The Washington Post reports that the width of a standard movie seat used to be 19 inches

1
The Current Situation

• The Washington Post reports that the width of a
  standard movie seat used to be 19 inches.
• It is now 23 inches..
• Journal of Pediatrics, 2006, reported that 1
  percent of all American infants and children
  more than 283,000 children are too big to fit
  in a car seat.

Susan Combs, Texas Comptroller of Public Accounts
2
The Current Situation

• Since 1970, the prevalence of obesity has doubled
  for preschool children
• And tripled for school-aged children
• Currently, 37 of school aged children are obese
  or overweight.

Strauss RS, Pollack HA. JAMA, 20012862845-8 Ogde
n et al JAMA 20062951549-55 Margellos-Anast et
al Public Health Reports. 123117-125
3
The Current Situation

• With a focus on obesity alone, 19 of school aged
  children are obese.
• Disproportionate numbers nationally
• African Americans 22
• Mexican Americans 23
• Non-Hispanic white 18

Ogden et al JAMA 20062951549-55 Margellos-Anast
et al Public Health Reports. 123117-125
4
The Current Situation

• The Prevalence of Obesity Among Children in Six
  Chicago Communities
• Sinai Improving Community Health Survey
• Door to door, population based health survey
• 501 randomly selected children aged 2-12 years

Humboldt Park Roseland North
Lawndale South Lawndale Norwood
Park West Town
Margellos-Anast H, Shah AM, Whitman S. Public
Health Reports. 123117-125.
5
The Prevalence of Obesity Among Children in Six
Chicago Communities

• Three stage sample design
• Communities by probability proportionate to size
  (PPS) sampling
• Households selected at random
• Household screen survey to an adult and a
  child/caretaker.
• Survey methodology Survey Research Laboratory of
  UIC

Margellos-Anast H, Shah AM, Whitman S. Public
Health Reports. 123117-125.
6
The Prevalence of Obesity Among Children in Six
Chicago Communities
Percent
Margellos-Anast H, Shah AM, Whitman S. Public
Health Reports. 123117-125.
7
The Prevalence of Obesity Among Children in Six
Chicago Communities

• Major findings
• Nearly half the children (aged 2 12) in five
  of six communities were obese compared to 16.8
  nationally.
• Prior community-level evaluations have found only
  23-25 of school children were obese.
• The prevalence of obesity exceeded the prevalence
  of overweight by a factor of four in Humboldt
  Park and a five in Roseland.
• Contrary to what would be expected.

Margellos-Anast H, Shah AM, Whitman S. Public
Health Reports. 123117-125.
8
The Decline in Cardiovascular Mortality Men
Age Adjusted All Races Out of hospital mortality
per 100,000 NEJM, McGovern,et al, 334, 1996
9
The Decline in Cardiovascular Mortality Women
Age Adjusted All Races Out of hospital mortality
per 100,000 NEJM, McGovern,et al, 334, 1996
10
The Current Situation - CVD

• While dramatic improvements in CVD mortality
  declines for over 40 years have been praised as
  one of the major health accomplishments of the
  twentieth century, recent data suggests that CVD
  mortality rate declines are slowing to 1.5 per
  year
• Despite significant and notable declines in
  stroke mortality for over 60 years, stroke
  mortality is no longer falling.

R Cooper et al. Circulation, 102, no. 25
(2000)3137-3147
11
The Current Situation - CVD

• Two well-designed population based studies
• Worchester, Mass
• Olmstead County, Minnesota
• have found that the rates of new cases of heart
  disease have not fallen from 1990 forward, and
  for women, may have actually risen.
• More recent concerns of potentially increasing
  incidence of CVD and CVD mortality in men and
  women.

Goldberg RJ et al. JACC, 33 6 (1999) 1533-1539.
Roger VL et al. Annals of Internal Med.1365
(2002) 34-348. Anciero et al. American J of
Med1174 (2004)228-233. Pearson TA. Health
Affairs 261?2007) 49-60
12
The Current Situation Life Expectancy

• The Reversal of Fortunes Trends in County
  Mortality and Cross County Mortality Disparities
  in the US
• NCHS data used to calculate life expectancy for
  all US counties between 1961 and 1999.
• Between 1961 and 1982, life expectancy improved.
• From 1983 to 1999, life expectancy declined
  significantly by 1.3 years for men and women in
  48 counties (men) and 783 counties (women)

Ezzati M, Friendman AB, et al. PLoS Med (5)4e66,
April 2008
13
The Current Situation Life Expectancy

• Of note, the higher disparity partly resulted
  from stagnation or an increase in mortality among
  the worst-off segment of the population, with
  life expectancy for approximately 4 of the male
  population and 19 of the female population
  having either had statistically significant
  decline or stagnation.

Ezzati M, Friendman AB, et al. PLoS Med (5)4e66,
April 2008
14
The Decline in Cardiovascular Mortality Men
Age Adjusted All Races Out of hospital mortality
per 100,000 NEJM, McGovern,et al, 334, 1996
15
The Apache Heart StudyIncidence of Confirmed CAD
Cases
16
ACUTE MYOCARDIAL INFARCTIONAMONG NAVAJO MEN
Klain, Coulehan, Arena, Janett, AJPH, 1988
Hospitalization rates per 1000
17
Acute MI and USA among the Hopi The Hopi Heart
Study
18
Acute Myocardial InfarctionsHopi Tribal Members
Average values 1957-66 from Seivers and average
for 1975-78 taken from Sievers and Fisher p,0.001
19
INCIDENCE OF CVD The Strong Heart Study
Fatal and Nonfatal Rates per 1000 person years.
The Rising Tide of CVD in AI The SHS,
Circulation, 1999
20
American Indian/Alaska Native Mortality Rates
Trends in Indian Health, 1997 Age-adjusted data
21
Carotid Atherosclerosis in Native Americans
22
Prevalence of CVD Among American Indians
Compared with other Groups
MMWR, Vol 52, Number 47, REACH Data, Nov. 28,
2003. p 1148-1152
23
MMWR The REACH Survey

• Among men and women in these four groups,
  American Indians had the highest prevalence of
  Cardiovascular disease
• as well as obesity, current smoking and
  diabetes.
• Men had the highest rates of hypertension and
  high blood cholesterol levels.

24
Alice K. Jacobs, M.D., President American Heart
Association

• American Indians and Alaska Natives appear to
  have developed the highest rates of
  cardiovascular disease within the US.

25
Percentage of Premature Heart Disease Deaths by
Ethnicity
MMWR, February 28, 2004
26
Percent of Death from Strokes in Those lt 65 years
MMWR, May 20, 2005
27
Disparity in Average Age of Death from Strokes
MMWR, May 20, 2005
28
Disparities Health Staff/100,000 people
AI/AN US Gap MDs 73.9 220.6 66
lower DDS 24.0 61.8 61 lower Nurses
229.0 849.9 73 lower RPh 42.8 71.3 40 lower

29
Pathways into Health

• Issues of Health Health Education Disparities
• Quality of care improved when patient and
  provider of same ethnicity
• IOMs study, Unequal Treatment Confronting
  Racial and Ethnic Disparities in Health Care
  provided a clear connection between poorer health
  outcomes for minorities and the shortage of
  minority health care providers.

30
Pathways into Health

• Issues of Health Education Disparities
• Within Arizona, only 31 American Indian students
  have graduated from medical school over the past
  two decades
• Very low enrollment rates
• Very high drop out rates (3 to 5 x higher)

31
Pathways into Health

• Issues of Health Education Disparities
• Native students represent only 0.3 of medical
  students
• Only 98 Native students graduating from medical
  school in 2004 among 125 Medical Schools.
• Only 9 Medical Schools across the nation have
  more than two American Indians in their
  graduating class.

Sequist, TD. Journal of Interprofessional Care
21(S2) 20-30
32
Pathways into Health

• Issues of Health Education Disparities
• AI/AN physicians make up only 0.002 of the total
  US physician workforce,
• compared to 4.4 African American, 5.1 Hispanic,
  73.8 White and 14.9 Asian/Native
  Hawaiian/Pacific Islander.

Sequist, TD. Journal of Interprofessional Care
21(S2) 20-30
33
Pathways into Health

• Issues of Health Education Disparities
• Native American students are frequently forced
  to endure educational environments that violate
  their rights to equal educational opportunity and
  ignore their cultural identities.
• U.S. Commission on Civil Rights, A Quiet Crisis

34
Pathways into Health

• Issues of Health Education Disparities
• Issues related to consideration of college
• Issues related to leaving reservations
• Cultural requirements
• Absenteeism

35
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36
Pathways into Health

• A focus on professional healthcare education for
  Native Americans
• Built upon Academic Tribal Indian health
  collaborations
• Regionalized centers of varied educational
  strengths
• Arizona the Southwest
• Northern Rockies
• Great Plains
• Alaska

37
Pathways into Health

• Objectives
• To recruit and educate Native American students
  in health career professions
• initially focusing on clinical laboratory
  science, followed by nursing and public health,
  radiology technology and subsequently pharmacy
  and medicine, among others.
• To create an inter-professional and culturally
  reinforcing educational environment using
  traditional and innovative curricular methods.
• To improve the health and health care of Native
  American communities by producing high quality
  graduates who remain in their home communities.

38
Pathways into Health

• A collaborative integrated approach to an
  issue of
• national importance
• Academic collaborators
• University of Arizona
• Northern Arizona University
• University of Alaska Anchorage and Fairbanks
• University of North Dakota
• University of New Mexico
• Arizona State University
• Georgetown University
• University of South Dakota
• Montana State University
• Harvard

39
Pathways into Health

• Tribal collaborators
• The Hopi Tribe
• The Navajo Nation
• The White Mountain Apache Tribe
• The Ute Mountain Ute Tribe
• Pasqua Yaqui Tribe
• Tohono Oodham Nation
• InterTribal Council of Arizona

40
Pathways into Health

• Further Tribal and Indian health collaborators
• Southcentral Foundation, Alaska
• Ute Mountain Ute Tribe
• Southern Ute Tribe
• Pueblo of Zuni
• Mescalero Apache Tribe
• Seattle Indian Health Board

41
Pathways into Health

• A collaborative integrated approach to an issue
  of national importance
• A Resolution from the
• National Congress of
• American Indians

42
Pathways into Health

• Current Directions
• National Advisory Council
• Everett Rhodes, MD, Former Director IHS (U of OK)
• Bette Keltner, RN, Ph.D., Dean, Nursing,
  Georgetown University
• H. Sally Smith, Chair, National Indian Health
  Board
• Margaret Knght, Executive Director, Association
  of American Indian Physicians
• John Lowe, RN, PhD, Associate Professor, Florida
  Atlantic University
• Judy Sherman, Friends of Indian Health
• George Blue Spruce, DDS, MPH, Asst Dean, Indian
  Affairs, Arizona School of Dentistry Oral
  Health
• Don Davis, MPH, Director, Phoenix Area HIS
• Wayne Taylor, Chairman, Hopi Tribe
• Jenny Joe, Ph.D., University of Arizona

43
Pathways into Health

• Organizational Structure
• Chairperson Michael Allison (Navajo)
• Vice Chair Carl Fox, PhD (Montana State)
• Secretary Fred Kopacz (Alaska)
• Treasurer Sean Clendaniel, MPH (Arizona)
• Executive Board
• Membership
• Subcommittees

44
Pathways into Health

• Current Directions
• Development of Laboratory Science Program (Med
  Tech)
• UND, NAU, IHS, e-HealthU Collaboration
• On-site Lab Science Bachelors and Certification
• Front End Workers Program
• Nursing and Public Health
• Radiology Technicians

45
Pathways into Health

• Laboratory Sciences Program
• IHS and Tribal employees in multiple states
• Currently employed in the laboratory
• Long Term Training approval by IHS
• Small Foundation Funding for Tribal Scholarships

46
Atlanta Begay, featured in the North Dakota
Medicine, Pathways Into Health article of the
Fall 2006 issue is the first student to train in
CLS at UND under Pathways Into Health.
Ms. Begay (top far right) is joined by other
AI/AN students pursuing Health Professions
education.
47
Pathways into Health Native Interprofessional
Development in Health Initiative

• Nursing and Public Health Committee

48
Activating the Pipeline New Horizons in
Accredited Work-Based Learning In
collaboration with the Robert Wood Johnson
Foundation Cruz Begay, PhD
49
Native Interprofessional Development in Health
Initiative

• Initial Focus Frontline workers
• CHRs, EMTs, Health Educators, Nurses, etc.
• Forefront of Indian health system
• Important pipeline
• Interprofessional Education
• Frontline workers need to be empowered to
  confidently contribute to Interprofessional
  teams.
• Students in nursing, public health, and other
  disciplines need preparation to work with
  frontline workers.

50
Pathways into Health

• Frontline workers are an important pipeline.
• AWBL may address many needs
• Place-bound adult learners.
• Need for collaborative, experiential learning.
• Learning that improves organizational
  performance.
• Orientation and preparation for additional degree
  
• programs.
• Credit toward degree completion or new degree.
• Setting for interprofessional training
• Provide Stimulus for Systems Change

51
Learning Circles for Health Technicians The
Robert Wood Johnson Foundation
Systems Change
52
Pathways into Health

• Initial sites
• Chinle Comprehensive Health Care Center (IHS)
• Winslow Indian Health Care Center (Tribal)
• Future plans
• Expand to Alaska
• Expand to Great Plains
• Expand to other sites in the southwest

53
Examples of Building Blocks
Settings
Methods

• Apprenticeships
• Internships
• Residency/Field Work
• On Site courses
• OJT
• Service Learning

• Collaborative Learning
• Problem-based Learning
• Experiential Learning
• Reflective Practice
• Activity-based Learning
• Community of Practice

54
Learning Circles for Health Technicians
What are we teaching?
55
Learning Experiences

• Problem-based learning sets in health promotion
  and disease control.
• Collaborative proposal development
• Summer/Winter Institute at THealth Center.

56
Native Interprofessional Development in Health
Initiative
Existing
Existing
Nursing Courses
CHR, ANHA Training
Employees
Students
Teams
Existing
Existing
Others
Health Education Courses
Students
Employees
Interprofessional Learning Experiences
57
Interprofessional Teams
Workers

• CHR, Community Health Aides (Alaska)
• Pre-baccalaureate Nurses
• Nursing Students
• Health Education Students
• Others

Students
Ad Hoc members, mentors from across the country,
can be brought into Teams.
58
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59
Additional Successes

• Pathwaysintohealth.org
• Description, Information on Partners
• Mentorship Availability
• Educational Opportunities
• A searchable national registry of successful
  pipeline activities underway in Indian
  communities
• Pathways Into Health Professional Development
  Conference
• Denver, Sept 2006
• Supplemental issue of Journal of
  Interprofessional Care
• Chicago, September 14, 2007
• Alaska, September 9 10, 2008

60
Additional Successes

• Interprofessional Education in Nursing Public
  Health Disciplines
• Followed by Dental, Pharmacy and Medicine
  integration
• Regional Collaborative Grants
• Regional Collaborative Conferences
• Business Plan Development
• Further expansion of Clinical Laboratory Sciences
  training opportunities nationally

61
Building a Healthier Chicago

CHAMPS
Community HeAlth Mobilization Projects
62
CHAMPS
Building a Healthier Chicago
VISION Build model community-wide
partnerships for health promotion that can be
replicated nationwide

63
CHAMPS
Building a Healthier Chicago
GOAL To improve the health of Chicagos
residents and employees through integration of
existing public health, medicine and community
health promotion activities

64
CHAMPS
Building a Healthier Chicago

• Our Objectives
• Convene a model collaboration of local and
  national stakeholders dedicated to building a
  Healthier Chicago.
• Strengthen and sustain our partners current and
  new efforts to promote health in Chicago.

65
CHAMPS
Building a Healthier Chicago

• Our Objectives (cont.)
• Promote and track the adoption of selected
  programs, practices, policies, and supportive
  environments throughout the health care
  organizations, worksites, schools, and
  neighborhoods of Chicago.

66
CHAMPS
Building a Healthier Chicago

• Our Objectives (cont.)
• Create a system of interventions that complement
  and reinforce each other to maximize reach and
  effectiveness
• Build Synergy!

67
Community Level Interventions

• Issues of organization
• Collaborative
• Community leadership
• Trust
• Commitment to each other and the intervention
• Culturally appropriate

68
Stages of Intervention Utilization
Decision to Adopt
Source Davis SM et al. Introduction
and Conceptual Model for Utilization of
Prevention Research. Am J Prev Med.
2007 33(1S)S1-S5.
69
CHAMPS
Building a Healthier Chicago

• Partners
• City of Chicago (DPH, Parks Rec, etc.)
• American Medical Association
• American Diabetes Association
• American Heart Association
• Midwest Business Group on Health
• Shaping Americas Health
• American Cancer Society
• American College of Cardiology
• Multiple Academic Institutions and Community
  Organizations

70
CHAMPS
Building a Healthier Chicago

• Our Federal Partners
• Federal Occupational Health
• Health Risk Appraisal
• The Presidents Council on Physical Fitness
• The Presidents Challenge
• The Surgeon Generals initiative on Obesity

71
CHAMPS
Building a Healthier Chicago

• Our Federal Partners (continued)
• The Office of Health Promotion and Disease
  Prevention
• Metrics from Healthy People 2010/2020
• Centers For Disease Control and Prevention
• The Office of Public Health and Science
• Regional Health Administrators

72
CHAMPS
Building a Healthier Chicago

Source CDPH
73
CHAMPS
Building a Healthier Chicago

Source CDPH
74
CHAMPS
Building a Healthier Chicago

Source CDPH
75
CHAMPS
Building a Healthier Chicago

76
The idea that individual health choices and
personal behaviors are the most important
determinants of chronic disease is an idea whose
time has come and gone.
George Mensah, MD.
77
Individual choices are important However, it is
unlikely that individually attempted changes in
lifestyles and behaviors alone can avert the
growing epidemic of chronic disease that we are
witnessing.
78

• Environmental, System Policy Changes
• are extremely important
• Based on our messages, will people choose to
  change their lifestyle when we have not corrected
  the issues that make that choice difficult?
• When there have no safe place to walk?
• When there is no produce in the local grocery
  store?
• When the health care provider is only financed
  for fixing the current illness?
• When the worksite is a place to sit, stress -
  and gain weight?
• When their school has no physical education?

79

• It is unreasonable to expect that people will
  change their behavior easily when so many forces
  in the social, cultural, and physical environment
  conspire against such change
• Institute of Medicine, 2003

80
The Social Ecological Model

• The aim must be to establish a health promoting
  environment in the social space in which persons
  make significant health decisions.
• The struggle is for the relevant space that
  various forces, some unconcerned with health ad
  some actually detrimental to it, have thus far
  too loosely preempted.
• Social ecology for health means deliberately
  occupying more of that social space and using it
  in the interest of health.

Breslow L. Am J Health Promotion 10253-257.
81
The choices we make

• are shaped
• by the choices we have

82
CHAMPS
Building a Healthier Chicago
How can we most effectively address these issues
?

83
Environmental Change Policies Practices Programs
Healthy Chicago Healthy Behavior Less Illness
Death
Collaborative Partnership
Changing Individual Behaviors
84
Environmental Change Policies Practices Programs
Healthy Chicago Healthy Behavior Less Illness
Death
Collaborative Partnership
Although partnerships have affected change in
community-wide behavior, the strongest evidence
shows that coalitions most effectively contribute
to changes in programs, services and practices.
Butterfloss FD Francisco VT. (2004) Health
Promotion Practice 5(2)108-114. Roussos ST and
Fawcett SB (2000) Annu Rev of Public Health
21369-402.
85
The Social Ecological Model

• The Social Ecological Model cuts across
  disciplinary lenses and integrates multiple
  perspectives and theories.
• This framework recognizes that behavior is
  affected by multiple levels of influence,
  including interpersonal factors, interpersonal
  processes, institutional factors, community
  factors, environmental factors, social factors
  and public policy.

86
CHAMPS
Partnership Functions
Build Awareness of What Works
Joint Projects
Widely Adopted, Strengthened Sustained
Prevention Measures
Information Sharing, Training, Collaborative Lea
rning
Market Effective Prevention Provide Incentives
Effective Health Promotion Interventions
Healthy Chicago
Healthy Places Environments
Evidence-Based Preventive Care
Build Synergies Between Prevention Initiatives
Tackle Barriers
Mobilize Assets
87
The Social Ecological Model

• We must
• ignite and build a social movement
• at private, public and policy levels in order to
  change broad scale social norms and create a
  social envionment supportive of health.

Sorenson G et al. Ann Rev Public Health
1998.19379-416
88
Building a Healthier Chicago

89
Building a Healthier Chicago
james.galloway_at_hhs.gov 312-353-1358