“Emerging Activities in Rural Areas” Richard F. Hamman, MD, DrPH Dean

1. “Emerging Activities in Rural Areas”Richard F. Hamman, MD, DrPH Dean

2. Overview Northern Colorado • Introduction • Rural activities • Training • Joint degrees • Questions Colorado State UC Denver AMC Campus

3. What is Public Health? Public Health is the science and art of protecting and improving the health of communities through education, promotion of healthy lifestyles, and research for disease and injury prevention. Focuses on entire populations Rather thanindividuals

4. “Health Care is vital to all of us some of the time but public health is vital to all of us all of the time” C. Everett Koop Former Surgeon General

5. Association of Schools of Public Health (ASPH) Report“Confronting the Public Health Workforce Crisis” KEY FACTS: • ASPH estimates that 250,000 more public health workers will be needed by 2020.  • The public health workforce is diminishing over time (there were 50,000 fewer public health workers in 2000 than in 1980), forcing public health workers to do more for more people with fewer resources. 

6. ASPH Report“Confronting the Public Health Workforce Crisis” • 23% of the current workforce – almost 110,000 workers – are eligible to retire by 2012.  • Documented and forecasted shortages of – • public health physicians • public health nurses • epidemiologists • health care educators • administrators

7. ASPH Report“Confronting the Public Health Workforce Crisis” • To replenish the workforce and avert the crisis, schools of public health will have to train three times the current number of graduates over the next 12 years (Note, this doesn’t even include the massive need to provide continuing, career long training to those already in the workforce)

8. Moose test positive for Chronic Wasting Disease Jeremy P. Meyer Denver Post Staff Writer Nov 9, 2006 Two bull moose legally harvested by hunters last month in northern Colorado tested positive for chronic wasting disease, the Colorado Division of Wildlife said today. Viral disease sickens hundreds in China The Associated Press May 19, 2007 BEIJING- An outbreak of a viral disease common in children has sickened almost 900 people in eastern Chinabut the outbreak has been contained, state mediasaid Saturday. Quarantine laws need strengthening in light of TB case, health official says By KEVIN FREKING Associated Press Writer June 9,2007 Grand Junction woman dies of West Nile The Associated Press Oct 21,2006 In the news Front Range on brink of clean-air violations Kim McGuire Denver Post Staff WriterNov 12, 2006 Plague found in Park Hill critters Jeremy P. Meyer Denver Post Staff Writer April 28,2007 Five squirrels and one rabbit found dead in the Park Hill neighborhood tested positive for plague, leading health officials to caution the public against handling dead animals. Wednesday, February 4, 2009 Vitamin Cottage recalls ground peanut butter amid salmonella outbreak Denver Business Journal Too many kids pudgy by preschool Study finds Latino children most at risk; using a bottle at age 3 a clue Lauran Neergaard Associated Press Dec 28, 2006 Washington - Too many kids are fat by preschool, and Latino youngsters are most at risk, says new research that's among the first to focus on children in poverty. Seventeen percent of U.S. youngsters are obese, and millions more are overweight. Chan: Bird flu huge global health threat ELIANE ENGELER Associated Press Writer May16.2007 GENEVA- “The U.N. health chief on Wednesday harshly criticized countries that do not share their H5N1virus samples, accusing them of crippling the worldin the fight against a possible flu pandemic.” New resistant bird-flu strainstrikes Asian fowl, people Randolph E. Schmid Associated Press We need a well trained public health workforce! E. coli triggers ground beef recall Two sickened by bacterium The Denver PostJune 4,2007 Denver - The Consumer Protection Division of the Colorado Department of Public Health and Environment suggested that Coloradans who purchased certain packages of Moran's ground beef at local Albertsons stores check to make sure it hasn't been recalled due to possible contamination with E. coli. Colorado mercury emissions higher? Kim McGuire Denver Post Staff Writer Dec10, 2006 Contaminated pet food fed to hogs in 5 states The Associated Press Apr 25, 2007

9. The Colorado School of Public Health is a collaboration of : • University of Colorado Denver • Colorado State University • University of Northern Coloradotogether with • CDPHE & Local Health Departments

10. Mission The mission of the Colorado School of Public Health is to promote the physical, mental, social and environmental health of people and communities in the Rocky Mountain Region and globally. • The mission will be accomplished through collaborations in education, population-based research, and community service that bring together institutions, agencies and diverse populations.

11. Schools of Public Health: July 1, 2008

12. Collaborations Academic Research UC Denver Medicine Nursing Dentistry Pharmacy Graduate Business Public Affairs Liberal Arts and Sciences Architecture and Planning Engineering CSUVeterinary Medicine & Biomedical Sciences Agricultural Sciences Applied Human Sciences Natural Sciences UNCEducation & Behavioral Sciences Natural & Health Sciences UCD Altitude Research Center • Barbara Davis Center for Childhood Diabetes • Center for Health Services & Policy Research • Colorado Comprehensive Cancer Center UCB, CU System Coleman Institute • Institute of Behavioral Sciences • CSUArthropod-Borne & Infectious Disease Laboratory • Center for Environmental Toxicology & Technology • Tri-Ethnic Center for Prevention Research • Center on Aging • High Plains Intermountain Center for Agricultural Health and Safety UNC • Center for Applied Gerontology Research • Center for Social Science Research • Collaborative •Bio-Defense & Emerging Infectious Diseases • Consortium for Human Nutrition • And others Colorado School of Public HealthCenter for Public Health Practice Rocky Mountain Prevention Research Center NIOSH MAP ERC Colorado Injury Control Research Center Center for Global Health Center for Native American / Alaskan Native Health Community Departments and AgenciesCO Dept of Public Health & Environment Local Health DepartmentsCommunity AgenciesAffiliated Health Care & Environmental Organizations And others University Linked Organizations Area Health Education Centers-UCD CSU Cooperative Extension Future Partners: Regional Universities, State and Community Colleges and Private Institutions

13. Educational Programs • Goal: Create effective educational programs characterized by collaborative, multidisciplinary approaches to educate and train highly competent and committed public health professionals and research scientists.

14. MPH concentrations • UC Denver • Applied Biostatistics • Community & Behavioral Health • Environmental & Occupational Health • Epidemiology • Health Systems Management & Policy • Generalist • CSU • Generalist • Focus areas in: Epidemiology, Environmental & Occupational Health, Global Health & Health Disparities, Health and Exercise, Health Communication, Public Health Nutrition • UNC • Community Health Education

15. Doctoral programs • UC Denver • MS/PhD in Biostatistics • PhD in Epidemiology • PhD in Health Services Research • DrPH (under development) • CSU • MS/PhD in Environmental & Occupational Health

16. Current Enrollment (Fall 2008) • MPH150 (50 new) • Includes 35 in MSPH • 4 DVM/MPH at CSU • 1 MPH at CSU • Will add about 25-30 from UNC in spring • Certificate Students60 (35 new) • PhD53 (10 new) • Bioinformatics 10 • Biostatistics 12 • Epidemiology 21 • Health Services Research 10 • MS Biostatistics23 • Preventive Medicine Residents6 • Occupational Medicine Residents5 • TOTAL297

17. Faculty

18. Center for Public Health Practice • Goal: Create a Center for Public Health Practice to bridge academic public health with state and local health agencies, healthcare providers, and community based organizations. Community Outreach Continuing Education Service Opportunities Research in Public Health Practice

19. Research • Goal: Advance the scientific basis for the practice of public health with research that addresses the important public health issues in Colorado and the Rocky Mountain region.

20. Biostatistical / Informatics methods Clinical trials methods Disease etiology and prevention Cancer, Diabetes (Type I, II), COPD, CVD, Injury, Autism, Skin cancer, Obesity, Depression Genetic epidemiology Diabetes, COPD, CVD, Cystic fibrosis Lifecourse epidemiology Obesity, CVD risk, Asthma, Autism, Diabetes, Birth defects, Behavioral interventions Community participatory research School policy, nutrition, physical activity, obesity prevention PH practice research network Environmental health Built environment, air pollution Occupational health Beryllium, methamphetamine labs, radiation workers Health services research Medicare, Medicaid, costs of prevention Health Policy Current Research - overview

21. Facilities Northern Colorado Fitzsimons Army Hospital Building 500 – 3rd Floor Colorado State UC Denver AMC Campus

22. Today Development Applicant status for accreditation Spring 2008 First class admitted Self Study Accreditation Fall 2010 Accreditation site visit Spring 2010 Timelines Accredited Phase II Operational Accredited Operational 2006 2007 2008 2009 2010 2011 2012 2013 2014

23. Rural Activities • San Luis Valley Programs • School Programs • HICHAS - High Plains Intermountain Center for Agricultural Health and Safety (CSU) • Community Exposures and the Oil and Gas Industry • Colorado Injury Control Research Center • Colorado Colorectal Cancer Screening Program • Public Health Practice-based Research Network • American Indian Alaskan Native Research (CAIANH) • Training

24. Rocky Mountain Prevention Research Center Family-Based Prevention of Type 2 Diabetes& its ComplicationsPrincipal Investigator: Julie A. Marshall, PhD Rocky Mountain Prevention Research Centerof the San Luis Valley Health StudiesUniversity of Colorado at Denver

25. SLV Healthy Family Project*funded by the National Institutes of Health • Purpose: • Prevention of type 2 diabetes and its complications • Translation of DPP findings • Population:Families at risk for developing type 2 diabetes and/or its complications • Primary, secondary and tertiary prevention • Social & physical factors support healthy behaviors • Design: • Randomized control trial of 250 families in SLV • Randomization ratio 2:1

26. Diabetes Prevention Program*Percent reduction in diabetes risk by race-ethnicity compared with placebo

27. Intervention Goals • Improve Diet • Increase physical activity • Achieve and maintain healthy weight • Improve disease management • Increase use of community resources Healthy Family Project

28. Realization that walking can be good quality time with family Realization that walking trails are close by Increase physical activity Nature Walk Realization that walking doesn’t cost money Realization that even when feeling tired, still can find energy to go for a walk Intervention Activity Mediating Factors Outcome

29. Community Resources Healthy Family Project Family Lifestyle Coach • Family • Home Health Care System • Worksite • Community • School

30. SLVHFP Intervention • Family Lifestyle Coach trained in behavior change strategies using Motivational Interviewing • Choose target behaviors and develop individualized action plan • Receive 12-16 home visits over a 4-8 month period Healthy Family Project

31. Outcomes • Weight loss, reduced weight gain • Biochemical markers of insulin resistance • Nutrition and physical activity changes • Use of community resources • Mediators of change Healthy Family Project

32. School-based programs • School Environment Project (San Luis Valley - 10 schools - CDC) • intervention to increase opportunities for physical activity and healthy eating through school environment and policy change • SLV Physical Education Collaborative (CCTSI) • planning grant to form a collaborative that will identify the current state of physical education in the SLV and barriers/facilitators to increasing quality and quantity of PE • Integrated Nutrition Education Program • 8 schools in the SLV (joint with Pediatrics) • What’s Working Project (45 rural low income elementary schools - RWJF) • evaluation study to understand the initial impact of federally mandated local wellness policy on school environment (nutrition and activity)

33. Local School Policy Evaluation (“What’s Working Project”) • Described the initial impact of the US federally mandated Local Wellness Policy in rural, low-income elementary schools located in Colorado. • Random sample of 45 rural elementary schools (40+% of students qualified for free or reduced-cost lunch) • Opportunities for physical activity did not change after the policy went into effect: • time in physical education increased by 14 min per week (P=0.10), but time for recess decreased by roughly 19 min per week (P=0.10) • Policies supporting student participation in physical education and recess did not change. • Local Wellness Policies were weakly worded and resulted in minimal impact • Barriers: (1) competing pressures facing school districts; (2) lack of resources devoted to the Local Wellness Policy; (3) principals’ lack of knowledge about the policy, and (4) lack of accountability mechanisms to ensure policy implementation

34. High Plains Intermountain Center for Agricultural Health and Safety • Mission: to reduce illness, injury, and fatalities in agriculture • Major areas: • organic dust lung disease in multiple regional settings • development of novel and user friendly biomarkers for pesticides • Engineering research related to development and retrofitting of tractor rollover protection structures • Strong emphasis on the large Hispanic workforce in the region and on children

35. High Plains Intermountain Center for Agricultural Health and Safety (HICAHS) • Current research • An intervention to improve the design of milking parlors at dairies to reduce injuries and long-term degenerative diseases • impact of exposure to dust, ammonia and bacterial endotoxins on respiratory disease rates of dairy workers • development of an educational CD about health and safety for 4-H programs • evaluating the effectiveness of health and safety information to agricultural workers

36. Potential Human Health Effects of Oil and Gas Development in Rural Colorado • Exposure to oil and gas activity and chemicals associated with it can adversely impact human health: • increased risk of cancers, pulmonary, cardiovascular, neurological, and other diseases; adverse birth outcomes and children’s health • Major gaps in the past assessment of air quality related to oil and gas development on the Western Slope • Garfield County air quality studies indicate that potential exposures to hazardous emissions exist • Acute problem with toxic emissions of uncertain proportions and a possible emergent problem for the health of the citizens of Garfield County due to unmeasured or under-measured toxics in Garfield County, despite the increase in oil and gas development known to produce these chemicals • Health Impact Assessment of oil and gas development in Colorado should be done Testimony to Colorado Air Quality Commission, October 2008

37. Colorado Garfield County Potential Exposure-Related Human Health Effects of Oil and Gas Development: Witter R, Stinson K,Sackett H, Putter S, Kinney G,Teitelbaum D,Newman L

38. Adverse health outcomesGarfield County, CO • Garfield County higher (vs. other West Slope counties) • Children hospitalized for seizures and headache, bronchitis, asthma, respiratory infection • Birth and pregnancy outcome disorders • Alcohol and drug disorders • 2000-2005: • Violent crime rates increased (per 10,000 residents): 8.5 to 19.7 • (Rape/other sex crimes, robbery, aggravated assault) • Drug violations increased: 19.4 to 39.7 Saccomano study 2000-2007

39. Colorado Injury Control Research CenterCSU-UC Denver collaborative Center • Drug use and risky behavior among rural youth • Laboratory based research • survival of sensory and motor neurons after injury • protective factors against brain injury • Motor vehicle mortality in rural and urban areas • Rehabilitation care for individuals suffering traumatic brain injuries • Risk communication for injuries • Community based traumatic brain injury prevention • Injury among disabled individuals • Alcohol-impaired Driving: Register of Controlled Studies 

40. Colorado Injury Control Research Center • Marketing Fall Prevention Classes to Older Adults in Faith-Based Congregations: Cluster Randomized Controlled Trial • Focused on Grand Junction and regional rural populations • Aims to increase use of fall prevention classes that are known to be effective among rural elderly through social marketing

41. Colorado Injury Control Research Center – Community Initiated Grant Program • Salud Family and Health Centers • Provide bicycle helmets & car seats to migrant families at two health fairs in Northern Colorado • Larimer County Department of Health and Environment - Newborn, Infant and Toddler Safety Project • Provide home environment safety training and equipment to prevent early childhood injuries • Centennial BOCES –Migrant Education Program, Greeley, CO Injury Prevention and Education for Migrant and Homeless Families • Provide migrant and homeless families with information, skills and resources to prevent and control intentional and unintentional injuries

42. Colorado Colorectal Cancer Screening Program • Funded by the tobacco tax revenues competitive grants program • Goal: Increase colorectal screening rates among Coloradans ages 50 and older to 75% by 2010. • Provide endoscopic colorectal screening to persons without health insurance who are under 250% Federal Poverty Level and who need screening • Encourage all Coloradans ages 50 and older to get screened • Began in January 2006, expanded statewide in November 2006 • Over 6500 patients screened to date • 24% had adenomas removed (most likely to progress to cancer) • 1% were diagnosed with cancer A partnership between the University of Colorado Cancer Center, community clinics and their screening partners

43. Local Public Health Agencies • 54 local public health agencies that serve 64 counties in Colorado • 15 organized health departments • 39 public health nursing services • Serve populations ranging in size from less than 1000 to over 1.2 million Organized health departments (color) Nursing services (white)

44. Colorado Public Health Practice-Based Research Network • Partnership between The Public Health Alliance of Colorado and CSPH • Develop network infrastructure to support communication, decision-making, training and priority setting • Develop data system infrastructure: performance measures, data on environmental health determinants; population-based health status and health behavior measures • Identify high priority research questions • Identify strategies and resources to institutionalize research as an integrated component of the public health system • Study the impact of SB08-194

45. Colorado Public Health Reauthorization ActSenate Bill 08-194 • Passed in June 2008 to address outdated laws • Define public health and core public health services • Require each local public health agency to have a county or district board of health • Expand powers and duties of the State Board of Health • Expand powers and duties of county/district boards of health • Outline powers and duties of local public health agencies and directors • Require a public health planning process to further develop the new model of public health service delivery and to address related workforce and funding issues

46. Center for American Indian Alaskan Native Health (CAIANH) • The CAIANH works in AI/AN communities across the nation • AI/AN populations remains one of the most rural in the US, though increasingly urbanized • AI/AN population is a relatively small proportion of the US population and, in urban areas, tends not to live in ethnic enclaves • Health research with AI/AN often takes place on or near reservations (or villages in Alaska)

47. Center for American Indian Alaskan Native Health (CAIANH) • Colorado: 2 pilot projects in southern Colorado communities: • Oral health intervention for young children using motivational interviewing with their parents • Evaluation of a diversion program in the Tribal Wellness Court for youth with substance-involved offenses • Northern Plains and the Southwest: • Longitudinal work with children, focusing on alcohol, unintended pregnancy, HIV prevention, other topics • Psychiatric epidemiology with Vietnam veterans • Largest psychiatric epidemiology study to date with AI/AN populations • Risk for CVD among those with and without posttraumatic stress disorder (PTSD) • Oral health interventions with young children and their parents

48. Center for American Indian Alaskan Native Health (CAIANH) • Oklahoma: • Treatment research among children with substance problems • The development of innovative treatment techniques for those with mental health problems • Alaska: • Health services research with the largest providers of health care in the state - focused on screening, detection, and management in primary care, and • Recovery services for those with substance problems.

49. Center for American Indian Alaskan Native Health (CAIANH) National: • The Special Diabetes Program for Indians - Competitive Grant Program • Data coordinating center for a congressionally-mandated evaluation of 2 intervention programs: • Prevent onset of diabetes among prediabetics using the DPP model • Case management to prevent CVD among diabetics • 66 grantees, of whom 85% are in rural areas, serving over 8,000 participants • The Circles of Care Program • Works with providers of child mental health care, mostly in rural settings, to increase the reach and effectiveness of these programs • Head Start Research Center • Trains investigators and is providing the basis for a detailed study of AI/AN Head Start Centers across the country

50. Training in rural areas • MPH students • Practicum; capstone project; electives • Community Health Assessment class • Preventive Medicine Residents • Training grant has focus on medically underserved communities: Salud FHC; Health District of Northern Larimer County; AHEC • Elective courses; visiting faculty • Other health sciences students interested in public health