Peer Reviewed: Community Health Status Indicators Project: The Development of a National Approach to Community Health

The Community Health Status Indicators Project (CHSI) 2008 provides 16-page reports for the 3141 counties in the United States, each of which includes more than 300 county-specific data items related to chronic and infectious diseases, birth characteristics or outcomes, causes of death, environmental health, availability of health services, behavioral risk factors, health-related quality of life, vulnerable populations, summary measures of health, and health disparities. The CHSI, originally initiated in 2000, provides county-level health profiles for all U.S. counties so that programs addressing community health can readily access community health indicators. Each county report also permits comparisons of a county''s health status with similar "peer counties," with all counties, and with national Healthy People 2010 objectives. Under the leadership of a public–private partnership, the CHSI Steering Committee updated each county report and added new information and features to create CHSI 2008. This new CHSI version includes data for 1994 through 2006 from multiple surveillance systems. New features include an enhanced Web site, an Internet mapping application, and a downloadable database of the indicators for all counties.     

Peer Reviewed: Community Health Status Indicators: Adding a Geospatial Component

An Internet mapping application is being introduced in conjunction with the release of the second version of the Community Health Status Indicators (CHSI) Report. The CHSI Geographic Information Systems (GIS) Analyst is an easy-to-use Web-based mapping application that provides new opportunities for the visualization, exploration, and understanding of the indicators. Indicators can be mapped and compared visually to other areas, including peer counties and neighboring counties. The Web site is accessible from a link on the CHSI Report Web site or directly from an Internet Web browser. In this paper, we discuss the conceptualization and implementation of this public health mapping application.     

Sharing a Playbook: Integrated Care in Community Health Centers in the United States

Objectives. We investigated basic measures used to assess collaboration between colocated providers and to gauge the extent to which health centers practice integrated care.Methods. We used the Assessment of Behavioral Health Services survey and the 2010 Uniform Data System to explore the elements of integrated care for behavioral health conditions. We used multivariable regression models to examine the correlates of integrated care.Results. More than 85% of health centers provided mental health services in 2010, and almost half offered substance use treatment. Health centers commonly reported shared access to information among behavioral health and medical providers and joint care planning. A higher degree of integrated care involving joint case conferences was less common. Health centers without electronic health records and those with lower percentages of total staff composed of behavioral health workers were less likely to provide integrated care.Conclusions. A 2-pronged strategy involving financial incentives and technical assistance to spread best practices might increase integrated care, particularly among health centers that are not maximizing the potential of electronic health records and health centers with low behavioral health staffing levels.The treatment of behavioral health conditions is a key component of quality care.1 Behavioral health encompasses mental health and substance use disorders as well as health behaviors.2 Improving access to screening and treatment services for mental health and substance use disorders is critical to the success of wider efforts to improve the health care system to pursue the triple aim3 of better health, better care, and lower per-person costs.4,5 However, medical and behavioral health care providers have historically practiced in isolation, with little communication or coordination. The need to better integrate behavioral and medical care is especially pronounced for underserved patients; according to the Institute of Medicine, “[t]he single greatest flaw of the mental health safety net is its nearly total disconnection from the core [general medical] safety net.”6^(p189)Mental health and substance use disorder services are frequently provided in primary care settings; in fact, many patients with behavioral health disorders never receive care in a specialty behavioral health setting.7,8 Community health centers are key portals of access to medical and behavioral health services in underserved communities.9 Community health centers are also called “federally qualified health centers” or “health centers.” We used data from federally qualified health centers that received grant funding in 2010 under Section 330 of the Public Health Services Act through the Bureau of Primary Care at the Health Resources and Services Administration of the US Department of Health and Human Services. Because many health center patients face additional access barriers—40% of health center patients were uninsured in 2010—treatment initiation and engagement might be improved if on-site behavioral health services are available where patients access medical care and links to social services.10 The “warm handoff” to a behavioral health provider can create trust, because colocation with medical services can destigmatize behavioral health treatment. Patients already visit health centers for medical and other types of services, so accessing behavioral health services on-site at the health center is likely to be convenient.11 In addition, colocating primary care and behavioral health services is a strategy to mitigate barriers to accessing care related to cultural beliefs among patients.12Health centers are required to provide mental health and substance use disorder services on-site or by referral. Most health centers have on-site behavioral health specialists, particularly larger health centers, those located in urban areas, in the Northeast and West, in local areas with greater availability of behavioral health specialists, and in states that allow Medicaid same-day billing for medical and behavioral health services.13,14 Health center capacity is expanding under the Affordable Care Act (Patient Protection and Affordable Care Act, Pub L No. 111-148, 124 Stat. 855 [March 2010]) to increase access to care for underserved patients and communities.15 Improving access to behavioral health services at health centers is currently a priority; more than 1 in 3 health centers received funding to expand behavioral health capacity in 2014 of more than $105 million.16Building on the foundation of colocated behavioral health specialists and primary care providers, health centers are exploring how to integrate behavioral health services into primary care.17,18 A commonly used continuum specifies 3 basic levels of orchestration between behavioral health and medical care: coordinated from 2 separate locations, colocated in a shared space, or integrated.10,19 The definition is still evolving, but integrated care is distinguished by colocated, team-based care and, optimally, a shared care plan with both behavioral health and medical elements.10,20–23Integrated care typically refers to providing behavioral health services in the primary care setting, whereas the closely related terms “coordination” and “collaboration” are used to describe shared access to information, communication, and consultation between medical and behavioral health providers, regardless of whether the services are colocated.24,25 We examined the processes used by primary care and behavioral health clinicians in health centers to conduct evidence-based activities to improve integration: colocating medical and behavioral health services, shared access to information in patient records, joint case conferences, and joint care planning.26It is important to note that colocating medical and behavioral health services does not necessarily lead to communication and collaboration; sustained technical assistance might be needed to support providers as they make the necessary changes to cultures, structures, and processes to allow more interdisciplinary communication and collaboration.27,28 Barriers to integrated care include a lack of consensus regarding team members’ roles29,30 and interprofessional conflict stemming from differing cultural norms and mental models of practice.31 The siloed and fragmented reimbursement landscape is another factor, particularly because reimbursement is often fee for service on the basis of the volume of patient encounters; funding streams that cover provider-to-provider communication might be necessary to support integrated care.32^,33Prohibitions on same-day billing for medical and behavioral health services are another roadblock.13,34 Additional financial barriers include staffing costs and health information technology (IT) implementation costs.35 There are many other issues related to health IT, including usability issues of care coordination and registry functions, limited interoperability hindering health information exchange, and additional privacy protections for information on substance use disorders.20,36–39We explored some basic measures that can be used to assess collaboration between colocated providers and to gauge the extent to which a health center is practicing integrated care. We asked 2 main questions. First, to what extent is integrated care occurring for health center patients with behavioral health conditions? Second, which health center characteristics are associated with practicing integrated care? We hypothesized that larger health centers, those with electronic health records (EHRs), and those with higher percentages of total staffing composed of behavioral health specialists might be more likely to provide integrated care.Our study makes a unique contribution to the literature by presenting nationally representative data on the elements of integrated care for patients with behavioral health conditions in health centers. The findings on contextual and health center characteristics associated with practicing integrated care in health centers might guide policies designed to reduce unmet needs for behavioral health treatment services among underserved patients.     

Environmental Health Indicators of Climate Change for the United States: Findings from the State Environmental Health Indicator Collaborative

Objective

To develop public health adaptation strategies and to project the impacts of climate change on human health, indicators of vulnerability and preparedness along with accurate surveillance data on climate-sensitive health outcomes are needed. We researched and developed environmental health indicators for inputs into human health vulnerability assessments for climate change and to propose public health preventative actions.

Data sources

We conducted a review of the scientific literature to identify outcomes and actions that were related to climate change. Data sources included governmental and nongovernmental agencies and the published literature.

Data extraction

Sources were identified and assessed for completeness, usability, and accuracy. Priority was then given to identifying longitudinal data sets that were applicable at the state and community level.

Data synthesis

We present a list of surveillance indicators for practitioners and policy makers that include climate-sensitive health outcomes and environmental and vulnerability indicators, as well as mitigation, adaptation, and policy indicators of climate change.

Conclusions

A review of environmental health indicators for climate change shows that data exist for many of these measures, but more evaluation of their sensitivity and usefulness is needed. Further attention is necessary to increase data quality and availability and to develop new surveillance databases, especially for climate-sensitive morbidity.     

Health Indicators of Native Hawaiian and Pacific Islanders in the United States

This study aimed to describe health indicators and behaviors of Native Hawaiian and Pacific Islander (NHPI) adults and to compare findings to previous reports on US NHPI and the US population. A sample of N = 100 (56 M, 44 F) NHPI adults aged 40–59 years completed an anonymous questionnaire addressing education and household income, tobacco use, physical activity, fruit and vegetable (F&V) consumption, cancer screening and health status. Objective measures of height and weight were taken to calculate body mass index (BMI). The study sample consisted of 49% current smokers and the majority was not meeting guidelines for physical activity (80%) or F&V consumption (99%). Cancer screening rates ranged from 0 to 57% and were higher among females. Mean BMI was 33.9 ± 7.5 kg/m² and 95% were overweight or obese. While 36.7% were hypertensive, only 11.1% were taking prescribed medication. Compared to both the general US population and available data for US NHPI, study participants reported higher prevalence of obesity and chronic conditions (hypertension, high cholesterol, diabetes, and angina/CHD) and lower levels of physical activity, F&V consumption and cancer screening rates. Study findings contribute to the limited knowledge regarding health behaviors of US NHPI. Comparisons to US data increase evidence of NHPI health disparities, while comparisons to previous NHPI studies emphasize the magnitude of unhealthy lifestyle behaviors and subsequent adverse health conditions for this particular sample. Further improvements to community outreach and recruitment strategies could successfully encourage high-risk individuals to participate in health promotion and behavior intervention studies to improve NHPI health behaviors.     

Socioeconomic inequality of cancer mortality in the United States: a spatial data mining approach

Background  

The objective of this study was to demonstrate the use of an association rule mining approach to discover associations between selected socioeconomic variables and the four most leading causes of cancer mortality in the United States. An association rule mining algorithm was applied to extract associations between the 1988–1992 cancer mortality rates for colorectal, lung, breast, and prostate cancers defined at the Health Service Area level and selected socioeconomic variables from the 1990 United States census. Geographic information system technology was used to integrate these data which were defined at different spatial resolutions, and to visualize and analyze the results from the association rule mining process.     

Income inequality, poverty, and population health: evidence from recent data for the United States

In this study, state-level US data for the years 2000 and 1990 are used to provide additional evidence on the roles of income inequality and poverty in population health. Five main points are noted. First, contrary to the suggestion made in several recent studies, the income inequality parameter is observed to be quite robust and carries statistical significance in mortality equations estimated from several observation sets and a fairly wide variety of specificational choices. Second, the evidence does not indicate that significance of income inequality is lost when education variables are included. Third, similarly, the income inequality parameter shows significance when a race variable is added, and also when both race and urbanization terms are entered. Fourth, while poverty is seen to have some mortality-increasing consequence, the role of income inequality appears stronger. Fifth, income inequality retains statistical significance when a quadratic income term is added and also if the log-log version of a fairly inclusive model is estimated. I therefore suggest that the recent skepticism articulated by several scholars in regard to the robustness of the income inequality parameters in mortality equations estimated from the US data should be reconsidered.     

Mapping gender variation in the spatial pattern of alcohol-related mortality: a Bayesian analysis using data from South Yorkshire, United Kingdom

Gender variation in the spatial pattern of alcohol-related deaths in South Yorkshire, UK for the period 1999 and 2003 was explored using two Bayesian modelling approaches. Firstly, separate models were fitted to male and female deaths, each with a fixed effect deprivation covariate and a random effect with unstructured and spatially structured terms. In a modification to the initial models, covariates were assumed estimated with error rather than known with certainty. In the second modelling approach male and female deaths were modelled jointly with a shared component for random effects. A range of different unstructured and spatially structured specifications for the shared and gender-specific random effects were fitted. In the best fitting shared component model a spatially structured prior was assumed for the shared component, while gender-specific components were assumed unstructured. Deprivation coefficients and random effect standard deviations were very similar between the gender-specific and shared component models. In each case the effect of deprivation was observed to be greater in males than in females, and slightly larger in the measurement error models than in the fixed covariate models. Greater variation was observed in the spatially smoothed estimates of risk for males versus females in both gender-specific and shared component models. The shared component explained a greater proportion of the male risk than it did the female risk. The analysis approach reveals the residual (unexplained by deprivation) gender-specific and shared risk surfaces, information which may be useful for guiding public health action.     

The United States needs a WHO health in prisons project

Some facts about imprisonment in the USA are used to justify the comment that US is a country that loves prisons. The lack of provision of rehabilitative type services is stressed and the example of Valley Fever in one area of California demonstrates the public health disasters which can occur with the present arrangements. The organisations concerned with prisons seem to support the idea of prisons as a business. The article is a plea for a WHO health in prisons project as the way forward.     

School Health Services in the United States: A View from the United Kingdom

Despite sharing both a common heritage and a common language, differences exist between life in the United States and the United Kingdom. During spring 1988, the author, who formerly served as editor for the Health Visitor, published by the Health Visitor's Association, completed a six-week study tour of school health services in the United States. In this article, she gives her impressions from the experience, including observations regarding salary, working conditions, professional preparation, and professional recognition. She concludes by identifying several poignant questions to clarify the school nurse's role and to set priorities for the optimal use of time and expertise.     

Health of foreign-born people in the United States: a review

This paper identifies the overarching patterns of immigrant health in the US. Most studies indicate that foreign-born individuals are in better health than native-born Americans, including individuals of the same race/ethnicity. They tend to have lower mortality rates and are less likely to suffer from circulatory diseases, overweight/obesity, and some cancers. However, many foreign-born groups have higher rates of diabetes, some infections, and occupational injuries. There is heterogeneity in health among immigrants, whose health increasingly resembles that of natives with duration of US residence. Prospective studies are needed to better understand migrant health and inform interventions for migrant health maintenance.     

Evaluating spatial and temporal patterns of tick exposure in the United States using community science data submitted through a smartphone application

Research initiatives that engage the public (i.e., community science or citizen science) increasingly provide insights into tick exposures in the United States. However, these data have important caveats, particularly with respect to reported travel history and tick identification. Here, we assessed whether a smartphone application, The Tick App, provides reliable and novel insights into tick exposures across three domains — travel history, broad spatial and temporal patterns of species-specific encounters, and tick identification. During 2019–2021, we received 11,424 tick encounter submissions from across the United States, with nearly all generated in the Midwest and Northeast regions. Encounters were predominantly with human hosts (71%); although one-fourth of ticks were found on animals. Half of the encounters (51%) consisted of self-reported peri‑domestic exposures, while 37% consisted of self-reported recreational exposures. Using phone-based location services, we detected differences in travel history outside of the users’ county of residence along an urbanicity gradient. Approximately 75% of users from large metropolitan and rural counties had travel out-of-county in the four days prior to tick detection, whereas an estimated 50–60% of users from smaller metropolitan areas did. Furthermore, we generated tick encounter maps for Dermacentor variabilis and Ixodes scapularis that partially accounted for travel history and overall mirrored previously published species distributions. Finally, we evaluated whether a streamlined three-question sequence (on tick size, feeding status, and color) would inform a simple algorithm to optimize image-based tick identification. Visual aides of tick coloration and size engaged and guided users towards species and life stage classification moderately well, with 56% of one-time submitters correctly selecting photos of D. variabilis adults and 76% of frequent-submitters correctly selecting photos of D. variabilis adults. Together, these results indicate the importance of bolstering the use of smartphone applications to engage community scientists and complement other active and passive tick surveillance systems.     

Skunk and raccoon rabies in the eastern United States: temporal and spatial analysis

Since 1981, an epizootic of raccoon rabies has spread throughout the eastern United States. A concomitant increase in reported rabies cases in skunks has raised concerns that an independent maintenance cycle of rabies virus in skunks could become established, affecting current strategies of wildlife rabies control programs. Rabies surveillance data from 1981 through 2000 obtained from the health departments of 11 eastern states were used to analyze temporal and spatial characteristics of rabies epizootics in each species. Spatial analysis indicated that epizootics in raccoons and skunks moved in a similar direction from 1990 to 2000. Temporal regression analysis showed that the number of rabid raccoons predicted the number of rabid skunks through time, with a 1-month lag. In areas where the raccoon rabies virus variant is enzootic, spatio-temporal analysis does not provide evidence that this rabies virus variant is currently cycling independently among skunks.