Getting a better job or more hours at work should be a boon to low-income individuals who are trying to lift themselves and their families out of poverty. But sometimes, instead, their families suffer more just when they should begin to thrive.

“Earning more income should always be a positive step forward, but for too many families a modest increase in income, especially when those increases are often temporary, does not make up for benefits that are lost as a result of the increase,” said Mariana Chilton, PhD, an associate professor and director of the Center for Hunger-Free Communities in the Drexel University School of Public Health and principal investigator of the Philadelphia site of Children’s HealthWatch, a multi-site research program investigating the impact of public policies and programs on the health of young children seen in hospitals, emergency rooms, and primary care clinics. “When incomes are unstable, benefits help families stay stable. A loss of benefits can have drastic impacts on a family, limiting their ability to purchase food and other basic necessities, and forcing families to return to benefit programs they were working so hard to leave.”

That cliff effect—losing benefits in the transition out of poverty—is the focus of a new policy report released today by Drexel’s Center for Hunger-Free Communities and Children’s HealthWatch based on Children’s HealthWatch data collected in Philadelphia from 2005 through 2013.

The analysis found that families who experienced a reduction of food stamp benefits (officially known as the Supplemental Nutrition Assistance Program, or SNAP) due to an increase in income were more likely to be food insecure or marginally food secure, than were families who received a consistent level of SNAP benefits.

The report was presented at a Shared Prosperity roundtable hosted by the City of Philadelphia’s Mayor’s Office of Community Empowerment and Opportunity (CEO) in support of Shared Prosperity Philadelphia, the city’s plan to fight poverty. Monthly roundtables bring together researchers, service providers and consumers, funders, and others to deepen knowledge and form more effective partnerships to address critical poverty issues.

The report indicates that losing or having a reduction of SNAP benefits due to income growth was associated with other sacrifices in the family’s health and health care, beyond access to food. Families whose SNAP benefits were reduced were more likely to include a family member who was forced to forgo health care due to cost. In households who lost SNAP benefits completely due to increased income, young children were twice as likely to have foregone needed health care due to cost and more likely to live in a household that made trade-offs between paying for other basic living expenses (food, rent or housing) to pay for health care.

These trade-offs and the fear of faring worse after benefit loss when earning higher wages are familiar for many people who live in poverty, including participants in the Witnesses to Hunger program in the Center for Hunger-Free Communities. Participant Imani Sullivan, for example, has described her first-hand experience with this struggle: “I was on my way to my job when my food stamps were cut off,” she said. “They had called me to work there overtime for one day and I thought to myself, ‘Well, if I go down here this one day, are they going to cut my food stamps off?’ I really didn’t know what to do. I don’t think it’s fair for us to get reprimanded for doing something positive.”

To help families in Philadelphia and nationwide have a clear and effective path out of poverty and into economic independence, the authors of the new policy report recommend three major types of solutions:

• Reducing barriers to employment for families of young children by implementing measures such as mandatory paid sick leave and increased access to affordable childcare.
• Providing wages that allow families to achieve self-sufficiency without need for benefit programs. (Currently, many working families rely on SNAP because they do not earn enough from working to make ends meet.)
• Developing processes for work support programs to help families move and stay off of benefit programs, e.g. by creating a more gradual decline in benefits.

The authors recommend developing creative solutions across local, state and federal policies.

“We are proud to partner with the Center for Hunger-Free Communities to support families as they increase their earned income,” said Eva Gladstein, Executive Director of CEO.  “We look forward to working with Dr. Chilton and partners at all levels of government to bring much needed relief to working families across Philadelphia.”

– See more at: http://drexel.edu/now/archive/2014/December/Working-Families-SNAP-Benefits-Report/

As the linked epidemics of obesity and diabetes continue to escalate, a staggering one in five U.S. adults is projected to have diabetes by 2050.

Ground zero for identifying ways to slow and stop that rise is Philadelphia, which has the highest diabetes rate among the nation’s largest cities. For public health researchers at Drexel University, it is also a prime location to learn how neighborhood and community-level factors — not just individual factors like diet, exercise and education— influence people’s risk.

A new Drexel study published this month in the journal Advances in Preventive Medicine adds new insight into the role of the physical and social environment on the risk of diabetes, zip code by zip code throughout the city. The researchers report that age-adjusted prevalence of diabetes in adults aged 18 and older in the city increased significantly between 2002 and 2010. Having diabetes is a strong risk factor for heart disease, even more so in minorities. Living in a disadvantaged neighborhood may play a critical role in a person’s risk of the disease, accounting for about 12 percent of the difference in risk between otherwise-similar groups.

Philadelphia is often referred to as comprising a patchwork of neighborhoods. As a result of this city-wide patchwork, “people who live in the same general area have huge variations in socioeconomic environment,” said Longjian Liu, MD, PhD, an associate professor and interim chair of the Department of Environmental and Occupational Health in Drexel’s School of Public Health. Liu was lead author of the new study. This report was coauthored by Ana E. Núñez, MD, a professor and associate dean for urban health equity, education and research in Drexel’s College of Medicine. “Philadelphia also has the worst health status among 67 counties in Pennsylvania.”

The communities people live in contribute to wellness or illness. To evaluate the health impact of disadvantaged urban communities, Liu and Núñez developed an indicator of people’s physical and social environment (PSE) based on their answers to certain questions on a large region-wide health survey. These questions asked about the availability of healthy food, use of local recreational facilities, helpfulness of neighbors and other factors, in addition to poverty level. The survey also asked more than 17,000 participants who lived in 46 Philadelphia zip codes about personal factors that affected their risk of diabetes. These questions included whether they were overweight or obese, their physical activity, fruit and vegetable intake, age, sex, race/ethnicity and smoking status.

Liu and Núñez found that scores for the physical and social environment varied widely across neighborhoods. The neighborhoods with worse PSE statuses had a higher prevalence of diabetes. In areas where residents had higher rates of overweight and obesity or lower education attendance, there were also higher rates of diabetes. Between the survey periods in 2002 and 2010, the number of neighborhoods with higher rates of diabetes increased substantially.

Using statistical models, the researchers determined that about 12 percent of the risk of diabetes correlated with neighborhood PSE factors when adjusted for respondents’ age and sex — meaning they would expect diabetes rates to drop by 12 percent if the neighborhood environment were improved. Another nearly 12 percent of risk correlated with education when adjusted for respondents’ age and sex. Excess weight (overweight or obese) and race/ethnicity still remained larger contributors to the odds of diabetes.

“Too often, we focus exclusively on the individual in solving the problem. Here we found that we also need to focus on the healthiness of the community if we want to improve overall health and ultimately decrease health care costs” Núñez said.

“We want to stop the epidemic of diabetes and eliminate health disparities in communities,” Liu said. He noted that although the risk of diabetes develops from an interaction between genes, lifestyle and environmental factors, the disease can be largely prevented by influencing its modifiable risk factors. To do so, we need to critically look at health policies that reduce risk at a larger community level. Working towards improving the health quality of an entire neighborhood or city shows promise in helping to reduce the risk of disease.

– See more at: http://drexel.edu/now/archive/2014/November/City-Diabetes-Map-Study/

Researchers from Drexel University in Philadelphia this week presented research on a wide range of public health topics emphasizing urban health challenges, geographic methods in public health, community resilience and more, at the 142nd annual meeting and exposition of the American Public Health Association in New Orleans.

A few selected highlights among the dozens of posters and presentations by faculty, staff and students from the Drexel University School of Public Health include:

What Makes Communities Resilient in Times of Adversity?

Psychologists have long studied what makes individuals resilient, but when groups and entire communities of people together face disaster, violence, or other disadvantages, how do they survive and thrive together? Amy Carroll-Scott, PhD, an assistant professor in the Drexel University School of Public Health, organized moderated a session encompassing multiple presentations on Monday, Nov. 17, “Understanding and Building Resilience for Healthier Communities. The session kicked off with her own systematic, cross-disciplinary literature review of community resilience. Carroll-Scott’s research examines the conditions and characteristics of neighborhoods to better understand community-level health disparities and community-driven efforts to address them.

Another Drexel team also presented work at this session, “Understanding How to Support and Build Resilience within Community Leaders,” based on a project done in partnership with a community organization in Southwest Philadelphia to help community leaders in high-crime, high-poverty neighborhoods. “Many times people in these community leadership roles can burn out without proper support and tools,” said Nicole Vaughn, PhD, an assistant professor at Drexel and co-leader of this project. Vaughn, along with Crystal Wyatt (a community research coordinator at Drexel) and Carey Davis, D.Min (co-leader of this project and director of CityLights Network) met with a small group of community leaders to understand the stressors associated with being the “go to” people for neighbors in crisis. They worked with these leaders to develop a plan to adapt the Sanctuary Model^® for communities. The Sanctuary Model^®, developed by project co-leader Sandra Bloom, MD, an associate professor at Drexel, is an evidence-based model for organizations to operate using trauma-informed approaches. “Many of these leaders wanted more in-depth training in the Sanctuary Model ^®and more opportunities for connecting, debriefing and self-care,” Vaughn said. “All of these identified needs are important if you’re shouldering the weight of the community’s issues.”

Additional panelists discussed the state of community resilience in public health, including the RAND Corporation’s Community Resilience Project, lessons learned from New Orleans-based efforts to build community resilience post-Katrina and grassroots community resilience teams focusing on reducing gun violence in New Haven, Ct. “This session at APHA will highlight important efforts in our field that draw from and strengthen community assets in order to overcome threats to residents’ health and well being,” said Carroll-Scott in advance of the session.

How Many Buses Must a Low-Income Mother Take to Get Prenatal Care?

Travel to care is a recognized challenge for low-income pregnant women seeking prenatal care. “As a nurse, I try to make sense of what the data may mean based on my experiences caring for real pregnant women in Philadelphia,” said Joan Bloch, PhD, an associate professor in Drexel’s College of Nursing and Health Professions and School of Public Health. “If a mother arrives 15 or 20 minutes late because of delays or the hassle of traveling by bus with young children in tow to all the locations for prenatal care services, she often won’t be seen.” So in her research aiming to reduce health disparities in preterm birth – which is associated with a stunning two-fold racial disparity in infant mortality – Bloch and her collaborators combined large-scale geographical map data with a case-vignette method she calls “ground truthing.” Bloch’s poster, “More than Just Bus Fare: Critical Theory and GIS to Deconstruct Prenatal Care Travel among Low-income Urban Mothers,” discusses this simulated case quantifying the challenges facing a low-income pregnant woman in a Philadelphia neighborhood with high preterm birth rates: She would need to make 25 visits to different facilities to get prenatal care, traveling nearly 180 miles and spending more than 19 hours—in just getting to care. Bloch said this type of approach is important to understand specifically what factors can be changed to shift health disparities in preterm births.

How Can We Link Big Data Sets to Provide Public Health Insight?

Combining large-scale data sets can help public health researchers unlock insights into questions unavailable in other ways. For Jennifer Taylor, PhD, an associate professor in Drexel’s School of Public Health, to learn what types of occupational injuries and illnesses are causing harm to firefighters and other emergency responders, answers lie in the linkage among employee rosters, worker’s compensation databases and hospitalization databases. But researchers like Taylor need the ability to match up an individual record in one database to another with certainty. “Often people don’t have the luxury of unique identifiers such as Social Security numbers because they are sensitive personally-identifying information,” Taylor said. At APHA, Taylor and Michael LeVasseur, a data manager on Taylor’s research project team and a doctoral candidate in epidemiology at Drexel, presented a roundtable for work comparing methods of linking data sets. Knowing which methods are most effective and accurate when connecting data sets that may be incomplete or contain some errors, is increasingly important as the reliance on big data in public health research grows. “By linking big data sets together, we get even bigger data, and that tells a more comprehensive and complete worker injury story,” Taylor said.

What Happens When EMTs Experience Assault by Patients?

A recent Drexel MPH graduate working with Taylor, Brittany Barnes, showed a poster for work done at a much smaller and more personal scale, “Expecting the unexpected: Assaults to EMTs/Paramedics,” including in-depth information gathered through interviews and focus groups with these emergency responders. “Most people have no idea that this happens,” Taylor said, and statistics show calls for medical service are increasing at 30 percent annually. When Barnes and Taylor spoke with paramedics in Philadelphia, most de-emphasized the physical injuries they sustained. Instead, “they wanted to talk about the psychological effect of being called to someone’s house and getting beat up,” Taylor said. “That’s not expected, and the impact stays with a person. We’re concerned about what this means for paramedics as their work is already quite high-stress, and now they are dealing with combative patients as well.”

Do Food Stamps Stave Off Harmful Effects of Diabetes?

For people with Type II diabetes, a healthy diet is part of the best medicine to maintain health and stave off complications. But a consistent healthy diet and consistent medical care can both be unaffordable for low-income individuals who live with food insecurity. Darryl Brown, PhD, an assistant professor in Drexel’s School of Public Health, investigated the health care expenditures and outcomes among low-income individuals with diabetes who received federal public assistance to better afford food, and benefit-eligible low-income individuals who did not receive the assistance. Brown and Drexel collaborator and associate professor Mariana Chilton, PhD, report in their poster that the group who received benefits from the Supplemental Nutrition Assistance Program (SNAP, commonly known as food stamps) had better diabetes outcomes and used more health care services for diabetes-associated health issues than the group who did not receive SNAP – despite the latter group being older and sicker. “The SNAP-eligible group who were older and sicker should be using more health care,” Brown said. “That they don’t suggests there’s an access issue, and SNAP benefits are supporting access to care.”

– See more at: http://drexel.edu/now/archive/2014/November/APHA-Public-Health-Research/

A health checkup involves some standard measures of physical health that any patient can find familiar: Height, weight, blood pressure, and so on. And medical professionals routinely ask about some behavioral measures such as alcohol and tobacco use. Medical and public health experts know there are many more social and behavioral aspects of people’s lives that have a direct impact on how healthy they are, and that taking those details into account can yield better diagnoses and treatments for individuals. If that information can be aggregated and collected at a population scale, it can also guide development of better-designed health care systems and improved population-wide health outcomes.

However, there is currently no standard agreement on which behavioral and social information medical professionals should collect from patients, and no systemic use of these measures in the U.S. health care system.

Today, a committee convened by the Institute of Medicine of the National Academies (IOM), released a set of recommendations of 12 social and behavioral measures that should be collected as part of patients’ electronic health records. Ana Diez Roux, MD, PhD, MPH, dean of the Drexel University School of Public Health, served on the IOM committee which developed the recommendations for these “psychosocial vital signs.” The committee made its selections based on criteria including the strength of the evidence that a given domain is associated with health; the usefulness of measuring the domain for research and for individual and population health; and the availability of standard and valid ways of measuring the domain, among other factors.

The domains and measures the IOM committee recommends collecting as part of electronic health records are:

• Alcohol use
• Race and ethnicity
• Residential address
• Tobacco use & exposure
• Census tract-median income
• Depression
• Education
• Financial resource strain
• Intimate partner violence
• Physical activity
• Social connections & social isolation
• Stress

The committee also weighed practical considerations of the changes in clinical practice required to collect these measures.

“The inclusion of social and behavioral data routinely into electronic health records can lead to real transformations in the ways in which doctors use information to diagnose and treat patients, and is also of enormous value for understanding the health of populations and what we can do to improve health for all,” said Diez Roux. When health data systems are designed to collect information about social factors including financial challenges and social isolation, not only are physicians better informed about the underlying determinants of their patients’ health, but data in aggregate can be de-identified and used by city and regional public health departments to better understand their populations’ broader needs.

– See more at: http://drexel.edu/now/archive/2014/November/Psychosocial-Vital-Signs/

Federal laws explicitly addressing post-traumatic stress disorder (PTSD) have overwhelmingly focused on the needs of military personnel and veterans, according to a new analysis published in the Journal of Traumatic Stress.

The study, authored by Jonathan Purtle, DrPH, an assistant professor at the Drexel University School of Public Health, is the first to examine how public policy has been used to address psychological trauma and PTSD in the U.S., providing a glimpse of how lawmakers think about these issues.

Purtle found that in federal legislation introduced explicitly to address PTSD, an overwhelming majority of the language – more than 90 percent of the mentions of PTSD in these bills – showed efforts were targeted exclusively at military personnel. More than 90 percent of mentions of PTSD in the bills were likewise intended to address consequences of combat exposure.

This emphasis does not match with the frequency of PTSD in the U.S. population.

“Although trauma and PTSD are serious issues affecting military populations, the raw number of people affected by PTSD includes substantially more civilians simply because the civilian population is so much larger,” said Purtle.

As an example, Purtle pointed to the specific language of the bill that created National PTSD Awareness Day. The text of that resolution describes PTSD as a “wound of war” that affects people in the military and does not acknowledge that PTSD exists among civilians.

Many types of traumatic events can cause PTSD, including violent injury, car accidents, surviving life-threatening diseases, sexual assault and natural disasters, as well as combat exposure. One-time and chronic exposure to traumatic events can also cause traumatic stress, involving some symptoms common in PTSD, without matching the full pattern of diagnostic criteria for PTSD.

Purtle also found that, just as lawmakers appeared to respond to PTSD as primarily a military concern, they applied the concept of traumatic stress (other than PTSD) as a concern affecting civilians. About 75 percent of the bill sections about traumatic stress that did not mention PTSD were targeted to civilians’ needs. For example, a number of bills were introduced to address the mental health needs of U.S. civilians after the terrorist attacks of September 11, 2001, but these bills did not explicitly mention PTSD.

“It’s almost as if lawmakers didn’t want to suggest that PTSD was also a disorder among civilians,” Purtle said. “This gives a sense of how elected officials at the federal level might think about the dimensions of this problem, and shows that it doesn’t match up with what’s known about who gets PTSD.”

Although most civilian-targeted bills Purtle examined did not explicitly mention PTSD, their policies addressing trauma among civilians may still help individuals experiencing PTSD. Civilians with PTSD, as well as military members and veterans, may also benefit from policies addressing PTSD and trauma that were established through state and local legislation or via non-legislative administrative policies. These other policies were outside the scope of Purtle’s analysis, and have not yet been studied. This study specifically included only federal legislation introduced to Congress between 1989 and 2009.

The emphasis on military personnel in legislation addressing PTSD may reflect the history of the disorder, which first became known through cases in military members and veterans following combat experiences. The federal government’s role in providing medical care for veterans could also contribute to the legislation’s heightened emphasis on military PTSD in contrast to civilian PTSD.

– See more at: http://drexel.edu/now/archive/2014/November/PTSD-Public-Policy-Study/