Texas Public Health JournalTPHA Journal Volume 69, Issue 3 3 Commissioner’s Comments Mumps Makes a...

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Texas Public Health AssociationPO Box 201540, Austin, Texas 78720-1540 phone (512) 336-2520 fax (512) 336-0533

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Subscriptions: Texas Public Health Journal, PO Box 201540, Austin, Texas 78720-1540. Rates are $75 per year. Subscriptions are included with memberships. Membership application and fees accessible at www.texaspha.org. Please visit the journal page for guidelines on submitting to the Texas Public Health Journal.

In This Issue

Texas Public Health JournalA quarterly publication of the

Texas Public Health Association (TPHA)

Volume 69, Issue 3 Summer 2017

President’s Message 2

TPHA Committees and Highlights of Their Exciting Activities 2

Commissioner’s CommentsMumps Makes a Comeback in Texas and the US 3

Poison Control NewsInsect Repellant Bands: Attracting Kids Not Insects 4

Book Review Rigor Mortis: How Sloppy Science Creates Worthless Cures, Crushes Hope, and Wastes Billions by Richard Harris 5

Public Health Practice CommentaryProtect the Prevention Fund 6

Original Peer-Reviewed Public Health Research Creating Momentum in Public Health Through Strategic Planning and Academic Partnerships 7

Sifting for Clues: Using Patient Healthcare Records to Identify Missed Opportunities for Tuberculosis Prevention 10

The Eff ects of Chronic Medical Conditions and Obesity on Self-Reported Disability in Older Mexican Americans 12

Developing Partnerships to Reduce Sodium in Worksite Cafeterias and Congregate Meal Programs 16

2 TPHA Journal Volume 69, Issue 32

EditorCatherine Cooksley, DrPH, ARGC

Managing EditorTerri S. Pali

Editorial BoardKaye Reynolds, DrPH - Co-chairCarol Galeener, PhD - Co-chair

Amol Karmarker, PhDKimberly Fulda, DrPH

Mathias B. Forrester, BSNatalie Archer, MPH, PhD

TPHA Executive BoardCarol M. Davis, MSPH, CPH, PresidentRachel Wiseman, MPH, President-ElectWitold Migala, PhD, 1st Vice President

Raouf Arafat, MD, MPH, 2nd Vice PresidentMelissa Oden, DHEd, LMSW-IPR, MPH, CHES,

Immediate Past PresidentLinda Kaufman, MSN, RN, APHN-BC (2020)

Lisette K. Osborne, RN-BC, MSN, CHEP (2020)Jennifer Smith, MSHP (2020)Rita Espinoza, MPH (2019)

Maram Museitif, MPH, CPH, CCRP (2019)Kaye Reynolds, DrPH (2018)Bobby Schmidt, MEd (2018)

TPHA Governing CouncilCarol M. Davis, MSPH, CPH, PresidentRachel Wiseman, MPH, President-ElectWitold Migala, PhD, 1st Vice President

Raouf Arafat, MD, MPH, 2nd Vice PresidentMelissa Oden, DHEd, LMSW-IPR, MPH, CHES,

Immediate Past PresidentLinda Kaufman, MSN, RN, APHN-BC (2020)

Lisette K. Osborne, RN-BC, MSN, CHEP (2020)Jennifer Smith, MSHP (2020)Rita Espinoza, MPH (2019)

Maram Museitif, MPH, CPH, CCRP (2019)Kaye Reynolds, DrPH (2018)Bobby Schmidt, MEd (2018)

Sophia Anyatonwu, MPH, CPH, CIC (2020)Elizabeth Cuevas (2020)

Martha Culver, DNP, RN (2020)Monica Hughes, BSN, RN, NE-BC (2019)

Lou Kreidler, RN, BSN (2019)Tijera Bell, MPH (2019)

Sheronika Denson, DrPH, MS (2018)Stephen L. Williams, MEd, MPA (2018)

Alexandra Garcia, PhD, RN, FAAN (2018)Sherri Fleming, Administration & Management

Section (2018)Bobby Schmidt, Med, Aging & Public

Health Section (2018)Elizabeth Cuevas, Epidemiology Section (2018)

Andrea McDonald, PhD, Health Education Section (2018)

Johanna DeYoung, BSN, DDS, MPH, Oral Health Section (2018)

Crysanne Randal, BSN, RN, CPH, Public Health Nursing Section (2018)

Leslie Allsopp, MSN, MPH, Environmental and Consumer Health Section (2018)Laura Abasi, Student Section (2018)

Bobby Jones, DVM, MPH, DACVPM, Parliamentarian

Catherine Cooksley, DrPH, ARGC Representative

Journal TypesettingCharissa Crump

* ( ) term expires

President’s MessageCarol M Davis, MSPH, CPH

Since 1932, the Texas Public Health Associa-tion (TPHA) has been promoting public health be-cause we believe that public health is everybody’s business. I am honored to serve as your president

for the 2017-18 year. I love being involved with TPHA and attending our conference be-cause it provides me an opportunity to see the amazing things that are done across Texas to protect health. The passion of our members inspires me. The dedication of our members humbles me.

As your president, for those members who want to become more involved with public health beyond your explicit job duties, I want to help you connect with opportunities within TPHA. Our organization can help you con-nect with public health professionals across the state. One opportunity that is available for all members of TPHA is participation on our committees. We have committees tasked with looking at professional development, mem-bership, legislation/policy/advocacy, market-ing, and conference planning.

Another opportunity available to our mem-bers is the TPHA Journal Editorial Board Chair position. This position is responsible for working with the Editorial Board to coor-dinate the solicitation, review, and approval of manuscripts for our journal.

Please reach out to me at [email protected] or to Terri Pali at [email protected] if you are interested in learning more about our com-mittees.

I fi rst became active in TPHA by serving on a committee. I had ideas and opinions about the TPHA conference I had just attended and was invited to contribute to the next conference by serving on the programs planning committee. It was a great experience and I had the op-portunity to help grow our annual conference.

I am looking forward to this next year because I am in a unique position to witness the excit-ing projects and wonderful accomplishments that will be done by our members both in public health practice and in academia. There may be uncertainty about budgets and health threats, but we have faced uncertainty before. Our dedication and our passion will help us continue to serve our communities and pro-tect the public’s health. TPHA is full of pub-

lic health leaders. Whether you are a health department director or a frontline employee. Whether you have decades of experience or are just getting your foot in the door. You are a public health leader.

We are public health leaders because we in-spire others to live healthier lives. We actively work to protect health and empower others to do the same. Reading this journal, attending public health conferences, and your involve-ment with TPHA demonstrates your desire to learn and continue to grow professionally. The next step is to share what you learn with others. Use your knowledge and experience to improve public health and then amplify your impact by sharing that knowledge and experi-ence with others. TPHA strives to support our members doing just that through this journal and our annual educational conference.

In closing, I look forward to working with you in promoting and protecting public health. Let your inner leader shine and I know we will continue to have substantial and meaningful impacts on the health of everyone in Texas.

STHtbpctibha

TPHA Committees and Highlights of Exciting Activities

Much more information can be found on our website at www.texaspha.org/page/TPHACom-mittees.

Legislative, Policy & Advocacy Committee-Help us propose public health resolutions and policy statements; monitor State and national policy; educate elected offi cials and the public; build coalitions and provide updates. Marketing Committee-Help us draft and rec-ommend Association marketing plans; dissemi-nate public health information; promote careers in public health and publicize TPHA sponsored meetings. Membership Committee-Help us move our Association forward by enhancing member benefi ts, seeking recipients for student scholar-ships and candidates for offi cer positions and growing our membership. Programs Committee-Help us arrange our annual meetings and serve on one or more subcommittee: Site Selection, Exhibit Procure-ment, Public Health Presentations, Local Ar-rangements and Awards.Planning and Operations Committee-Help us review actions of the Association governing bodies to insure decisions are implemented and operations remain current and consistent with our Constitution and Bylaws.Professional Development Committee-Help us coordinate internal/external training activi-ties on leadership, member orientation and offi -cer’s training to help our members succeed and keep our Association strong.

TPHA Journal Volume 69, Issue 3 3

Commissioner’s Comments

Mumps Makes a Comeback in Texas and the USDr. John Hellerstedt Texas Department of State Health ServicesFor years, mumps has not presented sig-nifi cant clinical challenges for most Texas medical providers and public health pro-fessionals. Widespread vaccination drove

down the incidence of mumps, and a disease that once aff ected tens of thousands of Texans a year had dwindled to a dozen or two cases reported annually for most of the last decade. However, that picture has changed signifi cantly over the last several months.

There have been small, isolated outbreaks in Texas in recent years, but an outbreak in Arkansas that started in August 2016 and has now grown to include nearly 3,000 cases, signaled that mumps has staged a serious comeback in the United States. We have seen multiple sig-nifi cant outbreaks in North Texas dating back to last year, and cases have been reported from many parts of the state. Already this year, DSHS has had more than 200 mumps cases reported, more than in any year since 1992. Unfortunately, I expect we will continue to see cases throughout the second half of the year.

We cannot ignore the resurgence of mumps and I encourage you keep it in mind as you talk about preventing communicable diseases in your communities. Of course, vaccination remains the centerpiece of prevention, but prevention and response eff orts cannot end there. Vaccination absolutely provides the best protection we can off er against mumps, and we need to keep talking about how important it is in preventing a host of diseases. Unfortunately, vaccination won’t

protect everyone. Research shows that about 12 percent of fully vac-cinated people won’t have a suffi cient immune response to prevent them from getting sick if they’re exposed to the mumps virus. That’s where reminders about good old fashioned hygiene come in. Hand-washing, covering coughs and sneezes, and not sharing food and drinks are also critical steps for the public to take to limit the spread of mumps.

Please remind health care providers in your communities to be on the lookout for mumps. They should maintain a high index of clini-cal suspicion and should report suspected mumps cases to the local health department or DSHS as soon as possible within one business day. We also recommend health care facilities take this opportunity to ensure they have up-to-date documentation of mumps immunity for all staff , not just health care providers.

We at DSHS stand by to assist you with outbreak investigations of mumps and other communicable diseases. The state public health lab in Austin can provide testing support, and our regional and central of-fi ce staff are available to provide assistance and guidance as needed.

Thank you for all you do to help keep Texans healthy and safe and for your willingness to work together to make mumps a disease that once again we don’t have to think much about.

At 1 month of age, HepB (1-2 months), At 2 months of age, HepB (1-2 months), DTaP, PCV, Hib, Polio, and RVAt 4 months of age, DTaP, PCV, Hib, Polio, and RVAt 6 months of age, HepB (6-18 months), DTaP, PCV, Hib, Polio (6-18 months), RV, and Influenza (yearly, 6 months through 18 years)*At 12 months of age, MMR (12-15

months), PCV (12-15 months)†

, Hib (12-15 months), Varicella (12-15 months), HepA (12-23 months)§, and Influenza (yearly, 6 months through 18 years)*At 4-6 years, DTaP, IPV, MMR, Varicella, and Influenza (yearly, 6

months through 18 years)*

2017 Recommended Immunizations for Children from Birth Through 6 Years Old

Birth1

month2

months4

months6

months12

months15

months18

months19–23months

2–3years

4–6years

HepB

RV RV RV

DTaP DTaP DTaP DTaP

Hib Hib Hib

PCV PCV PCV

IPV IPV IPV

MMR

Varicella

HepB HepB

DTaP

HepA§

MMR

Varicella

PCV

Hib

IPV

Influenza (Yearly)*

For more information, call toll free 1-800-CDC-INFO (1-800-232-4636)

or visit www.cdc.gov/vaccines/parents

Shaded boxes indicate the vaccine can be given during shown age range.

See back page for more information on vaccine- preventable diseases and the vaccines that prevent them.

FOOTNOTES:

* Two doses given at least four weeks apart are recommended for children aged 6 months through 8 years of age who are getting an influenza (flu) vaccine for the first time and for some other children in this age group.

§ Two doses of HepA vaccine are needed for lasting protection. The first dose of HepA vaccine should be given between 12 months and 23 months of age. The second dose should be given 6 to 18 months later. HepA vaccination may be given to any child 12 months and older to protect against HepA. Children and adolescents who did not receive the HepA vaccine and are at high-risk, should be vaccinated against HepA.

If your child has any medical conditions that put him at risk for infection or is traveling outside the United States, talk to your child’s doctor about additional vaccines that he may need.

NOTE: If your child misses a shot, you don’t need to start over, just go back to your child’s doctor for the next shot. Talk with your child’s doctor if you have questions about vaccines.

Is your family growing? To protect your new baby and yourself against whooping cough, get a Tdap vaccine. The recommended time is the 27th through 36th week of pregnancy. Talk to your doctor for more details.


Poison Control News

Insect Repellant Bands: Attracting Kids Not InsectsC. Lizette Villarreal, George M. LaytonSouth Texas Poison Center at UT Health San Antonio, San Antonio, [email protected] the summer months draw near, people are gearing up to protect themselves from insect bites, especially mosquitoes. With the risk of various illnesses transmitted by mosquitoes, such as West Nile, Den-gue, Chikungunya, or the Zika virus, people are quickly turning to a variety of topical insect repellents available to protect themselves. Primary defense against mosquito bites and mosquito-borne diseases are personal protection strategies such as topical insect repellents.1,2

Due to the variability of active ingredients in these products, there is a variation in the eff ectiveness of insect repellents and other personal protection strategies.3,4 Although natural or botanical alternatives to synthetic insect repellents have become increasingly popular,5 stud-ies show that the most eff ective active ingredients are diethyltolua-mide (DEET) and picaridin.3,4,6 Relatively few adverse clinical ef-fects have been reported with DEET and picaridin.3,7,8

In recent years, alternatives to topical insect repellents have ap-peared on the market. These include wearable products such as cloth or plastic wristbands or bracelets infused with synthetic (DEET) or natural (peppermint oil, citronella oil) repellents.9,10 The safety of these products is of concern as families use these products for fam-ily members of all ages. Several studies have indicated that these bands or bracelets have little or no eff ect at prevention of mosquito bites.4,9-11 Under federal law, companies that market products con-taining natural ingredients are exempt from having to demonstrate to the government that their products stand up to scientifi c review because these ingredients are considered to pose minimal risk.9 In at least one case, the United States Federal Trade Commission has charged one company with making deceptive statements about their insect repellent band.12

From 2003-2016, a total of 104 exposures were reported to the Texas Poison Center Network involving insect repellant bands. In Texas, over the last two years, there has been a drastic increase of exposures related to insect repellent bands, reaching as high as twenty-six cases reported each year. Over 50% of these exposures were reported in 2015 and 2016. A majority (n=63, 61%) of exposures occurred be-tween May through July, coinciding with the hottest months of the year and the height of mosquito season. Males compromised 43% (n=45) of exposures while females represented 57% (n=59). The route of the exposure (an exposure may involve more than one route) was ingestion (n=92, 88%), ingestion plus dermal (n=8, 8%), dermal contact (n=3, 3%), and ocular (n=1, 1%). Patients ages 0-5 years comprised 87% of exposures followed by patients ages 6-12 years (8%). The majority (n=99, 95%) of the exposures reported to Texas poison centers were unintentional.

Most (n=96, 92%) of the patients were managed on site (outside of a healthcare facility), six (6%) were already at or en route to a health-care facility when the poison center was contacted, one (1%) was referred to a healthcare facility by the poison center, and one (1%) was managed at an unspecifi ed other location. None of the exposures reported had a serious outcome, and no deaths were reported. The most frequently reported clinical eff ects were vomiting (n=4, 4%), abdominal pain (n=4, 4%), rash (n=3, 3%), and oral irritation (n=3, 3%). The most commonly reported treatments were dilution, irriga-tion, or wash (n=80, 77%); and food or snack (n=13, 13%).

In summary, children are curious and it is very common for them to explore the world with their mouth as evident in insect repellent band exposures. Although the data from the Texas Poison Center Network suggest that exposures to insect repellent bands are not likely to be serious and may be managed outside of a healthcare facility, it is important that families are aware of the risks that these products pose to young children. These bands are infused with various ingredients, and although there have been no serious outcomes related to these types of exposures, the development of new insect repellent products may pose additional risks. If you or your child is exposed to an insect repellent band and experience a rash or other reaction, or if you have questions after using these products, contact the Texas Poison Center Network at 1-800-222-1222.

REFERENCES1. Frances SP, Cooper RD. 2007. Personal protective measures against mos-quitoes: insecticide-treated uniforms, bednets and tents. ADF Health 8:50-56.2. Fradin MS. 1998. Mosquitoes and mosquito repellents: a clinician’s guide. Ann Intern Med 128:931-940.3. Goodyer LI, Croft AM, Frances SP, Hill N, Moore SJ, Onyango SP, Deb-boun M. 2010. Expert review of the evidence base for arthropod bite avoid-ance. J Travel Med. 17:182-192.4. Fradin MS, Day JF. 2002. Comparative effi cacy of insect repellents against mosquito bites. N Engl J Med 347:13-18.5. Osimitz TG, Grothaus RH. 1995. The present safety assessment of deet. J Am Mosq Control Assoc 11:274-278.6. Barnard DR, Xue RD. 2004. Laboratory evaluation of mosquito repellents against Aedes albopictus, Culex nigripalpus, and Ochierotatus triseriatus (Diptera: Culicidae). J Med Entomol 41:726-730.7. Charlton NP, Murphy LT, Parker Cote JL, Vakkalanka JP. 2016. The toxic-ity of picaridin containing insect repellent reported to the National Poison Data System. Clin Toxicol (Phila) 54:655 658.8. Sudakin DL, Trevathan WR. 2003. DEET: a review and update of safety and risk in the general population. J Toxicol Clin Toxicol 41:831-839.9. Leonard K. May 31, 2016. Wristbands gain popularity as mosquito repel-lent, but do they work? U.S. News & World Report. Available at http://www.usnews.com/news/articles/2016 05 31/want to prevent mosquito bites some say bracelets wont help. Accessed September 19, 2016.10. Webb CE, Russell RC. 2011. Do wrist bands impregnated with botani-cal extracts assist in repelling mosquitos? Gen Appl Ent 40:1-5. Available at https://cameronwebb.fi les.wordpress.com/2013/11/webbandrussell_repel-lentwristbands_gae.pdf. Accessed September 19, 2016.11. Jensen T, Lampman R, Slamecka MC, Novak RJ. 2000. Field effi cacy of commercial antimosquito products in Illinois. J Am Mosq Control Assoc 16:148-152.12. Federal Trade Commission. February 20, 2015. FTC charges company, owner with deceptively marketing mosquito repellent wristbands. Available at https://www.ftc.gov/news events/press releases/2015/02/ftc charges com-pany owner deceptively marketing mosquito. Accessed September 19, 2016.


Book Review: Rigor Mortis: How Sloppy Science Creates Worthless Cures, Crushes Hope, and Wastes Billions by Richard HarrisCarol A. Galeener, PhD, MPHThe science is settled. The western world reveres “science” above all else as the pure quest for the eternal truths of the universe. And no truths are more important than those of the life sciences, revealing to us: how embryogenesis propels us from the random meeting of egg and sperm to the unruly toddler and even more unruly teenager; how viruses mutate from relatively benign fellow travelers to agents deci-mating entire populations; how an errant cell opts for immortality beginning the downward spiral into “cancer.” In Rigor Mortis, Har-ris laments, not how much society spends on life sciences research exploring these questions, but rather how much of that expenditure is badly spent. As Harris describes in the clear prose of the award-winning science writer that he is, the science is not so settled. And it is often for reasons quite not so altruistic as the fi nding of “truth.” The unravelling of the mystique of life sciences research began in 2005 with the publication of a journal article by Stanford Professor John Ioannides, claiming to explain “Why Most Published Research Findings are False.” This highly cited article was a beginning, but the proverbial feces did not hit the fan until the 2012 publication in Nature of C. Glenn Begley and Lee Ellis’s commentary recounting Begley’s experiences at Amgen attempting to reproduce the results of 53 experiments that were at the time considered breakthroughs in the life sciences. Despite a great deal of attention given to employ-ing the same methods and materials, only a scant half dozen could be reproduced. Some results could not be reproduced even by the original study team. Peer reaction was swift and frequently vitupera-tive; however, it started a worthy discussion about science, experi-mentation, reproducibility, and generalizability. Somewhere in the Great Beyond, the good Dr. Hill was pointing to his Criteria, and promoting once again the importance of consistency in causality and the undervalued role of chance in the aff airs of mice and men.

Harris identifi es those factors that result in the parlous state of life science research today. Some of these are inherent in nature. The fi rst factor in this class is that mice are not men. Even our near genet-ic cousins, such as mice, have so often proven to be poor predictors of how humans will react to the same exposures that some reasonable scientists question whether animals should be used as predictors at all. Even within the same species reproducibility is problematic. For example, mice do not react consistently, depending on such seeming-ly small elements as microbiomes or exposure to diff erent bedding. Even co-operating labs studying cells in vitro may fi nd it diffi cult to reproduce each other’s work, depending on such bizarrely simple steps as whether the samples are shaken or stirred. Another “nature factor” is that a man is not men – the heterogeneity of individual hu-mans and their reactions to diseases that themselves may encompass great heterogeneity explains much of why clinical trials often fail in the very late and thus very expensive stages.

A second set of factors involves what may charitably be called, “sloppy science.” Study designs are frequently uncontrolled or un-derpowered for the important inferences they report. Experimenters may ignore strict attention to methods and materials in execution, and may not report these key elements necessary for reproducibility. For many years, some labs had studied what investigators thought were breast cancer cells, only to fi nd they had been studying HeLa-contaminated ovarian cancer cell lines. Other scientists skirt ethical boundaries by the insidious processes of p-hacking (a form of se-lective data reporting) or HARKing (hypothesizing after results are known.)

Finally, Harris addresses the ultimate causes that result in so much bad science being fl ogged by so many scientists. The incentives in academic research are not conducive to good, impactful science. Ju-nior scientists are frequently encouraged to publish to secure tenure and promotions, despite whether investigation results are impactful or not. More senior scientists may be tempted to “play the game” deciding what to publish in journals or what is worthy of grants.

Journals too bear a responsibility. Negative fi ndings are given short shrift, thus discouraging dissemination of information that may be of great value to society. There is no common process for identify-ing articles that have been found to be incorrect. Thus articles with incorrect fi ndings may be cited by researchers long after their “sell by” date has passed.

The prize for good science is large. The cost to the US taxpayer of producing science that is incorrect is estimated to be in the ballpark of $30 billion a year; the delay of eff ective treatments and avoidance of ineff ective treatments is additional to this considerable sum. Har-ris makes a good case that the current situation is not sustainable, and it is time for life scientists to set their house in order.

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Public Health Practice Commentary: Protect the Prevention FundCatherine L. Troisi, PhDTPHA member since 2004 and former TPHA Governing Councilor; Chair, APHA Action Board; Associate Profes-sor, Divisions of Management, Policy, & Community Health and Epidemiology and Coordinator, Leadership Studies Concentration at The University of Texas Health Science Center at Houston School of Public [email protected] tremendous improvements in the 20th century, the U.S. is still far from being the healthiest nation. According to a recent Com-monwealth Fund report1, we spend far more on healthcare than any other high-income country, but our lives are shorter and less healthy.

We must treat those who are sick and injured. But to become a healthier nation, we must also invest in prevention and wellness to prevent people from becoming sick in the fi rst place. The Prevention and Public Health fund – a key part of the Aff ordable Care Act – is a unique program doing just that. By keeping people healthier, costs are saved as well2. It is, however, interesting to note that only in public health do we need to continually justify saving lives and/or improving the quality of life with cost-saving arguments. New medi-cal interventions are not typically held to that same standard.

H.R. 1628, the American Health Care Act, now being considered in the United States Senate, would result in many disturbing conse-quences including an estimated 23 million people losing their health insurance coverage by 2026 and increased premiums and other out-of-pocket costs. An estimated more than 2.5 million Texans wouldlose insurance coverage adding to our already high rates of thoseuninsured. AHCA would cut more than $830 billion from the federal contribution to the Medicaid program over the next decade. The bill would also allow states to opt out of ACA protections that restrict insurance companies from charging higher premiums for people with pre-existing conditions and from the requirement that insurers cover 10 essential health benefi ts including maternity care, prescription drugs, and mental health and substance use disorder services. While it may appear costs are saved at the federal level from not providing coverage, this does not take into account increased insurance pre-miums and property taxes to cover uncompensated care and forces people to use emergency departments as their healthcare provider, the most expensive and least eff ective way to provide medical care for chronic, non-acute conditions.3, 4

However, there’s another equally disturbing aspect of the AHCA of which people may not be aware. It would repeal the Prevention and Public Health Fund meant to expand and sustain the national in-vestment in prevention and public health programs. The Prevention Fund represents 12% ($1 billion) of the Center for Disease Control and Prevention’s budget and this is on top of the cuts proposed in the President’s budget. The Prevention Fund is absolutely necessary to improve the health of Texans and to slow the rise of health care costs.

Texas faces signifi cant health and fi scal challenges that could be mitigated by a better and more reliably funded public health system. As documented by the Trust for America’s Health5 the Prevention Fund is a vital part of the eff ort to create such a system. Since 2010, the Prevention Fund has provided Texas with more than $150 million ($29 million in 2016 alone) to support a variety of public health ac-tivities. Repealing the Prevention Fund would result in a major loss of funding for core public health programs in Texas.

The monies that the Prevention Fund sends to Texas are crucial for improving the health of Texans. It supports programs to reduce to-bacco use including the 1-800-QUIT NOW telephone line with tips on quitting from former smokers. A recent study found that the cam-paign led to over 1.5 million smokers attempting to quit and pre-vented over 17,000 premature deaths. It’s worth noting here that

tobacco use is the number one cause of preventable deaths. The Pre-vention Fund also helps Texans prevent diabetes and obesity as well as heart disease through programs promoting healthy nutrition and physical exercise. Texas receives money to immunize children and low-income adults, helping all of us as a well-immunized population stops spread of infectious diseases.

The Texas Department of State Health Services received almost $1 million to upgrade the laboratories that detect outbreaks of disease and food borne illnesses and bioterrorism events. Without state-of-the-art laboratories, identifi cation of these outbreaks is delayed and so more people can get sick. Texas also received money to prevent healthcare associated infections, a major problem within healthcare facilities and one that could aff ect anyone entering a hospital or nurs-ing home.

Another program that the Prevention Fund supports in Texas is called the Preventive Health and Health Services Block Grant (over $6 mil-lion to Texas in 2016 alone). These are funds that gives Texas the fl exibility to respond rapidly to emerging health issues (think Zika) and to fi ll funding gaps that are leading causes of death and disability in Texas. Texas receives these block grants to address our unique public health needs in innovative and locally defi ned ways.

While personal responsibility for health is certainly part of the equa-tion, the Prevention Fund is intended to ensure a coordinated, com-prehensive, sustainable, and accountable approach to improving our country’s health outcomes through the most eff ective, evidence-based programs. It empowers states and communities to address their most pressing health needs. Loss of the Prevention Fund would make it harder for public health professionals to help protect Texans’ health and respond to public health emergencies.

The Texas Public Health Association sent letters to Senators Cornyn and Cruz in January stating their support for the Prevention and Pub-lic Health fund and stating “…by repealing this fund, we would not be able to sustain the progress we have made towards improving the health of Texans and risk eliminating, if not reversing, the gains we have already made.” As public health professionals, we need to work with businesses, schools, nonprofi ts, hospitals and insurers as well as individuals to come together to support the Prevention Fund and the health of all in our state.

Please join the leadership of the TPHA as we continue to advocate to preserve this fund by organizing advocacy eff orts in your area. To learn more about how, please contact me.

REFERENCES1. http://www.commonwealthfund.org/publications/press-releases/2015/oct/us-spends-more-on-health-care-than-other-nations accessed 15 January 20172. https://www.surgeongeneral.gov/priorities/prevention/strategy/appendix1.pdf accessed 9 June 20173. https://www.ncbi.nlm.nih.gov/books/NBK221653/ accessed 9 June 20174. https://www.ncbi.nlm.nih.gov/pubmed/22128684 accessed 9 June 20175. http://tfah.org/reports/prevention-fund-state-facts-2017/ accessed 7 June 2017


Original Peer-reviewed Public Health Research

Creating Momentum in Public Health through Strategic Planning and Academic PartnershipsLisa Campbell, DNP, RN, APHN-BC1, Donna Ernst, DNP, RN, NEA-BC, CNL, CGRN2, Francisco Javier Gonzales, DNP, RN, MBA/HCM, CCM, CPHQ, HACP3, Tammy Staff ord, DNP, MBA, RN4, Karen Walsh, DNP, RN, FNP-BC5, Jeff Watson, DNP, RN-BC, NEA-BC, NE-BC, CRRN1

1Texas Tech University Health Science Center School of Nursing, Lubbock, Texas2Texas Christian University Harris College of Nursing and Health Sciences, Fort Worth, Texas3University Medical Center of El Paso, El Paso, Texas4Fresenius Kidney Care, Midland, Texas5Verbena PLLC, Austin, TexasABSTRACTA strategic plan provides organizational direction and is one of seven pre-accreditation requirements of the Public Health Accreditation Board. However, developing a strategic plan requires an allocation of resources that can burden most local public health departments. The Victoria County (Texas) Public Health Department (VCPHD) leveraged resources and collaborated with an academic partner to de-velop a strategic plan in six weeks. Five Doctor of Nursing Practice students from Texas Tech University Health Sciences Center School of Nursing used the National Association of City County Health Of-fi cial’s (NACCHO) Developing a Local Health Department Strategic Plan: A How-To Guide as a roadmap for planning and facilitation. Preplanning included conducting a Strengths, Weaknesses, Oppor-tunities, and Threats (SWOT) analysis for each of the seven health department divisions. VCPHD leadership (director and managers) participated in a one-day planning session. As a result, a new orga-nizational vision, mission, and fi rst-time strategic plan were created. With adequate planning, any health department could apply the strat-egies outlined by the authors to create a strategic plan that creates positive momentum in an organization. Key Words: Strategic Planning, Collaboration, SWOT Analysis, Ac-ademic Partnerships, Public Health

BACKGROUNDA strategic plan is a necessary organizational compass and a Pub-lic Health Accreditation Board requirement.1 According to Bryson,2

strategic planning is a “deliberative, disciplined approach to produc-ing fundamental decisions and actions that shape and guide what an organization (or other entity) is, what it does, and why” (p. 8). If executed well, strategic planning taps into the collective wisdom, ensures an organization pursues signifi cance within the community, and creates public value.2-4

Successful strategic planning requires leadership to support the pro-cess, identifi cation of organizational champions who will manage implementation of the plan, and hiring a facilitator to free up leader-ship to participate fully in the process. A facilitator must quickly fa-miliarize themselves with the organization and establish close trust-ing relationships with leaders and champions.2 However, the cost of facilitation can be prohibitive for many local health departments and options can be limited. One solution we used to address the cost of facilitation was creatively leveraging resources with an academic partner to develop a strategic plan.

Many other local health departments, like the Victoria County Pub-lic Health Department (VCPHD, have never had a strategic plan.5

Several major issues faced the organization: lack of employee en-gagement, outdated internal and external policies/ordinances, and lack of community visibility. Dr. Lisa Campbell (fi rst author),the director of the VCPHD and Associate Professor at Texas Tech Uni-versity Health Sciences Center School of Nursing Doctor of Nursing

Practice (DNP) Program provided technical assistance to fi ve DNP students who facilitated the strategic planning process (Figure 1).

Population and Methods Situated in Victoria County, Texas, population 92,382,6 VCPHD serves a vastly rural area surrounded by the metropolitan areas of Houston, Austin, San Antonio, and Corpus Christi, each an approxi-mate two-hour drive from Victoria. The health department receives local and state funding and a variety of external grants. Divisions within the VCPHD include: administration, animal control, environ-mental health services (general sanitation, food inspections and per-mitting, mosquito control, septic facility inspection and permitting, water lab, and fl ood plain administration), epidemiology (added after strategic planning), HIV/AIDS resource program (HARP), public health emergency preparedness, public health nursing, and Women, Infant, Children Supplemental Nutrition Program (WIC).

Each DNP student took one to two divisions within VCPHD and con-ducted a Strengths, Weaknesses, Opportunities, and Threats (SWOT) analysis which served as a starting point for discussion of the current, overall condition of the organization.7,8 The SWOT analyses of the VCPHD divisions were performed using information provided by the Director, division managers, and the organization's website. The resulting SWOT analyses were used as the main method to orga-nize information about internal and external factors facing the or-ganization. The tool consisted of a matrix where the organization's strengths, weaknesses, opportunities, and threats were listed. Each important factor was assigned to one of these four categories and assisted the group in performing an evaluation of the impact of the level of risk each factor had on the organization as it currently stands. (Figure 2).

The strengths identifi ed were: staff , support from county offi cials,

Figure 1. Strategic Planning Process Schematic Note. The LHD and the AP are the same person.

Engage AcademicPartner

Capacity Building

Associate Professor(AP) School of

Nursing

Local HealthDepartment Director

(LHD)

5 Doctor of NursingPractice Students

Deployed

Pre-facilitationPlanning

SWOT AnalysisCompleted with 7

Divisions

Provided TechnicalAssistance to

Students

Support forStrategic Planning

Produced StrategicPlan Documents

FacilitatedStrategic Planning

Session

Strategic PlanImplementation


new leadership, and team work. The weaknesses included: image, record keeping, and resistance to change. The opportunities distin-guished were: proactive public relations, outreach and education, in-crease seasonal help, and program expansion. The threats described were: county funding, certain community members, and wages.

Once the SWOT analysis was completed and compiled to contextu-alize a global perspective, the next step was developing a strategic plan.7 Three DNP students traveled to Victoria from north and west Texas to facilitate the all-day strategic planning meeting with the leadership team. The students used NACCHO's Developing a Lo-cal Health Department Strategic Plan: A How-To Guide8 in the pre-

Figure 2. Strengths, Weaknesses, Opportunities and Threats (SWOT) Analysis Grid.

Strengths Weaknesses

Opportunities Threats

INTERNAL

EXTERNAL

POSITIV

E

NEG

ATIV

E

facilitation planning and facilitation phase of the strategic planning session. Institutional review board (IRB) review was not required for this project.

RESULTS For the public health department, a new direction emerged focused on community engagement. The key outcome of the facilitated work was the development of a framework for action, which included an organizational mission and vision, and a set of core values. Three fo-cused strategic goals were created to guide the immediate and long-term work of the public health department (see Figure 3).

The primary concern of the health department was achieving re-gional relevance in an ever-changing milieu. The goals developed targeted three vital areas hindering the organization’s ability to reach relevance: the lack of the public health department’s visibility in the community and to key stakeholders, a decline in frontline employee engagement, and dated internal and external policies.

Increasing visibility took the form of providing quarterly reports to key stakeholders (city council, county commissioners, and the board of health), developing a new organization website, and identifying and engaging with community members/organizations on opportuni-ties for public health outreach, engagement, and education. These actions led to numerous partnerships that positioned the health de-partment as a trusted source of health information. In addition, the health department was re-branded to better describe the provision of services and changed its name from the Victoria City/County Health Department to the Victoria County Public Health Department (VCPHD). The VCPHD was on its way to becoming a leading infl u-ence on the health of the community.

An additional step in improving visibility and employee engagement came from individual participation in an organization-wide meet-ing held on June 25, 2015, at the VCPHD facility. Those attending

Figure 3: Victoria County Public Health Department Strategic Plan

Note. The acronym ACE IT! was created by reordering the core values.

Mission: To promote, protect, and respond to the residents of Victoria County and the

communities we serve by providing public health services essential for healthy communities.

Vision: The Victoria County Public Health Department will be a recognized leader in

advancing the health and safety of the community.

Core Values: ACE IT!

Accountability: We shall strive to continually learn and improve in order to achieve the highest

ideals of public service and take responsibility for performance in all decisions and actions.

Customer Service: We shall value and respect diversity and recognize the benefit it brings in

service to the community and approach all people with respect, understanding, compassion, and

dignity. We shall continually provide the highest quality customer service by engaging and

listening intently to customer concerns and expectations.

Education: We shall continually seek to educate and learn; to build on our successes and failures;

and to cultivate openness and curiosity to learn from anyone, anywhere, anytime.

Integrity: We shall adhere to the highest ethical and moral standards in performing our duties and

conduct ourselves with a high level of professionalism while treating the community and

colleagues with fairness and respect.

Teamwork: We shall leverage the abilities of all team members to the greatest possible extent to

meet common goals and take the initiative in developing and executing solutions to community

health issues. We shall treat all team members, customers, partners, suppliers and any other

individuals with respect and sensitivity, recognizing the imperative of diversity.

Strategic Plan Goals: 1. Increase Visibility to Community and Stakeholders

2. Employee Engagement in Mission, Vision, and Values

3. Actively Engage in Internal and External Policy


this event included key stakeholders and community leaders within Victoria County and surrounding areas. The VCPHD department leaders each took part unveiling the new mission, vision, and values of the organization. An emphasis was placed on the re-branding of the organization, indicating a strong presence as a community leader in public health. The meeting was well received by the commu-nity members and was an authentic celebration of the VCPHD team members’ renewed dedication to health prevention and promotion. For the fi rst time, the employees engaged in something new within the public health department and realized a new emphasis on public health and their own personal and professional growth. The VCPHD leadership now took a proactive role by investing in and developing individual employees within each department.

A systems perspective was employed to address outdated policies and procedures. Department leaders collaborated on internal poli-cies and procedures, while simultaneously aligning these policy and procedures with the external city ordinances and county orders. The process included evaluations of and updates to all legal documents, including revisions to the comprehensive Health Insurance Portabil-ity and Accountability Act (HIPPA) policy and request for informa-tion policy. To promote ownership and stewardship asset manage-ment, policies were revised, such as the workplace attendance policy and purchasing policy.

The fi ve DNP students also gained unexpected insights and per-sonal successes from participating in this strategic planning process. These doctoral students shared learning by collaborating on the SWOT analysis process and forecasting changes needed for each di-vision within VCPHD. They gained a better appreciation of leading an organizational team while facilitating innovation and change. The DNP students were immersed into the diverse work of public health through engagement with public health professionals in anticipating the needs of the community served. Through their involvement with the project, the DNP students successfully met several of The Essen-tials of Doctoral Education for Advanced Nursing Practice,9 which constitutes the foundation of their studies. These included: Organi-zational and Systems Leadership for Quality Improvement and Sys-tems Thinking, Health Care Policy for Advocacy in Health Care, In-ter-professional Collaboration for Improving Patient and Population Health Outcomes, and Clinical Prevention and Population Health for Improving the Nation’s Health.9

DISCUSSION The development of a strategic plan moved the VCPHD one step closer in the Public Health Accreditation Board (PHAB) pre-accredi-tation process. However, this process was not without its challenges. A new director with a transformational leadership style required the creation of strong relationships built on trust, both within the depart-ment and the community. Developing a culture of trust is essen-tial for creating collaborative relationships within an organization.10

High levels of organizational trust increase productivity, improve employee morale, and decrease employee turnover. According to Bennis,11 “Trust is the lubrication that makes it possible for organiza-tions to work” (p.139). Through the development of our strategic plan, new relationships based on trust were formed which laid the foundation for a smooth transition.

Harnessing a workforce necessary to overhaul the health department was challenging. Creating a strategic plan began with a complete SWOT analysis of the organization and required more resources than the VCPHD could aff ord. The alternative was leveraging an academic partnership with Texas Tech University Health Sciences Center (TTUHSC) School of Nursing and began with the recruitment of DNP students with strong analytical skills to assist in the process. DNP students were off ered clinical time in exchange for their service

and a chance to participate in a program of considerable magnitude. VCPHD will gain by sustaining the partnership with TTUHSC to add further support to the development of future endeavors.

One of the most promising outcomes of restructuring the VCPHD was creating value within the community and for key stakeholders. The VCPHD increased visibility through the launch of a new website which off ered citizens easy navigation of services and improved ac-cess to care. Providing quarterly education to key stakeholders in the community promoted other partnerships for regional visibility and will ultimately increase trust and utilization of the VCPHD. This strategy will have a signifi cant long-term impact on the population health of Victoria County.

CONCLUSION For the fi rst time in the history of VCPHD, a strategic plan was de-veloped that increased accountability, improved customer service, provided robust community education, solidifi ed interdepartmental integrity, and promoted teamwork. Through new leadership and in-novative solutions, the VCPHD was transformed to address public health issues and meet its community’s needs. Deploying the stra-tegic plan that we developed will also serve as a roadmap for other health departments in their own strategic planning. Utilizing the DNP students as facilitators for development of our strategic plan was integral to their professional development. It provided a win-win solution which resulted in the VCPHD gaining a solid framework for future action and long-term direction for public health success. The DNP students gained immeasurable experience that enhanced their leadership skills for the future.

Acknowledgements: Devjani Roy, PhD, MBAl Paula J. Webb, DNP, RN, NEA-BC; and Patricia S. Yoder-Wise, RN, EdD, NEA-BC, ANEF, FAAN for manuscript review and feedback.

REFERENCES1. Public Health Accreditation Board [PHAB]. Public Health Accreditation Standards and Measures: Version 1.5. http://www.phaboard.org/wp-content/uploads/PHABSM_WEB_LR1.pdf. Accessed September 26, 2016.2. Bryson JM. Strategic planning for public and non-profi t organizations: A guide to strengthening and sustaining organizational achievement (4th ed). Jossey-Bass. San Francisco; 2011.3. The Instittue of Cultural Aff airs. Technology of Participation facilitation methods: Eff ective methods for participation. The Institute of Cultural Af-fairs. Chicago; 2000.4. The Instittue of Cultural Aff airs. Technology of Participation strategic planning: Focusing collective power for change. The Institute of Cultural Af-fairs. Chicago; 2005.5. Anderson J. Public health: The county's invisible safety net. County Prog-ress. 2016, March:14-17, 50.6. U.S. Census Bureau. Quick facts Victoria County: Populaiton estimate 2015. http://www.census.gov/quickfacts/table/PST045215/48469. Accessed December 15, 2016. 7. Harrison JP. Essentials of strategic planning in healthcare (1st ed). Health Administrator Press, Chicago; 2010.8. National Association of City County Health Offi cials [NACCHO]. De-veloping a local health department strategic plan: A how-to guide. http://r.search.yahoo.com/_ylt=A0LEVu_98OVWzmUAI24nnIlQ;_ylu=X3oDMTEyYms2cWRvBGNvbG8DYmYxBHBvcwMyBHZ0aWQDQjE3MTlfMQRzZWMDc3I-/RV=2/RE=1457938814/RO=10/RU=http%3a%2f%2farchived.naccho.org%2ftopics%2fi nfrastructure%2faccreditation%2fupload%2fStrategicPlanningGuideFinal.pdf/RK=0/RS=SpiLAcGxwDF8otB_DYUdE-cYntk4-2016. Accessed September 26, 2016.9. American Association of Colleges of Nurses [AACN]. The essentials of doctoral education for advanced nursing practice. http://www.aacn.nche.edu/publications/position/DNPEssentials.pdf. Accessed October, 15, 2016. 10. Hitch C. How to build trust in an organization [White Paper]. http://www.execdev.unc.edu. Accessed January 5, 2017. 11. Breaux K. Transforming! How managers become leaders. Leadership sto-ries from the military, business, and education. Traff ord Publishing. Indiana; 2013.


Sifting for Clues: Using Patient Healthcare Records to Identify Missed Opportunities for Tuberculosis Prevention Patrick Crowley, BS, BA1; Thaddeus Miller, DrPH, MPH2

1Texas College of Osteopathic Medicine, University of North Texas Health Science Center, Fort Worth Texas2Health Behavior and Health Systems, University of North Texas Health Science Center, Fort Worth [email protected]: Structured medical records reviews have potential to give broad insight into individual risks. How these might identify missed op-portunities in screening for tuberculosis (TB), readily observable TB risk indicators, or modifi able factors associated with the future develop-ment of active TB is incompletely understood. We explored the potential utility and limitations of structured medical records reviews in a local public health department setting. Methods: During fi ve weeks beginning June 2015, we requested all available current and historical medical records for consenting TB pa-tients in treatment in an urban public health department. We reviewed records to identify TB “prevention opportunities” - risk factors record-ed at any healthcare or clinical encounter that took place at least two months prior to the onset of classic TB symptoms.Results: Sixteen of 33 eligible patients provided medical records re-leases, and one or more healthcare providers returned records for 14 of these 16. TB risk factors were evident in 14/14 record sets, and preven-tion opportunities were identifi ed for 6/14 (n=12, range one to four).Discussion: Since TB is inherently preventable, every incident case rep-resents an individual who has ‘fallen through the cracks’ in otherwise successful TB prevention programs. We found that simple, accessible, and well-established methods may have potential to identify gaps in TB control strategies.

INTRODUCTIONProgress toward domestic tuberculosis (TB) elimination goals has be-gun to fl atten.1,2 While the incidence of TB (in the United States) is relatively low (in Texas, there are 4.9 cases per 100,000 residents), re-maining pockets of disease risk are a persistent threat to individual and public health in the US.3 From morbidity and mortality among acutely ill patients to the less visible but very real dangers posed by contagion and increasing antibiotic resistance, the direct and potential impacts of even relatively well-controlled TB are substantial.4-6

TB is inherently preventable, and every incident TB case arguably represents a missed prevention opportunity.7,8 TB risk is a function of many biological, clinical, environmental, social, behavioral, and system factors.7,8 Many of these, such as incarceration, nation of origin, and HIV status, are known and accounted for in public health strategies, but important gaps remain.8 How to fi nd such gaps is less clear. Due to the relatively low incidence of active TB, comprehensive prospective study of the complex systems driving TB risk is prohibitive. The same complexity poses challenges to retrospective study as well. While much clinical, social, demographic, and other data are routinely collected by outside providers, it is uncommon for this to be routinely available in its entirety to public health authorities.

Medical records for TB patients may hold important clues to TB risk and have potential as an accessible means to study local risk determinants. Medical records are ubiquitous, detailed, and may be available from the period well before a patient develops active TB. TB patients may visit multiple providers prior to and concurrent with treatment for TB for complaints unrelated to TB such as back pain, diabetes management, or medication refi lls. Each such contact represents a potential opportunity for clinicians to recognize and address identifi able TB risk factors, and it is of interest to health authorities to understand the opportunities and gaps associated with such interactions. Release and management of pro-tected medical records at the patient’s request is a routine activity in the clinical setting. Unfortunately, record sharing between providers can be inconsistent and the patient’s record on fi le at any particular institution cannot be assumed to be comprehensive.

The Tarrant County Public Health’s Tuberculosis Clinic (TCPH-TBC) manages all outpatient treatment for patients with known active TB in Tarrant County, Texas (pop. 2.2 million).9 Some patients are identifi ed directly by TCPH, but many are referred from other providers after sus-picion of TB. Within TCPH-TBC and similar settings, health records tend to be tightly focused on TB-related information and are often stan-dardized to facilitate reporting and surveillance. Consequently, health department medical records may provide little insight into how TB risk might have been identifi ed and acted upon prior to a patient developing active TB.

Patient records outside of the health department, including records from the referral source, can be accessed using routine practices and relative-ly modest investments of time and eff ort. We conducted a pilot project to explore the feasibility of obtaining and reviewing medical records from other healthcare providers for current TB patients as a means to identify prevention opportunities during the period prior to recorded onset of TB symptoms and eventual diagnosis.

METHODSDuring June-July 2015, we obtained and conducted a retrospective re-view of available clinical records among a convenience sample of con-senting patients under treatment for active TB by TCPH-TBC. Inclusion criteria included the ability to give informed consent or have it given by a guardian if a minor (with translator, if necessary), a confi rmed TB diagnosis, and a clinic visit scheduled during the study period.

During each eligible patient’s appointment, clinic staff introduced the investigator, briefl y explained the project, and invited the patient to con-sider taking part. A $15 stored value card was off ered for participation. Consenting participants completed a standard Texas medical records re-lease request form to request medical records from TCPH-TBC and all other health care providers they could recollect visiting since 2012 to be provided to the investigator for review. No other participant interview took place. The investigator collected, de-identifi ed, and securely stored records as they were received. Records were reviewed to identify “pre-vention opportunities,” defi ned as healthcare encounters that might rea-sonably have spurred clinical investigation of existing TB risk but did not, and that took place two or more months prior to the onset of classic TB symptoms or clinical activity that resulted in a diagnosis of TB or referral to the TCPH-TBC. Additional review identifi ed major medical and environmental risks for TB infection as defi ned by the Centers for Disease Control and Prevention (CDC) and health insurance status and type. 11-13

Abstracted data were compiled in an Excel database and all original and de-identifi ed records were destroyed. University of North Texas Health Science Center (UNTHSC) local Institutional Review Board (IRB) reviewed the project and determined it was “not human subjects research;” the same IRB approved our requested Health Insurance Por-tability and Accountability Act (HIPAA) waiver.

RESULTSOf the 33 unduplicated patients presenting for TB treatment during 16 TCPH-TBC clinic days during the study period, 16 (48.5%) consented to take part in the study. Reasons for non-participation included “unin-terested,” “upset or fatigued,” and “not asked.”

At least one usable clinical record from TCPH-TBC was obtained for 14 (87.5%) participants; 14/14 (100%) of these had one or more secondary sources of care identifi ed. We requested records from secondary sources


for all 14 participants and received one or more additional record for 8/14 (57.1%) within two months of request (Table 1).

Table 1: Clinical record sources, requests, and receipts

Requested Received

TCPH-TBC* 16 14

County health district inpatient 6 2

County health district outpatient 1 1

Other local inpatient 5 3

Other local outpatient 4 2

*Tarrant County Public Health – Tuberculosis Clinic

One or more TB risk (foreign-born, healthcare worker, incarceration, etc.) was identifi ed in all 14 record sets, and identifi able but preven-tion opportunities (e.g., the risk indicator was documented by a second-ary source of care prior to the onset of disease) were identifi ed in 6/14 (42.9%). We identifi ed a total of 12 prevention opportunities among these six participants, an average return of 0.86 missed prevention op-portunities per record reviewed and an average two missed opportuni-ties (range one to four) for any participant with at least one identifi ed missed opportunity.

All 14 record sets reviewed identifi ed participant nativity (11/14 or 78.6% were foreign-born), and insurance status could be identifi ed for 12/14 (85.7%). A majority (8/12 or 66.7%) were insured, four with Medicare/Medicaid and four with commercial insurance.

DISCUSSIONWe approached this study with very limited goals driven by a ques-tion: is it practical for a local public health department to use existing methods and sources to obtain meaningful information that might bol-ster their TB services? Within that question were others: Would patients give access to their prior medical records? Would other providers be responsive to these requests? Can prior medical records identify a po-tential “missed opportunity” for TB risk reduction – defi ned as visits to a provider at least two months prior to classic TB symptoms? In our very brief and limited study, we found the answer to each of these questions a modest but encouraging “yes.”

Our methods identifi ed missed opportunities to address TB risk prior to onset of TB symptoms for almost 20% (6/33) of TB patients during the study period. Such an approach is intuitive and accessible, and man-agement of medical records is a routine activity. We found an average of 0.86 TB prevention opportunities for each set of records obtained for patients in current TB treatment, suggesting a reasonable return for modest investments of time and eff ort. Other factors of interest were easily ascertained as well, including insurance status, nativity, and de-mographic information.

Hindsight is clear, but some of the patient TB risks recorded by clini-cians prior to the development of active TB seem to have off ered good opportunities for intervention. For example, we reviewed records for a healthcare worker with a positive Tuberculin Skin Test (TST) noted in 2009. Despite her subsequent continuous engagement in healthcare, in-cluding pregnancy and childbirth, we found no record of further TB risk evaluation or other follow-up until she ultimately developed active dis-ease more than fi ve years later. Another patient had received routine care to address diabetes mellitus and hypertension for at least three years be-fore Latent Tuberculosis Infection (LTBI) testing was recorded, despite being a current tobacco smoker and an immigrant from a TB-endemic region of Asia with self-reported TB exposure and ongoing tobacco use. Our study has many limitations. Our methods were designed to allow a brief, cursory, and non-scientifi c feasibility evaluation, and our fi ndings are neither generalizable nor robust. It is likely that unfulfi lled records requests and the possibility that obtained records were not comprehen-sive, current, or correct introduces an ascertainment bias into the data collected. Despite these limitations, our fi ndings suggest that medical

records from other providers are a potentially important data source to identify TB prevention opportunities. We found that simple, accessible, and well-established methods have the potential to identify TB preven-tion opportunities and contribute to informed decision-making, includ-ing unconventional risk characteristics we did not expect.

While TB is inherently preventable, every incident case represents a TB patient who has ‘fallen through the cracks’ in our otherwise quite suc-cessful public TB prevention programs. TB risk is multifactorial, and medical records can be a rich source of demographic, health system, socioeconomic, and clinical factors that comprise its determinants. Ob-taining and reviewing medical records of active TB patients from the period prior to their becoming sick is an accessible strategy to identify gaps in prevention strategies. Innovative approaches to address public health challenges need not be resource intensive, and technically sim-ple approaches may benefi t health authorities and the populations they serve. Progress toward US elimination goals and protecting the public from the underappreciated dangers of TB requires health authorities to turn lost opportunities for prevention into new opportunities for preven-tion.

Acknowledgements: We are grateful for the cooperation and encour-agement of Jeremy Gallups, Kimela Ledbetter, Penny Gore, and other Tarrant County Public Health TB Division staff , and to George Samuel, MD for his patience, assistance, and guidance. Finally, we gratefully ac-knowledge the intellectual and other contributions of CDC’s Tuberculo-sis Ellimination Studies Consortium and the University of North Texas’s Summer Research Fellowhip program that made this work possible.

REFERENCES1. World Health Organization (WHO), Global Tuberculosis Report 2016. Re-port from World Health Organization, Geneva, Switzerland. http://www.who.int/tb/publications/global_report/gtbr2016_executive_summary.pdf?ua=1. Accessed December 21, 2016.2. Salinas JL, Mindra G, Haddad MB, Pratt R, Price SF, Langer AJ. Leveling of Tuberculosis Incidence — United States, 2013–2015. MMWR Morb Mortal Wkly Rep 2016;65:273–278. 3. Texas Department of State Health Services, 2016. “TB Statistics.” https://www.dshs.texas.gov/idcu/disease/tb/statistics/4. Alavi-Naini R, Moghtaderi A, Metanat M, Mohammadi M, Zabetian M. Factors associated with mortality in tuberculosis patients. J Res Med Sci 2013;18(1):52-55.5. Haley C. 2017. Treatment of latent tuberculosis infection. Microbiol Spec 2017;5(2).6. De Vries G, Tsolova S, Anderson LF, et al. Health system factors infl uencing management of multidrug-resistant tuberculosis in four European Union coun-tries - learning from country experiences. BMC Public Health 2017;17:334. 7. Centers for Disease Control and Prevention (CDC). Unite to End TB. World TB Day 2017. Centers for Disease Control and Prevention Division of TB Elimination, Atlanta GA. https://www.cdc.gov/tb/worldtbday/. Accessed De-cember 21, 2016.8. U.S. Department of Health and Human Services. Healthy People 2020 Draft. U.S. Government Printing Offi ce; 2009. 9. Tarrant County, Texas, Demographics. Tarrantcounty.com. http://access.tar-rantcounty.com/en/administration/staff /economic-development-coordinator/demographics.html Accessed on January 24, 2017.10. The Attorney General of Texas. Authorization to disclose protected health information. Austin, Texas 2013. https://www.texasattorneygeneral.gov/fi les/agency/hb300_auth_form.pdf Accessed December 21, 2016.11. Commission on Social Determinants of Health (CSDH). Closing the gap in a generation: health equity through action on the social determinants of health. Final report of the Commission on Social Determinants of Health. World Health Organization: Geneva; 2008.12. Center for Disease Control and Prevention (CDC), Basic TB Facts. Divi-sion of Tuberculosis Elimination; 2012. http://www.cdc.gov/tb/topic/basics/risk.htm. Accessed on December 21, 2016.13. Hillemeier, M., Lynch, J., Harper, S., Casper, M., Data Set Directory of Social Determinants of Health at the Local Level. Centers for Disease Con-trol and Prevention, U.S. Department of Health and Human Services: Atlanta; 2004.


The Eff ects of Chronic Medical Conditions and Obesity on Self-Reported Disability in Older Mexican AmericansSanggon Nam, PhD, MS1, Soham Al Snih, MD, PhD2-4, Kyriakos Markides, PhD4, 5

1Department of Public Health Sciences, College of Health Science, California Baptist University2Division of Rehabilitation Sciences, School of Health Professions, University of Texas Medical Branch3Division of Geriatrics, Department of Internal Medicine, University of Texas Medical Branch4Sealy Center on Aging, University of Texas Medical Branch5Department of Preventive Medicine and Community Health, University of Texas Medical [email protected] investigated the eff ect of chronic medical conditions including obesity on self-reported disability and mobility in Mexican Ameri-cans aged 75 or over using data from the Hispanic Established Population for the Epidemiological Study of the Elderly (Hispanic EPESE) Wave 5 (2004–2005). Disability was assessed with a modi-fi ed version of the Katz activities of daily living (ADL) scale and mobility was assessed with the Rosow Breslau scale of gross mobil-ity function. The percentage of participants needing assistance with ADLs were as follows: 26.7% for transferring from a bed to chair, 26.6% for walking across a small room, 17.9% for dressing, 16.3% for using a toilet, 14.3% for grooming, and 8.2% for eating. Fifty percent reported limitation in the ability to walk ½ a mile and walk-ing up and down stairs. Multivariate logistic regression analysis after controlling for all covariates showed that arthritis, diabetes, stroke, and obesity were signifi cantly associated with any ADL limitation, walking up and down stairs, and walking 1/2 mile. Prevention of obesity and chronic medical conditions will help increase functional independence in this population.Key words: Chronic Medical Conditions, Obesity, ADL disability, Gross Mobility Function Aging, Older Mexican Americans

INTRODUCTIONThe presence of chronic medical conditions has been associated in previous research with old age and with functional limitations and disability.1–16 Additionally, obesity has been associated with several prevalent chronic conditions in older people.17–20 Chronic medical conditions in older adults, including obesity, substantially increase the primary US public health burden because, for older adults, physi-cal mobility limitations associated with chronic medical conditions including obesity increase the risk of morbidity and mortality as well as dependence on others.21–23

Obesity has been associated in previous research with decreased lower body function and mobility.14–16 The association of chronic diseases including obesity with self-reported disability and func-tional disabilities among older Mexican Americans has not received as much attention in the literature14, 23, 24 as have similar conditions among the general population of older people.15, 25, 26

Older Mexican Americans are a rapidly growing segment of the U.S. population with high rates of disability.14, 27, 28 The gap in research fo-cused on this population is critical because obesity is associated with serious health consequences including the development of chronic medical conditions. The objective of this study was to investigate the eff ect of chronic medical conditions including obesity on self-report-ed disability and functional limitations in older Mexican Americans age 75 and over using data from the Hispanic Established Population for the Epidemiological Study of the Elderly (Hispanic EPESE). We expected that chronic medical conditions including obesity would be associated with decreased mobility and increased disability, in line with the fi ndings of previous research.16–20

POPULATION AND METHODSThis analysis replicated a previous analysis of the baseline data from the 1993–1994 His-panic EPESE, at which point participants were age 65 and over.28 The present analysis used data from the 2004–2005 (Wave 5) Hispanic EPESE, which studied the same population, including many original participants, at age 75 and over. However, special attention was given to the associa-tion of obesity with ADL disability in the present study which was not examined in the previ-ously conducted studies.

Study PopulationData from Hispanic EPESE Wave 5 were used in the analysis. The Hispanic EPESE, a longi-tudinal, population-based study of non-institutionalized Mexican Americans age 65 and over, has been con-ducted in fi ve southwestern states (Arizona, California, Colorado, New Mexico, and Texas) and began in 1993–1994. This sample, us-ing area probability extraction procedures, was general-ized to the approximately 500,000 older Mexican Americans living in these fi ve southwestern states.

Wave 5 data was collected during 2004 and 2005. Of the original 3,050 participants inter-viewed at baseline (1993–1994), 1167 indi-viduals aged 75 years and over were re-interviewed. A representative sample of 902 Mexican Americans from the same region also age 75 and over were added for a total of 2069 participants. Measures included chronic medical conditions, body mass index (BMI), ac-tivities of daily living (ADL), instrumental activities of daily living (IADLs), and socio-demographic information. In-home interviews were conducted in Spanish or English depend-ing on the participant’s preference. The study had received Human Subjects approval from the In-stitutional Review Board of the University of Texas Medical Branch.

MeasuresSeven common prevalent chronic medical conditions were assessed: arthritis, cancer, diabe-tes, stroke, heart attack, hip fracture, and obe-sity. The latter was measured by using Body Mass In-dex (BMI) cal-culated from actual height and weight. Other conditions were based on self-report of a doctor’s diagnosis.

Standard BMI is calculated by dividing weight in kilograms by height in meters squared (km/m2). However, a non-metric approxi-mation can be calculated by dividing weight in pounds by height in inches squared and multiplying the result by 703.29 For this re-search, BMI was calcu-lated based on that formula using weights and heights from the data sample.29 Then, BMI was categorized into “underweight (less than 18.5),” “normal weight (18.5 – 25.0),” “overweight (25.0 – 30.0),” and “obese (more than 30)” based on the National Institutes of Health obesity standard.29 There were 426 cases with missing BMI, a lacuna which cannot be ignored because of its consider-able size (20.6%). Thus, non-BMI cases were retained in the analysis by creating a BMI category for them.


Functional limitations were measured using a modifi ed version of the Katz activities of dai-ly living (ADL) scale30 and the Rosow–Breslau scale of gross mobility function.31 The seven ADLs were walking across a small room, bathing, grooming, dressing, eating, transfer-ring from a bed to chair, and using a toilet. Additionally, the two items used from the Rosow–Breslau scale of gross mobility function were walking up and down stairs and walking a 1/2 mile.

Statistical AnalysisThe Statistical Analysis System (SAS: SAS Institute Inc., Cary, NC) version 9.2 was used in this analysis. The confi dence interval level for statistical signifi cance is 95%. Seven ADLs, two items from the Rosow Breslau scales, and an “any ADL” measure were used as out-comes for mul-tivariate logistic regression analysis as a function of seven chronic medical conditions including obesity, along with age and gender.

RESULTSTable 1 shows the sociodemographic characteristics of the sample of the 2004–2005 (Wave 5) Hispanic EPESE. Among the 2069 par-ticipants, the mean age was 81.9 (SD=5.15), 38.5% were men, and 61.5% women. Of these participants, 1158 or 56% were born in Mexico with the remain-der born in the U. S. About 80% were inter-viewed in Spanish. Two-thirds of the men were married as compared to 27% of the women. Years of education (75% less than 7 years) and household in-come (73.7% less than $15,000 a year) for the sample were quite low. Finally, 34.4% of the wom-en and 18.2% of the men reported living alone.

Table 2 presents the prevalence of seven chronic medical condi-tions—arthritis, cancer, dia-betes, stroke, heart attack, hip fracture, and obesity (BMI)—for the 2004–2005 Hispanic EPESE. Arthritis

Table 2. Prevalence of chronic diseases and BMI of 2004–2005 (Wave 5) Hispanic

EPESE participants (N=2069)

N (%)

Arthritis 1225 (59.3)

Cancer 149 (7.2)

Diabetes 690 (33.3)

Stroke 282 (13.7)

Heart Attack 341 (16.6)

Hip Fracture 155 (7.5)

BMI

Under weight (<18.5) 27 (1.3)

Normal weight(18.5 – 25) 515 (24.9)

Overweight (25-30) 630 (30.9)

Obese (� 30) 461 (22.3)

Missing 426 (20.5)

was the most prevalent condition (59.3%), followed by diabetes (33.3%), heart attack (16.6%), stroke (13.7%), hip fracture (7.5%), and cancer (7.2%). Approximately 24.9% of the sample were of nor-mal weight (BMI of 18.5 to 25.0), while 30.9% were overweight (BMI of 25.0 to 30.0), and 22.3% were obese (BMI of >30.0). Ap-proximately 20.6 % of the respondents were missing BMI values.

Table 3 shows the percentage of 2004–2005 Hispanic EPESE study participants with specifi c functional limitations of ADL and of the two Rosow Breslau items, walking up and down stairs (49.9%) and walking 1/2 mile (49.6%). The percentage of participants needing assistance with ADLs were as follows: 26.7% for transferring from a bed to chair, 26.6% for walking across a small room, 17.9% for dressing, 16.3% for using a toilet, 14.3% for grooming, and 8.2% for eating.

Table 1. Sociodemographic characteristics of 2004–2005 (Wave 5) Hispanic EPESE

participants (N=2069)

Men (N=797) Women (N=1272) Total (N=2069) Age N (%) N (%) N (%)

< 80 312 (39.2) 509 (40.0) 821 (39.7)

� 80 485 (60.8) 763 (60.0) 1248 (60.3)

Age (mean±SD) Year 81.8 ± 4.8 82 ± 5.3 81.9 ± 5.15

Country of Birth

US born 436 (54.7) 722 (56.8) 1158 (56.0)

Foreign born 361 (45.3) 550 (43.2) 911 (44.0)

Language of Interview

English 147 (18.4) 261 (20.5) 408 (19.7)

Spanish 650 (81.6) 1011 (79.5) 1661 (80.3)

Marital Status

Married 532 (66.6) 347 (27.3) 879 (42.5)

Not Married 265 (33.4) 925 (72.7) 1190 (57.5)

Years of Education

< 7 Years 609 (67.0) 943 (74.1) 1552 (75.0)

� 7 Years 232 (33.0) 329 (25.9) 517 (25.0)

Years of Education (mean±SD) 4.8 ± 4.1 5.0 ± 4.0 4.9 ± 4.0

Household Income

< 15,000 470 (67.0) 848 (78.2) 1318 (73.7)

� 15,000 232 (33.0) 237 (21.8) 469 (26.3)

Living Alone

Yes 146 (18.3) 437 (34.4) 583 (28.2)

No 651 (81.7) 835 (65.6) 1486 (71.8)


Table 4 presents the results of the logistic regression analysis of functional limitation indicators by age, gender, and selected chronic medical conditions including obesity of the 2004–2005 Hispanic EPESE. Age was signifi cantly associated with all functional limita-tion indicators, with odds ratios ranging from 1.05 (eating) to 1.12 (walking 1/2 a mile). Women reported more problems than men ex-cept with eating, transferring, and using the toilet. Arthritis and dia-betes were signifi cantly associated with most indicators. As expected (26), stroke had the greatest infl uence on functional limitations and was signifi cantly associated with all indicators. Heart attack was scarcely signifi cant for all indicators except going up and down stairs (OR=1.53, 95% CI =1.15- 2.05) and walking half a mile (OR=1.41, 95% CI =1.05- 1.90). Hip fracture was signifi cantly associated with bathing (OR=1.59, 95% CI = 1.03- 2.45), dressing (OR=1.55, 95% CI= 1.00- 2.41), going up and down stairs (OR=2.76, 95% CI = 1.75- 4.35), and walking 1/2 a mile (OR=2.26, 95% CI=1.43- 3.58).

Obesity (BMI > 30) was signifi cantly associated with diffi culty in walking across a small room (OR=1.50, 95% CI= 1.05- 2.15), any ADL limitation (OR=1.72, 95% CI= 1.26- 2.35), climbing stairs (OR=1.50, 95% CI=1.16- 2.07), and walking 1/2 a mile (OR=2.01, 95% CI=1.50- 2.71) as compared with normal BMI (BMI of 18.5 – 25.0). Missing BMI was signifi cantly associated with all items, with odds ratios ranging from 6.10 (personal grooming) to 17.80 (walking 1/2 a mile).

DISCUSSIONArthritis, diabetes, stroke, heart attack, hip fracture, and obesity af-fected all self-reported functional limitations among Mexican Amer-icans age 75 or older residing in the Southwestern United States. In harmony with previous research,27 these selected chronic diseases showed statistically signifi cant relationships with several functional limitations, and each functional limitation was mutually exclusive including age and gender.

Generally, compared with the 1993–1994 Hispanic EPESE (age 65 and over) baseline analysis,28 the prevalence of chronic medical conditions and the percentage with specifi c functional limitations increased in the 2004–2005 sample (age 75 and over). However, se-lected chronic medical conditions were less likely to aff ect gross mo-bility function in the latter sample as compared to the former. In addi-tion, this research fi nds that obesity, added in this analysis, is clearly associated with functional limitations and disability, especially with respect to transferring and walking. Although the impact of selected chronic diseases on gross mobility function is relatively smaller, se-verely obese people clearly have problems walking and transferring as compared to individuals with a normal BMI.

Compared to the previous analysis of date from the 1993–1994 His-panic EPESE,28 stroke also had a more signifi cant infl uence on all indicators for the sample studied here. This fi nding is still consistent with previous research.1, 4, 10 Arthritis (from 40.8% to 59.3%) and dia-betes (from 22.2% to 33.3%) were more likely to explain much of the self-reported disability as compared with the 1993–1994 Hispanic EPESE analysis.28 Arthritis and diabetes were signifi cantly associat-ed with most disability indicators except personal grooming and eat-ing. Arthritis was signifi cant for “any ADL” limitation, going up and down stairs, and walking half a mile, while diabetes was signifi cant for most indicators except bathing, personal grooming, eating, and using the toilet. Heart attack was less associated with gross mobility function as compared with the previous analysis due to the increased prevalence of heart attack (from 9.2% to 16.6%). Heart attack was only signifi cant in going up and down stairs, and walking half a mile. Finally, obesity emerges as a possible explanation for self-rated dis-ability in this analysis. Compared with normal BMI, obesity (BMI) is signifi cantly associated with walking across a small room, any ADL

Table 3. Percentage of 2004–2005 (Wave 5) Hispanic EPESE participants with specific

functional limitations (N=2069)

Needing help or unable to do (%)

N (%)

Walking across a small room 552 (26.6)

Bathing 520 (25.1)

Personal grooming 294 (14.3)

Dressing 370 (17.9)

Eating 169 (8.2)

Transferring (bed to chair) 552 (26.7)

Using toilet 338 (16.3)

Walk up and down stairs 1021 (49.9)

Walk 1/2 mile 996 (49.6)

Table 4. Logistic regression analysis of functional limitation indicators by age, gender, selected chronic diseases, and obesity of 2004–

2005 (Wave 5) Hispanic EPESE participants (N=2069)

Walk across

a small room Bathing Personal

grooming Dressing Eating Transferring Using toilet Any ADL

limitation Stairs of 2nd

floor Walk 1/2

mile Age 1.085

(1.061- 1.111) 1.105

(1.079- 1.132) 1.095

(1.068- 1.123) 1.089

(1.062- 1.116) 1.054

(1.023- 1.087) 1.067

(1.043- 1.090) 1.072

(1.045- 1.100) 1.102

(1.078- 1.127) 1.118

(1.093- 1.144) 1.123

(1.097- 1.150)

Gender female

1.442

(1.116 -1.865)

1.839

(1.402- 2.412)

1.511

(1.111- 2.055)

1.425

(1.066- 1.904)

1.025

(0.710- 1.478)

1.264

(0.991- 1.613)

1.254

(0.924- 1.702)

1.563

(1.242- 1.968)

1.928

(1.550- 2.398)

1.939

(1.554- 2.420)

Arthritis 1.632

(1.263- 2.108)

1.618

(1.240- 2.112)

1.211

(0.895- 1.637)

1.629

(1.217- 2.180)

1.241

(0.855- 1.802)

1.833

(1.432- 2.346)

1.424

(1.048- 1.934)

2.033

(1.615- 2.559)

1.974

(1.591- 2.448)

2.368

(1.900- 2.951)

Cancer 0.870 (0.548- 1.381)

1.279 (0.807- 2.025)

0.937 (0.551- 1.594)

0.911 (0.548- 1.514)

0.983 (0.523- 1.848)

0.921 (0.592- 1.433)

0.857 (0.501- 1.467)

1.231 (0.815- 1.860)

1.368 (0.912- 2.052)

1.378 (0.909- 2.091)

Diabetes 1.602

(1.246- 2.061)

1.641

(1.262- 2.133)

1.331

(0.986- 1.797)

1.473

(1.109- 1.956)

0.958

(0.658- 1.396)

1.462

(1.148- 1.861)

1.495

(1.107- 2.019)

1.455

(1.157- 1.830)

1.801

(1.440- 2.252)

1.818

(1.447- 2.283)

Stroke 2.214

(1.598- 3.068)

1.760

(1.254- 2.468)

2.341

(1.646- 3.330)

2.350

(1.667- 3.311)

2.953

(1.973- 4.421)

1.492

(1.081- 2.060)

2.264

(1.579- 3.248)

1.662

(1.208- 2.287)

1.794

(1.285- 2.503)

2.118

(1.502- 2.985)

Heart Attack 1.145 (0.837- 1.566)

1.341 (0.974- 1.846)

1.012 (0.703- 1.458)

0.982 (0.693- 1.392)

0.760 (0.479- 1.208)

0.972 (0.714- 1.322)

0.998 (0.690- 1.444)

1.102 (0.823- 1.476)

1.534 (1.146- 2.054)

1.409 (1.048- 1.896)

Hip fracture 1.498

(0.979- 2.294)

1.585

(1.027- 2.447)

1.196

(0.755- 1.894)

1.553

(1.003- 2.405)

1.039

(0.591- 1.825)

0.795

(0.518- 1.222)

1.187

(0.740- 1.905)

1.442

(0.953- 2.183)

2.762

(1.753- 4.353)

2.260

(1.428- 3.576)

BMI

<18.5 0.409

(0.086- 1.955)

1.610

(0.541- 4.792)

1.445

(0.386- 5.413)

2.414

(0.814- 7.158)

0.827

(0.105- 6.529)

0.721

(0.202- 2.572)

0.928

(0.198- 4.346)

1.040

(0.382- 2.832)

2.024

(0.836- 4.901)

2.068

(0.850- 5.034)

25-30 0.955 (0.671- 1.360)

1.123 (0.778- 1.621)

1.110 (0.705- 1.747)

0.990 (0.643- 1.525)

0.746 (0.397- 1.404)

1.056 (0.754- 1.478)

0.751 (0.461- 1.221)

1.244 (0.925- 1.673)

1.242 (0.950- 1.622)

1.442 (1.098- 1.893)

� 30 1.503

(1.051- 2.151)

1.280

(0.868- 1.886)

0.979

(0.592- 1.617)

1.145

(0.728- 1.800)

0.949

(0.497- 1.814)

1.364

(0.960- 1.937)

1.026

(0.627- 1.678)

1.720

(1.258- 2.351)

1.549

(1.159- 2.071)

2.013

(1.497- 2.706)

BMI not

reported

11.429

(8.137- 16.052)

13.094

(9.190- 18.657)

6.100

(4.100- 9.077)

8.587

(5.895- 12.510)

6.011

(3.663- 9.866)

9.254

(6.662- 12.856)

10.984

(7.411- 16.280)

12.733

(9.059- 17.896)

13.522

(9.146- 19.994)

17.797

(11.754- 26.947)

All numbers indicate odds ratios (95% �� Interval)


limitation, climbing stairs, and walking 1/2 a mile.

This study is subject to some limitations. First, due to intrinsic limita-tions of the cross-sectional design, causation cannot be established. Therefore, this analysis concerns the association between selected chronic medical conditions, including obesity, and certain functional limitations. However, this analysis consistently points toward a sig-nifi cant infl uence of selected chronic diseases on functional limita-tions, supporting existing research. A longitudinal analysis could more precisely predict a causal relationship between selected chronic diseases and functional limitations. Second, missing information on BMI was high. Missing BMI was signifi cantly associated with all functional limitations when compared to normal BMI. However, the missing BMI cases do not eff ectively explain the association be-tween obesity and ADL disability.

In summary, using the 2004–2005 Hispanic EPESE data, and con-sistently with the baseline 1993–1994 Hispanic EPESE analysis, we found an association between major chronic medical conditions and functional limitations among Mexican Americans participants age 75 and over. However, compared with the baseline Hispanic EPESE analysis, selected chronic medical conditions are less likely to aff ect gross mobility function, although the prevalence of selected chronic medical conditions and the percentage with specifi c functional limi-tations increased between the two samples. Additionally, this study showed obesity to be signifi cantly associated with decreased mobil-ity, suggesting a need for future research pertaining to this topic.

Funding: This work was supported by the National Institute on Aging (R01 AG10939) and in part by the UTMB Claude D. Pep-per Older Americans Independence Center NIH/NIA Grant # P30 AG024832 from the National Institute of Health and National Insti-tute on Aging, US

Acknowledgments: I am grateful to Kerstin Gerst Emerson, Holly Beard, and Majd AlGhatrif for their detailed and constructive com-ments. Please direct correspondence to Associate Professor Sang-gon Nam, Department of Public Health Sciences, California Baptist University, USA.

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Developing Partnerships to Reduce Sodium in Worksite Cafeterias and Congregate Meal ProgramsSarah L. Ullevig, PhD, RD, LD1, Ellen Spitsen2, Anne C. Heine, RD, LD,ScM,DrPH2, Alysse Swientek2, Kathleen Shields, CHES2 and Erica T. Sosa, PhD, MCHES1

1Department of Kinesiology, Health, and Nutrition, University of Texas at San Antonio, San Antonio, TX2Chronic Disease Prevention Section, San Antonio Metropolitan Health District, San Antonio, [email protected] sodium consumption is a worldwide public health concern and warrants immediate action to reduce sodium in the food envi-ronment. Public health departments are encouraged to partner with external entities to reduce sodium; however, multiple barriers to en-gaging and partnering with external entities exist. The purpose of this paper is to present strategies used to recruit and engage partners in implementing a sodium reduction initiative (SRI); identify barriers to implementation; and share lessons learned and recommendations for other local public health departments to successfully engage partners in implementing similar initiatives. The local health department used a multi-level approach to engage stakeholders and collaboratively assess opportunities for sodium reduction. As a result, the health de-partment engaged 6 worksites and 3 congregate venues. The SRI in-cluded partners who collectively served over 13,500 working adults, 3,500 children and 3,000 older adults. The partnerships reduced sodium across 269 total food items, total. Local health departments can eff ectively partner with community entities to implement sodium reduction initiatives by using multi-level approaches to collaboration over traditional prescriptive approaches. Lessons learned can assist other municipalities in implementing similar sodium reduction ini-tiatives in the food environment of their communities.

BACKGROUNDThe World Health Organization identifi es excessive sodium intake as a worldwide health issue, increasing the risk for hypertension, stroke, and other vascular-related illnesses.1 Americans typically consume 3000-5000 milligram (mg) of sodium per day,2 exceeding the rec-ommended 1500-2400 mg per day. Reducing dietary sodium intake potentially decreases associated disease risks.3-7 Sodium reduction is a public health priority supported by government institutions and ini-tiatives, including the National Heart, Lung, and Blood Institute, Di-etary Guidelines for Americans (DGAs) 2015, Healthy People 2020, and the Centers for Disease Control and Prevention (CDC).

The Institute of Medicine (IOM) reports that reducing individuals’ sodium intakes requires a public health initiative to positively im-pact the food environment through large scale changes in govern-ments and businesses.8 Environmental approaches are advantageous because consumers have little control over the sodium in processed and restaurant foods,9 the major sources of excess sodium in the diet.2

Environmental approaches can be used to gradually reduce sodium over time to increase consumer acceptance.10

The federal government does not mandate specifi c industry sodium standards as it does with public institutions like schools,10 but col-laborative partnerships can voluntarily pursue healthier sodium standards. The IOM supports the removal of sodium’s ‘generally recognized as safe’ designation and implementation of mandated so-dium regulations.11 National initiatives have engaged industry and government eff orts to increase the availability of pre-packaged low-sodium foods available to consumers.10 Similar local eff orts can re-duce sodium in places where people commonly eat, such as worksite cafeterias and congregate sites.

Despite the urgency for developing collaborative partnerships for so-dium reduction, signifi cant barriers exist and can impede progress.

As public health practitioners aim to partner with worksites and food service providers, some traditional barriers include limited resources to enable partners to source and purchase new products; limited time to coordinate and implement changes; lack of collaborative experi-ence between private and public sectors; and concerns of low-sodi-um product acceptability and sales.12 Additionally, partners experi-ence barriers to participation, such as inadequate resources or lack of access to appropriate resources; potential increased costs or loss of revenue; time limitations; competing interests; and lack of policy guidance.13 Though these barriers are widely recognized, research on how public health departments circumvent these barriers to suc-cessfully recruit and engage external partners in implementing public health approaches to reduce sodium intake is lacking.

The purpose of this paper is to present processes used to recruit and engage partners in developing and implementing a sodium reduc-tion initiative in worksites and congregate meal sites. The paper will highlight lessons learned, barriers to implementation, and provide recommendations for other local public health departments to suc-cessfully carry out similar initiatives.

Population and MethodsThe Centers for Disease Control and Prevention (CDC) created the Sodium Reduction in Communities Program (SRCP) to fund U.S. communities’ eff orts to create and implement local sodium reduction initiatives. One of these funded projects, The Sodium Reduction Ini-tiative (SRI), was led by the Chronic Disease Prevention Section in the local health department (San Antonio Metropolitan Health Dis-trict). The initiative aimed to reduce the amount of sodium served to Bexar county residents at worksites and at congregate sites that served meals to children, adults, and older adults.

Engaging Partners in Developing the SRITo impact a diverse range of people, the local health department iden-tifi ed food providers serving working adults, preschool and school-aged children, and older adults over 60 years of age. Worksites with onsite cafeterias that employed 800-1000 working-aged adults were identifi ed as potential partners. In addition, the local health depart-ment benefi tted from previous relationships with worksites through the ¡Por Vida! program,14 which developed meals moderate in calo-ries, sodium and fat. These previous partners were targeted for the SRI and if they did not meet the inclusion criteria, they were able to recommend other potential partners. Local health department staff met with worksite facility managers, chefs, food service directors, and human resources personnel at each potential worksite to discuss the SRI. The local health department presented potential worksites with information on excessive sodium’s relation to disease; the growing number of restaurants off ering lower sodium foods; com-munity obesity and diabetes rates; and how their worksite could im-pact employees by partnering with SRI. Common interests and goals were also presented to partners. Additionally, if an existing employee wellness program was present, the goals of the SRI were aligned with the wellness program’s goals.

Congregate sites, defi ned as sites that serve locally or federally fund-ed meals to eligible individuals, were identifi ed as potential partners for their ability to impact foods served to preschool children through


the PreK for SA program, school-aged children through the Sum-mer Feeding program, and older adults through the Senior Nutrition Program. One food provider had an existing contract with the city to oversee the food production and menu development for all afore-mentioned congregate sites. The local health department leveraged the existing relationship between the food provider and the operating city department to include participation in the SRI. The local health department highlighted mutually benefi cial goals to achieve higher nutrition standards and to benefi t the community.

Engaging Partners in Identifying Food Items for Sodium Reduc-tion and Healthy Item AnalysisOnce partners agreed to participate, the local health department’s health program specialist (HPS) and registered dietitian nutritionist (RDN) worked with companies’ key stakeholders and food distribu-tors to assess current sodium-related practices and recipe nutrient information. The Sodium Practices Assessment Tool (SPAT), a vali-dated tool to assess current sodium-related practices, was used to as-sess the food inventory and preparation practices in the kitchen prior to initiative implementation. Partners were active in completing the SPAT and providing details regarding policies, food inventory, and food preparation practices.

The nutrition information from the menu was analyzed by the RDN and nutrient analysis data were used to determine which foods con-tributed the most sodium throughout the menu cycle and therefore might be potential food items targeted for sodium reduction. The partners provided detailed recipes and worked with the local health department to identify potential changes that could be made to re-duce sodium throughout the menu. Sodium targets were determined by the DGA 2015 and other state and federally-mandated sodium requirements.2, 15, 16 For example, DGA 2015 sodium recommenda-tions are that less than 2300 mg should be consumed on a daily basis. DGA guided sodium targets for entrees (less than or equal to 325 mg), side items (less than or equal to 215 mg), and meals (less than or equal to 750 mg)2 for working adult populations. Senior congregate meal sodium targets were based on the DGAs and Dietary Reference Intakes (DRI)15 and included targets for entrees (less than or equal to 325 mg), side items (less than or equal to 215 mg) and meals (less than or equal to 1000 mg). The Summer Feeding congregate meals targets were based on the National School Lunch Program (NSLP) requirements for meals for grades K-5 for school year 2017-201816

and the meal target was set at less than or equal to 935 mg. There currently are no established NSLP recommendations for individual entrees and sides. The HPS and RDN worked with key stakehold-ers to develop an action plan for sodium reduction. Stakeholders included food service directors, kitchen managers, chefs, and other administrators. The worksites worked with their food distributors to identify cost-eff ective, lower-sodium alternatives and create alterna-tive recipes that had to pass quality control checks for taste and cost.

OUTCOMESPartnerships Established with Local Companies Nine local companies with worksite cafeterias agreed to participate in the SRI and six continued their established relationships through-out the entire project timeline. The fi ve worksites that remained were: a construction company (1 worksite), 2 hospital systems (5 worksite locations), a utility company (1 worksite), a medical device company (1 worksite) and a bank (1 worksite) fi gure 1. These six worksites together served over 13,500 working adults.

The local health department evolved the established relationship with the primary food provider for all three congregate areas (PreK for SA, Summer Feeding, and Senior Nutrition Program) to include the SRI, fi gure 1. These three congregates sites served about 8,000 people: 1,500 pre-school children, 3,500 school-aged children, and

3,000 older adults. The primary food provider remained engaged and an active partner throughout the project.

Engagement in Identifying Opportunities for Sodium Reduction and Health Item AnalysisThrough the SRI, the local health department and partners identifi ed 269 food items that could potentially be targeted for sodium reduc-tion across eight sites. The SRI implemented multiple sodium reduc-tion strategies, such as using lower sodium ingredients in recipes; removing high sodium ingredients; decreasing serving size; and re-ducing how frequently a higher sodium item is served. For example, some sites used lower sodium bases and sauces, reduced high sodium seasonings in their recipes, substituted a prepared product with a rec-ipe from scratch, and reduced the serving size of high sodium sauces. The local health department shared common strategies across sites to expedite the process to identify sodium reduction options, which are described in Table 1. Additional barriers encountered by the local health department and lessons learned are detailed as well.

DISCUSSIONThis paper aimed to present the process used to recruit and engage worksites and congregate sites in implementation of a community-wide sodium reduction initiative and to share lessons learned. The SRI worked with six companies and a food service provider to col-laboratively reduce the average sodium served at worksite cafete-rias and congregate sites, potentially impacting over 20,000 citizens in San Antonio. The SRI engaged community partners to develop site-specifi c sodium reduction plans that aligns with strategic sodium reduction goals and recommendations of the IOM and the NSRI.17

The SCRP funding allowed the SRI to overcome barriers including the labor needed for an extensive inventory and nutrient analysis. The inventory and nutrient analysis were spearheaded by the local health department staff , whose time was covered through the SCRP funding. This reduced the burden on the worksites and congregate sites. Additionally, the local health department was able to source alternative products through each companies’ food provider and develop a list of common lower sodium options to expedite future decisions.

Strengths of the SRI include a collaborative framework to create sim-ilar initiatives; an innovative approach to reducing sodium in foods and meals; and evidence of potential impact for similar initiatives. This paper describes a collaborative framework that other communi-ties can use to create similar initiatives in worksites or congregate sites and overcome commonly encountered barriers. The procedures

Figure 1: Sodium Reduction Initiative recruitment of worksites and congregate sites.

Year 1 1 Congregate site

3 Worksites

1 Worksite withdrew

due to management

changes 2 Congregate sites

4 Worksites recruited

Year 2 3 Congregate sites

6 Worksites

Year 3 3 Congregate sites

6 Worksites

2 Worksite recruited

2 Worksites

withdrew due to

management changes

and contract

constraints


can be adopted and easily tailored to a community’s needs. Finally, with 269 food items targeted for sodium reduction, this initiative presents evidence of potential impacts these collaborative eff orts might have on overall sodium served.

Limitations of this initiative included lack of lower sodium prod-uct availability, limited ability to request alternative lower sodium products, and the iterative process required for the nutrient analy-sis. Worksites had limited access to lower sodium products due to low buying power and contract constraints that inhibited product ac-cess. Nutrition analysis needed to be reactionary, taking into account changing menu cycles and menu off erings. Therefore, the nutrition analysis was an iterative process, repeatedly assessing menu changes and sodium content. The time required to identify, request, and assess cost-benefi ts for recommended modifi cations limited the number of implemented modifi cations. Local governments can utilize lessons learned from this study to implement similar sodium reduction initia-tives. Lessons learned from this study include the need for tailored implementation plans, uniformed product selection guides and buy-in from upper management and the site’s food service operator. Sites varied in their menu cycle length, types of food items served, food products available for purchase, contract limitations, and food dis-tributors. Therefore, tailored implementation plans were necessary. Future initiatives can benefi t from off ering multiple sodium reduc-tion strategies depending on the food served and prevalence of prod-uct use to result in impactful change. Due to the diff erences in foods available for purchase and limitations in food procurement contracts, future initiatives would benefi t from creating a uniformed product selection guide of lower sodium items available from individual food distributors. Additionally, sodium content of partners’ ingredient in-ventory can serve as a proxy to a comprehensive nutrient analysis as

a quicker, albeit less informative sodium reduction estimate for ini-tiatives with limited resources and time. Obtaining buy-in and using a collaborative approach were essential for eff ective implementation. Collaborative initiatives, such as the SRI, can be more eff ective in creating sustainable changes than traditional prescriptive approaches used in public health.

This paper provides essential information to guide public health de-partments and local companies in eff ectively collaborating to change the food environment, reduce sodium in the surrounding community, and provide more healthful options for their communities.

AcknowledgementsWe would like to acknowledge the community, worksite, and con-gregate partners who collaborated in designing, implementing and evaluating this project. We also thank the research team and data collectors for contributing to this project.

REFERENCES1. Institute of Medicine. Sodium Intake in Popoulations: Assessment of Evi-dence. Washington, DC: The National Academies Press; 2013.2. U.S. Department of Health and Human Services and U.S. Department of Agriculture. 2015 – 2020 Dietary Guidelines for Americans. 8th Edition. December 2015. Available at http://health.gov/dietaryguidelines/2015/guide-lines/.3. Graudal NA, Hubeck-Graudal T, Jürgens G. Eff ects of Low-Sodium Diet vs. High-Sodium Diet on Blood Pressure, Renin, Aldosterone, Catechol-amines, Cholesterol, and Triglyceride (Cochrane Review). American Journal of Hypertension. January 1, 2012;25(1):1-15.4. Frieden TR, Berwick DM. The “Million Hearts” Initiative — Pre-venting Heart Attacks and Strokes. New England Journal of Medicine. 2011;365(13):e27.

Table 1: Sodium Reduction Initiative strategies to circumvent typical barriers to sodium

reduction

Typical Barriers to Partnering with Community Entities for Sodium Reduction

SRI Strategies to Circumvent the Barrier

Inadequate resources or lack of access to

adequate resources

SRI funding supported health department

staff to complete nutritional analysis

Local health department’s RDN sourced

alternative products through food provider

Increased cost or loss of revenue Local health department staff identified

ingredients that were at equal cost or less to

the ingredient being replaced

Local health department contracted with

evaluators to collect sales data as a process

indicator so adjustments could be made if

revenues decreased

Time limitations Local health department developed list of

common strategies and lower sodium options

among common food providers to expedite

the process

Local health department could use

information from previous nutrient analysis to

identify changes that would result in the

greatest reduction of sodium

Competing interests Local health department presented SRI goals

in relation to the organizational goals of the

entity

Recruited entities who had employee wellness

programs already implemented and were

therefore more likely to share common

interests

Lack of policy Local health department worked with city

departments to implement standards in vendor

contracts

Lower sodium foods added to procurement


5. Fung TT, Chiuve SE, McCullough ML, Rexrode KM, Logroscino G, Hu FB. Adherence to a dash-style diet and risk of coronary heart disease and stroke in women. Archives of Internal Medicine. 2008;168(7):713-720.6. Sacks FM, Moore TJ, Appel LJ, et al. A dietary approach to prevent hy-pertension: A review of the dietary approaches to stop hypertension (DASH) study. Clinical Cardiology. 1999;22(S3):6-10.7. Sacks FM, Svetkey LP, Vollmer WM, et al. Eff ects on Blood Pressure of Reduced Dietary Sodium and the Dietary Approaches to Stop Hypertension (DASH) Diet. New England Journal of Medicine. 2001;344(1):3-10.8. Institute of Medicine. Strategies to Reduce Sodium Intake in the United States. Washington, DC: The National Academies Press; 2010.9. Appel LJ, Angell SY, Cobb LK, et al. Population-Wide Sodium Reduc-tion: The Bumpy Road from Evidence to Policy. Annals of Epidemiology. 2012;22(6):417-425.10. DeSimone JA, Beauchamp GK, Drewnowski A, Johnson GH. So-dium in the food supply: challenges and opportunities. Nutrition Reviews. 2013;71(1):52-59.11. Reeve B, Magnusson R. Food reformulation and the (neo)-liberal state: new strategies for strengthening voluntary salt reduction programs in the UK and USA. Public Health. 2015;129(4):351-363.12. Mugavero KL, Gunn JP, Dunet DO, Bowman BA. Sodium Reduction: An Important Public Health Strategy for Heart Health. Journal of Public Health Management and Practice. Jan-Feb 2014;20(101):S1-S5.13. Richardson AK. Investing in public health: barriers and possible solu-tions. Journal of Public Health. 2012;34(3):322-327.

14. Biediger-Friedman L, Sosa E, Shields K, Shutt A. A voluntary approach to improve menu options in restaurants through a local collaborative partner-ship. Texas Public Health Journal. 2014; 66(1):11–4.15. Texas Department of Aging and Disability Services (DADS)-Access and Intake Division. Nutrition Standards Dietary Reference Intakes and Dietary Guidelines for Americans. https://hhs.texas.gov/sites/default/fi les//docu-ments/doing-business-with-hhs/providers/long-term-care/aaa/AAA-PI314.pdf. Accessed June 19, 2017. 16. U.S. Department of Agriculture. Nutrition Standards in the National School Lunch and School Breakfast Programs; 77 Fed. Red. (January 26, 2012) (to be codifed at C.F.R. Parts 210 and 220). https://www.gpo.gov/fdsys/pkg/FR-2012-01-26/pdf/2012-1010.pdf. Accessed June 19, 2017.18. Choi SE, Brandeau ML, Basu S. Expansion of the National Salt Reduction Initiative: A Mathematical Model of Benefi ts and Risks of Population-Level Sodium Reduction. Medical Decision Making. January 1, 2016;36(1):72-85.

The Texas Public Health Association extends its gratitude to all who attended and those who contributed to the success of the 93rd Annual Education Conference held in Fort Worth in March!

We extend special thanks to: The Program Planning and Local Arrangements committees, conference session moderators, student volunteers, presenters and volunteers who reviewed a record number of submitted abstracts for breakout session presentations and posters!

The Texas Department of State Health Services Continuing Education Service, Office of Academic Linkages and the University of Texas School of Public Health for Continuing Education and Texas Department of State Health Services, Division for Regional and Local Health Services-Continuing Education Sponsor

Sponsors of our pre-conference and mobile workshops/trainings and/or goods and services:

· American Planning Association/Texas Chapter · Student Section, Texas Public Health Association · Tarrant County Public Health · Texas Department of State Health Services Division for Regional and Local Health Services · University of North Texas Health Science Center School of Public Health

· University of Texas Medical Branch, Department of Preventive Medicine & Community Health · Fort Bend County Health & Human Services · Fort Worth Convention and Visitors Bureau · Veronica Primeaux, Graphics Designer

Our Conference Exhibitors:

· City of Houston (Silver Level) · Grand Canyon University · Harris County Public Health (HCPH) · Netsmart · North Texas Poison Center · Patagonia Health Inc · Tarrant County Public Health (Platinum Level)

· Texas Chapter of American Planning Association · Texas Center for Nursing Workforce Studies · Texas DSHS Services Newborn Screening Unit · University of North Texas - Denton · UNTHSC School of Public Health (Platinum Level) · UT Medical Branch (UTMB)

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