TAG: "Public health"

Restricting firearms access for people who misuse alcohol may prevent violence


Existing policies largely ineffective in restricting firearm access for people who misuse alcohol.

By Carole Gan, UC Davis

Restricting access to firearms for people who misuse alcohol could prevent firearm violence, but policies that more clearly define alcohol misuse should be developed to facilitate enforcement, according to a review of existing research and public policies by the UC Davis Violence Prevention Research Program.

The analysis, published online April 30 in the peer-reviewed journal Preventive Medicine, summarizes studies on binge drinking and other forms of alcohol misuse in association with firearm access and use, including firearm violence. It also describes the shortcomings of existing policies designed to restrict access to firearms among those who are at high risk for violence due to alcohol misuse — particularly people with multiple prior convictions for alcohol-related offenses such as driving while under the influence (DUI).

“Both acute alcohol intoxication and chronic alcohol misuse are strongly associated with risk for committing firearm violence, whether that violence is directed at others or at oneself,” said Garen J. Wintemute, professor of emergency medicine, founding director of the UC Davis Violence Prevention Research Program and expert on gun violence as a public health problem.

“In any given month, an estimated 8.9 million to 11.7 million firearm owners binge drink. Both binge drinking and heavy chronic drinking are more common among firearm owners than in the general population. For men, there are as many alcohol-associated deaths from firearm violence as from motor vehicle crashes,” he said.

The article cites numerous studies that link aggressive firearm behaviors and alcohol misuse. These include a nationally representative study in which people who reported threatening others with a firearm were more likely than others to meet Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) criteria for alcohol abuse or dependence, and another that found people who misused alcohol were substantially more likely than others to exhibit a combination of angry behavior and either carry firearms outside the home or have firearms at home.

Similarly, many studies have linked suicide by firearm and alcohol intoxication, including a 2011 study that found the excessive consumption of alcohol was associated with an 86-fold increase (an increase of 8,600 percent) in the risk of firearm suicide or near-suicide.

Federal and state policies are largely ineffective in restricting firearm access for people who misuse alcohol, Wintemute writes. Federal statute prohibits individuals who are unlawful users of or addicted to any controlled substance from the purchase or possession of firearms, but the statute specifically excludes alcohol from its definition of a “controlled substance” and leaves alcohol-related restrictions for individual states to consider.

“While 37 states with jurisdiction over 65 percent of the U.S. population have some restrictions on acquiring, possessing or using firearms by those who are intoxicated or have a history of alcohol misuse, many of these policies are unenforceable because they rely on vague, inherently subjective definitions of intoxication or misuse, such as ‘habitual drunkard,’  ‘habitually in an intoxicated condition,’ ‘chronic alcoholic’ and ‘addicted to alcohol,’” Wintemute said.

Wintemute noted that in the few locations that more specifically define alcohol misuse by number of convictions for DUI or other alcohol-related offenses over time (Maryland, Pennsylvania, Indiana, and the District of Columbia), the data on enforcement are unavailable or suggest that enforcement is lacking.

“Policies that restrict firearm access by persons with other risk factors for violence have been shown to be effective,” said Wintemute, who also is the first Susan P. Baker-Stephen P. Teret Chair in Violence Prevention at UC Davis Health System.

“In California, prohibiting persons convicted of violent misdemeanors for 10 years following their convictions reduced their risk of arrest for a firearm-related or violent offense. The evidence strongly suggests that properly-crafted and well-enforced policies, like modern laws for drinking and driving, would help prevent firearm-related violence,” he said.

Research for the article, “Alcohol misuse, firearm violence perpetration, and public policy in the United States,” was funded in part by the California Wellness Foundation (grant no. 2013-159). The foundation played no role in study design or conceptualization; in the collection, analysis and interpretation of the data; in the writing of the report; or in the decision to submit the article for publication.

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Culturally tailored intervention may help reduce obesity in Latino children


Study finds meaningful improvements in child weight and BMI.

By Linda Anderberg, UC Berkeley

A recent collaborative study between UC Berkeley School of Public Health and Contra Costa County researchers evaluated the efficacy of a culturally tailored obesity intervention for Latino children, Familias Activas y Saludables, or Active and Healthy Families (AHF). The study results were published online in Academic Pediatrics.

The randomized controlled trial found that child body mass index (BMI) decreased in the AHF group and increased in the control group over a 10-week period. Children in the AHF group also had reduced triglyceride levels (a type of fat measured in blood), but no significant improvement in blood pressure. This randomized trial is the first to date to show a significant impact on BMI of a culturally tailored primary care program addressing obesity in Latino children.

“Latinos represent the largest minority ethnic group in the United States and suffer disproportionately from childhood obesity and type 2 diabetes,” says Jennifer Falbe, a postdoctoral research fellow at the school and lead author of the study. “Given the unique barriers some Latino communities face regarding diet and physical activity, there is an urgent need for culturally and linguistically tailored programs to address childhood obesity in these communities.”

AHF is a family-based group medical appointment program of Contra Costa County Public Health Clinic Services. It consists of five two-hour sessions that teach healthy eating and exercise habits, as well as parenting skills. AHF sessions were delivered in Spanish by a multidisciplinary team including a registered dietitian, a physician and a promotora — a community health worker who engaged families and facilitated understanding of the content of the sessions. The promotoras called families twice to check on progress, bridge communications gaps and remind families about the next session.

“We found that AHF resulted in meaningful improvements in child weight and BMI,” says Falbe. “AHF was unique in its delivery by a provider triad and its cultural relevance. Furthermore, unlike many interventions, the program is financially sustainable for the publicly funded health centers in which it was delivered.”

The U.S. Preventive Services Task Force has called for studies that address weight management in minority children and investigate efficient, primary care feasible interventions using allied health professionals. This study makes a valuable contribution to that evidence gap.

Co-authors of the study include Kristine Madsen, associate professor at the UC Berkeley School of Public Health; Nicole K. Tantoco, research assistant at the UC Berkeley School of Public Health; Hannah R. Thompson, research scientist at the UC Berkeley School of Public Health; and Annabelle A. Cadiz, Contra Costa Public Health, Contra Costa Health Services.

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Twitter could provide key details about transgender people’s health needs


UCLA study suggests that social media could help fill knowledge gap.

Sean Young, UCLA

By Enrique Rivero, UCLA

Transgender and gender-nonconforming people have a higher-than-average risk for AIDS and are more vulnerable than others to depression. But because stigma about gender identities makes them less likely to disclose information about themselves to researchers, it also has been difficult for doctors to understand the best ways to provide care for them.

New research by the University of California Institute for Prediction Technology suggests that social media could help fill that knowledge gap.

In a study published in the peer-reviewed journal JMIR Mental Health, the researchers reported that because transgender and gender-nonconforming people frequently use social media to discuss important health and social needs, resources like Twitter may provide a wealth of useful information for doctors and public health professionals.

“Transgender individuals are at risk for some of the most important public health problems, such as HIV, substance abuse and depression,” said Sean Young, the study’s co-author and the executive director of the institute, which is based in the UCLA Department of Family Medicine. “There has been little research studying transgender communities because they can be very closed communities who fear stigmatization. Our institute has studied how to use social big data to address public health needs and we wanted to apply this work to address the needs of transgender communities and researchers.”

Young and co-author Evan Krueger collected 1,135 tweets with 13 relevant hashtags, including terms like #trans or #girlslikeus. The tweets discussed issues such as violence, discrimination, suicide and sexual risk.

“This approach can be used to better understand people, prevent diseases and predict important trends — including views on policies that affect transgender populations or changes in health,” said Krueger, a doctoral student at the UCLA Fielding School of Public Health.

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UC Berkeley team takes top honors in Emory Global Health Case Competition


First-time entrants win prestigious international student competition.

The UC Berkeley team at the 2015 Emory Global Health Case Competition: Asha Choudhury, Chris Andersen, Jee Yun Kim, Richa Gujarati and Rosheen Birdie

By Linda Anderberg, UC Berkeley

When five UC Berkeley students assembled to enter the 2015 Emory Global Health Case Competition — the first time a Berkeley team had entered — they weren’t expecting to win. Nonetheless, they took the top prize at the prestigious international competition, which aims to promote awareness of and develop innovative solutions for 21st century global health issues. Twenty-four multidisciplinary teams from universities around the world competed in the challenge on Saturday, March 28, at the Rollins School of Public Health in Atlanta.

“The fact that they placed first among over two dozen elite universities in the United States and abroad is a testament to the innovative culture at Berkeley,” says Phuoc Le, assistant professor in the Interdisciplinary M.P.H. Program at the UC Berkeley School of Public Health, who served as a the team’s faculty adviser.

Rosheen Birdie, an undergraduate student majoring in public health and molecular and cell biology, was team captain and initially reached out to staff and faculty to find out how she would go about forming a team. She was put in touch with Hildy Fong, executive director of the UC Berkeley Center for Global Public Health, who connected her with Chris Andersen, a UC Berkeley School of Public Health student in the MS program in epidemiology who was also interested in the Emory competition. Birdie and Andersen then recruited more team members, using what Andersen describes as “a snowball approach.” Eventually, Asha Choudhury, a student in the UC Berkeley-UCSF Joint Medical Program; Jee Yun (Ashley) Kim, a molecular and cell biology undergrad; and Richa Gujarati, an M.B.A. student at the Haas School of Business, all joined the team.

“Our team represented more academic disciplines than some of our competitors, which I think gave us an advantage,” says Andersen. “This translated into ‘constructive friction’ between team members during our discussions on the case. Ultimately our differing perspectives produced a better product than any one of us could have come up with alone.”

The team prepared by reviewing cases from previous Emory competitions and going over proposed solutions. Le advised them on case format and presentation details. They also worked on fundraising for the five-person trip to Atlanta.

“Addressing global health challenges in the ‘real world’ requires collaboration, commitment, drive, and intelligence. This Berkeley team embodied all these traits from the moment they decided to participate, and they were tenacious and determined in preparing for the competition every step of the way — even when facing various logistical setbacks,” says Fong. “If this winning Berkeley team is a glimpse of the upcoming cadre of global health professionals, then our future is in good hands.”

The team received their global health case one week before the competition, finding out that they would be developing a strategy to reduce gun violence in Honduras. “I thought it seemed like a difficult problem to solve in a week,” Andersen recalls.

“The case subject was definitely surprising, but in a good way,” says Kim. “It challenged us to address gun violence as a multi-faceted public health issue and target its root causes. It was a great learning experience.”

Choudhury was impressed with the case because it was open to many different approaches. Birdie agrees. “It was a case with a lot of clues as to strategies you could take, but there wasn’t one obviously correct solution,” she says. “I’d recommend that future teams read it closely when they are preparing for the competition.”

After a week of preparation, the team traveled to Atlanta, where they had an intense day to finalize their strategy and presentation — working from noon on Friday to 2:30 a.m. on Saturday. The next morning, they made their last edits at 7:35 a.m., turned in their flash drive, and waited to make their 15-minute presentation followed by a 10-minute question-and-answer session with a distinguished panel of judges, including Rafael Flores-Ayala, team lead of the International Micronutrient Malnutrition Prevention and Control Program at the CDC and Asha Varghese, director of the Global Health Portfolio at the GE Foundation.

The Berkeley team’s strategy was titled “Breaking the Cycle of Violence” and involved a three-pronged approach that included the promotion of public safety, job production and economic development, and community building. The team segmented the drivers of violence into macro (lack of opportunity, poor education, U.S. demand for cocaine), meso (drug flow, corruption, culture of violence), and micro (access to firearms, conflict over territory) levels. They also categorized their strategies using these levels — for example, a cash transfer to incentivize education was at the macro level, while trading guns anonymously for cash was at the micro level.

“One of the most challenging aspects was getting all the relevant points into a 15-minute presentation,” says Birdie, “and ensuring that our solution was realistic, sustainable and scalable.”

After finishing in first place in their six-team round one, the UC Berkeley team continued on to the four-team finals, where they gave their presentation to all eight case competition judges and in front of many of the students from other universities. For winning the competition, they received a $6,000 award.

“One of the most rewarding aspects of the competition was learning how to work as a multidisciplinary team,” says Kim. “It was amazing to progress from each one of us having different ideas to forming one cohesive solution.”

Second place went to the team from the University of Kentucky, also first-time participants. The University of Miami team won third place, and Northwestern University earned Honorable Mention. Fourteen waitlisted teams competed in a video competition using the same case as the on-campus participants — with the University of Minnesota taking top honors.

Visit the Emory Global Health Institute website for more information about its global health case competitions.

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Secondhand smog


Scientists determine amount of ozone pollution drifting to California from overseas.

Ian Faloona, UC Davis

By Kat Kerlin, UC Davis

Approximately 10 percent of ozone pollution in California’s San Joaquin Valley is estimated to be coming from outside of the state’s borders, particularly from Asia, according to preliminary research presented today (March 31) by the University of California, Davis.

Secondhand smog from Asia and other international sources is finding its way into one of the nation’s most polluted air basins, the San Joaquin Valley. UC Davis atmospheric scientist Ian Faloona shared his research with air quality regulators and scientists today at a transboundary pollution conference near Yosemite National Park. The issue serves as an example of how air quality is a global — not just local — problem.

“To me, it’s an exciting new chapter of how we think of air pollution,” Faloona said. “How do we deal with this not just as an air district of a couple of counties, but as a nation and a global citizen of the planet? Traditionally, air pollution has always been considered an issue to be handled locally, ‘It’s your backyard, it’s your problem.’ But we’re going to have to treat air pollution to some extent how we treat greenhouse gases.”

[Audio clip (1 min, 3 sec) ]

Up in the air

When someone smokes a cigarette next to you, you know that secondhand smoke is harmful to your lungs, even though you aren’t the smoker. But what about when your neighbor is thousands of miles away, and the pollution they are emitting is from an industrial plant, millions of cars, or a raging wildfire?

Scientists have long known that a portion of ozone pollution was coming from overseas, but attempts to quantify just how much were hamstrung by coarse computer models that overlooked or broadly simplified California’s complex terrain.

Faloona describes California as if it were a human body: The Golden Gate bridge is the mouth, breathing in air from across the Pacific Ocean, sucking it through the throat of the Bay Area and into the lungs of the San Joaquin Valley. Previously unknown is how much air comes over the coastal mountain range and mixes from above into the bathtub of the San Joaquin Valley.

UC Davis researchers have spent the past three years trying to measure that contribution from a mountaintop air quality monitoring station near California’s Point Sur. They’ve also gathered it from a plane equipped with scientific instruments that measure air pollutant levels — a flying air monitoring station of sorts. The combined data has allowed them to analyze the “signature” of the sources and quantify how much of the valley’s ozone pollution is locally produced, and how much is drifting across from international sources.

Every little bit counts

The research comes as the U.S. Environmental Protection Agency has proposed tightening ozone limits from 75 parts per billion to between 65 ppb and 70 ppb, later this year. (A final rule is due Oct. 1.) In the San Joaquin Valley, which includes the cities of Fresno, Stockton and Bakersfield, asthma rates are roughly twice that of the rest of the state. Such a change by the EPA is expected to push much of the valley further out of compliance.

Air districts are financially penalized and considered out of compliance for going over federal ozone pollution thresholds, known as National Ambient Air Quality Standards. As they continue to work to improve local air quality, regulators have an increasing stake in being able to account for how much pollution is within their local control and how much is not.

“In addressing the tremendous public health challenge we face in reducing ozone, it is critical to accurately identify the sources of ozone pollution so that solutions can be appropriately targeted,” said Seyed Sadredin, executive director of the San Joaquin Valley Air Pollution Control District. “The scientific information being discussed at the transboundary ozone conference will be invaluable to many regions throughout the nation.”

Share the air

Faloona notes that the majority of the air pollution in California is coming from local sources, which requires further work. His research is not about pointing fingers but about having a clearer picture of where pollution comes from — and how a global community can help reduce it.

“One of the reasons I was so drawn to atmospheric science is because we’re intimately sharing this substance that’s totally vital to us,” Faloona said. “Air is something that we have to share. To me, it’s always been an obvious connector of people. We’re becoming more cognizant of how connected we are and how all of our decisions have to be made on a global scale from here on in.”

[Audio clip (27 sec) ]

The research was funded by the San Joaquin Valley Air Quality Control District.

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Emergency medicine physicians urge colleagues to prevent gun violence


Editorial follows Feb. 24 call to action by eight health professional organizations.

By Carole Gan, UC Davis

In an editorial posted online today (March 25) in the Annals of Emergency Medicine, two practicing emergency medicine physicians from UC Davis and Brown University — both thought leaders at the forefront of finding solutions to the public health crisis of gun violence — urge their colleagues to take direct action to protect the health and safety of patients and communities.

Their editorial follows the Feb. 24 call to action by eight health professional organizations, including the American College of Emergency Physicians and the American Bar Association, to reduce firearm injuries and deaths in the U.S. — unprecedented support that suggests mobilization to prevent firearm violence may be underway.

“Firearm violence causes nearly as many deaths as motor vehicle crashes,” said Garen J. Wintemute, an emergency medicine professor at UC Davis and a national authority on evidence-based strategies to prevent firearm violence. “Firearms are involved in most homicides and suicides, and the number of suicides by firearm is increasing — especially among older white men.

“Emergency medicine physicians have limited opportunities to prevent a death once a shooting has occurred, because most people who die from their wounds do so where they are shot. Gun ownership or having a gun in the household is a well-documented risk factor for a violent death. For that reason, we believe physicians should also work to help prevent shootings,” he said.

The authors describe how America successfully reduced motor-vehicle-related deaths by better vehicle and roadway design and public policies that make driving under the influence a crime. Yet no comparable public-health campaign focused on reducing gun violence has been launched.

The authors particularly emphasize the need for a national policy requiring background checks on all transfers of firearms to help prevent access to firearms by those who are prohibited from having them. They recommend adding two other high-risk groups to the list of individuals who are prohibited from purchasing firearms. These include persons with a history of violent misdemeanor convictions, such as assault and battery and domestic violence, as well as those with a documented history of addiction and alcohol abuse.

“Controlled studies of felons, those who have committed violent misdemeanors and persons prohibited for mental-health reasons have all shown reductions in risk for future violence of 25 percent or more when these individuals are denied firearm purchases,” said Megan Ranney, an emergency medicine physician and director of the Emergency Digital Health Innovation program at Rhode Island Hospital and the Warren Alpert Medical School of Brown University.

The authors also address mental illness and gun violence. While they agree with recommendations that focus on behavior and expanded access to treatment, they emphasize that serious mental illness directly accounts for only 4 percent of interpersonal violence. In contrast, mental illness is associated with between 47 and 74 percent of suicides. The risk of firearm injury increases when mental illness coexists with alcohol abuse, drug abuse and a history of prior violence.

“Physicians need to include questions about firearms when assessing risk of violence in their patients, and need to act on the information, especially when patients are expressing thoughts of dangerousness to themselves or others, are intoxicated or are in the emergency department for a violence-related injury,” Ranney said.

At a time when civilian fatalities from gunshot wounds for 2004 to 2013 have outnumbered combat fatalities from World War II, the authors welcome the unprecedented support from leading organizations of health and legal professionals for policy recommendations to reduce gun violence.

“Physicians can take direct action to protect the health and safety of patients and communities,” Wintemute said. “While we may not all agree on all the specifics, enough of us will agree on enough of them to make a difference for the better.”

The Violence Prevention Research Program is an organized research program of UC Davis that conducts leading-edge research to further America’s efforts to understand and prevent violence. Since its founding over 30 years ago, the program has produced a uniquely rich and informative body of research on the causes, nature and prevention of violence, especially firearm violence. Current areas of emphasis include the prediction of criminal behavior, the effectiveness of waiting period and background-check programs for prospective purchasers of firearms, and the determinants of firearm violence. For more information, visit www.ucdmc.ucdavis.edu/vprp.

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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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‘Sugar Papers’ reveal industry role in 1970s dental program


Sugar industry worked closely with NIH on research agenda on preventing tooth decay.

By Kristen Bole, UC San Francisco

A newly discovered cache of industry documents reveals that the sugar industry worked closely with the National Institutes of Health in the 1960s and ‘70s to develop a federal research program focused on approaches other than sugar reduction to prevent tooth decay in American children.

An analysis of those papers by researchers at UC San Francisco appears today (March 10) in the open-source scientific journal, PLoS Medicine.

The archive of 319 industry documents, which were uncovered in a public collection at the University of Illinois, revealed that a sugar industry trade organization representing 30 international members had accepted the fact that sugar caused tooth decay as early as 1950, and adopted a strategy aimed at identifying alternative approaches to reducing tooth decay.

Meanwhile, the National Institutes of Health had come to the conclusion in 1969 that focusing on reducing consumption of sucrose, “while theoretically possible,” was not practical as a public health measure.

Thus aligned, the sugar industry trade organization and the NIH worked in parallel and ultimately together on developing alternative research approaches, with a substantial portion of the trade organization’s own research priorities — 78 percent — directly incorporated into the 1971 National Caries Program’s first request for research proposals from scientists.

“The dental community has always known that preventing tooth decay required restricting sugar intake,” said first author Cristin Kearns, D.D.S., M.B.A., a UCSF postdoctoral scholar who discovered the archives. “It was disappointing to learn that the policies we are debating today could have been addressed more than 40 years ago.”

While tooth decay is largely preventable, it remains the leading chronic disease among U.S. children, according to the Centers for Disease Control and Prevention. The CDC estimates that more than half of American children and teens have cavities in their adult teeth, and 15.6 percent of children age 6 to 19 have untreated tooth decay, which can lead to tooth loss, infections and abscesses.

Kearns discovered the papers in a collection that was left to the University of Illinois library by the late Roger Adams, a professor emeritus of organic chemistry who served on the Sugar Research Foundation (SRF) and the scientific advisory board of the International Sugar Research Foundation (ISRF), which became the World Sugar Research Organization.

They include 1,551 pages of correspondence among sugar industry executives, meeting minutes and other relevant reports from between 1959 and 1971. Kearns and UCSF co-authors Stanton A. Glantz, Ph.D., and Laura A. Schmidt, Ph.D., analyzed the papers against documents from the National Institute of Dental Research (NIDR) to explore how the sugar industry may have influenced the research policies of the 1971 National Caries (Tooth Decay) Program.

The analysis showed that in the late 1960s and early 1970s, the sugar industry funded research in collaboration with allied food industries on enzymes to break up dental plaque and a vaccine against tooth decay. It also shows they cultivated relationships with the NIDR and that a sugar industry expert panel overlapped by all but one member with the NIDR panel that influenced the priorities for the NIH tooth decay program. The majority of the research priorities and initial projects largely failed to produce results on a large scale, the authors found.

“These tactics are strikingly similar to what we saw in the tobacco industry in the same era,” said Glantz, whose similar discovery in the 1990s of tobacco industry papers led to massive settlements between the industry and every U.S. state, and to the Department of Justice’s successful prosecution of the major tobacco companies and their research organizations under the Racketeer Influenced and Corrupt Organizations Act. The Legacy Tobacco Documents Library at UCSF now contains 14 million of those documents.

“Our findings are a wake-up call for government officials charged with protecting the public health, as well as public health advocates, to understand that the sugar industry, like the tobacco industry, seeks to protect profits over public health,” Glantz added.

While the authors recognize that the Adams papers provide a narrow window into the activities of one sugar industry trade association, they noted that the sugar industry’s current position remains that public health should focus on fluoride toothpaste, dental sealants and other ways to reduce the harm of sugar, rather than reducing consumption. They concluded that industry opposition to current policy proposals — including the World Health Organization’s newly released guidelines to reduce added sugar to less than 10 percent of daily caloric intake — should not be allowed to block this prudent public health standard.

“There is robust evidence now linking excess sugar consumption with heart disease, diabetes and liver disease, in addition to tooth decay,” said Schmidt, who also is principal investigator on the UCSF-led SugarScience initiative. “Times have definitely changed since that era, but this is a stark lesson in what can happen if we are not careful about maintaining scientific integrity.”

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Are we closing the gender gap?


UCLA report reveals marked inequalities in legal rights for women and girls around world.

The report found that although all but seven countries have made primary education tuition-free, 40 charge tuition before the end of secondary school. (Photo courtesy of UCLA's World Policy Analysis Center)

By Carla Denly, UCLA

On March 9, the United Nations will convene to evaluate the global community’s progress on gender equality in the 20 years since 189 countries adopted the Beijing Declaration and Platform for Action. The U.N. session will continue through March 20.

Closing the Gender Gap,” a new report by UCLA’s World Policy Analysis Center (World), reveals that more than 170 countries have legal barriers preventing women and girls from experiencing the same rights, protections and liberties as men and boys.

World’s new report and accompanying online resource bank take a heightened approach to global accountability and transparency by detailing the rights, laws and policies pertaining to gender equality in 197 countries and Beijing Platform signatories. The resource bank includes quantitatively analyzable data, policy briefs, mobile-friendly interactive maps, infographics, fact sheets and more.

Analysis by World shows that in most countries, gender inequality continues to be embedded in national constitutions, laws and policies:

  • More than 150 countries lack protections critical to ensuring women’s economic participation.
  • Sixty-one countries provide girls with less legal protection from early marriage than they do for boys.
  • Ninety-two countries guarantee paid leave to mothers of infants, but not to fathers, perpetuating inequalities in the burden of caregiving and limiting equal opportunities at work.

The U.S. is not immune from these concerns — here, for example, mothers are not ensured paid leave to care for their newborn children, making the U.S. the world’s only high-income country not to provide such a guarantee. And while more than 80 percent of countries in the world have a constitutional guarantee of gender equality, the U.S. does not.

Yet the report findings indicate that progress is possible. More than 95 percent of the 56 new national constitutions adopted around the world in the past 20 years legally guarantee gender equality. Good legislation and policies exist in all regions and at all country income levels.

“Citizens need and deserve to know their rights and how their country fares when compared to others,” said Dr. Jody Heymann, founding director of the World Policy Analysis Center and dean of the UCLA Fielding School of Public Health. “Only by getting data into the hands of citizens and leaders alike on what effective steps have been taken — and what haven’t — can we close the gender gap in our global community.”

The study examined whether laws treat women and men equally, and whether concrete steps have been taken to reduce inequality. Among the findings:

Constitutions

  • Constitutional guarantees are nearly universal in newly passed constitutions. More than 95 percent of the 56 constitutions that have been adopted since 1995 include guarantees for gender equality, compared with just 79 percent enacted before then. These protections of equality provide a foundation to challenge discriminatory laws.
  • Thirty-two constitutions still do not explicitly guarantee gender equality.
  • Eleven constitutions allow customary or religious law to supersede constitutional protections of gender equality, potentially jeopardizing equal rights for women.
  • Despite constitutional guarantees, discriminatory laws remain in place in many countries around the world.

Families and marriage

  • Only 56 constitutions guarantee equality within marriage and there has been little change in the level of protection over the past 20 years.
  • Legislation also lags behind in this area. Sixty-one countries allow girls to be legally married younger than boys.
  • Inequalities in the law contribute to more girls being married young than boys: Nearly five times more girls than boys are married before the age of 18.
  • While large gaps remain, many countries have strengthened child marriage legislation since Beijing. Among 105 low- and middle-income countries, the percentage of countries that allow girls to be married before age 18 with parental consent fell from to 56 percent in 2013 from 80 percent in 1995.

Families and work

  • One hundred and eighty-eight countries guarantee paid leave for new mothers (the U.S. does not), but only 96 countries provide paid leave for new fathers. This legal inequality reinforces social norms that women are responsible for care and limits women’s economic opportunities, contributing to lower employment rates and wages for women.
  • Caregiving doesn’t end at infancy. Eighty-one countries provide no leave that can be used to meet children’s health needs and five other countries place the burden of meeting children’s health needs solely on women. In 143 countries, no leave can be used to meet children’s educational needs and two other countries place the burden of meeting children’s educational needs solely on women.
  • As the global population ages, leave to care for adult family members is increasingly important. Ninety-seven countries do not provide any leave to meet adult family members’ health needs. This gap disproportionately affects women who carry far more of the elder caregiving globally.
  • Countries that do guarantee paid leave for men and women exist in every region and income level.

Education

  • All but seven countries have made primary education tuition-free, but 40 countries continue to charge tuition before the end of secondary school.
  • When cost is a barrier, girls are more likely to be kept out of schools than boys. Unsurprisingly, the regions with the largest gaps in secondary enrolment for boys and girls are also those that are most likely to charge tuition.
  • Among those countries with available expenditure data, 43 percent that charge tuition before the completion of secondary school spend less than 4 percent of their gross domestic product on education.

Economy and work

  • Only 64 countries constitutionally guarantee women protection from discrimination at work or guarantee equal pay for equal work.
  • Only 40 countries have legislative protections from gender discrimination in hiring and pay.
  • Of constitutions adopted in the past 20 years, 38 percent guarantee protection from discrimination at work, compared to only 12 percent of those that existed previously.

World’s findings provide an opportunity to examine countries’ progress in closing the gender gap, especially in critical areas that impact the daily lives of women and girls — access to quality education and the ability to remain in school, protection from child marriage, equal rights in employment, and policies that ensure health at work and at home.

“When the status of women and girls improves, population health improves and the economic strength of companies and countries increases. Entire families, communities, and countries are lifted up,” Heymann said.

The Maternal and Child Health Equity research program at McGill University helped develop longitudinal data on child marriage, breastfeeding breaks and maternal leave for the study.

The Bill & Melinda Gates Foundation provided grant support for this work to improve the quantity and quality of comparative policy data available in partnership with the Bill, Hillary & Chelsea Clinton Foundation’s No Ceilings Initiative.

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$13M gift launches new maternal and child health center


UC Berkeley’s School of Public Health to launch Wallace Maternal and Child Health Center.

By Jose Rodriguez, UC Berkeley

Dr. Helen Wallace, a world-renowned professor, mentor and advocate known for her passion for improving the lives of women and children, has left a bequest valued at more than $13 million to UC Berkeley’s School of Public Health. The funds will launch the Wallace Maternal and Child Health Center, the campus announced today (March 2).

The new center will engage in innovative, evidence-based research aimed at creating healthier generations of women, mothers, children and families in the United States. It will focus on educating and training public health leaders primarily, but not exclusively, from states west of the Mississippi River through interdisciplinary scholarships and fellowships. The funds also will create a new endowed chair.

By fostering partnerships at every level of research, from discovery science to implementation and dissemination of evidence, the Wallace Center will complement the school’s existing maternal and child health (MCH) program — one of the pre-eminent MCH leadership training programs in the nation — and the Bixby Center for Population, Health and Sustainability.

Wallace, who died in 2013 at the age of 99, mentored generations of students as a professor and chair of the school’s MCH program from 1962 to 1980. She laid important groundwork in the field by fostering collaboration across disciplines at a time when it was rare to do so, and she implemented these practices within the school, in research partnerships and in her writing. She was particularly interested in infant health, maternal mortality, health systems that improved health outcomes, and expanded delivery of health care to mothers and children.

“We are extremely excited and gratified to move our work forward with greater focus and commitment in the arena of maternal and child health, which was the vision of Dr. Helen Wallace,” said Dr. Stefano Bertozzi, dean of the School of Public Health. “The School of Public Health has been taking a leadership role on these issues at the global level for some time now through the Bixby Center for Population, Health, and Sustainability. The new Wallace Maternal and Child Health Center will deepen our work and allow us to focus on attracting and supporting students from the western United States.”

The Wallace Center will embody the values of the School of Public Health: equity, excellence, diversity, innovation, impact and collaboration. By supporting and engaging faculty and students and attracting new talent, the center will play an important role in workforce development while sustaining UC Berkeley’s reputation as a game-changer at the forefront of public health.

Wallace is remembered for visionary efforts that brought together scholars from separate disciplines, such as public health and social welfare, to advance common research goals, and for attracting the school’s first maternal and child health training grant from the federal government.

“She was well-known for mentoring her students and ensuring that what they learned on campus was put to use to benefit society,” said Sylvia Guendelman, professor and chair of the maternal and child health program at UC Berkeley. “She inspired her students to be leaders, to make a positive difference in the world.”

Among the leaders Wallace trained was Dr. Peter van Dyck, who served as associate administrator of the U.S. Health Resources and Services Administration’s Maternal and Child Health Bureau from 1999 to 2011.

“Helen Wallace assured me and others at Berkeley that in maternal and child health, we could touch individual children as well as influence public health by implementing good policy,” said van Dyck. “She was correct. She was a great mentor.”

Guendelman, who will lead the planning effort, said that the center will allow new generations of students to see Wallace’s “vision, spirit and effort endure over time.”

Wallace received her bachelor’s degree from Wellesley College in 1933, her master’s in public health cum laude from the Harvard School of Public Health in 1943 and her medical degree from the Columbia University College of Physicians and Surgeons in 1937.

She was the author of 336 journal articles and 16 textbooks — most recently, ”Health and Welfare for Families in the 21st Century,” the second edition of which was published in 2003. Besides serving as the national health chair of the National Congress of Parents and Teachers, Wallace was secretary of the maternal and child health section and a member of the committee on child health of the American Public Health Association.

She was, in addition, assistant editor of the Journal of the American Women’s Medical Association, as well as a diplomate of both the American Board of Pediatrics and the American Board of Preventive Medicine. She consulted with the World Health Organization in many countries including Uganda, the Philippines, India, Turkey, Iran, Thailand, Burma, Sri Lanka and Nepal, and trained numerous physicians in Africa and Asia.

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On-board school bus filtration system reduces exposure to pollutants


UCLA-developed technology would protect children from harmful exposure.

By Kim Irwin, UCLA

An on-board air filtration system developed specifically for school buses reduces exposure to vehicular pollutants by up to 88 percent, according to a study by researchers at the UCLA Fielding School of Public Health.

The high-efficiency cabin air, or HECA, system could help protect the 25 million American children who commute on school buses nearly every day. Children are more susceptible to air pollution than adults because they breathe more quickly and their immune and cardiovascular systems are still developing, said Yifang Zhu, the study’s senior author and an associate professor in the department of environmental health sciences.

Pollution reduction was even greater under freeway driving conditions, which was surprising because freeways have particularly high pollutant concentrations due to traffic congestion and increased emissions. The study found that the air inside buses with the HECA system was as clean as air near the beach in Santa Monica, California.

The study appears today (March 2) in the early online edition of the peer-reviewed journal Environmental Science and Technology.

“During school bus commuting, children can be exposed to significantly greater levels of air pollutants than a typical resident in the South Coast air basin,” Zhu said. The South Coast air basin encompasses all of Orange County, California, and the non-desert regions of Los Angeles County, Riverside County, and San Bernardino County.

“Studies have shown that exposure to high levels of vehicle pollution is associated with pulmonary and cardiovascular health risks, including oxidative stress, mitochondrial damage and acute pulmonary inflammation,” she said.

Studies have also found that children exposed to pollutants from vehicles tend to perform less well in school.

The new study tested six school buses without children on board while the buses were still, and while they were driving on freeways and major arterial roadways in Los Angeles. Researchers tested the air both inside and outside of the buses for vehicle-emitted particulate matter, including black carbon and fine and ultrafine particles, down to a few nanometers in size.

A study funded by the California Air Resources Board more than a decade ago was the first to find serious air quality problems inside diesel-powered school buses. That study led to efforts to retrofit school buses with exterior pollution-reducing devices. While that method is promising for minimizing emissions from buses’ tailpipes, it doesn’t always provide cleaner air inside the buses. A majority of school buses today are not equipped with any interior mechanical filtration systems, said Eon Lee, the study’s first author and a postdoctoral researcher in Zhu’s lab.

A previous study by Zhu and her team found that commercially available household air purifiers can reduce pollutant levels inside school buses by about 50 percent. However, they are not designed to work in moving vehicles.

As part of the new study, researchers developed a prototype on-board HECA filtration system for buses and installed two in the rear of each of the six buses tested. Air was drawn in through diffusers on the sides of each unit and fed through the HECA filter. The filtered air was then delivered at a constant rate through air ducts.

“School buses are by far the safest way to transport children between school and home,” Zhu said. “Our goal is to make it also the cleanest way.”

A long-term follow-up study will evaluate how much exposure can be reduced by operating the HECA filtration system in a large number of school buses with children aboard, Zhu said.

“The developed HECA filtration system has great potential to substantially reduce children’s exposure to vehicle pollutants while commuting inside school buses,” the study states.

The study was funded by the California Air Resources Board. The HECA filtration system was developed in collaboration with IQAir North America.

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