TAG: "Health disparities"

Public health researchers go to church to promote hepatitis B screening


UCLA team held small group discussions in more than 50 L.A.-area Korean churches.

To reach a vulnerable population largely unaware of the health risks, a team from the Fielding School for Public Health held small group discussions in more than 50 Los Angeles-area Korean churches. (Photo by UCLA-Kaiser Permanente Center for Health Equity)

By Dan Gordon, UCLA

For the large Korean American-community in Los Angeles, chronic infection with the hepatitis B virus looms as a significant — and too often unspoken — health threat, associated with the highest rates of liver cancer for any ethnic group in Los Angeles. Knowing one’s hepatitis B status can be critical — it allows those who test HBV-negative to be immunized against the virus while pointing the way toward early treatment as well as more vigilant efforts to prevent transmission for those who are positive. But most adults in L.A.’s Korean-American community have never been screened and are unaware of whether they carry the virus.

In an effort to change that, a research team from the UCLA Fielding School for Public Health’s Kaiser Permanente Center for Health Equity and Center for Cancer Prevention and Control Research, working in partnership with leaders of Los Angeles’ Korean-American community, set out to increase HBV screening in the population through small group discussions led by trained community members. For their study testing the impact of this strategy, they chose unlikely venues: 52 Korean churches in Los Angeles.

“When we started, people questioned the feasibility of having discussions about a sexually transmitted virus at church,” said Roshan Bastani, the Fielding School professor with leadership roles in both centers who headed the study. “But if you want to target a general population of Koreans in Los Angeles, you have to go where they tend to gather. We learned that most Koreans go to church, and that it’s not just religious but also a social experience where non-religious services are delivered to members. In talking with church leaders and other members of the community, we were encouraged to pursue what they saw as an important project.”

If not treated, chronic HBV infection can lead to liver cirrhosis in as many as 1 in 4 carriers, which can ultimately progress to liver cancer. HBV is also highly infectious — spread not only via sexual contact and sharing needles, but also through household items such as razors or toothbrushes, or from an infected mother to her child during birth.

Because it is so common in many Asian countries, HBV disproportionately affects Asian Americans, particularly newer immigrants. The problem is particularly serious among Korean Americans. In Los Angeles, an estimated 12 percent of the Korean-American population is infected — and because the virus causes no symptoms until the liver damage becomes severe, the majority of them doesn’t know it. Although routine HBV vaccination of children has been implemented in the United States and much of Asia for two decades, most adults were born before childhood HBV vaccination became commonplace and can benefit from immunization only once they are tested and found to be HBV-negative. The potential for uninfected adults to get vaccinated, and for carriers to receive early treatment and monitoring while taking measures to prevent transmission to others, all point to the public health benefits of promoting HBV screening.

The Fielding School team relied heavily on the wisdom of its Korean-American community partners for both the design and implementation of an intervention aiming to increase screening. A seven-member community advisory committee included two church pastors, a pastor’s wife, a church elder, a church health leader, a physician and a representative of a Korean-American, nonprofit, faith-based organization. Fifty-one bilingual community members were hired as staff members for the study and trained to administer surveys and facilitate the small group discussion sessions with the churches — ensuring that the intervention could be sustained beyond the three-year study period.

One member hired for the study team with deep roots in the Los Angeles Korean community, Hosung Kim, was assigned the task of inviting the participation of pastors and other church leaders. “My role was to convince them that our project could improve the lives of their members through health care awareness,” said Kim, who covered the activities of Korean churches as a reporter working for a Korean newspaper chain. “I explained that because the overwhelming majority of Korean immigrants participate in Sunday services, this would provide the best opportunity to recruit participants … Most of the responses were very positive.”

Of the 52 Korean churches that participated, half were randomly assigned to the study’s intervention arm, which featured small group discussions on hepatitis B among Korean adults who had either not previously been tested or couldn’t recall their results; the other half, which served as the control group, discussed nutrition and physical activity. The HBV discussions provided facts about hepatitis B and liver cancer, the risk for Koreans, and the rationale for testing. Through scripts and role-playing, participants were guided on how to bring up the topic with their doctors and encouraged to discuss HBV with family and friends. Testing and vaccination were framed within Korean medicine concepts of keeping the body healthy.

The project identified and addressed factors that prevent many Koreans from getting tested, even when they are aware of the HBV risk. Many participants expressed fear about the consequences of learning they were infected, or the potential for bringing shame to their family if they tested positive. There was also concern about the cost of the test — 57 percent of the study participants reported lacking health insurance. In an effort to overcome that barrier, the project staff provided a list of clinics offering low-cost or free HBV screening.

In the end, the discussions proved highly effective: Participants in the intervention group were three times more likely to get a hepatitis B test than those who were in one of the groups that discussed nutrition and physical activity.

“Few previous studies have attempted to identify effective strategies to promote hepatitis B screening among Koreans,” said Beth Glenn, associate professor of health policy and management and a member of the study team. “We were excited to see that a one-time, small-group discussion intervention produced a meaningful increase in hepatitis B screening in a population at high risk for hepatitis B and liver cancer.”

Any concerns the Fielding School team had about testing the intervention in Korean churches were quickly eased.

“For some of our projects, even when we are actively recruiting, it can be hard to find people to participate,” said Alison Hermann, project director for the study. “In this case we would simply go to the churches, set up a table with our banner, and people would come to us. Part of it had to do with the sense of community in the churches, where if something was going on, members wanted to know about it. But we also found that the interest in health-related issues was tremendous.”

This story originally appeared in the UCLA Fielding School of Public Health magazine’s Fall 2014 issue.

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Insuring undocumented residents could help solve multiple health care issues


UCLA health policy care analysis finds four key problem areas for Latinos under ACA.

Alex Ortega, UCLA

By Mark Wheeler, UCLA

Latinos are the largest ethnic minority group in the United States, and it’s expected that by 2050 they will comprise almost 30 percent of the U.S. population. Yet they are also the most underserved by health care and health insurance providers.

Latinos’ low rates of insurance coverage and poor access to health care strongly suggest a need for better outreach by health care providers and an improvement in insurance coverage. Although the implementation of the Affordable Care Act of 2010 seems to have helped (approximately 25 percent of those eligible for coverage under the ACA are Latino), public health experts expect that, even with the ACA, Latinos will continue to have problems accessing high-quality health care.

Alex Ortega, a professor of public health at the UCLA Fielding School of Public Health, and colleagues conducted an extensive review of published scientific research on Latino health care. Their analysis, published in the March issue of the Annual Review of Public Health, identifies four problem areas related to health care delivery to Latinos under ACA:

  • The consequences of not covering undocumented residents.
  • The growth of the Latino population in states that are not participating in the ACA’s Medicaid expansion program.
  • The heavier demand on public and private health care systems serving newly insured Latinos.
  • The need to increase the number of Latino physicians and non-physician health care providers to address language and cultural barriers.

“As the Latino population continues to grow, it should be a national health policy priority to improve their access to care and determine the best way to deliver high-quality care to this population at the local, state and national levels,” Ortega said. “Resolving these four key issues would be an important first step.”

Insurance for the undocumented

Whether and how to provide insurance for undocumented residents is, at best, a complicated decision, said Ortega, who is also the director of the UCLA Center for Population Health and Health Disparities.

For one thing, the ACA explicitly excludes the estimated 12 million undocumented people in the U.S. from benefiting from either the state insurance exchanges established by the ACA or the ACA’s expansion of Medicaid. That rule could create a number of problems for local health care and public health systems.

For example, federal law dictates that anyone can receive treatment at emergency rooms regardless of their citizenship status, so the ACA’s exclusion of undocumented immigrants has discouraged them from using primary care providers and instead driven them to visit emergency departments. This is more costly for users and taxpayers, and it results in higher premiums for those who are insured.

In addition, previous research has shown that undocumented people often delay seeking care for medical problems.

“That likely results in more visits to emergency departments when they are sicker, more complications and more deaths, and more costly care relative to insured patients,” Ortega said.

Insuring the undocumented would help to minimize these problems and would also have a significant economic benefit.

“Given the relatively young age and healthy profiles of undocumented individuals, insuring them through the ACA and expanding Medicaid could help offset the anticipated high costs of managing other patients, especially those who have insurance but also have chronic health problems,” Ortega said.

The growing Latino population in non-ACA Medicaid expansion states

A number of states opted out of ACA Medicaid expansion after the 2012 Supreme Court ruling that made it voluntary for state governments. That trend has had a negative effect on Latinos in these states who would otherwise be eligible for Medicaid benefits, Ortega said.

As of March, 28 states including Washington, D.C., are expanding eligibility for Medicaid under the ACA, and six more are considering expansions. That leaves 16 states who are not participating, many of which have rapidly increasing Latino populations.

“It’s estimated that if every state participated in the Medicaid expansion, nearly all uninsured Latinos would be covered except those barred by current law — the undocumented and those who have been in the U.S. less than five years,” Ortega said. “Without full expansion, existing health disparities among Latinos in these areas may worsen over time, and their health will deteriorate.”

New demands on community clinics and health centers

Nationally, Latinos account for more than 35 percent of patients at community clinics and federally approved health centers. Many community clinics provide culturally sensitive care and play an important role in eliminating racial and ethnic health care disparities.

But Ortega said there is concern about their financial viability. As the ACA is implemented and more people become insured for the first time, local community clinics will be critical for delivering primary care to those who remain uninsured.

“These services may become increasingly politically tenuous as undocumented populations account for higher proportions of clinic users over time,” he said. “So it remains unclear how these clinics will continue to provide care for them.”

Need for diversity in health care workforce

Language barriers also can affect the quality of care for people with limited English proficiency, creating a need for more Latino health care workers — Ortega said the proportion of physicians who are Latino has not significantly changed since the 1980s.

The gap could make Latinos more vulnerable and potentially more expensive to treat than other racial and ethnic groups with better English language skills.

The UCLA study also found recent analyses of states that were among the first to implement their own insurance marketplaces suggesting that reducing the number of people who were uninsured reduced mortality and improved health status among the previously uninsured.

“That, of course, is the goal — to see improvements in the overall health for everyone,” Ortega said.

Other authors of the study were Arturo Vargas Bustamante of UCLA and Hector Rodriguez of UC Berkeley. Funding was provided by the National Heart, Lung, and Blood Institute (P50 HL105188).

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Welltopia: A new online resource for California


Comprehensive website aims to reduce health disparities.

By Carole Gan, UC Davis

Welltopia, a new website launched today (Feb. 25) by the California Department of Health Care Services (DHCS) and the UC Davis Institute for Population Health Improvement (IPHI), offers a wide range of essential resources to help Californians, especially those on limited incomes, build healthier lives and communities.

Designed to complement the popular Welltopia by DHCS Facebook page, the new website serves as a comprehensive resource connecting individuals, families and communities to credible information that addresses the social determinants of health and other leading causes of preventable death.

Many studies have shown that access to health care, education, employment, housing, nutritious foods and physical activity are among the fundamental drivers of health for individuals and their communities. Making reliable information and resources available for people of all ages is key to creating healthy environments.

“We developed Welltopiato be a convenient and trusted source of information covering all three aspects of health — physical, mental and well-being,” said Neal Kohatsu, DHCS medical director. “We’ve made every effort to ensure that the resources are both accurate and accessible to consumers.”

The Welltopia site organizes information into five categories — Well Body, Well Mind, Jobs & Training, Health Insurance, and Basic Needs. It includes information on nutrition, physical activity, smoking cessation, alcohol- and drug-abuse prevention, stress management, health insurance, residency, and social services, among others. The site also contains videos, photos and graphics with information about health-related programs. There are free applications, such as fitness trackers, women’s health information, recipes and food journals to track daily calorie intake, and links to CalFresh, education, job placement resources and other social services.

“Welltopia should be the first stop for persons seeking reliable information about the many determinants of health,” said Kenneth W. Kizer, IPHI director. “Its friendly format quickly guides users to practical and trustworthy sources.”

The Department of Health Care Services manages California’s form of Medicaid, known as Medi-Cal, which helps millions of low-income Californians obtain access to affordable, high-quality health care, including medical, dental, mental health, substance use disorder services, and long-term services and supports. DHCS aims to preserve and improve the health of all Californians.

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Undocumented farmworkers use Medicaid half as often as documented farmworkers


UC Davis study finds that greatest predictor of farmworker use of Medicaid is having children.

J. Paul Leigh, UC Davis

By Karen Finney, UC Davis

Undocumented farmworkers are half as likely as those who are documented to use Medicaid, the federal health insurance program available to low-income individuals and families, according to a new study from UC Davis Health System. The research also shows that the greatest predictor of farmworker use of Medicaid, which provides coverage for prenatal, pediatric and emergency care regardless of documentation status, was having children.

“Undocumented agricultural workers are using Medicaid at about half the rate of documented immigrants and citizens, and they appear to be using it in accordance with the law,” said J. Paul Leigh, senior author of the study, professor of public health sciences and researcher with the Center for Healthcare Policy and Research. “There’s a perception that undocumented farmworkers are overusing Medicaid resources, but our findings indicate the opposite.”

In conducting the study, which is published online in the Journal of Occupational and Environmental Medicine, Leigh analyzed records from the U.S. Department of Labor’s National Agricultural Workers Survey (NAWS) on 41,324 farmworkers from 1993 through 2009, about half of whom were migrants working without residency, citizenship or visas.

Because the NAWS database is the only nationally representative sample of undocumented workers, it is a rare source of information on demographics and income at both individual and household levels for this often elusive group. Given that almost 50 percent of Medicaid recipients are children, the data on households rather than individual adults was particularly relevant to the current study.

Leigh found that undocumented farmworker heads of household were 52 percent less likely to use Medicaid than their documented counterparts: 22.6 percent of documented farmworker heads of household and only 12.2 percent of undocumented farmworker heads of household reported that one or more family members received Medicaid services over two-year intervals during the 16-year study period.

The odds of receiving Medicaid benefits for documented heads of household with one child were 6.57 times greater than that of documented heads of household with no children. One-child undocumented heads of household were 8.4 times more likely to utilize Medicaid than childless documented heads of household.

“Simply having children is the best determinant of Medicaid use,” said Leigh. “Use by undocumented, unmarried males appears to be extremely rare.”

The seemingly disproportionate effect of children on undocumented versus documented heads of household may be explained by access to non-government health insurance options, according to Leigh. Documented workers are much more likely than undocumented workers to have employer-sponsored health insurance, which families typically prefer over Medicaid. Undocumented heads of household, even those with children who are U.S. citizens, rarely have that choice.

“Undocumented workers don’t have any other place to go for health insurance,” Leigh said. “As soon as they have a child in the family, undocumented workers are much more likely to use Medicaid.”

Higher income, either for individuals or families, was associated with lower odds of Medicaid use for both documented and undocumented heads of household. There were also variations by region, with California having the highest odds of Medicaid use.

This is one in a series of studies of health care utilization prepared by Leigh, an expert in economics and occupational illnesses. Next in the pipeline is a study of those who use food stamps and the U.S. Department of Agriculture’s Special Supplemental Nutrition Program for Women, Infants and Children, which provides supplemental foods, health care referrals, and nutrition education for low-income women and young children who are deemed at nutritional risk.

“Medicaid Use by Documented and Undocumented Farm Workers” was co-authored by Yoon-Kyung Chung of the Korea Energy Economics Institute in Seoul and Ph.D. graduate of the UC Davis Department of Economics. It was supported by the National Institute for Occupational Safety and Health (grant number 2U54OH007550-11). The study is available online.

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Hispanics develop alcoholic liver disease at younger ages than others


The difference is between four and 12 years earlier than Caucasians or African Americans.

Valentina Medici, UC Davis

By Karen Finney, UC Davis

Hispanics develop alcoholic liver disease (ALD), a common cause of liver-disease death, between four and 12 years earlier than whites/Caucasians or African Americans, according to a new study from UC Davis Health System.

While previous research indicated that Hispanics tend to have more severe ALD than other populations, the new study — published online in the journal Alcoholism: Clinical and Experimental Research — is believed to be the first to pinpoint racial and ethnic disparities in the ages at which symptoms first appear.

“Clinicians typically evaluate older patients for liver disease when moderate or heavy alcohol use has been long term,” said senior author Valentina Medici, associate professor of internal medicine. “We should be more aggressive in counseling patients about the importance of sobriety and testing them for ALD at younger ages, especially our Hispanic patients.”

An expert on liver metabolism and physiology, Medici and the study team reviewed records of nearly 800 UC Davis Medical Center patients diagnosed between 2002 and 2010 with one of the three, progressive stages of ALD caused by alcohol consumption — alcoholic fatty liver, alcoholic hepatitis or alcoholic cirrhosis.

The team also assessed patients’ drinking patterns, laboratory data, body mass indexes and additional health conditions such as metabolic syndrome and diabetes. Patients who had diseases such as hepatitis B or who were HIV-positive were excluded from the study to avoid potential confounding effects on ALD onset and severity.

The results showed that the most striking differences were in the average ages of onset of alcoholic fatty liver: 41 for Hispanic patients, 51 for whites/Caucasians and 53 for African Americans. This is the first stage of ALD and the point at which intervention can be most successful at reversing liver damage.

The average ages of onset for alcoholic hepatitis were 41 for Hispanic patients, 47 for whites/Caucasians and 48 for African Americans. For alcoholic cirrhosis, the average ages of onset were 49 for Hispanics, 53 for whites/Caucasians and 54 for African Americans.

The team also found that Hispanics who had end-stage ALD were more likely to be obese and diabetic than White/Caucasian and African American patients in the study.

“Our findings suggest that alcoholic liver disease is caused by more than chronic alcoholism,” said Charles Halsted, a study co-author and professor emeritus of internal medicine. “Future research should focus on genetic, metabolic and environmental factors that may increase the susceptibility of Hispanics to this disease.”

Funding for the study was provided by grants to Medici from the National Institutes of Health (numbers K08DK084111 and R03DK099427) and the UC Davis Division of Gastroenterology and Hepatology. Additional contributors to the research were lead author Robert Levy, Blythe Durbin-Johnson and Andreea Catana of UC Davis.

The study — titled “Ethnic Differences in Presentation and Severity of Alcoholic Liver Disease — is available online at http://onlinelibrary.wiley.com/journal/10.1111/(ISSN)1530-0277/earlyview.

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Rate of Latino physicians shrinks as Latino population swells


UCLA study calls for action at national, state levels to increase ranks of Latino physicians.

By Enrique Rivero, UCLA

Latinos are one of the fastest growing ethnic groups in the United States, with their numbers having risen 243 percent since 1980. Yet the number of Latino physicians per 100,000 Latinos has declined by 22 percent during that period, according to new research.

In 1980, there were 135 Latino physicians for every 100,000 Latinos in the U.S.; by 2010, that figure had dropped to just 105 per 100,000. Meanwhile, the national rate of non-Hispanic white physicians increased from 211 for every 100,000 non-Hispanic whites to 315 per 100,000.

The numbers point to a worsening shortage of doctors who have the language skills and cultural familiarity needed to serve Latino patients, according to a new study from UCLA’s Center for the Study of Latino Health and Culture. The study, published online by the peer-reviewed journal Academic Medicine, calls for action at the national and state and levels to increase the ranks of Latino physicians.

Dr. Gloria Sanchez, the paper’s lead author, said the shortage could negatively affect health care for U.S. Latinos.

“For example, there is a shortage of health care professionals that, at minimum, have the language skills to communicate effectively with patients, provide quality care and avoid harmful outcomes for a growing majority of patients not only in California but in the nation as a whole,” said Sanchez, an associate clinical professor of family medicine at the David Geffen School of Medicine at UCLA and faculty member at Harbor–UCLA Medical Center.

The study drew U.S. Census data from 1980 through 2010 in five states with large Latino populations — California, Florida, Illinois, New York and Texas. The researchers found similar declines in the rates of Latino physicians in each of the five states, albeit with small variations.

The study is an update to a 2000 paper by David Hayes-Bautista, a UCLA professor of medicine and director of the Center for the Study of Latino Health and Culture at the Geffen School of Medicine who also was a co-author of the new paper. The earlier research found Latinos made up 4.8 percent of all physicians in California, while making up 30.4 percent of the state’s population; the same study projected that the number of Latino physicians in California would decrease 6 percent by 2020.

Sanchez said the researchers were surprised by the 22 percent drop in the rate of Latino physicians, a decline that was in stark contrast to the 49 percent increase in non-Hispanic white physicians over the same period.

Prior research has found that Latino physicians are far likelier than non-Hispanic whites to practice in communities with large concentrations of Latinos, and that underrepresented minorities such as Latinos, African-Americans and Native Americans are more likely than non-Hispanic whites to practice in areas with large underserved minority populations.

Other research has shown that Latino patients who have limited English-language skills visit doctors less frequently than those with stronger English proficiency.

The study did have some limitations: The researchers were limited by the strengths and weaknesses of the self-reported census data, and the census does not consider issues related to quality of care.

The findings point to a need for further research into Latinos’ health care needs, Sanchez said.

“Our research finds a very concerning trend of a growing Latino population that may not have the ability to find physicians who can provide language and culturally concordant care,” she said. “It demonstrates the urgent need for analysis of how the rapidly growing Latino population will have adequate access to high-quality care both now and in the future.”

The study’s other co-authors were Theresa Nevarez of UCLA and Werner Schink of the California Department of Social Services. The research was funded by the UCLA Hispanic Center of Excellence.

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Study taps into healthy drink choices


Low-quality water in rural immigrant communities could be prompting kids to drink sugary beverages.

The water study is part of a five-year project investigating whether community-based intervention can help prevent childhood obesity.

By Jeannette Warnert, ANR

Having established a link between obesity and sugary beverages, doctors and nutritionists recommend that children instead drink plain tap water. In virtually all of the United States and California, tap water is the best drink available for good health.

However, a team of UC Cooperative Extension and UC Davis scientists have found that low-quality tap water in some rural immigrant communities could be an obstacle to making this healthy dietary change.

The study was conducted in conjunction with a five-year research and outreach project underway in Firebaugh and San Joaquin, small communities in the San Joaquin Valley with high Mexican-American populations. The researchers are investigating whether a community-based intervention – involving nutrition education, a monthly voucher of $25 to purchase fruit and vegetables, and a physical activity program – can help prevent childhood obesity in Californians of Mexican descent living in low-income rural communities. UC Agriculture and Natural Resources and UC Davis were recipients of a $4.8 million National Institute for Food and Agriculture grant to carry out this research.

Twenty-seven mothers in the study shared with the researchers whether they use tap water and gave their perceptions of tap water quality. In addition, the researchers assessed local water quality by the frequency of violations reported by Cal EPA and contaminant-level data from the California Department of Public Health.

Contamination concerns

All 27 mothers said they avoid drinking tap water due to unpleasant taste, dirty or yellow appearance, excessive iron or general “contamination.” Most of the women rely instead on bottled, and to a lesser extent, home filtered water for drinking and cooking.

“This cost is an extra burden for these families, many of whom have limited incomes,” said Lucia Kaiser, UC Cooperative Extension specialist in the Department of Nutrition at UC Davis.

The mothers shared in interviews that at least 38 percent of their children aged 3 to 8 years old drank sugar-sweetened beverages – such as soda, energy drinks, powered drink mixes or fruit punch – more than two or three times per week.

“The children may be drinking sugar-sweetened beverages so frequently because of real or perceived low quality of water coming from their taps,” Kaiser said. “I’m not surprised. One time I was in our Firebaugh office and turned on the tap and the water came out brown. “

Two state-regulated water systems serve the majority of people in Firebaugh and San Joaquin. The rest rely on at least 11 small public or private systems. All of the 13 systems have had monitoring violations in the last 12 years. Two have had reporting violations, indicating that they either did not test for contaminants or did not report their findings.

Seeking solutions

The mothers’ perception that tap water was unappealing or contaminated was confirmed when the researchers took a close look at regulatory analyses reports from previous years. There were low-levels of arsenic detected, which fell above the benchmark for safe drinking water in the U.S. The analyses also detected high levels of manganese and iron, which are considered secondary contaminants and do not have enforceable limits set by the EPA. However, the World Health Organization has set health benchmarks for manganese, which were exceeded in some samples.

“The neurotoxic effects of manganese and chronic exposure to low levels of arsenic warrant further study,” Kaiser said. “Even if it’s not dangerous, the high level of manganese and iron can give the water an off taste.”

Regardless, removing the contaminants may not matter if perceptions and drinkability are not improved. A possible solution is better communication.

“A simple step could be sending easy-to-understand water quality reports to all residents,” Kaiser said. “Sending reports to renters in addition to property owners and in Spanish as well as English will help raise awareness about the safety of local tap water.”

The study was funded in part by the UC Davis Center for Poverty Research, which developed a two-page policy brief outlining the research findings. UC Davis doctoral student Caitlin French was the main author. Other contributors, in addition to Kaiser, were postdoctoral researcher Rosa Gomez-Camacho, UC Cooperative Extension nutrition, family and consumer sciences advisor Cathi Lamp and UC Davis nutrition professor Adela de la Torre.

In the policy brief, the authors included some additional suggestions to address the issue:

  • Increase state funds to agencies working to identify who is at risk in order to bring more water systems into compliance
  • Provide subsidies for home water filters
  • Provide subsidies to private well owners in exchange for testing reports
  • Step up outreach to owners of targeted private water systems in known problem areas
  • Provide funding for additional research to inform outreach messages about substituting tap water for sugar-sweetened beverages

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Act of courage: Life after the ‘die-in’


UCSF med students sparked a national movement with #whitecoats4blacklives; what’s next?

UC San Francisco professional students led a national movement via social media that examined how racial disparities impact health care. (Photo by Leland Kim, UC San Francisco)

By Leland Kim and Laura Kurtzman, UC San Francisco

A group of UCSF medical students gathered in a closed meeting last month to talk about race, racism and racial disparities.

They were troubled by recent grand jury decisions not to indict white police officers who were involved in the deaths of two unarmed African American men, Michael Brown in Ferguson, Mo., and Eric Garner in New York City, and wanted to channel their frustration into something constructive.

The students, including many from the UCSF Underrepresented In Medicine (UIM) mentoring program, decided to hold a “die-in” at UCSF while wearing their white coats, symbolic of those in the health profession. They and their peers of all ethnic backgrounds tapped into student networks across the country.

In just five days, a national movement called #whitecoats4blacklives was born.

It catalyzed thousands of students, faculty and staff in more than 80 colleges across the country. At UCSF, students from all professional schools (dentistry, medicine, nursing and pharmacy) and the Graduate Division participated, as well as some faculty and staff members.

The hashtag dominated social media on Dec. 10, garnering widespread media attention and sparking a much-needed national conversation about racism being more than a just criminal justice issue.

Organizers of the student #whitecoats4blacklives die-in were invited to participate in the School of Medicine leadership retreat to share their experiences. (From left) Frederick Jamison, Angela Broad, Faby Molina, Adali Martinez, Donald Richards, Stephen Villa, Sidra Bonner and Nicolás Barceló. (Photo by Elisabeth Fall)

“As students, we were able to use the momentum from the #whitecoats4blacklives movement to demonstrate the urgency of dealing with the issues of race, micro-aggressions and inequality that affects UCSF faculty, staff, students and most importantly the patients we all serve,” said student organizer Sidra Bonner, a second-year student in the School of Medicine. “It is my hope that this movement leads to improvement of the social medicine curriculum, specifically continued learning and skill development around this issue of bias, creation of a robust mentorship/advising system for all students, as well as commitment to strengthening the pipeline for underrepresented students in medicine by increased availability of scholarships and administrative support.”

A priority for the university

The die-in had a ripple effect across UCSF.

A student-initiated town hall held two days after attracted faculty members, deans and many of the University’s top leaders, who talked openly with students about the UCSF’s ongoing challenge with diversity.

Chancellor Sam Hawgood, M.B.B.S., has made race and racial inequities a priority in his administration.

“This is an issue that goes beyond any one school or department; this is a campus issue,” he said. “Diversity is going to be an important priority for the entire UCSF community. I thank our students for initiating this conversation.”

And organizers of the School of Medicine’s annual leadership retreat this month decided to change the event’s agenda to discuss the enduring question of race in America – and how racial dynamics play out at UCSF.

“Our students are asking us to acknowledge, to think and to do something about the problem of racial and ethnic injustices,” said Bruce Wintroub, M.D., interim dean of the School of Medicine, introducing a daylong colloquy that was rich in both data and personal stories about what it means to be black and brown in America.

“It is very easy to talk about racial disparities at other places,” he said. “It is much harder for us to take an honest look at the problems we have at UCSF.”

Groundbreaking discussion of race

The leadership retreat, which took place on Jan. 8 and 9, was the first one ever to focus solely on race/ethnicity and health disparities. It came as the School of Medicine has launched a six-year, $9.6 million effort to hold its departments accountable for achieving diversity, provide the resources to recruit and retain a more diverse faculty, create a culture of diversity and inclusion and expand the pool of scientific talent, which gets smaller at each level of training.

“This retreat was the first time in my 32 years at UCSF that I feel we have started to have an authentic conversation about race and the impact of racism and unconscious bias on our students, faculty and patients,” said Renee Navarro, M.D., Pharm.D., vice chancellor of diversity and outreach. “I applaud the students who organized and implemented the #whitecoats4blacklives movement. They were the spark that led to this event.”

Some of those students were invited to participate in the leadership retreat and share their experiences with the group to help facilitate organizational change.

At times, nervous energy was palpable as students recalled instances of racism on campus. Some community members, participants noted, have accused UCSF being an “elitist ivory tower.”

White faculty members listened attentively, and some were candid enough to admit that they hadn’t really thought about racism and its impact on students and patients in a meaningful way.

“Being on the panel and speaking to an audience of accomplished and powerful people at UCSF were terrifying,” said Angela Broad, a second-year medical student. “It was really difficult sharing those experiences but the informal conversations I had throughout the day were very heartening. So many faculty, deans and staff thanked me for sharing my story.”

Compelling presentations and anecdotes by faculty of color helped shape the day’s conversation.

Neal Powe, M.D., M.P.H., M.B.A., vice chair of the Department of Medicine and chief of medical services at San Francisco General Hospital and Trauma Center, shared a story about being pulled over by the police in North Carolina while in town to give a lecture. A police officer suspiciously questioned Powe about his destination, instructed him to keep his hands on the steering wheel and asked him if he had drugs in the car.

Guest speaker Denise Rodgers, M.D., focused on the impact of race and racism on health and health care in her talk, helping the audience to understand how a climate of violence affects their patients and their health.

“When we teach about homicide, do we reinforce the stereotype of violent, lawless black men who should be feared and for whom there is little hope for change?” asked Rodgers, vice chancellor of Rutgers Biomedical and Health Sciences. “When we teach about homicide, do we talk about poverty, unemployment, poorly-performing schools, inadequate access to social and mental health services as contributors to the homicide rates we see?”

Nurturing a pipeline of UCSF talent

This year, one-third of first-year medical students are underserved minorities (black, Latino, Native American or Pacific Islander), the highest percentage of any medical school in California.

Despite having one of the most diverse student populations in the nation, a recent survey found that nearly one-third of students who are black, Latino and Native American reported feeling shunned or ignored or having experienced behavior they found intimidating, offensive or hostile, and 21 percent said it interfered with their ability to learn. That was double the percentage reported by whites and a third higher than reported by Asians.

Talmadge King, M.D., chair of the Department of Medicine, said the medical school is doing well at recruiting students, but many are not staying for their residency training.

Retention drops more at the fellowship training level and then essentially stops at the faculty level. Similar statistics also apply to the other professional schools and the Graduate Division.

King believes the best long-term strategy is for UCSF to build its own pipeline of talent, beginning with middle and high school, so students learn to love science and have an association to UCSF. “Places that have really focused on that are beginning to have success,” he said. ”It takes a long time, but it actually works.”

Turning words into action

UCSF leadership will review and evaluate ideas that were generated by the retreat participants and determine the priorities and tactics to move them forward. This effort is aligned with the campus obligation to the University of California Office of the President to identify initiatives in the UC-wide Climate Survey. Those initiatives will include one that is focused on establishing a “climate of inclusion.”

Meanwhile, the students who organized the #whitecoats4blacklives event have formalized the creation of the national White Coats for Black Lives organization that was born out of the movement. They are connected with 83 representatives of various medical schools throughout the country and are in the process of creating a national board for their student organization.

They will also be actively involved in working with faculty and leadership to achieve the goals identified during the leadership retreat.

“I have never felt so inspired by UCSF – what it is and what it can be,” said student organizer Nicolás Barceló, a fourth-year medical student who attended the retreat. “My decision to attend UCSF was motivated by the belief that its capacity to effectively address the social determinants of health, it stands alone. No other institution can bring together the resources, talent and dedication to social justice that you see at UCSF. No one.”

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Kids of melanoma survivors need better protection from sun’s harmful rays


UCLA study is first to include Latinos, whom have often been left out of skin cancer prevention research.

Credit: Sean Brenner, UCLA

By Reggie Kumar, UCLA

UCLA researchers have found that children of melanoma survivors are not comprehensively adhering to sun protection recommendations, despite them being at an increased risk for developing the disease as adults.

In the study led by Beth Glenn, associate director of the UCLA Jonsson Comprehensive Cancer Center’s Healthy and At-Risk Populations Research Program, researchers asked parents about their attitudes toward melanoma prevention, how at risk for melanoma they believed their child to be, and their current use of sun protection strategies for their child. They found that about three-quarters of parents relied on sunscreen to protect their child against sun exposure, but less than a third of parents reported that their child wore a hat or sunglasses or attempted to seek shade when exposed to the sun.

Additionally, Glenn said, 43 percent of parents surveyed reported that their child experienced a sunburn in the past year. This is concerning because sunburns are a major risk factor for melanoma.

The UCLA researchers used the California Cancer Registry (which tracks all cases of cancer across the state) to identify and survey 300 melanoma survivors with children ages 17 and younger during a three-year period. The study targeted both non-Latino white melanoma survivors and for the first time Latino melanoma survivors as well.

Latinos have often been left out of skin cancer prevention research due to a common misconception that sun protection is not important for this group.

“Sunburns were common among the children in our study despite their elevated risk for skin cancer. Also, children of Latino survivors were just as likely as children of non-Latino white survivors to have experienced a recent sunburn, which highlights the importance of including this group in our work,” said Glenn, associate professor of Health Policy and Management in the UCLA Fielding School of Public Health.

The survey results will be used to apply for additional funding to develop an intervention program that combines a text message reminder system with educational materials and activities for parents and children. The intervention program is designed to help melanoma survivors more effectively monitor and properly protect their child against UV radiation.

“Protecting kids against the sun’s harmful rays at an early age is vitally important. Our goal is to develop an intervention that will help parents protect their children today and help children develop sun safe habits that will reduce their risk for skin cancer in the future,” said Glenn.

The study will be published online Jan. 13 in the journal Cancer Epidemiology, Biomarkers & Prevention.

The research was supported in part by the National Cancer Institute.

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Trending: Full-time employment with no health benefits


In 2012, nearly half of uninsured Californians were in families with a full-time worker.

By Venetia Lai, UCLA

Almost half of the 6.9 million Californians who lacked insurance in 2012 were in a family with a full-time worker, according to a new report from the UCLA Center for Health Policy Research.

The State of Health Insurance in California report also found that the number of adult workers with job-based health insurance declined between 2009 and 2012. Full-time workers saw a drop of 2.9 percentage points to 63.6 percent and part-time workers dropped 2.2 points to 39.6 percent.

The report is based on data from the 2011-12 California Health Interview Survey, which is the nation’s largest state-based health survey and one of the largest health surveys in the United States. Because the data were collected just before full implementation of health care reform, the latest State of Health Insurance in California report will serve as a baseline to gauge the effects of the Affordable Care Act.

“Health care reform filled a huge and growing gap in job-based insurance,” said Shana Alex Charles, lead author of the study and director of the Health Insurance Program at the Center for Health Policy Research. “Sadly, health insurance is no longer a guarantee provided by many employers.”

Latinos still in the medical “shadows”

According to the report, Latinos had the lowest rate of job-based health coverage — 33.9 percent, compared to 63.3 percent of whites — and the highest rate of not having insurance, 28.4 percent.

Although nearly a third of low-income adult Latinos had Medi-Cal, 1 in 4 still lacked a usual source of care, the report noted, and 17.2 percent of adult Latinos covered by job-based insurance didn’t see a doctor in 2011-12, a much higher rate than either non-Latino whites or African Americans.

“This report shows us where we were, and it wasn’t a good place,” said Gerald Kominski, director of the Center for Health Policy Research and co-author of the study. “From here on out we can accurately measure how California’s health improves under reform.”

Young adults gain job-based coverage in ACA reform

In an early example of the benefits of health care reform, the study found that adults ages 19-26 were the only age group that gained health coverage from 2009 to 2012, with job-based coverage for them jumping to from 23.2 percent to 27.1 percent. That was an increase of 254,000 people. This age group also experienced the largest drop in the rate of people without insurance; this rate went from 28.9 percent in 2009 to 26 percent in 2012.

But for older adults, the percentage of those covered by job-based insurance plummeted. In the 40- to 54-year-old age group, more than half a million people  lost job-based coverage — a drop from 49 percent in 2009 to 45.4 in 2012.

“With job-based coverage shrinking year after year and nearly a third of California’s Latino community without health coverage, California was poised and ready for the implementation of the Affordable Care Act,” said Robert Ross, president and CEO of The California Endowment, which co-funded the report along with the California Wellness Foundation. “I’m confident we’ll see improvements in health coverage rates when the 2014 enrollment numbers are crunched.”

High-deductible plans create “underinsurance”

Among people with insurance, high deductibles played a big role in whether people put off having medical procedures. Californians with high-deductible plans that they purchased directly from an insurance company delayed or went without needed medical care at a rate double that of those without high-deductible plans, 16.1 percent versus 6.6 percent.

While the share of workers carrying individually purchased insurance is small — about 5 percent of full-time workers and 9.5 percent of part-time workers — the burden falls on many who are small business owners, according to the report.

“These data underscore the importance of Covered California’s Small Business Health Options Program,” said Judy Belk, president and CEO of the California Wellness Foundation. “It makes getting health insurance much more affordable for small businesses. People should not have to put their health at risk because insurance premiums are too high.”

Other findings include:

White, middle class and uninsured. Among whites with a family income higher than 400 percent of the federal poverty level (about $92,200 for a family of four in 2012), 1 in 4 went without insurance all or part of the year.

Public health insurance programs protect millions. One-fifth of Californians under age 65 in 2012 — 6.4 million people — were insured by Medi-Cal and the Healthy Families programs. That included nearly 2.6 million low-income children ages 0-11. This represented an 8-percentage-point jump from 2009 — the biggest increase of any age group — to 40.3 percent covered. This increase underscores the importance of public health insurance programs in maintaining the health of children. Nearly 70 percent of children covered by Medi-Cal are Latino.

With the release of the report, policy analysts and health advocates have a tool to measure the extent to which ACA reforms changed health access and health outcomes among the state’s residents in 2014.

“While the clear early success of the ACA in enrolling young adults in private coverage is promising, our data show that even the insured have delays in care, problems affording deductibles, and other access barriers that we hope will be addressed,” Charles said.

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UC students bring attention to impact of racial disparities in health care


Students stage “white coat die-ins” nationwide, including at UCSF, other UC medical schools.

UC San Francisco professional students led a national movement via social media that examined how racial disparities impact health care. (Photo by Leland Kim, UC San Francisco)

By Leland Kim, UC San Francisco

A group of UCSF School of Medicine students started a nationwide movement to bring attention to the impact of racial disparities in health care. They led more than 2,000 students in 80 medical schools across the country in a “white coat die-in” where they lay down in their white coats to protest recent grand jury decisions not to indict white police officers who killed Michael Brown and Eric Garner, unarmed African American men in Ferguson, Missouri, and New York City, respectively.

At UCSF, more than 150 students and some faculty and staff members gathered in front of the UCSF Parnassus Library at noon on Dec. 10. Making sure not to block the sidewalk or entrance to the library, they lay down for 45 minutes in silence. Many closed their eyes. Some held hands.

“As health professional students, we really want to emphasize the fact that what happens in the community bears relation to what happens in our work,” said event organizer Nicolás Barceló, a fourth-year student in UCSF School of Medicine. “The context in which our patients live contextualizes the type of care we need to provide.”

This movement started at UCSF several weeks before the “die-in” when a core group of students of color in the UCSF Underrepresented In Medicine (UIM) program, and their white allies within the School of Medicine, worked with established networks of the Student National Medical Association (SNMA), the Latino Medical Students Association (LMSA), and the PRIME Program of UC medical schools to raise awareness. Soon after the hashtag #whitecoat4blacklives was born.

“Using social media as the primary driver, and with the help of incredible individuals, many of whom we had never met, our idea became a shared cause,” said Barceló. “Students at UPenn were responsible for creating the national Facebook group. The national press release disseminated through Physicians for a National Health Program (PNHP), which was a product of the collaboration between students from UCSF, UPenn, Brown and Mt Sinai. The artwork of white coats becoming flying doves – perhaps most symbolic of the movement –was created by a student at UCSF.”

The School of Medicine-led event also included participation by students in the School of Dentistry, School of Nursing and School of Pharmacy. Students from other UC medical schools also participated at their locations. The hashtag #WhiteCoats4BlackLives generated close to 2,000 posts or mentions on Twitter, Facebook and Instagram on the day of the event, reaching more than one million people. It was covered by local and national media, including MSNBC, the Huffington Post and the San Francisco Chronicle.

“This movement is particularly important because in the end we’re here to advocate for our patients, to be the voice for those who are not heard,” said Daniela Brissett, a second-year School of Medicine student who helped organize the event. “Health care disparities for people of color are ever growing and we need to change that. It’s the responsibility of us, as well as our faculty and our deans. And it starts here, and it starts with the resources we need to provide for our patients.”

Some faculty members and members of the leadership team, including Renee Navarro, Pharm.D., M.D., vice chancellor of diversity and outreach, came out to support the students.

“It’s been an incredible catalyst to bring together students,” said Barceló . “We couldn’t be more grateful for the support we’ve received from our administration, from our Vice Chancellor Dr. Renee Navarro.”

“I am inspired by our students,” Navarro said. “I’m inspired by our collaboration, the solidarity across our schools, across our faculty, our students and our staff coming together on such a critically important issue, and recognizing as deliverers of health care, this is such an important component of what we do and we should have a voice in this.”

As a follow up, the student organizers of the “die-in” scheduled a town hall meeting on Dec. 12 at Cole Hall to share reflections on violence and racial bias in the community as well as in the health care system. They also brainstormed ideas for organized student response with several deans and some faculty members.

“We look forward to having productive conversations with leadership here at UCSF and other UC campuses to amend our curriculum, to increase diversity both in the students and in the faculty,” Barceló said. “Ultimately we want to improve relations between our institutions and the communities we serve.”

In the days following the “die-in,” several other college campuses in other parts of the country hosted town halls and open meetings to discuss and develop a plan for institutional change.

At the national level, student leaders of the movement are deciding how to proceed in effecting change. They hope to systematically reform the policies and practice of medicine to more adequately address racism and violence as major determinants to health.

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Cloudy water, even if it is safe, affects rural immigrants’ health


UC Davis researchers examine connection between water quality, childhood obesity.

Cloudy tap water may have a greater effect for California’s rural immigrants than merely leaving behind a bad taste, according to a new policy brief released by the Center for Poverty Research at the University of California, Davis.

Researchers looked at the connection between water quality and childhood obesity in two poor immigrant communities in California’s Central Valley — San Joaquin and Firebaugh. Poor-quality tap water, or even a perception that the water is bad, combined with environmental factors such as lack of access to healthy foods and nutrition education, likely contribute to health disparities in these communities, the study finds.

“If the tap water that comes out looks dirty or has a poor taste, they’re not going to have a lot more confidence in the drinking system here,” said Lucia Kaiser, a UC Cooperative Extension specialist in the Department of Nutrition at UC Davis and the study’s co-principal investigator. “The immigrant populations in these communities come from Mexico, where they may have experienced unsafe drinking water in rural areas,” she said.

Kaiser interviewed 27 mothers from these communities after giving a class on the health effects of sugar-sweetened beverages. Most of the women reported relying on purchased and, to a lesser extent, home-filtered water for drinking and cooking. Kaiser said that the additional cost represents an extra burden on these low-income families.

“In these communities, more than a third can’t afford to put enough food on their table, and now they have to buy drinking water, too. Every expense really matters,” said Kaiser.

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