Communities (NNSC). Retrieved from https://www.nnscommunities.org/blog/statement-on-the-death-ofgeorge-floyd/

19 Corbie-Smith, G. (2021). Vaccine hesitancy is a scapegoat for structural racism. JAMA Health Forum, 2(3), e210434 https://doi.org/10.1001/jamahealthforum.2021.0434

20. Tung, E. L., Johnson, T. A., O’Neal, Y., Steenes, A. M., Caraballo, G., & Peek, M. E. (2018, November). Experiences of community violence among adults with chronic conditions: Qualitative findings from Chicago. Journal of General Internal Medicine, 33(11), 1913 1920. https://doi.org/10.1007/s11606-018-4607-3

21 Alang, S., McAlpine, D. D., & Hardeman, R. (2020, August). Police brutality and mistrust in medical institutions. Journal of Racial and Ethnic Health Disparities, 7(4), 760 768. https://doi.org/10.1007/s40615-020-00706-w

22 The Community Based Public Safety Collective (2022, Aug). Landscape analysis report for City of Wilmington, Delaware. Discussion draft: Landscape analysis report for City of Wilmington, Delaware. Retrieved from https://www.wilmingtonde.gov/home/ showdocument?id=11078&t=637988464139392778

23. Fowser, M. (n.d.). Wilmington officials scrutinize report with recommendations to reduce gun violence. WDEL 101.7FM. Retrieved from https://www.wdel.com/news/wilmington-officialsscrutinize-report-with-recommendations-to-reduce-gun-violence/ article_adf1c990-3848-11ed-82e6-9ba849bd58bd.html

24. Congressionally Directed Spending Requests | U.S. Senator Christopher Coons of Delaware. (n.d.). Retrieved from https://www.coons.senate.gov/services/appropriations-requests/cds/FY2022

Flu vaccine available at many locations

With seven laboratory confirmed cases of flu, including one pediatric case, as of October 11, the Division of Public Health (DPH) is urging all Delawareans 6 months of age and older to get their annual flu vaccine as soon as possible. It may be a potentially serious and active flu season, and flu vaccine protects against flu-related illness, hospitalization, and death.

Flu vaccine is available to the public at many pharmacies (including many within grocery stores), participating medical provider offices, and Federally Qualified Health Centers (for their patients) Flu vaccine is also offered to uninsured and underinsured individuals at Public Health Clinics, and at community based locations where DPH mobile units provide additional health services. Many employers and schools offer the flu vaccine on site. Use DPH’s Flu Vaccine Finder page at flu.delaware.gov to easily find vaccine sites.

The Centers for Disease Control and Prevention advises flu vaccination for groups at high risk of having serious flu complications, such as:

• all children ages 6 months to 59 months

• all people ages 50 years and older (Individuals ages 65 years and older should receive higher dose or adjuvanted influenza vaccines.)

• people with chronic underlying medical conditions

• people who are immunocompromised

• people who are/will be pregnant during flu season

• American Indian or Alaskan Native persons

• residents of nursing homes and other long term care facilities.

DPH recommends flu vaccine for those who live or work with infants under 6 months of age and those who live or work in congregant settings such as long-term care and correctional facilities.

flu.delaware.gov or call 1 800 282 8672.

DPH awards eight community grants to advance healthy lifestyles

The Division of Public Health’s (DPH) Physical Activity, Nutrition, and Obesity Prevention Program (PANO) awarded mini grants to eight community partners as part of the Advancing Healthy Lifestyles (AHL) Initiative. Using a health equity lens, the AHL Initiative aims to improve community health and reduce chronic conditions through policy, systems, and environmental approaches.

The grants support projects that provide outreach and education and opportunities for physical activity, access to healthy food, and maintaining a healthy weight. For example, the 4 H Cooperative Extension will promote physical activity in schools, the community, and the workplace, including Walk with Ease, Walk Across Delaware, Walking through the Holidays, and “plogging.” The Boys and Girls Club of Delaware will enhance educational opportunities on a mini farm, facilitate food education/nutrition programs, and enhance their partnerships with local partners.

The City of Newark’s grant supports the establishment of a second community garden to foster community and a healthy lifestyle. The Delaware Breast Cancer Coalition’s grant supports a free and public 12 week health education program for individuals at risk for chronic disease, including breast cancer, to increase physical activity and nutritional knowledge.

Other awardees are Delaware Greenways of Northern Delaware, the Inner City Cultural League of Dover, the Worship Christian Center of Camden/Dover, and YMCA of Delaware.

For more information, watch the 28-minute webinar: https://www.healthydelaware.org/CommunityPartners/Advancing-Healthy-Lifestyles#mini-grantinitiative-webinar or contact Shebra K. Hall, MPA, PANO Program Administrator, at 302-744-1011 or shebra.hall@delaware.gov

Children ages 5-11 years can now receive the COVID-19 bivalent vaccine

Children ages 5 through 11 years who completed their primary COVID 19 vaccination series are now eligible to receive the updated (bivalent) booster vaccine. The Centers for Disease Control and Prevention signed off on this October 12, 2022, following the Food and Drug Administration’s authorization. Pfizer BioNTech’s bivalent booster is available to children ages 5 through 11 years, and Moderna’s is for children and adolescents ages 6 through 17 years.

The bivalent booster doses add Omicron BA.4 and BA.5 spike protein components to the current vaccine composition, helping to restore protection that has waned since previous vaccination and targeting recent Omicron variants that are more transmissible and immune evading.

The Division of Public Health (DPH) recommends that all eligible Delawareans get vaccinated without delay for protection from severe COVID 19 disease, hospitalization, and death. Individuals are eligible if they completed their primary series (gotten both doses of a two dose vaccine) at least two weeks ago. Visit de.gov/getmyvaccine for vaccination sites. More than 29,000 adult Delawareans have received the bivalent booster dose.

Between March 11, 2020 and October 13, 2022, Delaware had 310,819 positive COVID 19 cases and 3,121 deaths. As of October 13, there were 105 current COVID 19 hospitalizations with eight critically ill

For information about bivalent boosters, visit de.gov/boosters. For COVID data, visit DPH’s My Healthy Community data portal. For COVID 19 information, visit https://coronavirus.delaware.gov/, call Delaware 2-1-1, or email delaware211@uwde.org. Individuals who are deaf or hard of hearing can text their ZIP code to 898-211 weekdays 8:00 a.m. to 9:00 p.m. and Saturdays 9:00 a.m. to 5:00 p.m.

Monkeypox vaccine eligibility expands

The Division of Public Health (DPH) expanded monkeypox (MPX) vaccine eligibility on September 22 to include all gay, bisexual and transgender or nonbinary persons having sex with men, or females having sex with gay, bisexual, non binary, or transgender males. Delaware also expanded vaccine eligibility to health care workers who provide direct patient care to confirmed or suspected MPX cases in Emergency Departments, urgent care centers, Federally Qualified Health Centers, DPH clinics, STI/HIV or sexual health clinics, and those at occupational risk such as laboratory staff who handle specimens.

Forty-one MPX cases were reported to DPH as of October 14, including 27 cases in New Castle County, five cases in Kent County, and nine cases in Sussex County.

The Centers for Disease Control and Prevention reported 27,317 MPX cases in the U.S. as of October 14, with Pennsylvania, New Jersey, Maryland, and Washington, D.C. each having between 506 and 812 cases.

For more information, including vaccination, visit de.gov/monkeypox. Email questions to DPHCall@delaware.gov.

Many extra benefits and services available because of COVID 19 will end in the coming months when the public health emergency comes to an end. Delaware offers many free social service, health, financial, and employment resources. For more information, contact the organizations listed at https://www.dhss.delaware.gov/dhss/dss/files/DHSS_C OVIDPlanNowFreeResourcesFlyer5 2 2022English.pdf

Public can order free fentanyl test strips to prevent unintentional fatal overdoses

To prevent unintentional overdoses, the Division of Public Health’s (DPH) Office of Health Crisis Response (OHCR) is including fentanyl test strips in its Narcan kits distributed to the public. Fentanyl test strip kits can also be ordered online from DPH

Individuals can test marijuana, cocaine, meth, ecstasy, and other substances for fentanyl, a synthetic opioid. Fentanyl is unable to be detected by sight, taste, smell, or touch. The highly sensitive test strips will detect fentanyl down to 0.1 mcg/ml. Fentanyl is now the leading cause of drug overdose deaths in Delaware, found in more than 80 percent of fatal overdoses. According to Division of Forensic Science data, there were 515 overdose deaths in Delaware in 2021, an increase of 15 percent from 2020. Fentanyl was found in 83% of those deaths. Most overdoses are unintentional, and individuals using may not realize the strength of the drug they are using or that it contains fentanyl.

Said DPH Interim Director Dr. Rick Hong: “ …After a test strip detects fentanyl, an individual can choose not to use the drug based on the risk. However, if they choose to use, they can implement alternative harm-reduction strategies, like going slow, not using as much, or/and not using alone We will continue to discourage drug use and encourage people to seek treatment, but for persons with substance use disorder, we are using a compassionate approach to help raise awareness and empower friends and family to act in an emergency situation ”

To order fentanyl test strips, visit helpisherede.com/understanding addiction/what is fentanyl For treatment and recovery services, visit HelpIsHereDE.com or call the 24/7 Crisis Hotline: in New Castle County, call 1 800 652 2929; in Kent and Sussex counties, call 1 800 345 6785. For free 24/7 counseling, coaching, and support, as well as links to mental health, addiction, and crisis services call the Delaware Hope Line at 1 833 9 HOPEDE.

Source: 2020 State Unintentional Drug Overdose Reporting System (SUDORS) fact sheet Delaware Department of Health and Social Services, Division of Public Health, Office of Health Crisis Response, August 2022

#MyReasonWhyDE campaign launches

DPH recently teamed up with The Cause to educate Delaware youth about Substance Use Disorder (SUD) through its #MyReasonWhyDE campaign Four workshops were held in Wilmington with funding from the federal Substance Abuse and Mental Health Services Administration

The youth created short Public Service Announcement videos in which influencers provide reasons to not use drugs and share SUD information and resources. The PSAs promote the positive aspects of their lives that keep them happy, healthy, drug free, and engaged in their community

The #MyReasonWhy campaign is part of DPH’s long term strategy to work with partner organizations in the community and state, such as school systems, to promote resiliency and positive messaging. Youth who are interested in creating a PSA video should visit MyReasonWhyDE.com. Partners interested in promoting alternatives to drugs can contact Katie Capelli at katie.capelli@delaware.gov.

New resources for pharmacists

The Division of Public Health and partners in the medical community created new substance use disorder resources for pharmacists. The Delaware-specific, evidence based education materials aim to reduce the risk of unintentional opioid prescription overdose deaths. These materials are available on the health care provider page at HelpIsHereDE.com.

State’s cancer mortality rates decline

Delaware’s cancer mortality rate has further declined, according to the latest cancer data from the Division of Public Health (DPH). In the 15 years between 2005 and 2019, all site cancer mortality rates decreased an average of 1.7% per year in both Delaware and the U.S. During the same period, all site cancer incidence rates decreased an average of 1.1% per year in Delaware and an average of 0.7% per year in the U.S.

While progress continues to be made, Delaware’s 2015 to 2019 all site cancer incidence rate (468.8 per 100,000 population) is 4 percent higher than the U.S. rate (449.0 per 100,000 population. Between 2005 and 2019, incidence rates for all site cancer decreased an average of 1.8% per year among non Hispanic White males and remained stable for non Hispanic White females. During that same period, incidence rates for all-site cancer decreased an average of 3.1% per year among non Hispanic Black males and remained stable for non-Hispanic Black females.

The state’s cancer mortality rate further declined. For 2005 to 2019, mortality rates for all-site cancer decreased by an average of 1.6% per year among non Hispanic White males and decreased an average of 1.8% per year among non Hispanic White females. From 2005 to 2019, all site mortality rates decreased an average of 2.5% per year among non Hispanic Black males and remained stable for non Hispanic Black females.

Among Delaware females for 2015 to 2019, breast cancer had the highest incidence (136.1 per 100,000 population) and lung cancer had the highest mortality (34.5 per 100,000 population). Among Delaware males for 2015 2019, prostate cancer had the highest incidence (125.9 per 100,000 population) and lung cancer had the highest mortality (49.1 per 100,000 population).

Non-Hispanic Black Delawareans are disproportionately more affected by breast, prostate, and colorectal cancers compared to non-Hispanic White and Hispanic Delawareans. Lung cancer affects more non-Hispanic white Delawareans.

For more information, read the report s Cancer Incidence and Mortality in Delaware, 2015 2019 and Census Tract Level Cancer Incidence in Delaware, 2013 2017 Four accompanying tables depict age adjusted rates for the 23 top site specific cancer types by both gender and race and include comparative U.S. statistics.

This graph is found within Cancer Data Brief: Breast Cancer Incidence and Mortality in Delaware, 2014 2018, https://dhss.delaware.gov/dhss/dph/dpc/cancer.html

Cancer program producing data briefs

DPH’s Cancer Prevention and Control Bureau recently published a breast cancer data brief and plans to produce several other cancer data briefs over the next two years.

For the five year period 2014 to 2018, breast cancer was the most commonly diagnosed cancer among females in the U.S. and Delaware. Of the 4,278 breast cancer cases diagnosed in Delaware in 20142018, 99 percent (4,237 cases) were diagnosed in females and 1 percent (41 cases) were diagnosed in males. Non-Hispanic Black females (138.7 per 100,000 population) had a higher breast cancer incidence rate compared to non-Hispanic White females (135.7 per 100,000 population) and Hispanic females (101.6 per 100,000 population).

In 2020, 73 percent of Delaware females ages 40 and older reported having a mammogram in the past two years, compared to a national median of 72 percent. For early breast cancer detection in females without breast symptoms, the Delaware Cancer Consortium recommends:

 Females 40 years of age and older should get a mammogram and clinical breast exam annually.

 Females 18 to 39 years of age should get a clinical breast exam annually.

To read the cancer data briefs, visit DPH at https://dhss.delaware.gov/dhss/dph/dpc/cancer.html.

Find screening recommendations and services at www.healthydelaware.org.

Interns at the Delaware Academy of Medicine/Delaware Public Health Association research a ‘gap’ in public health, and create a program to close that gap. They choose a public health theory or model to inform their program, and create a logic model to describe it. The Student Internship Program is open to any high school, undergrad, or graduate student, in Delaware and beyond. If you or someone you know would like to apply, please check out our webpage, https://delamed.org/programs/student-internship/

STUDENT SPOTLIGHT

Racism in Medicine: Targeting Microaggressions in Delaware Healthcare (TMDH)

INTRODUCTION

According to Oxford Languages, racism is defined as “prejudice, discrimination, or antagonism directed against a person or people on the basis of their membership in a particular racial or ethnic group, typically one that is a minority or marginalized.”1 Due to racism in healthcare, people of color (POC) are experiencing higher rates of adverse health outcomes, including death.2 Racism and discrimination can affect generations of people, some of whom are physicians, nurses, and health professionals.

HEALTH OUTCOMES

The disparities in health outcomes between race and ethnicity are well documented and have become more apparent throughout the COVID pandemic. POC have disproportionately higher rates of mortality and disease in comparison to their White counterparts.3–5 Hispanic patients, regardless of native-language, had a significantly higher mortality rate and reduced access to healthcare compared to White patients.5 Among children (<18 years), Latino patients had the highest rates of hospitalization compared to White patients. American Indian or Alaska Native patients had the highest rates among adults aged 18 to 49 years. American Indian or Alaska Native, Black, and Latino patients, aged 65 years and older, had higher rates than White patients. Although hospitalization rates are positively correlated with age across all racial and ethnic groups, POC are more likely to be hospitalized, receive ICU care, or die with COVID-19–associated illness compared with White patients.3

Studies also show that patients of color report higher rates of delayed care and diagnoses in various specialties.6–8 One study showed higher rates of appendicitis perforation and delayed diagnosis among non-Hispanic Blacks (NHB) when

compared to non-Hispanic Whites (NHW).9 Additionally, NHB children had the lowest rates of diagnostic imaging and a lower likelihood of definitive imaging when compared to NHW children. These findings suggest that patients with appendicitis symptoms may be treated differently based on race and ethnicity.

MICROAGGRESSIONS

A microaggression is “a comment or action that subtly and often unconsciously or unintentionally expresses a prejudiced attitude toward a member of a marginalized group (such as a racial minority).”10 Microaggressions are classified into three subgroups: microassaults, microinsults, and microinvalidations.11 Microassaults are often conscious biases or discriminatory verbal abuse or behaviors. Examples of microassaults include calling an Asian patient “oriental” or a POC “colored.” Microinsults are generally unintentional remarks that are insensitive and derogatory to a person’s racial identity or background. Saying “you speak English well” to a Hispanic physician or nurse or assuming that they do not speak English entirely are examples of microinsults. Microinvalidations are behaviors and statements that are meant to invalidate one’s feelings, thoughts, and experiences.11 Telling a POC healthcare professional that they only got to their position as a “diversity hire” is an example of microinvalidation.

Research indicates that microaggressions may lead to a slew of adverse psychological effects such as depression, stress, anxiety, and suicidal thoughts.12–15 Additionally, there has been a correlation between microaggressions and somatic symptoms. Some conditions include high blood pressure, headaches & migraines, chronic infections, and excessive alcohol use.16

A 2021 study found that gender and whether or not an individual is under-represented in medicine (URM), influences their experiences with racism and microaggressions.17 A person is URM if they are Black/African American, Native American, Mexican American, and/or Mainland Puerto Rican. Female first-year medical and dental students showed significantly higher rates of witnessing and personally experiencing microaggressions than male students.17 Additionally, URM students reported significantly higher rates of experiencing microaggressions compared to non-URM students.

This phenomenon can also be seen in physicians of color. Seventy-one physicians of color completed a Racial and Ethnic Microaggressions Scale, Professional Quality of Life Scale, and a demographics questionnaire.18 Of the 71 participants, 23.3% (n=17) reported that a patient refused their care specifically because of their race or ethnicity.18 Participants who reported English as their second language reported significantly more instances of racism than their native-English peers. Furthermore, the occurrence of microaggressions was positively correlated with secondary traumatic stress and racism from patients and peers.18

There is a gap in research about the underlying cause of health outcomes across all racial and ethnic groups. One possible explanation is that POC are reluctant to participate in studies due to the history of unethical medical practices, such as the Tuskegee experiments.19 Another may be due to fear of discrimination by medical professionals. Microaggressions, whether unconscious or conscious, can negatively affect the physician-patient experience. By preventing and addressing such occurrences, there is a potential to improve long-term outcomes.

NATIONAL PROGRAMMING

Although there are initiatives to combat discrimination and promote diversity, there is a lack of movement in addressing microaggressions nationally.20 The only resource of note was from the National Institutes of Health (NIH). The NIH cites the Diversity in the Classroom booklet by The University of California, Los Angeles’s (UCLA) office of Diversity & Faculty Development as a tool to prevent, identify, and counter microaggressions.21 Diversity in the Classroom is prefaced by “UCLA’s Principles of Community” which compromise of “we” statements about how UCLA plans to foster a welcoming and inclusive campus environment.21

CURRENT PROGRAMMING IN DELAWARE

In 2015, the Delaware Division of Public Health and the University of Delaware’s School of Public Policy & Administration created the Health Equity Guide for Public Health Practitioners and Partners which outlines techniques and tools to help all workplaces and institutions in adopting health-promoting policies.22 The guide also addresses racial inequalities through social determinants of health and population-based strategies of Healthy People 2020. The Division of Public Health is in the process of implementing The National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care

(the National CLAS Standards).2 CLAS is a strategy to improve health outcomes by tailoring services to an individual’s culture and language preference. The CLAS standards also provide an outline for health care organizations to introduce culturally and linguistically appropriate services.

SOCIAL COGNITIVE THEORY

Social Cognitive Theory (SCT), formerly known as Social Learning Theory (SLT), was developed by Albert Bandura.23 SCT accounts for the interaction between people (personal factors), their behavior, and their environments. There are six constructs in SCT: reciprocal determinism, behavioral capability, observational learning, reinforcements, expectations, and self-efficacy.

Reciprocal determinism is the principal construct of SCT. It means an individual can be both an agent for change and a responder to change. Behavioral Capability refers to a person’s ability to perform a behavior through the use of resources, knowledge, and/or skills. In other words, an individual must understand what the desired behavior is, and how to perform it. Observational Learning, or modeling, reasons that people can witness and observe the desired behavior conducted by others, and then imitate the actions. Reinforcements are “the [positive or negative] internal or external responses to a person’s behavior that affect the likelihood of continuing or discontinuing the behavior.”24 Expectations refer to the anticipated consequences of an individual’s behavior and generally stem from past experiences. Self-efficacy is the belief or confidence an individual has to successfully perform a behavior despite barriers or obstacles.

SCT IN PRACTICE

Much like SCT, reciprocal determinism is at the core of Targeting Microaggressions in Delaware Healthcare (TMDH). The program is designed so that individuals can recognize microaggressions, prevent them from occurring, or counter them upon witnessing an occurrence. This enables an individual to be both an agent and responder for change. Behavioral capability will be managed through lecture-style workshops and informational websites & brochures. This will provide the resources and knowledge needed in order to address microaggressions. Observational learning will be targeted through role-playing workshops and website videos. TMDH focuses on both intrinsic and extrinsic reinforcements. The intent is that an individual chooses to engage in anti-microaggression behavior in order to relieve personal emotional distress while also facilitating a positive social environment. In regards to expectations, participants may have a negative perspective due to their previous experience with microaggressions. TMDH intends to alleviate negative feelings by creating a safe place to learn and communicate in its workshops, which will in turn make participants more amenable to behavioral change. Selfefficacy is targeted much like the constructs of behavioral capability and observational learning. By teaching how to acknowledge and respond to microaggressions the aim is that participant self-efficacy will increase.

PROGRAM DESCRIPTION

TMDH is a two-pronged program that will address microaggressions through didactic workshops at various health institutions and public advertisements placed throughout Delaware (see Appendix A). The first prong is targeted towards participating health institutions and Health Care Providers (HCPs) in which they will participate in biweekly workshops. Prior to workshops, participants will be emailed a survey regarding their knowledge of microaggressions (see Appendix B). One workshop will be lecture-based teaching the participants what microaggressions are, what they look like in a healthcare setting, and how to address them. The second workshop will be conducted through role-playing where participants will reenact reallife scenarios experiences submitted by the participants or research team. After workshops are concluded, a post-survey will be sent to participants about their experience in the workshops and whether their knowledge has improved.

The second prong is targeted towards the general public in Delaware. An informational website will be created that encompasses definitions, explanations, and short role-playing videos about microaggressions. The website will also contain optional pre and post-survey that the public can partake in. Advertisements about the website will be posted on buses and billboards throughout the state. Outcomes will be measured by metrics such as website clicks and survey responses. All participants, in either prong, are welcome regardless of race, sex, gender, sexual orientation, and socioeconomic status. Additionally, informational brochures will be provided to all participating institutions to display in patient waiting rooms (see Appendix C). Following the completion of this program, participants will increase their self-efficacy and knowledge about what are microaggressions and how to combat them. Moreover, participants may improve their social support and promote an inclusive and welcoming work environment.

DISCUSSION

The Social Determinants of Health Healthy People 2030 outlines five domains of social determinants of health (SDOH): Economic Stability, Education Access and Quality, Health Care Access and Quality, Neighborhood and Built Environment, and Social and Community Context.25 The TMDH program is designed to target three out of the five domains at a minimum. It is well documented that educational interventions and programming are effective in creating behavior change.26 Education Access and Quality is a focal point of TMDH. Both prongs of the program contain an educational component. For HCPs, the workshops are organized to recognize and diminish the occurrence of microaggressions through lecture and roleplaying activities. The public will learn about microaggressions either through informational brochures in patient waiting rooms or the informational website displayed on public advertisements.

TMDH targets Health Care Access and Quality through its first prong geared toward health institutions. Educating HCPs about how to identify and combat microaggressions, may mitigate poor patient experiences. Discrimination has been linked to poor health care delivery due to both patient and physician bias.27,28 It is noted that some individuals may avoid seeing a physician entirely out of fear of discrimination. By

alleviating the occurrence of microaggressions and correctly addressing them, HCPs can conduct high-quality care and therefore be more comforting to the patient.

Social and Community Context encompasses the relationships individuals make whether in their home, school, work, or community. Lack of social support can make precarious situations worse—whether in an unsafe environment or racism and discrimination.25 Positive relationships and experiences can encourage more welcoming and inclusive environments. In addition to addressing microaggressions, TMDH aims to foster social support among employees in the participating health institutions through their interactions in workshops.

HEALTH INEQUITY

Microaggressions are a byproduct of larger systems of health inequity. Studies show that experiences of discrimination, such as microaggressions are likely to increase the risk of adverse health outcomes.12–15 By educating HCPs and the public about microaggressions and its consequences, TMDH strives to minimize such occurrences in patient-physician interactions. Workshops conducted within participating health institutions allow for safe and open conversation among HCPs. By allowing such conversations, microaggressions can be prevented and in turn promoting improved health outcomes and health care delivery for both HCPs and patients.

REFERENCES

1. Oxford Languages. (2022). Definition of Racism. Oxford Learner’s Dictionaries | Find definitions, translations, and grammar explanations at Oxford Learner’s Dictionaries. Retrieved from https://www.oxfordlearnersdictionaries.com/us/

2. Delaware Division of Public Health. (2022). Bureau of Health Equity. Health Equity homepage - Delaware Health and Social Services - State of Delaware. Retrieved from: https://www.dhss.delaware.gov/dhss/dph/mh/healthequity.html

3 Acosta, A. M., Garg, S., Pham, H., Whitaker, M., Anglin, O., O’Halloran, A., . . . Havers, F. P. (2021, October 1). Racial and ethnic disparities in rates of covid-19–associated hospitalization, Intensive Care Unit Admission, and inhospital death in the United States from March 2020 to February 2021. JAMA Network Open, 4(10), e2130479 https://doi.org/10.1001/jamanetworkopen.2021.30479

4. Eguia, E., Fahmy, J. N., Cobb, A. N., Sweigert, P., Aranha, G. V., Abood, G., Baker, M. S. (2021, April). Non-Hispanic Blacks undergoing distal pancreatectomy have higher riskadjusted rates of morbidity and are more likely to be high-cost outliers. American Journal of Surgery, 221(4), 759 763 https://doi.org/10.1016/j.amjsurg.2020.02.050

5. Velasco, F., Yang, D. M., Zhang, M., Nelson, T., Sheffield, T., Keller, T., Hollingsworth, J. W. (2021, November). Association of Healthcare access with intensive care unit utilization and mortality in patients of Hispanic ethnicity hospitalized with Covid-19. Journal of Hospital Medicine, 16(11), 659 666. https://doi.org/10.12788/jhm.3717

6 Constantino, J. N., Abbacchi, A. M., Saulnier, C., Klaiman, C., Mandell, D. S., Zhang, Y., Geschwind, D. H. (2020, September). Timing of the diagnosis of autism in African American children. Pediatrics, 146(3), e20193629 https://doi.org/10.1542/peds.2019-3629

7 Joseph, N. P., Reid, N. J., Som, A., Li, M. D., Hyle, E. P., Dugdale, C. M., . . . Flores, E. J. (2020, December). Racial and ethnic disparities in disease severity on admission chest radiographs among patients admitted with confirmed Coronavirus Disease 2019: A retrospective cohort study. Radiology, 297(3), E303 E312. https://doi.org/10.1148/radiol.2020202602

8. Reeder-Hayes, K. E., Mayer, S. E., Olshan, A. F., Wheeler, S. B., Carey, L. A., Tse, C. K., Troester, M. A. (2019, November 15). Race and delays in breast cancer treatment across the care continuum in the Carolina Breast Cancer Study. Cancer, 125(22), 3985 3992. https://doi.org/10.1002/cncr.32378

9 Goyal, M. K., Chamberlain, J. M., Webb, M., Grundmeier, R. W., Johnson, T. J., Lorch, S. A., . . . Alpern, E. R., & the Pediatric Emergency Care Applied Research Network (PECARN). (2021, September). Racial and ethnic disparities in the delayed diagnosis of appendicitis among children. Acad Emerg Med, 28(9), 949 956 https://doi.org/10.1111/acem.14142

10. Merriam-Webster Dictionary. (2022). Microaggression definition & meaning. Merriam-Webster. Retrieved from: https://www.merriam-webster.com/dictionary/microaggression

11 Ehie, O., Muse, I., Hill, L., & Bastien, A. (2021, April 1). Professionalism: Microaggression in the healthcare setting. Current Opinion in Anaesthesiology, 34(2), 131 136 https://doi.org/10.1097/ACO.0000000000000966

12. Cheah, C. S. L., Wang, C., Ren, H., Zong, X., Cho, H. S., & Xue, X. (2020, November). Covid-19 racism and Mental Health in Chinese American families. Pediatrics, 146(5), e2020021816 https://doi.org/10.1542/peds.2020-021816

13 Hu, Y.-Y., Ellis, R. J., Hewitt, D. B., Yang, A. D., Cheung, E. O., Moskowitz, J. T., Bilimoria, K. Y. (2019, October 31). Discrimination, abuse, harassment, and burnout in surgical residency training. The New England Journal of Medicine, 381(18), 1741 1752. https://doi.org/10.1056/NEJMsa1903759

14. Moody, A. T., & Lewis, J. A. (2019). Gendered racial microaggressions and traumatic stress symptoms among Black women. Psychology of Women Quarterly, 43(2), 201 214. Retrieved from: https://doi-org.udel.idm.oclc.org/10.1177/0361684319828288 https://doi.org/10.1177/0361684319828288

15. Wright, L. N., & Lewis, J. A. (2020). Is physical activity a buffer? Gendered racial microaggressions and anxiety among African American women. The Journal of Black Psychology, 46(2–3), 122 143. Retrieved from: https://doi-org.udel.idm.oclc.org/10.1177/0095798420929112 https://doi.org/10.1177/0095798420929112

16 Robinson-Wood, T., Balogun-Mwangi, O., Weber, A., ZekoUnderwood, E., Rawle, S.-A. C., Popat-Jain, A., . . . Cook, E. (2020). “What is it going to be like?”: A phenomenological investigation of racial, gendered, and sexual microaggressions among highly educated individuals. Qualitative Psychology, 7(1), 43 58 https://doi.org/10.1037/qup0000113

17 Sandoval, R. S., Dunleavy, S., Afolabi, T., Said, J. T., Connor, J., Hossain, A., . . . Chatterjee, A. (2022, May). Equity in medical education: Addressing microaggressions and discrimination on the wards. Medical Teacher, 44(5), 551 558. https://doi.org/10.1080/0142159X.2021.2006617

18 Serafini, K., Coyer, C., Brown Speights, J., Donovan, D., Guh, J., Washington, J., & Ainsworth, C. (2020, April). Racism as experienced by physicians of color in the health care setting. Family Medicine, 52(4), 282 287. https://doi.org/10.22454/FamMed.2020.384384

19. Jones, J. H. (1993). Bad blood: The Tuskegee Syphilis Experiment. Free Press.

20 Biden, J. R. (2021, June 25). Executive order on diversity, equity, inclusion, and accessibility in the federal workforce. The White House. Retrieved from: https://www.whitehouse.gov/briefing-room/presidentialactions/2021/06/25/executive-order-on-diversity-equity-inclusion-andaccessibility-in-the-federal-workforce/

21 NIH Diversity Office. (2016). Microaggressions | SWD at NIH. Microaggressions. Retrieved from: https://diversity.nih.gov/sociocultural-factors/microaggressions

22 UCLA Office of Diversity & Faculty Development. (2014). Diversity in the classroom - UCLA equity, diversity ... diversity in the classroom. Retrieved from: https://equity.ucla.edu/wp-content/uploads/2016/06/ DiversityintheClassroom2014Web.pdf

23. Knight, E. K., Ransford, G., Gugerty, P., Dugan, E., & CodesJohnson, C. (2015, June). Health Equity - Guide for Public Health Practitioners and Partners. Delaware Health and Social Services - State of Delaware. Retrieved from: https://www.dhss.delaware.gov/dhss/dph/mh/files/ healthequityguideforpublichealthpractitionersandpartners.pdf

24 Bandura, A. (1971). Social Learning Theory. New York City; General Learning Press.

25. Healthy People 2030, U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Retrieved from: https://health.gov/healthypeople/objectives-and-data/socialdeterminants-health

26 LaMorte, W. W. (2019). Behavioral change models. The Social Cognitive Theory. Retrieved from: https://sphweb.bumc.bu.edu/otlt/mph-modules/sb/ behavioralchangetheories/behavioralchangetheories5.html

27 Cusack, L., Del Mar, C. B., Chalmers, I., Gibson, E., & Hoffmann, T. C. (2018, May 2). Educational interventions to improve people’s understanding of key concepts in assessing the effects of health interventions: A systematic review. Systematic Reviews, 7(1), 68 https://doi.org/10.1186/s13643-018-0719-4

28 Hennein, R., Tineo, P., Bonumwezi, J., Gorman, H., Tiako, M. J. N., & Lowe, S. R. (2022). “They wanted to talk to a ‘real doctor’”: Predictors, perpetrators, and experiences of racial and ethnic discrimination among healthcare workers. Journal of General Internal Medicine https://doi.org/10.1007/s11606-021-07143-3

29. Deloitte Development LLC. (2021). Deloitte 2021 DEI transparency report. Diversity, equity, and inclusion transparency report. Retrieved from: https://www2.deloitte.com/content/dam/Deloitte/us/Documents/aboutdeloitte/dei-transparency-report.pdf

TARGETING MICROAGGRESSIONS IN DELAWARE HEALTHCARE (TMDH) LOGIC MODEL

Goal Implementation Activities/Objectives

Define & Structure

1 Survey Delaware hospitals & health offices interest in program for new and current hires

2 Establish workshop framework for health institutions

Identification & Engagement 1 Pre-program survey about microaggressions sent to participating Health Care Providers (HCPs)

2 Informational brochures created to disperse at health institutions

3 Institute didactic lecture & role-playing workshops

4 Post-program survey about microaggressions sent to participating HCPs

Short Term Deliverables

4/2022 - Primary outreach to health institutions

Mid Term Outputs Long Term Outcomes

5/2022- Interested institutions representatives attend informational meeting

4/2022 - framework created 5/2022- framework & goals shared with institutions

6/2022 – presurvey sent to health institutions and clinics in Delaware

Marketing & Advertising

1 Design advertisements for buses and billboards about the program/ website

6/2022- institutions send feedback/ comments/concerns

7/2022 – responses collected Survey sent as new participants are onboarded; responses analyzed and utilized to drive workshops

5/2022 – 1000 brochures created 6/2022Brochures given to 50 institutions in Delaware

6/2022Workshop activities/ lessons finalized

8/2022Post-survey sent one month after workshops

7/2022Two workshops per month held

Brochures are given to more institutions as they join program

HCPs utilize what they learned in future interactions

9/2022Responses collected Responses analyzed & used for improvements/ feedback

4/2022Ad designs completed 5/2022Ads posted

Public is aware of website & features

Website Design

1 Create an informational website about microaggressions (including survey) for the public

4/22- website created 6/22- generate 10k website clicks -1k survey responses

Financial Support

1 Seek alternate funding streams (hospital, pharmacy, insurance companies) to offset costs

3/2022 - extra funding is obtained to offset costs

8/22- generate 100k website clicks -10k survey responses

APPENDIX B. TARGETING MICROAGGRESSIONS IN DELAWARE HEALTHCARE

ONLINE PRE AND POST-SURVEY

This survey will take 10-15 minutes to complete. Your answers will aid the research team in understanding the occurrence of microaggressions in healthcare and properly educating Delaware medical professionals. No answers are wrong so please share your experience and opinion to the best of your ability.

Some questions are derived from Deloitte’s 2021 DEI Transparency Report. 29

other identifying information that you wish to include (sexual orientation, religion, marital status, veteran or active military, disability status, national origin, etc.)

MICROAGGRESSIONS

7. What is your definition of the term “microaggression”?

8. Have you been the recipient of a microaggression at your workplace?

a. Yes

i. When did this occur?

ii. Without saying any names, explain the event. b. No

9. How often are you the recipient of microaggressions? a. Never b. Rarely c. Unsure d. Sometimes e. Frequently

10. Have you witnessed a microaggression at your workplace? a. Yes, i. When did this occur? ii. Without saying any names, explain the event. b. No

11. How often do you witness a microaggression? a. Never b. Rarely c. Unsure d. Sometimes e. Frequently

12. Has the occurrence of microaggressions negatively affected mental health? a. Yes, i. How so? b. No

13. Has the occurrence of microaggressions negatively affected your physical health? a. Yes, i. How so? b. No

14. Has the occurrence of microaggressions negatively affected your ability to perform job-related tasks? a. Yes, i. How so? b. No

15. How confident are you in your ability to address biases and microaggressions in the workplace?

a. 1) extremely unconfident � 3) somewhat unconfident � 5) neither confident nor unconfident�7) Somewhat confident� 10) extremely confident Please rate your response to the following statements:

16. My workplace fosters an inclusive and welcoming environment.

a. Strongly agree b. Agree c. Neutral d. Disagree e. Strongly disagree

17. My workplace provides opportunities to connect with and learn about others who have different backgrounds, identities, and experiences.

a. Strongly agree b. Agree c. Neutral d. Disagree e. Strongly disagree

18. I can be myself at work.

a. Strongly agree b. Agree c. Neutral d. Disagree e. Strongly disagree

19. What initiatives or programs, if any, are you aware of that your company fosters an inclusive workplace? Thank you for completing this survey.

Take the

out of the

MINORITY HEALTH LEXICON

Advocate

A person who speaks on behalf of someone, protects their rights, and assists in activities related to ensuring access to care, system navigation, resource mobilization, etc.

AIAN

Stands for American Indian/ Alaska Native

Asylum Seeker

A person who has le their country and is seeking protection from persecution and serious human rights violations in that country, but whose request has not yet been processed.

Children’s Health Insurance Program

Low-cost health insurance coverage to children in families that earn too much money to qualify for Medicaid.

Comorbidity

e simultaneous presence of two or more diseases or medical conditions in a patient.

Deferred Action Status

An immigration status the executive branch can grant to illegal immigrants to delay their deportation.

Deferred Action for Childhood Arrivals

US immigration policy that provides temporary relief from deportation and work authorization to certain young undocumented immigrants (see https://www.uscis.gov/DACA).

Deportation

e expulsion of a person or group of people from a place or country.

Dichotomization

Divided or opposed; split.

Discrimination

e unjust or prejudicial treatment of di erent categories of people or things, especially on the grounds of race, age, or sex.

Exploitation

Treating someone unfairly in order to bene t from their work.

Extrapolate

To extend something to an unknown situation by assuming that existing trends will continue or similar methods will be applicable

Feasibility

e state or degree of being easily or conveniently done.

Federal Poverty Level (FPL)

An economic measure used to decide whether the income level of an individual or family quali es them for certain federal bene ts and programs (see https://www.investopedia.com/terms/f/fpl.asp).

Health Disparities

Preventable di erences in the burden of disease, injury, violence or opportunities to achieve optimal health that are experienced by socially disadvantaged populations.

Health Equity

e absence of unfair, avoidable, or remediable di erences among groups of people; the attainment of the highest level of health for all people.

Health Literacy

e ability to obtain, read, understand, and use healthcare information in order to make appropriate health decisions and follow instr uctions for treatment.

Immigrant

A person who comes to live permanently in a foreign country.

Interconception

e period of time between pregnancies.

Low-Dose Computed Tomography (LDCT)

e only recommended screening test for lung cancer; low amounts of radiation are used to create clear images of the lungs.

HEALTH LEXICON

Medicaid

A medical assistance program for low-income patients’ medical expenses.

Medicare

A medical insurance program for people over the age of 65, young disabled individuals, and patients on dialysis.

Microaggression

Everyday verbal, nonverbal, and environmental slights, snubs, or insults (intentional or not) that communicate hostile, derogatory, or negative attitudes toward stigmatized or culturally marginalized groups.

Microassault

Derogative racial verbal or nonverbal attacks meant to hurt a marginalized individual.

Microinsult

Verbal and nonverbal communications that subtly convey rudeness and insensitivity, and are demeaning to a person’s racial heritage or identity.

Microinvalidation

Verbal comments or behaviors that exclude, negate, or nullify the psychological thoughts, feelings, or experiential reality of a person of color; o en unconscious.

Migrant

A person who moves from one place to another, especially in order to nd work or better living conditions.

Morbidity

e condition of su ering from a disease or medical condition.

Pharmacologic

Referring to the branch of medicine concerned with the uses, e ects, and modes of action of drugs and medications.

Preconception

e time period before birth.

Psychosocial

e interrelation of social factors and individual thought and behavior.

Refugee

A person who has been forced to leave their country in order to escape war, persecution, or natural disaster.

Social Determinants of Health

Economic and social conditions that in uence individual and group di erences in health status; the conditions in the environments where people are born, live, learn, work, play, worship and age that a ect a wide range of health, functioning, and quality-of-life outcomes and risks.

Temporary Protected Status

A temporary immigration status given by the US government to eligible nationals of designated countries (as determined by the Secretary of Homeland Security) who are present in the United States.

Thalassemia

A group of hereditary blood disorders caused by faulty hemoglobin synthesis; widespread in Mediterranean, African, and Asian countries.

Tra cking

e recruitment, transportation, transfer, harboring, or receipt of illegal goods and/or people through force, fraud, or deception, with the aim of exploiting them for pro t.

Undocumented Immigrant

Anyone residing in a given country without legal documentation. is includes people who entered the country without inspection or permission from the government, and those who entered legally but whose documentation is no longer valid. ese individuals are not quali ed for government assistance.

Visas

A conditional authorization indicating the holder is allowed to enter, leave, or stay for a speci c period of time in a country. Visas include tourist visas, immigration and naturalization visas, student visas (for studying abroad), and business/work visas (for working abroad).

Xenophobia

Dislike or prejudice against people from other countries.

MINORITY HEALTH RESOURCES

Federally Qualified Health Centers

FQHCs are “safety net” providers (community health centers, public housing centers, outpatient health programs funded by the Indian Health Service) and programs serving migrants and the homeless. The main purpose of the FQHC Program is to enhance the provision of primary care services in underserved urban and rural communities https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/fqhcfactsheet.pdf

Henrietta Johnson Medical Center

https://www.hjmc.org/office-locations.html

Claymont

2722 Philadelphia Pike Claymont, DE 19703 302-655-6187

Westside Healthcare

Southbridge

601 New Castle Avenue Wilmington, DE 19801 302-655-6187

*Dental Clinic on Site

https://www.westsidehealth.org/locations-hours/

1892 W. 4th Street Wilmington, DE 19805 302-655-5822

404 Fox Run Drive Bear, DE 19701 302-836-2864

La Red Health Center

908-B E 16th Street Wilmington, DE 19802 302-575-1414

1020 Forrest Avenue Dover DE 19904 302-678-4622

http://www.laredhealthcenter.org/index.cfm?ref=60100

21444 Carmean Way Georgetown, DE 19947

*Dental Clinic on Site

Other Resources

300 High Street Seaford, DE 19973

27 Marrows Road Newark, DE 19713 302-455-0900

21 West Clarke Avenue Milford, DE 19963

*Dental Clinic on Site

Delaware Healthy Mother and Infant Consortium - https://dethrives.com/dhmic Delaware Medical Assistance Program - https://medicaid.dhss.delaware.gov/

MINORITY HEALTH RESOURCES

Delaware Hospitals & Veterans Administration Services

New Castle County

ChristianaCare

Christiana Hospital

4755 Ogletown-Stanton Road Newark, DE 19718 302-733-1000 https://christianacare.org/

ChristianaCare

Wilmington Hospital 501 W. 14th Street Wilmington, DE 19801 302-733-1000 https://christianacare.org/

ChristianaCare

Middetown Emergency Department 621 Middletown Odessa Rd Middletown, DE 19709 https://christianacare.org/

Bayhealth Hospital Kent Campus 640 S. State Street Dover, DE 19901 302-674-4700 https://www.bayhealth.org

Bayhealth Hospital Sussex Campus 100 Wellness Way Milford, DE 19963 https://www.bayhealth.org

Tidal Health Nanticoke 801 Middleford Road Seaford, DE 19973 302-629-6611 https://tidalhealth.org

Sussex County VA Clinic 21748 Roth Avenue Georgetown, DE 19947 800-461-8262 x 2300 https://www.va.gov/ wilmington-health-care/locations/ sussex-county-va-clinic/

St. Francis Hospital 701 N. Clayton Street Wilmington, DE 302-421-4100 https://www.trinityhealthma.org/ location/saint-francis-healthcare

Nemours Children’s Hospital, Delaware 1600 Rockland Road Wilmington, DE 302-651-4200 https://www.nemours.org/locations/ wilmington-ai-dupont-childrens-hospital.html

Wilmington VA Medical Center 1601 Kirkwood Highway Wilmington, DE 302-994-2511 https://www.va.gov/wilmington-health-care/

Kent County

Kent County VA Clinic 655 South Bay Road, Suite 3C Dover, DE 19901 800-461-8262 x 2400 https://www.va.gov/wilmington-health-care/ locations/kent-county-va-clinic/

Sussex County

Beebe Healthcare Margaret H. Rollins Lewes Campus 424 Savannah Road Lewes, DE 19958 https://beebehealthcare.org

Beebe Healthcare South Costal Emergency Department 32750 Roxana Road Frankford, DE 19945 302-291-6900 https://beebehealthcare.org

From the Archives: the Healing Arts in History

Edgewood: The Black Sanitorium for the White Plague

On the first page of its 1947 anniversary program, Edgewood Sanatorium (see Figure 1) proudly claims to be the “first sanatorium in the United States to be used exclusively for tuberculosis Negros.” Piedmont Sanatorium in Lynchburg, VA, made a similar declaration, even though it opened two years after Edgewood in 1917 and six years after the Wilson, NC, facility. Pickford Sanatorium in Southern Pines, NC, wins the title of being the first, having opened in 1899. This bit of trivia, however, does not take away from Edgewood’s historical significance. As a segregated facility managed by a Black doctor, the sanitorium is simultaneously a celebration of broader access to healthcare for Black Delawareans and a representation of the disastrous impact of racism in healthcare.

Around 1900, while tuberculosis (TB) killed an average of 195 people per 100,000 nationally, the rate for Black Americans was 500-600 per 100,000.1 Even though the microbial cause was discovered in 1882, heredity was thought to play a significant role in the disease well into the 1920s. Rather than attributing malnutrition and poor, overcrowded living conditions, White doctors pointed to Black bodies themselves as the cause of high mortality rates. In addition to being physically inferior and incurable, Blacks were considered too ignorant and slovenly to implement sanitation measures necessary for disease prevention.2 In 1896, a leading doctor predicted that the “Negro tuberculosis problem” would wipe out the race entirely from the United States.3 This unfavorable prognosis was not universally accepted, although fewer public resources were used to care for Black patients suffering from the “white plague.”

In 1907, the president of the Delaware Anti-Tuberculosis Society, Emily Bissell, introduced the Christmas Seal Sale. By 1912, the Society collected approximately $90,000 in donations to support the construction of the Hope Farm Sanitorium in Brandywine Springs. The State Legislature kicked in funding for the operation of the facility. Despite contracting TB at rates significantly higher than other populations, Hope Farm kept only a few beds in a separate unit for Black patients. In 1914, the State Legislature agreed to appropriate $10k for establishing a separate facility only if the Anti-Tuberculosis Society could raise matching funds. Edgewood opened in 1915 with Dr. Conwell Banton, a Black doctor from Wilmington, as Medical Director for the forty-bed segregated sanatorium. Black men and women rallied behind Edgewood, forming the Edgewood Sanitarium Auxiliary to raise money for patients. In 1921, the Auxillary was 300 members strong.2

While Edgewood offered Black patients an alternative to the often undignified experiences with White doctors, it suffered from chronic underfunding. In the 1920s, Brandywine Sanitorium (formerly Hope Farms) received $65,000 in annual funding, while Edgewood only received $12,000 from the state.2 This disparity had dire consequences. White patients at Brandywine measured their stay in years. Edgewood’s average stay was measured in months. The facility was staffed by six nurses, with Dr. Banton visiting three times a week. Even after a new building was constructed in 1939, the additional eighteen beds did little to reduce the number of patients who spent years on the waitlist to get treatment at Edgewood. Many patients were already in the advanced stages of the disease when they were finally admitted. The lack of beds at Edgewood contributed to the spread of TB in Black communities. Cramped and overcrowded housing reduced opportunities for quarantine, thus increasing exposure to infection within communities and increasing the need for beds. The ramifications of this disparity were devastating. In 1946, deaths among the state’s White population were 29.7 per 100,000 and 136.9 per 100,000 for the Black population. In Wilmington, the situation was even worse, with Black deaths from TB at 165 per 100,000.4

As if the staggering death toll of Black patients was not enough, the absurdity of segregation had negative consequences for some White patients as well. Since neither Brandywine nor Edgewood had equipment for major surgery, patients were taken to Memorial Hospital. However, only three beds were available for tuberculosis patients (dropping to two by 1950). With all the beds in the same room, patients had to be scheduled for surgery based on gender and race rather than need, creating a “terrific bottleneck of surgery piling up at the Brandywine and Edgewood Sanitoria.”5 Despite the devastating and unnecessary consequences, the sanitoria were not integrated until 1957.

Edgewood may not have been the ‘first’ Black sanatorium in the country, but losing status as an answer to a question in trivia does not diminish the facility’s significance in Delaware history.

Despite incredible hardships and severe limitations, Edgewood served tuberculosis patients that were otherwise excluded from medical care. While it is a painful reminder of the tragic effects of segregation and inequity, Edgewood should also be remembered for the heroic efforts of the staff and the community to keep the sanatorium open for over 40 years.

REFERENCES

1. Merrill, R., Davis, S., Lindsay, G., & Khomitch, E. (2016, September). Explanations for 20th century tuberculosis decline: How the public gets it wrong. Journal of Tuberculosis Research, 4(3), 111–121. Retrieved from https://www.scirp.org/journal/paperinformation.aspx?paperid=70106 https://doi.org/10.4236/jtr.2016.43014

2 Prus, D. (2021). “The white plague seems to love the black victim:” The racialization of tuberculosis in the antituberculosis campaign and black resistance to the “Negro tuberculosis problem,” 1870-1930. Clark University. Retrieved from https://commons.clarku.edu/history_honors_papers/2

3. The Morning News. (1955, September 25). Dr. Banton is honored for fight on tuberculosis. The Morning News, 1, 9.

4. Bunn, N.A. (1947, Sep 14). Jim Crow TB sanatorium is modern, but inadequate. The Sunday Morning Star, 3.

5. The Morning News. (1950, Sep 14). State doctors to hear new trends in TB fight. The Morning News, 32.

Index of Advertisers

The Nation's Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

American Public Health Association

The DPH Bulletin - September 2022 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Delaware Division of Public Health

The DPH Bulletin - Special Flu Edition 2022 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Delaware Division of Public Health

2022 Communicable Disease Summit and PrEP Conference . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Delaware Division of Public Health Health Plan Connect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Quality Insights

Mid-Atlantic Partnership Regional Conference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Delaware Public Health Association

Robert O . Y . Warren, MD Memorial Seminar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

American Academy of Pediatrics - Delaware Chapter

The DPH Bulletin - October 2022 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

Delaware Division of Public Health

APHA 2022 Annual Meeting and Expo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85

The American Public Health Association Submission Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86

Delaware Journal of Public Health

. . . . . . 12 Delaware Division of Public Health

Boston | November 6-9, 2022

Make plans to gather with friends and colleagues from around the nation, and world, for four days of insightful presentations, engaging activities and face-toface networking. With more than 1,000 presentations, we’re covering nearly every public health topic. Plus, the 2022 Annual Meeting and Expo is the culmination of APHA’s 150th anniversary celebration, so we’ve got even more planned than normal for this exciting educational event.

Important reminder: The 2022 mid-term elections will be Tuesday, Nov. 8, so be sure to vote early.

Can’t travel? We’re hosting a digital version of APHA 2022 on Nov. 14-16. This will in clude access to recordings of more than 120 sessions from the Annual Meeting. Of course, the Featured and General Sessions are included, along with up to two ses sions selected by each APHA Section. You’ll even be able to participate live in the

Public Health

Delaware Journal of Submission Guidelines

updated April, 2020

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

e 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.

The initial submission should be clean and complete, without edits or markups, and contain both the title and author(s) fulls name(s). Submissions should be 1.5 or double spaced with a font size of 12. Initial submissions must also contain a cover letter with concise text (maximum 150 words). Once completed, articles should be submitted via email to Elizabeth Healy at 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.

Cover Letters must address the following four article requirements:

1. A description of what the paper adds to current knowledge, in particular with respect to material previously published in DJPH, and if systematic reviews exist on the topic.

2. The public health importance of the paper.

3. One sentence summarizing the main message(s) of the paper, which may be used to disseminate the paper on social media.

4. For individual or group randomized trials, provide the date of trial registration and the NCT number from www.Clinicaltrials.gov or other approved registry. In the cover letter only, not in the paper. Do NOT include the trial registration or NCT number in the abstract or the body of the manuscript during the initial submission.

All manuscripts must be submitted via email to Elizabeth Healy at ehealy@delamed.org.

To view additional information for online submission requirements, please refer to the website for the Delaware Journal of Public Health: https://djph.org/sample-page/submit-an-article/

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.

Con icts 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.

Nondiscriminatory Language

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.

Abstracts

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

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

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.

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