Emerging Activities in Rural Areas Richard F. Hamman, MD, DrPH

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Emerging Activities in Rural AreasRichard F.
Hamman, MD, DrPH Dean
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Overview

• Introduction
• Rural activities
• Training
• Joint degrees
• Questions

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What is Public Health?
Public Health is the science and art of
protecting and improving the health of
communities through education, promotion of
healthy lifestyles, and research for disease and
injury prevention.
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Health Care is vital to all of us some of the
time but public health is vital to all of us
all of the time C. Everett Koop Former Surgeon
General
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Association of Schools of Public Health (ASPH)
ReportConfronting the Public Health Workforce
Crisis

• KEY FACTS
• ASPH estimates that 250,000 more public health
  workers will be needed by 2020. 
• The public health workforce is diminishing over
  time (there were 50,000 fewer public health
  workers in 2000 than in 1980), forcing public
  health workers to do more for more people with
  fewer resources. 

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ASPH ReportConfronting the Public Health
Workforce Crisis

• 23 of the current workforce almost 110,000
  workers are eligible to retire by 2012. 
• Documented and forecasted shortages of
• public health physicians
• public health nurses
• epidemiologists
• health care educators
• administrators

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ASPH ReportConfronting the Public Health
Workforce Crisis

• To replenish the workforce and avert the crisis,
  schools of public health will have to train three
  times the current number of graduates over the
  next 12 years
• (Note, this doesnt even include the massive need
  to provide continuing, career long training to
  those already in the workforce)

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Viral disease sickens hundreds in China The
Associated Press May 19, 2007 BEIJING- An
outbreak of a viral disease common in children
has sickened almost 900 people in eastern
Chinabut the outbreak has been contained, state
mediasaid Saturday.
Moose test positive for Chronic Wasting
Disease Jeremy P. Meyer Denver Post Staff Writer
Nov 9, 2006 Two bull moose legally harvested by
hunters last month in northern Colorado tested
positive for chronic wasting disease, the
Colorado Division of Wildlife said today.
Quarantine laws need strengthening in light of TB
case, health official says By KEVIN FREKING
Associated Press Writer June 9,2007
Grand Junction woman dies of West Nile The
Associated Press Oct 21,2006
In the news
Front Range on brink of clean-air violations Kim
McGuire Denver Post Staff Writer Nov 12, 2006
Plague found in Park Hill critters Jeremy P.
Meyer Denver Post Staff Writer April 28,2007 Five
squirrels and one rabbit found dead in the Park
Hill neighborhood tested positive for plague,
leading health officials to caution the public
against handling dead animals.
Wednesday, February 4, 2009 Vitamin Cottage
recalls ground peanut butter amid salmonella
outbreak Denver Business Journal
Too many kids pudgy by preschool Study finds
Latino children most at risk using a bottle at
age 3 a clue Lauran Neergaard Associated Press
Dec 28, 2006 Washington - Too many kids are fat
by preschool, and Latino youngsters are most at
risk, says new research that's among the first to
focus on children in poverty. Seventeen percent
of U.S. youngsters are obese, and millions more
are overweight.
Chan Bird flu huge global health threat ELIANE
ENGELER Associated Press Writer May16.2007
GENEVA- The U.N. health chief on Wednesday
harshly criticized countries that do not share
their H5N1virus samples, accusing them of
crippling the worldin the fight against a
possible flu pandemic. New resistant bird-flu
strainstrikes Asian fowl, people Randolph E.
Schmid Associated Press
We need a well trained public health workforce!
E. coli triggers ground beef recall Two sickened
by bacterium The Denver Post June 4,2007 Denver
- The Consumer Protection Division of the
Colorado Department of Public Health and
Environment suggested that Coloradans who
purchased certain packages of Moran's ground beef
at local Albertsons stores check to make sure it
hasn't been recalled due to possible
contamination with E. coli.
Colorado mercury emissions higher? Kim McGuire
Denver Post Staff Writer Dec10, 2006
Contaminated pet food fed to hogs in 5 states The
Associated Press Apr 25, 2007
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The Colorado School of Public Health is a
collaboration of

• University of Colorado Denver
• Colorado State University
• University of Northern Coloradotogether with
• CDPHE Local Health Departments

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Schools of Public Health July 1, 2008
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Collaborations
Academic
Research
UC Denver Medicine Nursing Dentistry Pharmacy Gra
duate Business Public Affairs Liberal Arts and
Sciences Architecture and Planning
Engineering CSUVeterinary Medicine
Biomedical Sciences Agricultural Sciences
Applied Human Sciences Natural Sciences
UNCEducation Behavioral Sciences Natural
Health Sciences
UCD Altitude Research Center Barbara Davis
Center for Childhood Diabetes Center for Health
Services Policy Research Colorado
Comprehensive Cancer Center UCB, CU
System Coleman Institute Institute of
Behavioral Sciences CSUArthropod-Borne
Infectious Disease Laboratory Center for
Environmental Toxicology Technology
Tri-Ethnic Center for Prevention Research
Center on Aging High Plains Intermountain
Center for Agricultural Health and Safety UNC
Center for Applied Gerontology Research Center
for Social Science Research Collaborative Bio-
Defense Emerging Infectious Diseases
Consortium for Human Nutrition And others
Colorado School of Public Health Center for
Public Health Practice Rocky Mountain Prevention
Research Center NIOSH MAP ERC Colorado Injury
Control Research Center Center for Global
Health Center for Native American / Alaskan
Native Health
Community
Departments and AgenciesCO Dept of Public
Health Environment Local Health
DepartmentsCommunity AgenciesAffiliated Health
Care Environmental Organizations And
others University Linked Organizations Area
Health Education Centers-UCD CSU Cooperative
Extension
Future Partners Regional Universities, State
and Community Colleges and Private Institutions
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Educational Programs

• Goal Create effective educational programs
  characterized by collaborative, multidisciplinary
  approaches to educate and train highly competent
  and committed public health professionals and
  research scientists.

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MPH concentrations

• UC Denver
• Applied Biostatistics
• Community Behavioral Health
• Environmental Occupational Health
• Epidemiology
• Health Systems Management Policy
• Generalist
• CSU
• Generalist
• Focus areas in Epidemiology, Environmental
  Occupational Health, Global Health Health
  Disparities, Health and Exercise, Health
  Communication, Public Health Nutrition
• UNC
• Community Health Education

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Doctoral programs

• UC Denver
• MS/PhD in Biostatistics
• PhD in Epidemiology
• PhD in Health Services Research
• DrPH (under development)
• CSU
• MS/PhD in Environmental Occupational Health

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Current Enrollment (Fall 2008)

• MPH 150 (50 new)
• Includes 35 in MSPH
• 4 DVM/MPH at CSU
• 1 MPH at CSU
• Will add about 25-30 from UNC in spring
• Certificate Students 60 (35 new)
• PhD 53 (10 new)
• Bioinformatics 10
• Biostatistics 12
• Epidemiology 21
• Health Services Research 10
• MS Biostatistics 23
• Preventive Medicine Residents 6
• Occupational Medicine Residents 5
• TOTAL 297

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Faculty
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Center for Public Health Practice

• Goal Create a Center for Public Health Practice
  to bridge academic public health with state and
  local health agencies, healthcare providers, and
  community based organizations.

Community Outreach Continuing Education
Service Opportunities Research in Public Health
Practice
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Research

• Goal Advance the scientific basis for the
  practice of public health with research that
  addresses the important public health issues in
  Colorado and the Rocky Mountain region.

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Current Research - overview

• Biostatistical / Informatics methods
• Clinical trials methods
• Disease etiology and prevention
• Cancer, Diabetes (Type I, II), COPD, CVD, Injury,
  Autism, Skin cancer, Obesity, Depression
• Genetic epidemiology
• Diabetes, COPD, CVD, Cystic fibrosis
• Lifecourse epidemiology
• Obesity, CVD risk, Asthma, Autism, Diabetes,
  Birth defects, Behavioral interventions

• Community participatory research
• School policy, nutrition, physical activity,
  obesity prevention
• PH practice research network
• Environmental health
• Built environment, air pollution
• Occupational health
• Beryllium, methamphetamine labs, radiation
  workers
• Health services research
• Medicare, Medicaid, costs of prevention
• Health Policy

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Facilities
Fitzsimons Army Hospital Building 500 3rd Floor
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Timelines
Accredited
Phase II
Operational
Accredited
Operational
2006
2007
2008
2009
2010
2011
2012
2013
2014
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Rural Activities

• San Luis Valley Programs
• School Programs
• HICHAS - High Plains Intermountain Center for
  Agricultural Health and Safety (CSU)
• Community Exposures and the Oil and Gas Industry
• Colorado Injury Control Research Center
• Colorado Colorectal Cancer Screening Program
• Public Health Practice-based Research Network
• American Indian Alaskan Native Research (CAIANH)
• Training

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Family-Based Prevention of Type 2 Diabetes its
ComplicationsPrincipal Investigator Julie A.
Marshall, PhD
Rocky Mountain Prevention Research Centerof the
San Luis Valley Health StudiesUniversity of
Colorado at Denver
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SLV Healthy Family Projectfunded by the
National Institutes of Health

• Purpose
• Prevention of type 2 diabetes and its
  complications
• Translation of DPP findings
• Population Families at risk for developing type
  2 diabetes and/or its complications
• Primary, secondary and tertiary prevention
• Social physical factors support healthy
  behaviors
• Design
• Randomized control trial of 250 families in SLV
• Randomization ratio 21

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Diabetes Prevention ProgramPercent reduction in
diabetes risk by race-ethnicity compared with
placebo
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Intervention Goals

• Improve Diet
• Increase physical activity
• Achieve and maintain healthy weight
• Improve disease management
• Increase use of community resources

Healthy Family Project
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Realization that walking can be good quality time
with family
Realization that walking trails are close by
Increase physical activity
Nature Walk
Realization that walking doesnt cost money
Realization that even when feeling tired, still
can find energy to go for a walk
Intervention Activity
Mediating Factors
Outcome
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Community Resources
Healthy Family Project
Family Lifestyle Coach

• Family
• Home

Health Care System

• Worksite
• Community
• School

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SLVHFP Intervention

• Family Lifestyle Coach trained in behavior change
  strategies using Motivational Interviewing
• Choose target behaviors and develop
  individualized action plan
• Receive 12-16 home visits over a 4-8 month period

Healthy Family Project
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Outcomes

• Weight loss, reduced weight gain
• Biochemical markers of insulin resistance
• Nutrition and physical activity changes
• Use of community resources
• Mediators of change

Healthy Family Project
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School-based programs

• School Environment Project (San Luis Valley - 10
  schools - CDC)
• intervention to increase opportunities for
  physical activity and healthy eating through
  school environment and policy change
• SLV Physical Education Collaborative (CCTSI)
• planning grant to form a collaborative that will
  identify the current state of physical education
  in the SLV and barriers/facilitators to
  increasing quality and quantity of PE
• Integrated Nutrition Education Program
• 8 schools in the SLV (joint with Pediatrics)
• Whats Working Project (45 rural low income
  elementary schools - RWJF)
• evaluation study to understand the initial impact
  of federally mandated local wellness policy on
  school environment (nutrition and activity)

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Local School Policy Evaluation (Whats Working
Project)

• Described the initial impact of the US federally
  mandated Local Wellness Policy in rural,
  low-income elementary schools located in
  Colorado.
• Random sample of 45 rural elementary schools
  (40 of students qualified for free or
  reduced-cost lunch)
• Opportunities for physical activity did not
  change after the policy went into effect
• time in physical education increased by 14 min
  per week (P0.10), but time for recess decreased
  by roughly 19 min per week (P0.10)
• Policies supporting student participation in
  physical education and recess did not change.
• Local Wellness Policies were weakly worded and
  resulted in minimal impact

• Barriers (1) competing pressures facing school
  districts (2) lack of resources devoted to the
  Local Wellness Policy (3) principals lack of
  knowledge about the policy, and (4) lack of
  accountability mechanisms to ensure policy
  implementation

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High Plains Intermountain Center for Agricultural
Health and Safety

• Mission to reduce illness, injury, and
  fatalities in agriculture
• Major areas
• organic dust lung disease in multiple regional
  settings
• development of novel and user friendly biomarkers
  for pesticides
• Engineering research related to development and
  retrofitting of tractor rollover protection
  structures
• Strong emphasis on the large Hispanic workforce
  in the region and on children

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High Plains Intermountain Center for Agricultural
Health and Safety (HICAHS)

• Current research
• An intervention to improve the design of milking
  parlors at dairies to reduce injuries and
  long-term degenerative diseases
• impact of exposure to dust, ammonia and bacterial
  endotoxins on respiratory disease rates of dairy
  workers
• development of an educational CD about health and
  safety for 4-H programs
• evaluating the effectiveness of health and safety
  information to agricultural workers

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Potential Human Health Effects of Oil and Gas
Development in Rural Colorado

• Exposure to oil and gas activity and chemicals
  associated with it can adversely impact human
  health
• increased risk of cancers, pulmonary,
  cardiovascular, neurological, and other diseases
  adverse birth outcomes and childrens health
• Major gaps in the past assessment of air quality
  related to oil and gas development on the Western
  Slope
• Garfield County air quality studies indicate that
  potential exposures to hazardous emissions exist
• Acute problem with toxic emissions of uncertain
  proportions and a possible emergent problem for
  the health of the citizens of Garfield County due
  to unmeasured or under-measured toxics in
  Garfield County, despite the increase in oil and
  gas development known to produce these chemicals
• Health Impact Assessment of oil and gas
  development in Colorado should be done

Testimony to Colorado Air Quality Commission,
October 2008
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Potential Exposure-Related Human Health Effects
of Oil and Gas Development Witter R, Stinson K,
Sackett H, Putter S, Kinney G,Teitelbaum D,
Newman L
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Adverse health outcomesGarfield County, CO

• Garfield County higher (vs. other West Slope
  counties)
• Children hospitalized for seizures and headache,
  bronchitis, asthma, respiratory infection
• Birth and pregnancy outcome disorders
• Alcohol and drug disorders
• 2000-2005
• Violent crime rates increased (per 10,000
  residents) 8.5 to 19.7
• (Rape/other sex crimes, robbery, aggravated
  assault)
• Drug violations increased 19.4 to 39.7

Saccomano study 2000-2007
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Colorado Injury Control Research CenterCSU-UC
Denver collaborative Center

• Drug use and risky behavior among rural youth
• Laboratory based research
• survival of sensory and motor neurons after
  injury
• protective factors against brain injury
• Motor vehicle mortality in rural and urban areas
• Rehabilitation care for individuals suffering
  traumatic brain injuries
• Risk communication for injuries
• Community based traumatic brain injury prevention
• Injury among disabled individuals
• Alcohol-impaired Driving Register of Controlled
  Studies 

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Colorado Injury Control Research Center

• Marketing Fall Prevention Classes to Older Adults
  in Faith-Based Congregations Cluster Randomized
  Controlled Trial
• Focused on Grand Junction and regional rural
  populations
• Aims to increase use of fall prevention classes
  that are known to be effective among rural
  elderly through social marketing

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Colorado Injury Control Research Center
Community Initiated Grant Program

• Salud Family and Health Centers
• Provide bicycle helmets car seats to migrant
  families at two health fairs in Northern Colorado
• Larimer County Department of Health and
  Environment - Newborn, Infant and Toddler Safety
  Project
• Provide home environment safety training and
  equipment to prevent early childhood injuries
• Centennial BOCES Migrant Education Program,
  Greeley, CO Injury Prevention and Education for
  Migrant and Homeless Families
• Provide migrant and homeless families with
  information, skills and resources to prevent and
  control intentional and unintentional injuries

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Colorado Colorectal Cancer Screening Program

• Funded by the tobacco tax revenues competitive
  grants program
• Goal Increase colorectal screening rates among
  Coloradans ages 50 and older to 75 by 2010.
• Provide endoscopic colorectal screening to
  persons without health insurance who are under
  250 Federal Poverty Level and who need screening
  
• Encourage all Coloradans ages 50 and older to get
  screened
• Began in January 2006, expanded statewide in
  November 2006
• Over 6500 patients screened to date
• 24 had adenomas removed (most likely to progress
  to cancer)
• 1 were diagnosed with cancer

A partnership between the University of Colorado
Cancer Center, community clinics and their
screening partners
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Local Public Health Agencies

• 54 local public health agencies that serve 64
  counties in Colorado
• 15 organized health departments
• 39 public health nursing services
• Serve populations ranging in size from less than
  1000 to over 1.2 million

Organized health departments (color) Nursing
services (white)
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Colorado Public Health Practice-Based Research
Network

• Partnership between The Public Health Alliance of
  Colorado and CSPH
• Develop network infrastructure to support
  communication, decision-making, training and
  priority setting
• Develop data system infrastructure performance
  measures, data on environmental health
  determinants population-based health status and
  health behavior measures
• Identify high priority research questions
• Identify strategies and resources to
  institutionalize research as an integrated
  component of the public health system
• Study the impact of SB08-194

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Colorado Public Health Reauthorization ActSenate
Bill 08-194

• Passed in June 2008 to address outdated laws
• Define public health and core public health
  services
• Require each local public health agency to have a
  county or district board of health
• Expand powers and duties of the State Board of
  Health
• Expand powers and duties of county/district
  boards of health
• Outline powers and duties of local public health
  agencies and directors
• Require a public health planning process to
  further develop the new model of public health
  service delivery and to address related workforce
  and funding issues

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Center for American Indian Alaskan Native Health
(CAIANH)

• The CAIANH works in AI/AN communities across the
  nation
• AI/AN populations remains one of the most rural
  in the US, though increasingly urbanized
• AI/AN population is a relatively small proportion
  of the US population and, in urban areas, tends
  not to live in ethnic enclaves
• Health research with AI/AN often takes place on
  or near reservations (or villages in Alaska)

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Center for American Indian Alaskan Native Health
(CAIANH)

• Colorado 2 pilot projects in southern Colorado
  communities
• Oral health intervention for young children using
  motivational interviewing with their parents
• Evaluation of a diversion program in the Tribal
  Wellness Court for youth with substance-involved
  offenses
• Northern Plains and the Southwest
• Longitudinal work with children, focusing on
  alcohol, unintended pregnancy, HIV prevention,
  other topics
• Psychiatric epidemiology with Vietnam veterans
• Largest psychiatric epidemiology study to date
  with AI/AN populations
• Risk for CVD among those with and without
  posttraumatic stress disorder (PTSD)
• Oral health interventions with young children and
  their parents

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Center for American Indian Alaskan Native Health
(CAIANH)

• Oklahoma
• Treatment research among children with substance
  problems
• The development of innovative treatment
  techniques for those with mental health problems
• Alaska
• Health services research with the largest
  providers of health care in the state - focused
  on screening, detection, and management in
  primary care, and
• Recovery services for those with substance
  problems.

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Center for American Indian Alaskan Native Health
(CAIANH)

• National
• The Special Diabetes Program for Indians -
  Competitive Grant Program
• Data coordinating center for a congressionally-man
  dated evaluation of 2 intervention programs
• Prevent onset of diabetes among prediabetics
  using the DPP model
• Case management to prevent CVD among diabetics
• 66 grantees, of whom 85 are in rural areas,
  serving over 8,000 participants
• The Circles of Care Program
• Works with providers of child mental health care,
  mostly in rural settings, to increase the reach
  and effectiveness of these programs
• Head Start Research Center
• Trains investigators and is providing the basis
  for a detailed study of AI/AN Head Start Centers
  across the country

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Training in rural areas

• MPH students
• Practicum capstone project electives
• Community Health Assessment class
• Preventive Medicine Residents
• Training grant has focus on medically underserved
  communities Salud FHC Health District of
  Northern Larimer County AHEC
• Elective courses visiting faculty
• Other health sciences students interested in
  public health

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Joint Degree Programs

• MD/MPH
• Proposed to start July 2009
• In the approval process
• 5 year program 42 credit hours
• 9 elective credits from MD curriculum MSA
• DVM/MPH
• Collaborative with CSU Veterinary Medicine
• 5 students/year 4 year history
• Discussing MSN/MPH, others

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Website http//publichealth.ucdenver.edu
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Questions?