Insights in Public Health Electronic Cigarettes: Marketing to Hawai‘i's Adolescents

Electronic cigarettes (e-cigarettes) are an emerging phenomenon that is becoming increasingly popular among adolescents. Current e-cigarette use among adolescents has more than doubled in the past few years nationally and more than tripled in Hawai‘i, despite the fact that safety in terms of health and injury from use is widely unknown. The use of e-cigarettes among adolescents is of particular concern because they may act as a gateway to smoking conventional tobacco cigarettes, substitute for cigarettes where smoking would normally not be allowed, and weaken the effect of clean air policies, and displace effective smoking cessation treatments. Additionally, the use of e-cigarettes may lead to the use of conventional cigarettes. There is special concern that e-cigarette companies are recruiting adolescents who would not have otherwise tried smoking by using tactics such as offering e-cigarettes in attractive flavorings and using the same successful strategies to market their product as tobacco companies have used for conventional cigarettes in past decades. It has been shown that exposure to cigarette marketing is related to initiation and progression in adolescent smoking. Yet, there remains no regulation on the marketing of e-cigarettes to adolescents. It can be extrapolated that expanded regulation that includes limits on the marketing of e-cigarettes may help decrease use among adolescents and prevent the possible increase of smoking rates.     

Project Kealahou: Improving Hawai‘i's System of Care for At-Risk Girls and Young Women through Gender-Responsive,Trauma-Informed Care

Project Kealahou (PK) is a six-year, federally-funded program aimed at improving services and outcomes for Hawai‘i''s female youth who are at risk for running away, truancy, abuse, suicide, arrest and incarceration. PK builds upon two decades of sustained cross-agency efforts among the state''s mental health, juvenile justice, education, and child welfare systems to promote system-of-care (SOC) principles of community-based, individualized, culturally and linguistically competent, family driven, youth-guided, and evidence-based services. In addition, PK emphasizes trauma-informed and gender-responsive care in serving its target population of females ages 11–18 years who have experienced psychological trauma.Results from the first four years of the implementation of PK in the Department of Health''s (DOH) Child and Adolescent Mental Health Division (CAMHD) highlight the serious familial, socioeconomic, functional, and interpersonal challenges faced by the young women who receive services in Hawai‘i''s SOC. Despite the challenges faced by PK youth and their families, preliminary results of the evaluation of PK show significant improvements across multiple clinical and functional domains of service recipients. A financial analysis indicates that these outcomes were obtained with a minimal overall increase in costs when compared to standard care alone. Overall, these results suggest that PK may offer a cost effective way to improve access, care, and outcomes for at-risk youth and their families in Hawai‘i.     

Insights in Public Health: For the Love of Data! The Hawai‘i Health Data Warehouse

Data form the framework around which important public health decisions are made. Public health data are essential for surveillance and evaluating change. In Hawai‘i, public health data come from a multitude of sources and agencies. The Hawai‘i Health Data Warehouse (HHDW) was created to pull those data into a single location and to present results in a form that is easy for the public to access and utilize. In the years since its creation, HHDW has built a second consumer-focused web site, Hawai‘i Health Matters, and is now introducing new functionality on the original site that allows users to define their own enquiry. The newly adopted Indicator-Based Information System (IBIS) uses a web interface to perform real-time data analysis and display results. This gives users the power to examine health data by a wide range of demographic and socioeconomic dimensions, permitting them to pinpoint the data they need.     

Insights in Public Health: The Hawai‘i Home Visiting Network: Evidence-Based Home Visiting Services in Hawai‘i

Home visiting services are cost-effective and improve the health of children and families among those at increased risk. From 1985–2008, home visiting services in Hawai‘i were provided primarily through state funding of the Hawai‘i Healthy Start Program, but the program was severely reduced due to the economy and state budget changes over the past decade. The Maternal and Child Health Branch (MCHB) in the Family Health Services Division responded to these changes by seeking out competitive grant opportunities and collaborations in order to continue to promote home visiting services to those children and families in need. In 2010, the MCHB was awarded a federally funded Maternal, Infant and Early Childhood Home Visiting (MIECHV) grant for home visiting services to promote maternal, infant, and early childhood health, safety and development, strong parent-child relationships, and responsible parenting. In 2011, the MCHB was also awarded a competitive MIECHV development grant that funded the re-establishment of the hospital Early Identification program. Families in need of additional support identified through this program are referred for family strengthening services to a network of existing home visiting programs called the Hawai‘i Home Visiting Network (HHVN). The HHVN is supported by MIECHV and a small amount of state funds to assist programs with capacity building, training, professional development, quality assurance, and accreditation/certification support. The MIECHV grant requires that programs are evidence-based and address specific outcome measures and benchmarks. The HHVN provides home visiting services to families prenatally through 5 years of age that reside in specific at-risk communities, and is aimed at fostering positive parenting and reducing child maltreatment using a strength-based approach by targeting six protective factors: (1) social connections, (2) nurturing and attachment, (3) knowledge of parenting and child development, (4) parental resilience, (5) social and emotional competence of children, and (6) concrete supports for parents. This article provides an introduction to the HHVN as a diverse network of evidence-based home visiting programs with services currently available on all islands, and highlights aspects of home visiting programs that support the Family-Centered Medical Home (FCMH) model. The HHVN provides important services to families at risk and uses evidence-based practices to yield positive results. Health care professionals can support this network to promote the health of children and families by being aware that these home visiting services exist and encouraging families at-risk to participate. Continued collaboration and expanded partnerships with health providers can help strengthen the home visiting network and improve outcomes for children and families in Hawai‘i.     

Insights in Public Health: Protecting Public Health Through Governmental Transparency: How the Hawai‘i Department of Health's New “Stoplight” Placarding Program is Attempting to Influence Behavioral Change in Hawai‘i's Food Industry

Reducing the occurrence of and influencing the rapid correction of food illness risk factors is a common goal for all governmental food regulatory programs nationwide. Foodborne illness in the United States is a major cause of personal distress, preventable illness, and death. To improve public health outcomes, additional workforce was required due to long standing staffing shortages and was obtained partially through consolidation of the Hawai‘i Department of Health''s (HDOH) two food safety programs, the Sanitation Branch, and the Food & Drug Branch in July 2012, and through legislation that amended existing statutes governing the use of food establishment permit fees. Additionally, a more transparent food establishment grading system was developed after extensive work with industry partners based on three possible placards issued after routine inspections: green, yellow, and red. From late July 2014 to May 2015, there were 6,559 food establishments inspected statewide using the placard system with 79% receiving a green, 21% receiving a yellow, and no red placards issued. Sufficient workforce to allow timely inspections, continued governmental transparency, and use of new technologies are important to improve food safety for the public.     

Insights in Public Health: Public Health Laboratory Workforce Outreach in Hawai‘i: CLIA-Focused Student Internship Pilot Program at the State Laboratories

Chronically understaffed public health laboratories depend on a decreasing number of employees who must assume broader responsibilities in order to sustain essential functions for the many clients the laboratories support. Prospective scientists considering a career in public health are often not aware of the requirements associated with working in a laboratory regulated by the Clinical Laboratory Improvement Amendments (CLIA). The purpose of this pilot internship was two-fold; introduce students to operations in a regulated laboratory early enough in their academics so that they could make good career decisions, and evaluate internship methodology as one possible solution to workforce shortages. Four interns were recruited from three different local universities, and were paired with an experienced State Laboratories Division (SLD) staff mentor. Students performed tasks that demonstrated the importance of CLIA regulations for 10–15 hours per week over a 14 week period. Students also attended several directed group sessions on regulatory lab practice and quality systems. Both interns and mentors were surveyed periodically during the semester. Surveys of mentors and interns indicated overall positive experiences. One-on-one pairing of experienced public health professionals and students seems to be a mutually beneficial arrangement. Interns reported that they would participate if the internship was lower paid, unpaid, or for credit only. The internship appeared to be an effective tool to expose students to employment in CLIA-regulated laboratories, and potentially help address public health laboratory staffing shortfalls. Longer term follow up with multiple classes of interns may provide a more informed assessment.     

Insights in Public Health: Initiating Bicycle Sharing in Hawai‘i: Lessons Learned from a Small Pilot Bike Share Program

In 2011, a small pilot bike share program was established in the town core of Kailua, Hawai‘i, with funding from the Hawai‘i State Department of Health. The Kailua system consisted of two stations with 12 bicycles, and the goal was to secure additional funding to expand the station network in the future. Community feedback consistently indicated support for the bike share program. However, system metrics showed low levels of usage, averaging 41.5 rides per month (2011–2014). From observational data, users were primarily tourists. With minimal local staff, the bike share program had limited resources for promotion and education, which may have hindered potential use by local residents. Management of station operations and bike maintenance were additional, ongoing barriers to success. Despite the challenges, the pilot bike share program was valuable in several ways. It introduced the bike share concept to Hawai‘i, thereby helping to build awareness and connect an initial network of stakeholders. Furthermore, the pilot bike share program informed the development of a larger bike share program for urban Honolulu. As limited information exists in the literature about the experiences of smaller bike share programs and their unique considerations, this article shares lessons learned for other communities interested in starting similar bike share programs.     

Insights in Public Health: Is the Gap Growing? Patterns in Poverty-related Disparities in Nutrition and Physical Activity in Hawai‘i

A recent Harvard study on national dietary trends found that the gap in healthy dietary behaviors between low-income and middle/upper-income Americans widened between 2000 and 2010. Hawai‘i Behavioral Risk Factor Surveillance System (BRFSS) data from 2001–2009 on differences in obesity-related behaviors between moderate-high income, low-income, and poverty-level Hawai‘i residents were examined to explore whether Hawai‘i data on obesity-related behaviors reflected this national trend. While most differences between groups were not statistically significant, a consistent pattern was seen across all measures that suggested a growing gap between low-income and moderate/high income Hawai‘i residents. Data from community studies on pedestrian injury, park use, transportation, and healthy food access were examined. This data suggests that individuals residing in low-income neighborhoods in Hawai‘i experience higher barriers to the adoption of healthier behaviors. Further data is needed to document poverty-related gaps in the adoption of health behaviors among youth and within Hawai‘i''s ethnic groups, communities and geographic areas.Dietary behavior and physical activity contributes to obesity in both children and adults, and to chronic conditions such as diabetes, stroke, and cardiovascular disease.¹ Both governmental and nonprofit organizations have invested substantially in campaigns to improve dietary behavior and physical activity in the United States, in order to reduce obesity and related chronic disease risk within our population. The nation''s Healthy People 2020 goals increased emphasis on the need to address the social determinants of health in health promotion efforts, addressing socioeconomic and environmental health disparities in order to improve the nation''s health.² However, when current physical activity and nutrition outcomes in the population are viewed through the lens of socioeconomic disparity, a concerning picture is emerging.A recent examination of national dietary behavior data found that while middle- and upper-income Americans have shown modest improvements in dietary behavior between 2000 and 2010, those living in poverty have experienced no changes.³ As a result, the disparity in dietary behaviors related to chronic disease has doubled between low-income and other Americans in the past decade.Due to recent changes in the administration and weighting of the Behavioral Risk Factors Surveillance System (BRFSS), Hawai‘i does not have an equivalent 10-year data set to draw from. When one looks at state BRFSS data on nutrition and physical activity by income groupings, however, a similar pattern emerges. Dietary and physical activity disparities appear to be widening between moderate/upper-income (income greater than 185% of the federal poverty limit, [FPL]), low-income (incomes between 130–185% of the FPL), and poverty-level (those with incomes below 130% of the FPL) Hawai‘i households.In 2001, the percentage of Hawai‘i residents consuming the recommended 2 fruits and 3 vegetables per day was 12.8% among middle/upper income Hawai‘i residents, 12.2% among low-income Hawai‘i residents, and 10.9% among those in poverty.⁴ By 2009, consumption of the recommended servings of fruits and vegetables increased modestly among moderate/upper-income individuals (15.3%), while remaining nearly flat among low-income individuals (12.7%). Those living in poverty (13.7%) surpassed the low-income group, but still lagged several percentage points behind moderate/high income Hawai‘i residents.Similar results can be seen for physical activity. In 2001 there was no appreciable difference in the percentage meeting physical activity recommendations among moderate/upper income (52.9%), and low-income (51.6%) Hawai‘i residents.⁵ Those in poverty (45.2%) had the lowest percentage of individuals meeting physical activity recommendations. Between 2001–2009, the moderate/upper income group showed steady improvement over time (55.1%), while the percentage meeting recommendations among the low-income group (51.5%) remained unchanged. Those in poverty (49.7%) caught up to the low-income group, but lagged substantially behind the middle/upper-income group.Similar trends can be seen in leisure-time physical activity,⁶ and overweight and obesity⁷ over the same time span. Sugar-sweetened beverage consumption among adults has received more recent attention, but changes between 2011 and 2012 suggest that a similar pattern is emerging.⁸ It should be noted that few of these gaps are statistically significant. However, the patterns are consistent across a wide range of dietary behavior and physical activity indicators, and all point in the direction of slowly widening disparities in healthy behaviors between low-income and moderate/upper income Hawai‘i residents.This pattern is not unique to nutrition and physical activity behaviors. Other risk behaviors that have been the targets of extensive public campaign development, such as tobacco smoking prevalence and seat-belt use, show similar trends over the same time period–health behavior improving among moderate/higher income group, with little to no change among the low-income residents, and those in poverty improving just enough to catch up with the stationary low-income residents.^9,10Disparities in income and socioeconomic status (SES) between ethnic groups may be a substantial contributor to the link between ethnicity and health disparities.^11–13 In Hawai‘i, poverty is disproportionately concentrated among Native Hawaiians, Filipinos, and Pacific Islanders.¹⁴ These same populations bear a disproportionate burden of diabetes and heart disease in Hawai''i.¹⁵ Over the past decade, a significant amount of work has gone into reaching these populations through cultural tailoring of campaign messages and intervention design.¹⁶ However, there is some evidence to suggest that media-based campaigns aimed at the general population, even when culturally tailored for specific ethnic populations, do not effectively reach the lower-income individuals within these groups.¹⁷While health disparities have complex causes, it is clear that socioeconomic differences in the ability to act on health behavior recommendations contributes to the disproportionate burden of diabetes, heart disease, stroke, and other chronic conditions seen in many populations. These differences come in many areas—differences in behavioral environment, in resources, in economic and social constraints to action.¹⁸In Hawai‘i, for example, low-income households are disproportionately concentrated in urban Honolulu, particularly within the neighborhoods of Kalihi, Moilili, Makiki, Salt Lake, Waikiki, Chinatown, and Palolo, as well as in Waipahu and on the Waianae Coast.¹⁹ A study of pedestrian injuries and fatalities by neighborhood shows that residents in these neighborhoods are disproportionately at risk of injury when walking in their neighborhoods.²⁰ Between 2007–2011, there were 13 pedestrian deaths and 171 pedestrian injuries serious enough to warrant ambulance service in the Kalihi-Palama neighborhood. Similar rates were seen across other low-income areas in urban Honolulu, as well as in the low-income communities of Waianae (10 deaths, 105 injuries), and Waipahu (6 deaths, 113 injuries). By contrast, in the more affluent neighborhoods of East Honolulu, Kahala/Waialae residents experienced only 3 deaths and 28 injuries, while those in Hawai‘i Kai saw no deaths and only 21 pedestrian injuries. This is not a slight difference – pedestrians in Kalihi, Waianae, and Waipahu assume a 4 to 8 times higher risk of being injured or killed by a car when walking in their neighborhoods than do pedestrians in East Honolulu or Kailua. Clearly, in order to act on recommendations to increase walking and active transportation, people living in Kalihi-Palama, Waipahu, and Waianae need concentrated, coordinated efforts to improve their neighborhood''s safety for walkability and bikeability.An examination of grocery store, farmers'' market, and public transportation shows that residents of the Puna and Waianae areas experience disparities in terms of access to bus transportation, grocery stores, and other sources of healthy food, while residents of lower-income urban Honolulu areas have greater environmental access to fast-food outlets and convenience stores than do residents in upper-income neighborhoods like Kahala or Hawai‘i Kai.²¹ Parks in low-income Honolulu neighborhoods are significantly less-used than parks in middle- and upper-income neighborhoods, reflecting differences in facilities, safety, and access concerns between neighborhoods that contribute to differences in physical activity rates in these communities.²²Adopting a healthy lifestyle can be challenging for any household, but for low-income families, making “the healthy choice” can require more time, resources, and skills than are readily available.²³ In addition to environmental constraints, low-income parents often have less time, more responsibilities, and more life stressors and time conflicts than middle- or higher-income parents.²⁴ Access to healthy food is more limited in low-income communities, and the cost of fruits and vegetables is a substantial barrier for those with limited resources.²⁵While substantial attention has been paid to disparities between ethnic populations, age groups, and island or county of residence in Hawai‘i, data on poverty-related disparities have been less well-documented. Data that would allow policy-makers or program planners to examine disparities in health behaviors between upper- and lower-income groups within geographic communities, ethnic groups, age groups, or genders is not easily accessible. There is no population data within the state that can be used to identify poverty-related disparities in obesity, physical activity or nutrition behavior among children or youth. There is an old adage in evaluation: “What gets measured, gets done.” I would propose a corollary—a gap that is invisible tends to be overlooked.     

Primary Care and Public Health Services Integration in Brazil’s Unified Health System

Objectives. We examined associations between transdisciplinary collaboration, evidence-based practice, and primary care and public health services integration in Brazil’s Family Health Strategy. We aimed to identify practices that facilitate service integration and evidence-based practice.Methods. We collected cross-sectional data from community health workers, nurses, and physicians (n = 262). We used structural equation modeling to assess providers’ service integration and evidence-based practice engagement operationalized as latent factors. Predictors included endorsement of team meetings, access to and consultations with colleagues, familiarity with community, and previous research experience.Results. Providers’ familiarity with community and team meetings positively influenced evidence-based practice engagement and service integration. More experienced providers reported more integration and engagement. Physicians reported less integration than did community health workers. Black providers reported less evidence-based practice engagement than did Pardo (mixed races) providers. After accounting for all variables, evidence-based practice engagement and service integration were moderately correlated.Conclusions. Age and race of providers, transdisciplinary collaboration, and familiarity with the community are significant variables that should inform design and implementation of provider training. Promising practices that facilitate service integration in Brazil may be used in other countries.The integration of primary care and public health is a key strategy, recommended nationally and internationally, for assisting underserved populations; it encourages community-focused initiatives and transdisciplinary approaches to practice. Integration allows health providers (e.g., physicians, nurses, health workers) to use individual- and community-level interventions to influence, respectively, individual behavior and community health.1–3 Brazil’s Sistema Único de Saúde (Unified Health System) was created as a result of Brazil’s 1988 federal constitution and the 1990 Lei Orgânica da Saúde (Organic Health Law). This law aimed to establish a large, decentralized health system offering free, universal care from medical consultations to organ transplants, health campaigns, and sanitation.4 This system struggles with access, quality, and service coordination (e.g., scheduling, monitoring) mainly because it is incorporated under a single legal structure that contradicts decentralization and affects the integration of services that different sectors of the Sistema Único de Saúde, such as hospitals, provide.5To integrate primary care and public health, the Sistema Único de Saúde employs the Estratégia Saúde da Família (ESF; Family Health Strategy), a transdisciplinary approach used by health providers. ESF reflects “the new public health” paradigm, positing that integration best addresses health and environmental issues affecting communities.6–8 The World Health Organization recommends that diverse providers pursue community-level outcomes and medical cost reductions through service integration.9 Established in 1994 as the Programa de Saúde da Família, today the ESF consolidates a model of assistance operationalized by professional teams, including nurses, physicians, and community health workers (CHWs), that serve about 4000 individuals per team.10,11In Brazil, service integration is accomplished by transdisciplinary collaboration—providers delivering primary care alongside public health interventions (e.g., disease prevention campaigns).11–14 Providers strive to engage in evidence-based practice (EBP), which is characterized by providers assessing the impact of environmental issues (e.g., water supply) on health and by incorporating patient input and research findings into diagnosis and treatment. EBP is encouraged by training local providers in integration methods.15,16 ESF has improved adult patients’ awareness of their diagnoses and prognoses and their adherence to children’s immunization schedules and has decreased infant mortality, hospitalizations, and medication costs.10,11,17–19