Public Health, Community And Populationbased Research

1
Public Health, Community And Population-based
Research
Childrens Health Research Summit Jan. 28, 2008,
8 am-1 pm, UTSA Downtown Campus
Fernando A. Guerra, M.D., M.P.H. Director of
Health - San Antonio Metropolitan Health District
Brad H. Pollock, M.P.H., Ph.D. Professor and
Chairman - Department of Epidemiology
Biostatistics School of Medicine - University of
Texas Health Science Center
http//www.sanantonio.gov/health/ http//www.uthsc
sa.edu/
2
Objective

• Discuss opportunities to conduct population-based
  research in the San Antonio area
• What are some of the major public health issues
  affecting our population?
• What sorts of studies have been done?
• What resources are available to promote
  population-based childrens research in San
  Antonio?

3
Local Organizations Conducting Health Research

• San Antonio Metropolitan Health District
• UT Health Science Center at San Antonio
• UTSA
• UT School of Public Health Regional Campus
• Southwest Foundation for Biomedical Research
• Southwest Research Institute

4
Points to Ponder

• Public Health A local health department has a
  very important role in the community, to apply
  surveillance, analysis and interventions to
  ensure health.
• Population-based Research Public Health has
  experience in collection, analysis, and
  presentation of population-based clinical and
  demographic data that highlight health
  disparities
• Academic Research Requires careful study design
  and protection of individuals (IRB). It takes
  into consideration the impacts, both benefit and
  potential harm on those being studied.
• Before anything else, we must assure the good
  health, safety, well-being and critical needs of
  the population.

5
A Local Public Health Department Has Many
Opportunities For Population-based Research

• Hurricane Katrina/Rita shelters
• National Childrens Study
• Clinical Translational Science Award (CTSA)
• Community Health Assessments
• Maternal Health Disparities
• Prenatal Care and Adverse Birth Outcomes among
  Documented and Undocumented Hispanics in Texas
• Health Care Disparities

6
Research Under Emergency Conditions

• Many researchers from across the US wanted to
  have access to the Hurricane Katrina/Rita
  shelters to conduct research on the mental and
  physical health and social issues of the
  evacuees.
• Initially there was no process, later access for
  researchers was restricted.
• Residents began to complain that they were
  surveyed to death and they never got anything
  from it.
• Researchers need both
• IRB approval from their governing agency
• Permission from the organization in charge of the
  shelter

7
Research Under Emergency Conditions cont.

• Because disasters happen very quickly, plans for
  data collection must occur before the disaster
  occurs to ensure human subject protections. We
  need to have ready
• IRB templates
• Needs assessment survey instruments with trained
  staff
• Surveillance forms and experienced surveillance
  team
• Ability to track patient populations and have
  them connected to a information system for the
  short and long term.
• Define Special Need
• Allow Environmental Health inspectors to view
  shelters before setting up
• A local system should be pre-established to
  approve, coordinate and provide information to
  researchers.

8
Research Under Emergency Conditions cont.

• Establish a group to oversee data collection by
  Non-Public Health Agencies
• Verification of IRB approval
• Regulate the number and types of surveys being
  conducted within the shelter
• Residents receive a benefit from participating in
  the surveys
• There must be particular attention to the needs
  of pregnant women, infants, children, and the
  elderly

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Public Health and National Childrens Study

• The Public Health department was asked to
• Aggregate five years of Bexar County births
  (126,453) to census blocks
• Develop a 2010 population estimate (2000
  population (Births01,02,03,04,05)/5)10deaths01
  ,02,03,04,05)/5)10).05)10
• Rate of change by block 2000 to 2010 (2010
  Population Estimate 2000 population)/ 2000
  population
• This data will be used to form segments of the
  expected number of births by census block over
  the 4-year enrollment period.
• These segments will be stratified to ensure
  proportionate representation of geographic,
  demographic and socioeconomic subpopulations.

Migration.05
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Public Health and Clinical Translational
Science Award (CTSA)

• Public health resources that may apply to the
  CTSA
• Health Profiles Public Health has experience in
  collection, analysis, and presentation of
  population-based clinical and demographic data
  that highlight health disparities
• Vital Stats These databases contain demographic
  data, as well as clinical data.
• TWICES A state-wide, web-based system utilized
  at the point of care of preventive health and
  screening functions.
• The San Antonio Immunization Registry Contains
  immunization records of children, adolescents and
  adults in the region is also contained within
  this database.
• Statewide databases on communicable disease,
  HIV/STD,

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Lack of Education is a High Risk Health Indicator

• Educational attainment is critical for reducing
  disparities. It assures financial security,
  health literacy, good health, and global
  competitiveness.
• San Antonios toughest health problem, is the
  prevalence of poverty that continues to run its
  course through the community.
• According to the 2000 Census, only 10 of Bexar
  County Hispanics have earned at least a 4-year
  college degree.
• Health literacy is the degree to which
  individuals can understand the health system and
  make appropriate decisions

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Math is a Gatekeeper" Course for Students TAKS
Grade 9 Math Who Met Standard by District
2005-2006 Education Statistics
13
SAT Mean Total Score by School District 2005
Economically Disadvantaged Children by School
District 2005
Generally, SAT scores are lower for the largely
Hispanic inner city schools
14
Bexar County Age Distribution (Hispanic, NH White
African American)
NH White
African American
Hispanic
Male
Female
Male
Female
Male
Female
Age

Source 2000 Census
15
Projected Population of Bexar County by Race and
Ethnicity, 1950-2040
Population
Year

Source U.S. Census and Texas State Data Center
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Bexar County/ San Antonio Community Health
Assessments

• Health Profiles highlight existing and emerging
  health issues facing our community.
• Information is provided on maternity statistics,
  child abuse numbers, immunization rates, obesity,
  asthma, communicable diseases, deaths, etc.

http//www.sanantonio.gov/health/profiles
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Bexar County Scorecard Maternal Health
HP 2010
Status
YR 2006
Maternal Indicators
Total Births
26,194
Mother's Age lt18
1,350
5
5
Low Birth Weight
2,543
10
lt 5
Late Prenatal Care
lt 10
7,365
28
Births to Single Mothers
10,977
42
Premature lt37 Weeks
3,622
13.8
7.6
Medicaid Births
13152
50
Births to mothers BMI 30 above before pregnancy
6,316
24
Births occurring lt 24 mos previous birth
4,392
17
Infant Deaths
177
6.76
4.5
Preliminary data subject to change.
18
Bexar County 2006 Births to Mothers lt22 Yrs. by
Birth Order and Age ( 77 Medicaid)
Birth order of infant not given in birth record
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Bexar County Maternal Health Disparities

• Unplanned childbearing, financial issues,
  substance abuse, depression or domestic violence
  may contribute to having a low birth weight baby
• To counter low birth weight, prematurity, and
  infant mortality among women of color, the
  health care system must talk to women about
  preconceptual health and the importance of
  identifying and treating medical conditions, such
  as hypertension and diabetes, prior to pregnancy
• Based on pilot tests conducted in San Antonio in
  2007, among 40 survey participants, 72 of
  mothers claimed they did not plan on getting
  pregnant.

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Prenatal Care and Adverse Birth Outcomes

• Undocumented Hispanic immigrants had the lowest
  utilization of prenatal care, more pronounced in
  counties closer to Mexico, and the lowest rates
  of adverse birth outcomes.
• Inadequate PNC is associated with adverse birth
  outcomes in all ethnicities, although the effects
  are stronger for documented Hispanics.
• These findings support public funding of routine
  PNC to undocumented Hispanic immigrants.
• Birth certificate data from 2005 for Bexar, El
  Paso, Dallas, and Harris counties, were used for
  this analysis.

Andrea Ries Thurman MD et al. Prenatal Care
Adequacy and Adverse Birth Outcomes among
Documented and Undocumented Hispanics in Texas
unpublished 2008
21
Health Care Disparities

• Studies reveal uninsured patients do not receive
  primary/preventive treatment for
  life-threatening/chronic conditions
  (hypertension, diabetes, heart disease).
• Bexar County Uninsured 372,000 (24.3).
• How many others move on and off insurance? Or are
  underinsured (no preventive care, catastrophic
  care only)?
• Even if everyone were covered, inner cities and
  rural areas lack personnel/facilities to provide
  care for all residents.
• Early death is often preceded by high medical
  bills and loss of wages

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Disparities in Premature Deaths from Heart Disease

• Reducing premature death from heart disease and
  eliminating disparities will require preventing,
  detecting, treating, and controlling risk factors
  for heart disease in young and middle-aged
  adults.
• Nationally In 2001, approximately 17 of all
  deaths from heart disease occurred among persons
  aged lt65 years these deaths occurred
  disproportionately among racial/ethnic
  minorities.
• The determinants of these disparities are not
  clear, variations might reflect differences in
  risk factors for heart disease, access to medical
  and emergency care.
• Blacks have a higher prevalence of high blood
  pressure than whites
• Hispanics are less likely than whites to have
  their blood pressure checked, to be aware of
  having high blood pressure or to be treated and
  controlled for high blood pressure.
• In the United States, greater proportions of
  blacks and Hispanics than whites lack health-care
  coverage and cite cost as a barrier to obtaining
  health care.

MMWR February 20, 2004 / 53(06)121-125
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2005 Bexar County Deaths by CauseAge Specific
Rate 45-64 per 100k
Rate
Hispanic
NH White
Rate




Diabetes mellitus
82
52.4
35
25.4
Chronic liver disease and cirrhosis
56
35.8
21
15.3
Acute myocardial infarction
52
33.2
30
21.8
Cerebrovascular diseases
47
30.0
16
11.6
Malignant neoplasms of liver
41
26.2
13
9.4
Alcoholic liver disease
33
21.1
10
7.3
Chronic ischemic heart disease
32
20.5
22
16.0
Malignant neoplasms of colon, rectum and anus
30
19.2
19
13.8
Renal failure
19
12.1
9
6.5
Septicemia
18
11.5
8
5.8
Motor vehicle accidents
15
9.6
12
8.7
Malignant neoplasm of stomach
15
9.6
4
2.9
Malignant neoplasms of kidney and renal pelvis
14
8.9
11
8.0
Hypertensive heart disease
13
8.3
7
5.1
Human immunodeficiency virus (HIV) disease
12
7.7
5
3.6
Viral hepatitis
11
7.0
8
5.8
156,428
137,597
2005 Bexar County Population Estimate
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Summary-Health Disparities

• Educational attainment is critical for reducing
  disparities. It assures financial security,
  health literacy, good health, and global
  competitiveness.
• To reduce health disparities - consider the
  determinants of health, i.e. genetic factors,
  behavioral factors, environmental factors,
  values, and access to health care.
• Public health approach define the problem,
  collect and analyze the data, determine the
  causes of the problem, take necessary action.

For more information, contact John Berlanga
jberlanga_at_sanantonio.gov
Partnerships to Achieve Health Equity,
11/1/2007, Alexandria, Va. - David Satcher, M.D.,
Ph.D.
25
Childrens Health Research at The University of
Texas Health Science Center at San Antonio
(UTHSCSA)

• Examples
• Infrastructure to support population-based/communi
  ty research

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South Texas Minority-Based Community Clinical
Oncology Program (CCOP)

• Christus Santa Rosa Childrens Hospital
• Methodist Childrens Hospital
• Wilford Hall Medical Center, Lackland AFB
• Driscoll Childrens Hospital (Corpus Christi)

Continuously funded by the National Cancer
Institute since 1990

• Participate on Childrens Oncology Group research
  protocols
• Serve as a platform for conducting regional
  childhood cancer research investigations

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Obesity and Childhood Leukemia

• Using the South Texas MB-CCOP consortium, we
  identified a cohort of 307 newly diagnosed
  children with acute lymphoblastic leukemia
• We assessed obesity and the change in body mass
  index over the course of treatment

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Demographic Correlates of Body Size Changes in
Children Undergoing Treatment for Acute
Lymphoblastic Leukemia

• Jacques Baillargeon, Ph.D., Anne-Marie Langevin,
  M.D., Margaret Lewis, M.S., Jaime Estrada, M.D.,
  James J. Grady, Ph.D., Judith Mullins, M.D.,
  Aaron Pitney, M.D., Brad H. Pollock, M.P.H.,
  Ph.D.

Pediatr Blood Cancer, 49793-6, 2007
29
Therapy-related Changes in Body Size in Hispanic
Children with Acute Lymphoblastic Leukemia
Jacques Baillargeon, Ph.D., Anne-Marie Langevin,
M.D., Margaret Lewis, M.S., James J. Grady,
M.P.H., Dr.P.H., Paul J. Thomas, M.D., Judith
Mullins, M.D., Jaime Estrada, M.D., Aaron Pitney,
M.D. Nancy Sacks, M.S., R.D., Brad H. Pollock,
M.P.H., Ph.D.
Cancer, 1031725-9, 2005
30
Transient Hyperglycemia in Hispanic Children with
Acute Lymphoblastic Leukemia

• Jacques Baillargeon, Ph.D. Anne-Marie Langevin,
  M.D., Judith Mullins, M.D., Guillermo DeAngulo,
  M.D., Paul J. Thomas, M.D., Jaime Estrada, M.D.,
  Aaron Pitney, M.D., Brad H. Pollock, M.P.H., Ph.D.

Pediatr Blood Cancer, 441-4, 2005
31
Adolescents with Cancer An Underserved
Population

• Adolescents with cancer have poorer survival than
  younger children and older adults

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Relative Change in 5-Year Survival(19751997,
NCI SEER Program)
2.4
1.8
Underserved
Average AnnualIncrease
All Age Average 1.5 / yr
1.2
0.6
0
25
0
5
10
15
20
30
35
40
45
50
55
60
65
70
75
-0.3
Age at Diagnosis (Years)
33
Adolescents with Cancer An Underserved
Population

• Adolescents with cancer have poorer survival than
  younger children and older adults
• Possible reasons
• Less access to state-of-the art (protocol)
  therapy
• Different tumor biology
• Lower adherence to prescribed treatment

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Re-Mission Video Game Intervention

• Primary Objective Determine the effects of
  playing a interactive video game, Re-Mission, on
  treatment adherence
• Secondary Objectives Determine the effects on
  health-related quality of life, self-care
  behaviors, knowledge, stress, and locus of
  control

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Description of the Intervention

• Action game
• English, Spanish, or French game modes are
  available

36
6MP Adjusted for Game-PlayObjective measure of
adherence to oral chemotherapy (in Rx subset)
6MMP adjusted for game-play
6TG adjusted for game-play
p .008
p .015
Re-Mission
Control
Plasma 6MMP (log10)
Baseline Follow-up
37
MEMS Medication Event Monitoring
SystemObjective behavioral measure of adherence
to oral antibiotics (in Rx subset)
MEMS access events
MEMS Adherence Failure
p .008
p .013
Fraction of participants with MEMS lt 10 Rx
Control Re-Mission
38
Pilot Study of the Genetic Epidemiology of
Childhood Cancer Objectives

• Assess feasibility of collecting/banking
  pediatric blood samples along with demographic,
  health, and exposure data from childhood cancer
  cases and their biological parents.
• Determine the proportion of eligible subjects who
  choose to participate, respondent burden,
  completeness of questionnaires.
• Obtain preliminary estimates of the genotypes
  associated with childhood cancers
• Formulate analytic etiological hypotheses and
  develop a statewide protocol

39
Inter-Institutional Collaborations
40
Education Collaborations

• UTHSCSA-UTSA
• PhD in Biostatistics
• Computational Biology Initiative
• UTHSCSA-Regional Campus UT SPH
• Proposed DrPH in Environmental and Occupational
  Health and Community Health Practice
• UTSA-Regional Campus UT SPH
• PhD in Applied Demography

41
Resources

• UTHSCSA Dept. of Epidemiology and Biostatistics
• Biostatistics core resources
• Biomedical informatics core resources
• Institute for Health Promotion Research
• National Childrens Study (NCS)
• UTHSCSA Clinical Translational Science Award
  proposal
• UTHSCSA-UTSA Computational Biology Initiative
• SBC Genomics Computing Center at the SFBR
• San Antonio Immunization Registry System (SAMHD)
• Proposed UTSA Center for Geographic Information
  Systems (GIS)

42
The Future
43
San Antonio Public Health Institute?

• Workgroup was formed 18 months ago to identify
  barriers to seamless research and educational
  collaboration
• UT School of Public Health San Antonio Regional
  Campus
• UTHSCSA
• UTSA
• SAMHD
• Possible future physical home