Delaware Journal of Public Health - May 2022

Delaware Journal of

Volume 8 | Issue 2

May 2022

Public Health A publication of the Delaware Academy of Medicine / Delaware Public Health Association

Behavioral Health & Trauma Informed Care

County Health Rankings & Roadmaps www.delamed.org | www.djph.org

2022 State Report - Delaware

Delaware Academy of Medicine

Board of Directors: OFFICERS S. John Swanson, M.D. President Lynn Jones, FACHE President-Elect Professor Rita Landgraf Vice President Jeffrey M. Cole, D.D.S., M.B.A. Treasurer Stephen C. Eppes, M.D. Secretary Omar A. Khan, M.D., M.H.S. Immediate Past President Timothy E. Gibbs, M.P.H. Executive Director, Ex-officio DIRECTORS David M. Bercaw, M.D. Lee P. Dresser, M.D. Eric T. Johnson, M.D. Erin M. Kavanaugh, M.D. Joseph Kelly, D.D.S. Joseph F. Kestner, Jr., M.D. Brian W. Little, M.D., Ph.D. Arun V. Malhotra, M.D. Daniel J. Meara, M.D., D.M.D. Ann Painter, M.S.N., R.N. John P. Piper, M.D. Charmaine Wright, M.D., M.S.H.P. EMERITUS Robert B. Flinn, M.D. Barry S. Kayne, D.D.S.

Delaware Public Health Association

Advisory Council:

Omar Khan, M.D., M.H.S. Chair Timothy E. Gibbs, M.P.H. Executive Director Louis E. Bartoshesky, M.D., M.P.H. Gerard Gallucci, M.D., M.H.S.

Delaware Journal of

May 2022

Public Health Volume 8 | Issue 2

A publication of the Delaware Academy of Medicine / Delaware Public Health Association

3 | I n This Issue Omar A. Khan, M.D., M.H.S. Timothy E. Gibbs, M.P.H.

4 | Guest Editors Erin Booker, L.P.C. Meghan McAuliffe Lines, Ph.D.

6|P ediatric Integrated Primary Care: A Population Health Approach to Meeting the Behavioral Health Needs of Children and Families Meghan McAuliffe Lines, Ph.D.

14 | M anagement of Sudden Unexpected Infant Deaths in the Emergency Department: A Family-Centered Care Protocol Stephanie Anne Deutsch, M.D., M.S., F.A.A.P. Jennifer L. Macaulay, M.S.W. Nadine Smith, D.O., F.A.A.P. Allan De Jong, M.D., F.A.A.P.

22 | M ultidisciplinary Team Approach to Addressing Child Sexual Abuse at Nemours Children’s Health, Delaware Allison T. Dovi, Ph.D. Jennifer L. Macaulay, M.S.W. Andrea Repine, A.P.R.N. Allan De Jong, M.D., F.A.A.P. Randall E. Williams, M.P.A. Stephanie Anne Deutsch, M.D., M.S., F.A.A.P.

28 | C ounty Health Rankings & Roadmaps 2022 State Report - Delaware

40 | A ctions Against Racism: Bringing Together TraumaInformed Practices, SocialEmotional Learning, and Racial Socialization to Combat Racism in Schools Danielle R. Hatchimonji, Ph.D. Kira Branch, Psy.D. Danika Perry, Psy.D. Tia N. Barnes, Ph.D.

50 | A ccommodating Developmental Disabilities in the Social Determinants of Health: A Brief Inquiry into the Applicability of Metrics to the Lives of Individuals with Developmental Disabilities in Delaware Ankita Mohan Jody A. Roberts, Ph.D.

56 | D omestic Violence: A Public Health Problem Requires a Public Health Solution Erin Ridout, M.S.W., M.P.H.

58 | G lobal Health Matters March-April 2022 Fogarty International Center

70 | P romoting Burnout Prevention Through a Socio-Ecological Lens Amy D. Habeger, Ph.D., L.C.S.W. Tana D.J. Connell, Ph.D., L.M.S.W. Rona L. Harris, M.H.S., L.B.S.W. Chanda Jackson, D.S.W.

76 | Disclosure of a Dementia Diagnosis: Minimizing Medical Trauma

Richard E. Killingsworth, M.P.H. Erin K. Knight, Ph.D., M.P.H. Melissa K. Melby, Ph.D.

78 | T rauma-Related Dissociation and the Dissociative Disorders: Neglected Symptoms with Severe Public Health Consequences Stacey M. Boyer, Psy.D. Jennifer E. Caplan, M.A. Lisa K. Edwards, M.A.

86 | T rauma: A Gateway to Substance Use Disorder Julia Lawes, M.S.

88 | A Call to Action for Delaware: Why Recruiting and Sustaining a Culturally and Linguistically Diverse Behavioral Health Workforce is Integral to Trauma-Sensitive Care Kathleen Seipel, L.C.S.W.

92 | T rauma-Informed Life Christopher Moore Catherine Dukes, Ph.D., L.C.S.W.

94 | I ntervening with Opioid-Exposed Newborns: Modifying an Evidence-Based Parenting Intervention Christiana Martin, M.A. Hung-Wei Bernie Chen, M.A. Mary Dozier, Ph.D.

106 | F rom the Archives: The Healing Arts in History Sharon Folkenroth Hess, M.A.

108 | Resources

of Advertisers 111 | Index

James M. Ellison, M.D., M.P.H. Sehba Husain-Krautter, M.D., Ph.D.

Mia A. Papas, Ph.D. Karyl T. Rattay, M.D., M.S. William J. Swiatek, M.A., A.I.C.P.

Delaware Journal of Public Health Timothy E. Gibbs, M.P.H. Publisher Omar Khan, M.D., M.H.S. Editor-in-Chief Erin Booker, L.P.C. Meghan McAuliffe Lines, Ph.D. Guest Editors Liz Healy, M.P.H. Managing Editor Kate Smith, M.D., M.P.H. Copy Editor Suzanne Fields Image Director ISSN 2639-6378

COVER

Adopting a traumainformed approach is not accomplished through any single particular technique or checklist. It requires constant attention, caring awareness, sensitivity, and possibly a cultural change at an organizational level.

The Delaware Journal of Public Health (DJPH), first published in 2015, is the official journal of the Delaware Academy of Medicine / Delaware Public Health Association (Academy/DPHA).

only the opinions of the authors and do not necessarily reflect the official policy of the Delaware Public Health Association or the institution with which the author(s) is (are) affiliated, unless so specified.

Submissions: Contributions of original unpublished research, social science analysis, scholarly essays, critical commentaries, departments, and letters to the editor are welcome. Questions? Write ehealy@delamed.org or call Liz Healy at 302-733-3989.

Any report, article, or paper prepared by employees of the U.S. government as part of their official duties is, under Copyright Act, a “work of United States Government” for which copyright protection under Title 17 of the U.S. Code is not available. However, the journal format is copyrighted and pages June not be photocopied, except in limited quantities, or posted online, without permission of the Academy/ DPHA. Copying done for other than personal or internal reference use-such as copying for general distribution, for advertising or promotional purposes, for creating new collective works, or for resale- without the expressed permission of the Academy/DPHA is prohibited. Requests for special permission should be sent to ehealy@delamed.org.

Advertising: Please write to ehealy@delamed.org or call 302-733-3989 for other advertising opportunities. Ask about special exhibit packages and sponsorships. Acceptance of advertising by the Journal does not imply endorsement of products.

Copyright © 2022 by the Delaware Academy of Medicine / Delaware Public Health Association.

Opinions expressed by authors of articles summarized, quoted, or published in full in this journal represent

I N T H I S I S SU E Trauma Informed Care (TIC) has been evolving since the 1970s when the term Post Traumatic Stress Disorder (PTSD) was first used to describe substance use and mental disorders in soldiers returning from the Vietnam War. Over time, behavioral experts have come to realize that any past trauma and current behavior may be linked.

When referring to children, we add the term “Adverse Childhood Experiences,” or ACEs, to our lexicon, and now understand that ACEs have “a tremendous impact on future violence victimization and perpetrations, and lifelong health and opportunities.”1 This issue of the Delaware Journal of Public Health includes articles by Delaware experts, and covers a range of topics from ACEs to domestic violence, racism to dementia. This issue also includes Delaware’s County Health Rankings Report (CHR) for 2022, which includes several new tools and findings, making this report the most useful to date.

This year the theme of the Rankings is “A Just Recovery to Achieve Economic Security and Health for All.” The full Rankings can be accessed at https://www.countyhealthrankings.org/ As we learn to live with COVID-19, perhaps the best lessons are based on what we already knew from common sense and empathy: handwashing, wearing a mask in close quarters, and getting vaccinated will help to slow the spread.

Most importantly, recognizing that, as the CHR puts it, “The COVID-19 pandemic both revealed and worsened barriers to health and well-being such as racism, discrimination and disinvestment.” Thus, we have the opportunity to be our best selves while also following the science. We must continue to pursue science-based public health policies which arc us towards justice for all.

As always, we welcome reader input and theme suggestions, as well as submissions. Stay well!

REFERENCES 1. L. (2021, Apr). A micro-history of trauma informed care. https://www.lostvoices.org/a-micro-history-of-trauma-informed-care/

Omar A. Khan, M.D., M.H.S. Editor-in-Chief, Delaware Journal of Public Health

DOI: 10.32481/djph.2022.05.001

Timothy E. Gibbs, M.P.H Publisher, Delaware Journal of Public Health

3

Erin Booker, L.P.C. Vice President, Behavioral Health and Social Care Integration, ChristianaCare

I am grateful to have been given the opportunity to be a Guest Editor on what I consider to be an essential issue of the Delaware Journal of Public Health. As a Behavioral Health professional, the topic of trauma is one I have dedicated much of my career to. I have seen the significant impact and pain it has inflicted on lives while simultaneously being given the gift of seeing the beauty in the healing journey.

The word trauma can often be misunderstood, and in doing so it can strip people of their very real experiences, so I hope that this issue will help to shed light on the reality that trauma can present itself in many different ways, and that no one trauma is more or less impactful or real than another.

Healing from trauma is a complicated process, but what I know is that in order to heal, you must start by acknowledging your experience. For many, the ability to do that is closely connected to the feeling of being heard and removing the feeling of isolation. As you walk through your life, I ask that you take the time to truly see people and give them the safe space to show up authentically, because in that authenticity many will find the courage needed to begin their healing process.

As a community we have the power to create a healing environment. That is something I wake up every morning excited to be a small part of, and I hope that each of you will join me.

Meghan McAuliffe Lines, Ph.D. Clinical Director, Integrated Primary Care & School-Based Health, Department of Psychology, Nemours Children’s Health; Clinical Associate Professor of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University

I am grateful for the opportunity to serve as a Guest Editor for this issue of the Delaware Journal of Public Health focused on Behavioral Health and Trauma-Informed Care. Behavioral health is a vital element of overall health and wellbeing, and as such public health approaches to improve the behavioral health of the population are of paramount importance. Multifaceted, evidence-based strategies across the lifespan and care continuum are essential to addressing the growing needs of the population.

The focus on Behavioral Health and Trauma-Informed Care for the current issue of the DJPH is timely.

There have been dramatic increases in mental health symptoms globally during the COVID-19 pandemic, related to fear, uncertainty, isolation, grief, and loss. Moreover, scholars have cited the impact of “dual pandemics” of COVID-19 and systemic racism, in which communities of color have been disproportionately impacted by racial trauma and disparities in care during the pandemic. These circumstances emphasize the importance of a trauma-informed and culturally-responsive lens when evaluating and treating behavioral health concerns.

The collection of articles included in this special issue highlight the robust research and practice related to behavioral health, social determinants of health, and trauma-informed care that is happening in Delaware.

We are fortunate to have so many experts conducting behavioral health scholarly and applied work with different clinical populations and cultural groups across settings and contributing their knowledge and expertise to this issue. In addition to client- and patient-centered work, a trauma-informed approach reinforces the importance of considering the vicarious trauma experienced by clinicians as well. Several articles in this issue also look at the provider perspective as related to burnout, wellness, and workforce development, which must not be overlooked if we are going to build a sustainable behavioral health workforce.

I hope you enjoy reading the special issue, and it sparks interest in advocacy and collaboration with partners statewide to address the behavioral health needs of our community.

4 Delaware Journal of Public Health - May 2022

Read online here

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Pediatric Integrated Primary Care: A Population Health Approach to Meeting the Behavioral Health Needs of Children and Families Meghan McAuliffe Lines, Ph.D. Clinical Director, Integrated Primary Care & School-Based Behavioral Health, Nemours Children’s Health, Delaware; Clinical Associate Professor of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University

ABSTRACT Addressing the behavioral health needs of the population is a growing public health concern; a significant portion of the population struggles with behavioral health challenges yet access to care is limited due to a multitude of barriers. Research has demonstrated that integration of behavioral health providers into the primary care team is an effective means of increasing care access and reducing barriers to care. While there has been an uptake in integrated primary care (IPC) in adult healthcare, there is significant opportunity for expanding IPC in pediatrics.

Nemours Children’s Health has developed a model IPC program to serve children and youth in Delaware and train future behavioral health professionals. Policy to support payment for IPC services and fund workforce development will be essential to sustaining the Nemours program as well as expanding this and other IPC models in order to serve more children and youth in Delaware and beyond.

RATIONALE FOR INTEGRATED PRIMARY CARE Behavioral health conditions are a common and costly public health concern. It is estimated that 13 million adults in the United States experienced significant mental illness in the past year, and the economic impact of mental illness is over $300 billion annually.1 Behavioral and physical health are inextricably linked, where individuals with mental health comorbidities often experience poorer physical health than the general population, and physical health conditions may contribute to or exacerbate behavioral health concerns.2 Yet despite the clear linkage between physical and behavioral health, behavioral healthcare has historically been isolated from the medical system, both in terms of care provision and payment. This often results in poorer access to behavioral health care, particularly for historically underrepresented populations, thus further widening existing health disparities for minoritized groups (such as Black, Latin@, and other minoritized populations).3 This separation also likely contributes to the stigma that exists in many communities with seeking out care for behavioral health concerns.

Integration of behavioral health care into the primary care setting increases access to much-needed care in a safe, comfortable and destigmatized environment. This is critical for ensuring equitable access to high quality, evidence-based, and trauma-informed care for all patients, particularly those from underrepresented groups.

Models of integrated primary care (IPC), in which behavioral health providers deliver care as members of the primary care team, can often provide earlier access to care through a shorter wait time to service (typically ranging from same day to a few weeks for IPC, vs. several months for an outpatient therapist) as well as being referred for care sooner than they might otherwise be referred to a provider outside of the practice (resulting in prevention or earlier intervention).4,5 6 Delaware Journal of Public Health - May 2022

IPC models are consistent with healthcare models that have emerged in recent decades to improve and reform the healthcare system. The Quadruple Aim, adapted from the widely accepted Triple Aim, is a framework that aims to reduce healthcare costs, improve population health outcomes, improve patient care, and improve provider well-being.6–8 The Quadruple Aim is in alignment with IPC models, and is consistent with Value-Based Care (VBC).

VBC is an advancement in payment reform, that moves away from a traditional fee-for-service model in which healthcare providers are paid for treating “sick” patients, to incentivizing health promotion and wellness. VBC places emphasis on rewarding healthcare providers and health systems for administering preventive care, improving population health outcomes, and increasing care quality. Given the close connection between physical and behavioral health, VBC is in clear philosophical alignment with the preventative nature of primary care and adds a clear and compelling financial incentive to the already existing clinical rationale for move more rapidly towards IPC models.

RATIONALE FOR PEDIATRIC INTEGRATED PRIMARY CARE IPC models have developed a foothold in adult primary care but are still relatively less common in pediatrics. Pediatric IPC models have been present for over 40 years9 and have begun to gain traction in recent years. Emerging data suggest that IPC is a key approach to addressing the growing behavioral health needs of our nation’s youth and further spreading and scaling of pediatric IPC models is needed.

Mental health concerns are among the most prevalent health concerns for children and adolescents in the United States, DOI: 10.32481/djph.2022.05.002

with 10-20% of youth each year meeting criteria for a mental health diagnosis, but more than 50% of them never receiving the needed treatment.10,11 Youth from minoritized racial and ethnic groups and youth living in poverty are at higher risk of mental health challenges yet are even less likely to receive behavioral health treatment than youth overall.12–14 Moreover, youth mental health needs have skyrocketed in the wake of the COVID-19 pandemic and the heightened racial trauma in the U.S. following the murders of Breonna Taylor, Ahmaud Arbery, George Floyd, and too many others, leading to multiple pediatric expert organizations coming together to declare a national emergency in child and adolescent mental health, particularly for youth of color, and calling for policy changes and advocacy to meet the critical needs.15 The American Academy of Pediatrics recommends 12 well-child visits with a child’s primary care provider (PCP) between the age of 0-3 years, followed by annual visits from ages 3-21 years.16 Since children have a consistent, longitudinal relationship with their PCP and relatively frequent contact, particularly in the early years, IPC is a seamless fit for pediatrics. Integrating a behavioral health provider as part of the primary care team is an opportunity to reduce access barriers related to stigma, time, and transportation, and increase comfort and trust with seeking behavioral health services. IPC also connects logically with the pediatric primary care focus on prevention and provides an opportunity to truly move behavioral healthcare “upstream” and take a population health approach to whole child wellness. Pediatric integrated care provides population-level care to more children, removes barriers to obtaining care, and increases access to high quality, culturally-relevant, evidence-based practices.17 Pediatric IPC offers the opportunity for a continuum of services ranging from prevention and health promotion activities (e.g., HealthySteps, an integrated, preventive program for at-risk early childhood patients ages 0-3 and their caregivers) to more traditional mental health interventions.18 Untreated mental health needs during childhood are associated with negative health outcomes (poorer mental and physical health, increased substance use, increased suicide risk).19 Conversely, several studies to date indicate positive outcomes for youth who receive behavioral health services in primary care. These include outcomes related to HealthySteps20–25 (e.g., higher social-emotional screening scores, higher rates of vaccination, lower rates of childhood obesity, decrease in maternal depression symptoms, increase in safe parenting practices) as well as other services along the integrated primary care continuum (mental health symptom reduction, better continuity of care).26–28 While the cost savings in pediatrics is not always as readily apparent as in the adult literature, there is still a financial impact of pediatric IPC with public health implications.

Untreated mental health needs in childhood yield higher costs (i.e., higher health care service utilization) in adulthood.19 Conversely, pediatric IPC services have demonstrated short term medical cost-offset in some studies and have potential implications for longer term cost savings.29,30

PEDIATRIC INTEGRATED PRIMARY CARE AT NEMOURS CHILDREN’S HEALTH Nemours Children’s Health is one of the largest integrated pediatric health systems in the country with multispecialty pediatric hospitals in Delaware and Florida, and additional outpatient locations in Delaware, Florida, Pennsylvania, and New Jersey. As the only pediatric health system in Delaware, Nemours has a main hospital campus in Wilmington, outpatient specialty services in Milford, as well as 12 pediatric primary care clinics throughout the state that serve as the primary care medical home for approximately 30% of the children in Delaware. These primary care clinics are recognized by the National Committee for Quality Assurance (NCQA) as pediatric Patient Centered Medical Homes (PCMH), a model that emphasizes interdisciplinary teams, care coordination, and quality improvement. As part of the medical home model, behavioral health providers are integrated into the care team at all 12 Nemours Children’s Health primary care practices in Delaware.

Nemours has been a national leader in pediatric IPC, integrating the first behavioral health providers into pediatric primary care practices in 2002. Behavioral health providers at Nemours see patients and families for 45-minute new patient and follow-up visits within the primary care clinic when referred by their PCP for emotional, behavioral, developmental, or health behavior concerns. Behavioral health providers are also available in the moment for “warm handoffs,” with real time consultations during a patient’s medical visit. Depending upon the presenting concerns, a warm handoff may consist of any of the following: a brief introduction to behavioral health services in the practice and encouragement for scheduling follow up, brief assessment and psychoeducation or brief intervention, risk assessment and treatment planning, and a more comprehensive same day visit if conducive to the provider and family schedule. In addition to visits with patients, behavioral health providers also engage in population-level screening initiatives, participate in case consultation with other members of the care team, co-manage common behavioral health conditions with PCPs (e.g., ADHD, functional GI disorders, sleep problems), and engage in quality improvement efforts within clinic.

Over the past 20 years, the Nemours IPC program has demonstrated significant growth in several ways. Behavioral health providers started out in two practices and are now integrated into all 12 practices in Delaware. There has been an increase in total provider time across the clinics, starting with two trainees spending a half-day per week in primary care under supervision, whereas now there are approximately 12 full-time equivalents (FTE) of licensed provider time, and an additional 4-5 FTEs of trainee time across 12 practices. Each clinic has between .5 FTE and 2.0 FTE of behavioral health provider time based upon patient and training needs. This increase has allowed for several factors to take place: the behavioral health providers have become an integral part of the care team within the practices, behavioral health is involved in both episodic and longitudinal care of patients along with PCPs, and Nemours has been able to contribute to workforce development of behavioral health providers entering the workforce trained to deliver pediatric IPC services.

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While there has been significant institutional support that has promoted program growth and sustainability, there continue to be systems level challenges that interfere with full integration. As stated earlier, physical and mental health care have historically been separated from one another and IPC presents an opportunity to bring them together for holistic care. Although clinical models of integration have served to remove some of this separation, there is still room for further integration in pediatrics. In many institutions, physical health is further along on the VBC journey than behavioral health is, so fee-for-service contracts limit the services for which IPC providers can be reimbursed. The Nemours team has had success with obtaining grant funding to pilot early childhood integration models (e.g., integrated well child visits, preventive care), but further policy change will be needed at the payor level to truly spread and scale these efforts as they are not covered in a traditional fee-for service model (which typically requires a mental health diagnosis).

POLICY AND ADVOCACY IMPLICATIONS There are several recent policy efforts that support IPC at the federal and state level. The Affordable Care Act requires that primary care providers perform a number of preventive services as part of routine care, many of which are related to behavioral health care (e.g., developmental and autism screening, behavioral assessment, depression screening, drug and alcohol assessments.31 IPC providers are often engaged in supporting these efforts within the PCMH. The Mental Health Parity and Addiction Equity Act (MHPAEA) mandates equal insurance coverage for behavioral health care.32 While this law is fundamental, additional policy work to ensure compliance with mental health parity laws is warranted.15 Just as Delaware has been a clinical leader in pediatric IPC, Delaware lawmakers have set an example for other states with innovative policy. In 2022, Delaware introduced House Bill 303, which if enacted will require insurance to cover an annual behavioral health well check with a licensed behavioral health provider. This could be a step toward true mental health parity, allow for coverage of integrated well visits, and provide support for a public health approach to behavioral health care.

Additional policies to support payment for fully integrated models of behavioral health in primary care that represent the full continuum from prevention to intervention for the pediatric lifespan are essential. There is research to support that these models are effective in reaching families, improving outcomes, and saving costs, so providers and health systems need policy support to disseminate sustainable programs.

The Nemours IPC program has been fortunate to receive several grants from HRSA to support the training and education of psychology and social work trainees, and will continue to seek out opportunities to garner support for workforce development. However, there continues to be a national shortage in behavioral health providers, and the shortage is even more significant when considering providers who represent racial, ethnic, or linguistic diversity. Education and training support programs to incentivize individuals to pursue careers in behavioral health, and workforce development funding for organizations to support licensure and incentivize retention in Delaware are critical. We must invest in our workforce in order to provide optimal care for our children and families.

Dr. Lines may be contacted at Meghan.Lines@Nemours.org 8 Delaware Journal of Public Health - May 2022

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Interventions for adolescent mental health: An overview of systematic reviews. J Adolesc Health, 59(4S), S49–S60. https://doi.org/10.1016/j.jadohealth.2016.06.020 20. Gross, R. S., Briggs, R. D., Hershberg, R. S., Silver, E. J., Velazco, N. K., Hauser, N. R., & Racine, A. D. (2015, October). Early child social-emotional problems and child obesity: Exploring the protective role of a primary care-based general parenting intervention. J Dev Behav Pediatr, 36(8), 594–604. https://doi.org/10.1097/DBP.0000000000000212 21. Briggs, R. D., Silver, E. J., Krug, L. M., Mason, Z. S., Schrag, R. D. A., Chinitz, S., & Racine, A. D. (2014).

Healthy Steps as a moderator: The impact of maternal trauma on child social-emotional development. Clinical Practice in Pediatric Psychology, 2(2), 166–175. https://doi.org/10.1037/cpp0000060

22. Guyer, B., Barth, M., Bishai, D., Caughy, M., Clark, B., Burkom, D., . . . Tang, C. (2003). Healthy steps: The first three years: The Healthy Steps for Young Children Program National Evaluation. https://ztt-healthysteps.s3.amazonaws.com/documents/139/ attachments/2003_HS_National_Evaluation_Report.pdf?1539967 23. Johnston, B. D., Huebner, C. E., Tyll, L. T., Barlow, W. E., & Thompson, R. S. (2004, May). Expanding developmental and behavioral services for newborns in primary care; Effects on parental well-being, practice, and satisfaction. American Journal of Preventive Medicine, 26(4), 356–366. https://doi.org/10.1016/j.amepre.2003.12.018 24. Johnston, B. D., Huebner, C. E., Anderson, M. L., Tyll, L. T., & Thompson, R. S. (2006, August). Healthy steps in an integrated delivery system: Child and parent outcomes at 30 months. Archives of Pediatrics & Adolescent Medicine, 160(8), 793–800. https://doi.org/10.1001/archpedi.160.8.793 25. Buchholz, M., & Talmi, A. (2012, July). What we talked about at the pediatrician’s office: Exploring differences between healthy steps and traditional pediatric primary care visits. Infant Mental Health Journal, 33(4), 430–436. https://doi.org/10.1002/imhj.21319 26. Burkhart, K., Asogwa, K., Muzaffar, N., & Gabriel, M. (2020, February). Pediatric integrated care models: A systematic review. Clinical Pediatrics, 59(2), 148–153. https://doi.org/10.1177/0009922819890004 27. Shah, R., Kennedy, S., Clark, M. D., Bauer, S. C., & Schwartz, A. (2016, May). Primary care–based interventions to promote positive parenting behaviors: A meta-analysis. Pediatrics, 137(5), e20153393. https://doi.org/10.1542/peds.2015-3393 28. Weersing, V. R., Brent, D. A., Rozenman, M. S., Gonzalez, A., Jeffreys, M., Dickerson, J. F., . . . Iyengar, S. (2017, June 1). Brief behavioral therapy for pediatric anxiety and depression in primary care: A randomized clinical trial.

JAMA Psychiatry, 74(6), 571–578. https://doi.org/10.1001/jamapsychiatry.2017.0429 29. Dopp, A. R., Smith, A. B., Dueweke, A. R., & Bridges, A. J. (2018). Cost-savings analysis of primary care behavioral health in a pediatric setting: Implications for provider agencies and training programs. Clinical Practice in Pediatric Psychology, 6(2), 129–139. https://doi.org/10.1037/cpp0000231 30. Buchholz, M., Burnett, B., Margolis, K. L., Millar, A., & Talmi, A. (2018). Early childhood behavioral health integration activities and HealthySteps: Sustaining practice, averting costs. Clinical Practice in Pediatric Psychology, 6(2), 140–151. https://doi.org/10.1037/cpp0000239 31. Patient Protection and Affordable Care Act, 42 U.S.C. § 18001 (2010).

32. Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA, P.L. 110-343).

9

The DPH Bulletin

From the Delaware Division of Public Health

April 2022

Delaware Flood Awareness Week is May 9-13, 2022; know your risk

DPH launches expanded booster awareness campaign For the best protection against COVID-19, Delawareans should get a booster dose of the vaccine.

People who are boosted were five times less likely to get COVID-19 than unvaccinated persons and two times less likely than fully vaccinated persons, according to the Centers for Disease Control and Prevention (CDC).

The Division of Public Health (DPH) just launched an expanded booster campaign to clarify that everyone 12+ is eligible for boosters, that they are important to increase protection from waning vaccine immunity, and that you are better protected by getting one even after you had COVID without one.

Only 49 percent of eligible Delawareans have received a booster, according to DPH. Booster uptake is highest in the 65+ age group (74 percent) and lowest in the 12-17 age group (26 percent).

A second booster dose of the Pfizer-BioNTech and Moderna COVID-19 vaccines is available for certain immunocompromised persons and those over the age of 50, at least four months after their first booster. People in these categories may choose to get a second booster four months after their first: • Persons over age 50 (Pfizer and Moderna) • Persons 12+ (Pfizer) or 18+ (Moderna) with certain levels of immunocompromise (organ transplants, stem cell replacement, cancer or HIV treatment, or taking immunosuppressants).

• Persons who received J&J for their initial vaccine and booster (should get mRNA second booster).

Learn more about booster eligibility at de.gov/boosters. To find vaccination sites, visit de.gov/getmyvaccine.

Delaware Flood Awareness Week (May 9-13) alerts Delawareans about increasing flood risks from the impacts of climate change and sea level rise, leading to more frequent extreme weather events including hurricanes and tornadoes.

The Delaware Department of Natural Resources and Environmental Control (DNREC), the Delaware Emergency Management Agency (DEMA), and the Federal Emergency Management Agency (FEMA) are partnering to help the public become better informed about flood insurance, which provides financial security and ensures quick recovery of personal property from flood damage. That’s important in Delaware, the country’s lowest-lying state, where just a few inches of rainfall can cause significant damage to homes and businesses yearround and coastlines are vulnerable to flooding from storm surges or tides during coastal storms.

Delaware and more than 50 communities across the state participate in FEMA’s National Flood Insurance Program (NFIP). Each community adopted a floodplain ordinance that meets or exceeds the minimum NFIP requirements for development in the 100-year floodplain, according to DNREC’s Floodplain Management Program.

In coordinating the state’s NFIP coverage, the program helps communities enforce minimum floodplain management standards in keeping with federal regulations and promotes adoption of higher standards to reduce flood risk. Recently, the program introduced the interactive Delaware Flood Planning Tool to help Delawareans make informed decisions on a specific area or property.

Additionally, the Delaware Homeowner’s Handbook to Prepare for Natural Hazards from DNREC, DEMA, and Delaware Sea Grant advises homeowners on actions they can take to help protect their properties from flooding.

Visit these links or call the Floodplain Management Program at 302-739-9921 for more information.

10 Delaware Journal of Public Health - May 2022

20th Annual Diabetes Wellness Expo is May 10 at the fairgrounds in Harrington The 20th Annual Diabetes Wellness Expo will be held on May 10, 2022, at the Delaware State Fairgrounds. The free public event will be held from 9:00 a.m. to 3:00 p.m. in the Kent Open Air Barn at 18500 S. DuPont Highway in Harrington.

People with diabetes, pre-diabetes, caregivers, employers, and health professionals are encouraged to attend to learn how to prevent complications of the chronic disease, such as kidney failure, adult blindness, lower-limb amputations, heart disease, and stroke.

More than 50 exhibitors and educational seminars will provide information about diabetes management, nutrition, exercise, medication adherence, foot care, and depression.

Diabetes and blood pressure screenings and dental and eye exams will be offered.

Complimentary $10 lunch vouchers will be available first-come, first-served.

The public event is sponsored by the Delaware Diabetes Coalition (DDC), the Division of Public Health (DPH)’s Diabetes and Heart Disease Prevention and Control and Physical Activity, Nutrition and Obesity Prevention (PANO) programs, Bayhealth, Simon Eye Associates, and AmeriHealth Caritas Delaware.

The prevalence of diagnosed diabetes in Delaware (13 percent) exceeds the U.S. prevalence of 11 percent. In a survey, more than 98,700 Delaware adults reported in 2019 that they had been diagnosed with diabetes, according to The Burden of Diabetes in Delaware, 2021. An additional 75,100 (2019) Delaware adults reported being diagnosed with pre-diabetes. Progression to type 2 diabetes can be prevented or delayed by losing weight, engaging in at least 150 minutes of physical activity weekly, and improving one’s diet.

To register or become a vendor for this event, visit www.dediabetescoalition.org/wellness-expo/. Send questions to director@dediabetescoalition.org.

To learn more about diabetes management and prevention programs and resources, click here; or call DPH at 302-744-1020.

The DPH Bulletin – April 2022

Healthy Heart Ambassador Blood Pressure Self-Monitoring Program Do you have diabetes and/or hypertension?

About six out of 10 people who have diabetes also have high blood pressure, according to the Centers for Disease Control and Prevention (CDC). High blood pressure increases the risk of heart disease and stroke.

A normal blood pressure level is less than 120/80 mmHg. Individuals can manage their high blood pressure by checking it with a blood pressure monitor at home, at the doctor’s office, or at some pharmacies or clinics.

Delawareans in need of help with controlling their hypertension can sign up for the Division of Public Health’s (DPH) Healthy Heart Ambassador – Blood Pressure Self-Monitoring Program.

For information or to enroll, call 302-208-9097, email DHSS_DPH_HHA@delaware.gov, or visit https://www.healthydelaware.org/Individuals/Heart/ Healthy-Heart-Ambassador-Program#intro.

Percentage of middle and high school students who reported current (past 30-day) use of select tobacco products, any tobacco product, any combustible tobacco product, or two or more tobacco product types, by school level* – National Youth Tobacco Survey, United States, 2021

* Overall estimates were reported among 20,413 U.S. middle and high school students. School level was determined by self-reported grade level: high school (grades 9–12; n = 10,515) and middle school (grades 6– 8; n = 9,763).

Click here to read the summary in the Centers for Disease Control and Prevention’s March 11, 2022 Morbidity and Mortality Weekly Report.

Page 2 of 4 11

Salads add fruits and vegetables to diets with crunch, zest, and sweetness A healthy diet supports a healthy immune system and can help prevent chronic diseases such as obesity, type 2 diabetes, cardiovascular diseases, and some cancers.

The U.S. Department of Agriculture and U.S. Department of Health and Human Services recommends Americans eat 1.5 to 2.5 cups of fruit and two to four cups of vegetables each day.

However, the Centers for Disease Control and Prevention (CDC) reports that the percentage of U.S. adults meeting fruit and vegetable intake recommendations is low. In 2019, only 12 percent of adults met fruit intake recommendations and 10 percent met vegetable intake recommendations.

Eating salads is an easy and versatile way to incorporate more fruits and vegetables into your diet.

Salads can be made with fresh fruit such as melons, berries, apples, citrus, and grapes. Berries and citrus add sweet or zesty flavor. The American Heart Association suggests creating salads with leafy greens like spinach or romaine. Raw vegetables like carrots, cucumbers, and broccoli can add crunch and flavor to salads, while roasted beets, potatoes, and squash add some sweetness. Beans, a hard-boiled egg, tuna, or grilled chicken add protein. Mixing in cooked whole grains like couscous, barley, or quinoa make you feel fuller.

To learn more about eating healthy, visit the 2020– 2025 Dietary Guidelines for Americans. The CDC recommends that you wash fruit and vegetables before eating, cutting, or cooking. Healthy Delaware’s Healthy Living Blog offers salad and other recipes to create with fresh produce.

Spring is the perfect time to start growing fruit and vegetables in your backyard, patio, or even in containers, indoors or outdoors. The Delaware Master Gardeners provide helpful videos, tips, and workshops to grow fruit and vegetables. For gardening advice, call the Master Gardeners’ Helplines in each county: New Castle County, 302831-2667; Kent County, 302-730-4000; and Sussex County, 302-856-7303, ext. 535.

The DPH Bulletin – April 2022 12 Delaware Journal of Public Health - May 2022

Managing stress can improve your outlook, relationships, and even productivity at work Let’s face it – the last two years have been stressful for all of us!

Although some stress can be beneficial, too much can negatively affect job productivity and relationships with co-workers, lead to job turnover, and result in lateness and absenteeism. Stress also can cause unhappiness, difficulties focusing, fatigue, and decreased enthusiasm. It can also have a significant impact on your physical and mental health, as it can lead to problems such as hypertension and heart disease, not to mention anxiety and depression.

There are things you can do while at work to reduce stress levels and become a happier person overall.

Follow these tips from the American Psychological Association: • Make your workspace comfortable. Add plants or other elements to make you feel happier.

• Take a walk, do yoga, or get some fresh air on your breaks. Getting some exercise benefits the body and can improve sleep.

• Learn how to relax. Meditation, deep breathing exercises, and mindfulness (where one actively observes present experiences and thoughts without judging them) can help decrease stress.

• Talk to your supervisor. Plan how to manage identified stressors by improving time management skills, identifying employer-sponsored wellness resources, clarifying work expectations, and getting support from colleagues.

For more information about reducing work stress, visit https://www.apa.org/topics/healthy-workplaces/work-stress and https://www.health.harvard.edu/blog/how-tohandle-stress-at-work-2019041716436.

Page 3 of 4

Hoarding: A recognized illness leading to health and safety issues

According to the Diagnostic & Statistical Manual of Mental Disorders-2013 (DSM-5), hoarding disorder is a recognized psychiatric illness characterized by a “persistent difficulty, discarding, or parting with possessions regardless of their value.” The clutter inhibits the use of the home as designed. A person may experience distress and fear of getting rid of things (disposophobia) and may resist interventions.

The disorder afflicts 13 million Americans, of whom 6.2 percent are age 55 and older (Johns Hopkins University research), said Gail Weinberg, Trainer/Educator III with the Delaware Department of Health and Social Services’ Division of Services for Aging and Adults with Physical Disabilities. Hoarding impacts individuals of all ages, races, ethnicities, and socioeconomic and educational levels. Dementia and other cognitive issues, medical problems, and mobility issues contribute to hoarding situations. Individuals who hoard may have strong emotional attachment to items, fear forgetting the significance of items, or have experienced trauma.

“Seventy-five percent of individuals who hoard have a co-occurring behavioral health issue such as anxiety, depression, obsessive compulsive disorder, or attention deficit disorder,” Weinberg said. They often have difficulty making decisions and organizing.

Extreme clutter presents numerous health and safety risks: falls, fires, insect and rodent infestations, and illness and allergies caused by expired food, mold, and unsanitary conditions. First responders are hindered by narrow walkways weaving through piles of possessions. Individuals who hoard may have problems with landlords, neighbors, and code officials; face eviction and homelessness; and be rejected from home health aide services.

Weinberg emphasizes that a hoarding disorder is a treatable behavioral health disorder. Individuals who hoard should seek a therapist with experience treating hoarding or obsessive-compulsive disorders and who employs cognitive behavioral therapy. To find such a provider, call the local hospital’s referral line or visit Help is Here Delaware at HelpisHereDE.com and 833-9-HOPEDE.

The DPH Bulletin – April 2022

Tips to address individuals who hoard • Do no harm. Clean-outs should be a gradual process of slowly cleaning small areas unless there is an extreme environmental emergency.

• Sorting small piles can make the task more manageable. Try the three-pile approach: keep, discard, and donate.

• Be patient, stay calm, and do not argue.

Getting rid of possessions can be distressing.

• Listen, empathize, affirm, and redirect.

• Do not clean up without the individual, as that will upset them. Hoarders have a mental map of where things are.

• Enlist a team of helpers to make a realistic plan. Search the DonationTown Directory (http://www.donationtown.org/charity/) for charities that accept and/or pick up certain donated items or call them directly.

Habitat for Humanity, GreenDrop, Friendship House, Goodwill, the Salvation Army, and other organizations accept donated items.

• Read Buried in Treasures: Help For Compulsive Acquiring, Saving And Hoarding, 2nd edition by Dr. Randy Frost and Dr. Gail Steketee. Children of hoarders can visit a grassroots support group at https://childrenofhoarders.com/wordpress/.

Faith and recovery conference is May 11

The Faith Forward Collaborative Healing Substance Addiction is sponsoring the “Engaging Faith in Recovery” Conference on May 11, 2022 to educate faith communities about substance use disorder.

The free event is from 8:30 a.m. to 2:30 p.m. at Delaware State University’s Martin Luther King Building, located at 1200 N. Dupont Highway in Dover.

The Reverend Erica Poellot, director of the national Faith in Harm Reduction Coalition, is the keynote speaker.

CEUs are available for a $10 fee.

Registration is required. To register, visit https://www.faithforwardcollaborativede.org/.

Page 4 of 4 13

Management of Sudden Unexpected Infant Deaths in the Emergency Department: A Family-Centered Care Protocol Stephanie Anne Deutsch, M.D., M.S., F.A.A.P.; Jennifer L. Macaulay, M.S.W.; Nadine Smith, D.O., F.A.A.P.; Allan De Jong, M.D., F.A.A.P. Nemours Children’s Health, Delaware

ABSTRACT Objective: To establish a standardized, trauma informed and family-centered emergency department (ED) sudden and unexpected infant death (SUID) management protocol at Nemours Children’s Health, Delaware for medical professionals and multidisciplinary team (MDT) collaborators, informed by national clinical practice guidance, and respective of both family and investigative needs. SUID are emotionally distressing for involved family members, often precipitated by profound grief and confusion as the family interacts with many mandated public agencies during the course of a medicolegal death investigation. Although SUID necessitates consideration of child abuse and neglect as a contributory factor, and accurate determination of death cause may have critical implications for other family members and public health, prioritizing family needs in a trauma informed manner is paramount. Collaboration between MDT partners to provide optimal care to families following SUID involves transparent family communication, attending to medical and mental health needs of surviving family (especially siblings), and respecting medicolegal investigative constraints. Many institutions lack standardized approaches to SUID cases, which may precipitate increased family distress and delay initiation of necessary medicolegal death procedures. Methods: An MDT expert panel consisting of medical, legal, law enforcement, and child welfare professionals was convened at Nemours Children’s Health, Delaware in 2018 over a 3-month period to analyze and implement an enhanced, family-centered, trauma informed hospital protocol. Results: Using exploratory inquiry and dialogue to elicit important protocol goals, a family-centered protocol with revised, coordinated roles for MDT members was developed with enhanced focus on communication, family-, and team-oriented care. Conclusions: Implementation of a family-centered, ED-based protocol standardizing the approach to SUID effectively supports medicolegal death investigative procedures while prioritizing trauma informed, supportive, sensitive ED care for grieving families. Policy implications: Health care institutions serving children and their families should develop and implement trauma informed, family-centered protocols to ensure sensitivity during medicolegal death investigations.

DISCLOSURE This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

BACKGROUND The sudden and unexpected death (SUID) of an infant or child is highly emotionally distressing for all involved. This traumatic experience is further complicated as family members or direct caregivers are frequently the first to discover or provide aid to an unresponsive loved one, often overwhelmed by nearimmediate feelings of loss, difficulty regulating emotions or thoughts, and shock at the inexplicable, incomprehensible nature of the loss.1 First responders and emergency medical personnel may be recruited to provide emergent resuscitative care and/or transportation to an emergency department (ED) hospital setting, where eventual death pronouncement may involve interaction and communication with multiple professionals from a variety of disciplines.1 Interactions and events between professionals and grieving family members during this crisis period and immediately after death can positively or negatively impact bereavement and adjustment to life without the person, becoming an intimate part of the family’s history of the experience, and are therefore of critical significance.2 14 Delaware Journal of Public Health - May 2022

What follows SUID is a publicly mandated process of medicolegal death investigation, typically involving multiple public agencies (law enforcement, child protective services, medical examiner or coroner) to ascertain accurate cause of death.1 Of paramount importance, analysis of death cause has potential health- and safety-related implications not only for other immediate family members, but also for the general public, such as when death is attributed to an underlying or heritable medical condition, infectious cause, consumer product, or even child maltreatmentrelated etiology. Failure to accurately identify death cause may impact the future safety of surviving children in the home or result in errors in prosecution when deaths are not accurately attributed to maltreatment.1,3,4 In-depth exploration of maltreatment is warranted, as national statistics suggest infants are most vulnerable to fatality from abuse or neglect; nearly half of abuse-related deaths nationally involve infants less than one year of age.5 Distinguishing a natural infant death from those due to accidental, abusive, or neglectful causes may be difficult in the ED setting,3 particularly when obvious external physical exam or radiologic findings supportive of maltreatment are absent. These SUID cases therefore involve comprehensive, multidisciplinary team (MDT) collaboration across medical, social, and child DOI: 10.32481/djph.2022.05.003

protective services (CPS), law enforcement (LE), the medical examiner (ME), legal and other sectors to accurately identify death cause through thorough medical and radiologic assessment, forensic autopsy, evidence collection, scene investigation, and clinical history review.1,3 However, families thrust into immediate interactions with a multitude of cross-sector professionals while in crisis may naturally perceive the medicolegal process as highly distressing, confusing, intrusive, or even overwhelming, and may lack understanding of or agreement with the importance of the investigative process.1,6–9 Distress may additionally permeate the experience of involved hospital ED staff, tasked with notifying multiple MDT partners while sharing worries that investigative involvement, such as by LE or CPS, may potentially increase family trauma after the death experience.

infant death scene became chaotic, with voiced confusion by ED staff over the need to involve the ME, CPS, and LE even though the circumstances around his death were unclear. Confusion delayed initiation of medicolegal death procedures, primarily out of concern that involvement of investigators would further stress the grieving family. Ultimately, the ME was contacted and declared jurisdiction, abruptly restricting all contact of family members with JM and causing his family to feel stigmatized and express sentiments around a “crime scene.” JM’s case highlights the need to establish local protocols to ensure medicolegal death investigative partners are expeditiously engaged while maintaining a compassionate, family-centered, and traumainformed approach to minimize family and MDT collaborator distress and optimize accurate ascertainment of death cause.

Families involved with SUID therefore deserve compassionate, non-accusatory, trauma-informed and family-centered interactions with involved MDT members; it has been suggested that “parents and other caregivers deserve an investigation that is sensitive to their grieving state and not one that is accusatory or insensitive to the emotions they are feeling.”10 The 2014 joint policy statement by the American Academy of Pediatrics Committee on Pediatric Emergency Medicine, the American College of Emergency Physicians Pediatric Emergency Medicine Committee, and the Emergency Nurses Association Pediatric Committee identified key principles and practices for addressing child deaths in the ED setting, prioritizing delivery of “patient centered, family focused, and team oriented care.”4 Development of written protocols, such as those addressing whether family member presence is permitted at resuscitation or after death to reduce distress in immediate crisis periods, was recommended.11 Despite this and other clinical guidance,1,3 many health care institutions lack standardized, family-centered approaches to SUID cases.

Because responding to SUID cases in the ED setting is extremely complex, the purpose of this study was to develop and implement a trauma-informed, family-centered ED-based protocol to support medicolegal death investigative procedures after SUID in a compassionate and sensitive manner, prioritizing family needs and preferences.

The following case example typifies challenges facing medical professionals involved in SUID cases. Three-week-old JM was found unresponsive in his crib, resuscitative efforts upon arrival to the ED were futile, and he was pronounced deceased. His parents were at his bedside in the ED, multiple other family members arrived, and hospital staff including Pastoral Care and Child Life were gathered for support. However, the unexpected

METHODS In 2018, a panel of MDT experts was convened from jurisdictional medical, judicial, CPS, LE, and legal arenas within the jurisdiction of Delaware’s level 1 pediatric trauma center, Nemours Children’s Health (Figure 1). The taskforce met twice over the course of approximately 3 months to collaborate and information-share regarding the roles and responsibilities of each agency involved in an SUID case. Panel members were selected based on their interest in the subject matter and role in the SUID process.

The expert panel used informal, exploratory inquiry and dialogue to explore barriers to family-centered care, and identified strengths/weaknesses associated with the existing ED-based response to SUID cases. Using themes and ideas that emerged from this dialogue, the MDT developed through consensus agreement an enhanced ED-based protocol with revised and coordinated roles for MDT members premised on communication, family-, and team-oriented care.

Figure 1. Multidisciplinary Team Expert Think Tank

15

RESULTS Geography & Placement

Through exploratory inquiry and dialogue facilitated by EDbased medical experts, the first identified barrier in the SUID case management process was the physical geography and placement situation of family members during the resuscitation event in the ED setting. The MDT panel reviewed that unique to local state protocol, a 9-1-1 notification to emergency medical services automatically generates an LE response. Therefore, when an infant arrives at the ED setting, LE personnel from the jurisdiction where 9-1-1 was called typically present in tandem with the infant and family. If the infant is critically ill, has a suspicious history that is concerning for abuse or neglect, if cardiopulmonary resuscitation is in progress, or if the child is visibly injured, LE personnel frequently remain in the ED throughout the assessment.

Often, a family member may be permitted to travel in an ambulance with the child; however, sometimes family members are held at the scene by LE personnel, impacting the family’s ability to participate in end of life bedside medical care. Explicit safety concerns may also prevent families from entry into the ED, a determination typically made by LE personnel prior to hospital arrival. If the family travels with the infant or child, they are welcomed to the bedside to be observers of attempted resuscitation, with the support of an identified health care staff member, and LE personnel will generally position themselves inside or outside of the room. If the family are not permitted to travel with the infant and held at the scene, and the infant was already pronounced deceased upon family arrival, family are typically not be allowed to enter the infant’s room until the ME or LE personnel granted permission.

Geographical space constraints in the ED also pose a challenge to accommodate additional visitors. Relatives or other family supports arriving at the hospital are typically supported in a designated waiting area or choose to return home. Reviewing the possible geographic or situational placements of family members in the ED setting was a priority area of exploration for the MDT panel , as ED-based medical experts highlighted literature that supported family/caregiver presence at the bedside improved emotional and psychological outcomes for surviving family members when they are observers of the resuscitation of their family member.12

ME Involvement

A second identified barrier was time to involvement of the ME. The ME was typically contacted by the ED medical team or unit supervisor, and during the initial call, the ME was often asked what restrictions must exist at the bedside, exploring inquiries such as can family be present, can they touch the decedent’s body, can memory making be completed, etc. The ME often restricted family contact following death pronouncement and limited viewing of the body, touching, and memory making until his or her arrival. Response time was variable, and frequently perceived as delayed. The ME sometimes granted medical staff permission to complete photo documentation before his or her arrival, which might contribute to familial perceptions of the ED setting as a “crime scene” and criminalization of the SUID. Once the ME arrived to the bedside, there was typically limited time before the infant was transported off premises to the ME’s office, and most 16 Delaware Journal of Public Health - May 2022

families were instructed to meet with investigators at either the ME’s office, local police station, or CPS agency.

Investigative partners, including CPS and LE, were variably contacted by ED medical staff. The MDT panel discussed that families might be offered the opportunity to engage in supervised contact with their deceased loved one,1 and that members of the ED and other hospital staff should be educated around appropriate anticipatory guidance reflecting such parameters and other bereavement supports, while LE personnel remain present to enforce any restrictions around bodily contact that have been established by the investigators. Any physical contact with the deceased’s body (either by family members or MDT professionals) requires direct consent from the ME in the hospital’s jurisdiction.

Strengths

A notable identified strength was the involvement of Hospital Pastoral Care, Child Life, and volunteers, who are often contacted by medical ED staff to offer support to family members or engage in legacy building activities such as handprints/molds or hair clippings, after ME consent. The Child Life professional was also consulted to provide interventions around informing surviving siblings or other family members about the death at the request of the primary caregivers, as well as provide books and educational materials related to coping with grief and loss. If legacy building activities were prohibited by the ME, the family would be informed that handprints, molds, and other activities could be explored in conjunction with the ME’s office or local funeral home following the medicolegal death investigation. The act of legacy building and religious rituals has been recognized as an important detail by all members of the working group, with the noted commitment to support both within the context of the SUID investigation.

Themes

Key themes emerging from panel dialogue included enhanced need for family participation and communication, dynamic reassessment of family’s needs and wants during ED management, transparency (clearly defining for family members expectations of the medicolegal death investigation process), rapport building and support (including offering support for termination of breast feeding, notification of the primary care pediatrician or next of kin), and anticipatory guidance post-hospital discharge (meaning, discussion of autopsy, funeral arrangements, and scene investigations, etc.).

Process refinement was discussed by MDT think tank experts and through consensus opinion, the following steps were developed: Step 1. Rapid, efficient mobilization of the MDT (Table 1). The panel established that assessment for immediate safety of all parties, followed by a clear definition of roles and responsibilities based on the needs of the case, was necessary. Orienting the grieving family to the resuscitation and postmortem process and providing clear communication around the necessity of a medicolegal SUID investigation were prioritized as necessary action steps. The panel identified that LE personnel and the hospital social workers were often best positioned to provide information to the family regarding SUID medicolegal investigation within the context of their professional roles, as this dyad could support legal expectations/procedures.

Table 1. Mobilization of Multidisciplinary Team Response to Sudden and Unexpected Infant Death Action

Responsible Party

Contact Child Welfare Agency (assess safety of household contacts, coordinate medical evaluations)

Hospital Social Worker/hospital staff

Contact Law Enforcement (LE) if not initiated by a 9-1-1 call

Hospital Social Worker/Child Welfare

Contact Medical Examiner (ME) Office

Hospital staff/Social Worker

Contact Pastoral Care (address initial religious needs of family, provide support)

Hospital staff

The panel clarified that parents/legal guardians or an identified support person should be accommodated in the ED patient care area if no active threats to physical safety were identified.

Scenarios that involved a known violent incident (such as a firearm related incident) may raise concern for imminent safety and impact caregiver participation in the resuscitation. Physical space constraints in the ED may also impact family presence.

If the infant arrives to the ED via emergency medical services, the medical team should anticipate the simultaneous arrival of family members, permitting a member of the medical team to greet the caregiver and support their presence at the bedside during the resuscitation and medical care.

There may also be instances in which an infant will arrive unaccompanied by a family member/caregiver. If the child dies prior to the caregiver’s arrival, the caregiver should be supported in a hospital waiting room that can provide privacy until further guidance is provided by LE personnel and the ME regarding family presence with the deceased. Once death is declared, LE personnel are responsible for securing the body of the deceased and the scene for ME jurisdiction.

Step 2. Establishing the jurisdiction of the ME in the SUID case.

Does the death of the person meet criteria for ME involvement, and if so, to what extent? If the ME accepted the death for further investigation, several parameters require clarification, such as postmortem photo documentation, radiologic imaging, and physical care of the body. It is recommended that all intravenous lines and tubing remain in place on the body, and communication regarding organ donation should be facilitated by the organ procurement organization with the ME, following consent for donation by the family; an SUID investigation does not preclude organ donation.13 Upon death and jurisdiction declaration by the ME, he or she should identify stipulations and parameters regarding family presence at the bedside and the movement of the infant’s body for postmortem imaging or procedures. Any interaction and observation of the body by family or other MDT members

should be discussed with the ME (Table 2). This includes continued physical care of the body in the ED setting. The MDT recognized that religious needs may require physical handling or touching of the body, and prioritized discussion of these elements with the ME so that they can be accommodated within the context of the family’s religious preferences.

Step 3. Assessment of the medical and mental health needs of surviving family members, with specific attention to siblings and other minor children in the household. An ageappropriate physical examination with occult trauma screening is recommended for all children in the household, given that immediate cause of death is unknown and could include acute illness, underlying health or genetic conditions, toxic exposure, abusive or accidental trauma, and sleep-related injury.14 Prompt intervention with a medical professional in the ED setting could potentially be lifesaving. Emotional health should also be assessed in the context of the medical crisis. Children may need help processing experiences like hearing and seeing first responders in their home, or understanding why their parent/ caregiver is crying. The emotional health of the children should be repeatedly assessed, and appropriate services should be available and accessible (bereavement counseling, ongoing therapeutic interventions for complex psychological and emotional needs that may arise in the future, etc.). Assessment of surviving children for suicidal and/or homicidal ideations to ensure immediate personal safety should be prioritized.

Engagement with the ED setting was viewed by MDT panel members as useful to assess for immediate psychosocial needs of the family, including identification of religious/cultural needs, assisting family with logistics of funeral/burial arrangements, and mobilization of extended family members and friends to help the parent/caregiver navigate this crisis period. Legacy building or memory making activities should also be facilitated during this step if possible, as well as provision of guidance and strategies to disclose or talk about the death of the infant to other surviving children and family members, at the explicit direction of the family.

Table 2. Hospital-Based MDT Response to Sudden and Unexpected Infant Death Action

Responsible Party

Photo documentation, evidence collection (clothing, bottles, diapers, blankets)

Medical Examiner, Nurse Examiner team

Chain of custody protocols for evidence

Law Enforcement

Enforcement of restrictions. No one is permitted contact with decedent (including family members) unless for postmortem imaging. All tubes/lines/bandages should remain intact from pronouncement until otherwise directed by the Medical Examiner

Hospital staff/Law Enforcement

Recommend/Perform postmortem imaging

Medical Examiner, Hospital staff 17

Step 4. Directives around comprehensive medical record documentation. What the infant was wearing on arrival to the ED, the names/relationships of those present, and events that occurred either pre-hospital or during medical care delivery (i.e.: reported events that lead to the current state of health, the attempt to insert an intravenous line, or give a medication during resuscitation) should be documented (Table 3).

Step 5. Debriefing forum. An informal process for MDT debriefing was recommended to occur before the MDT leaves the ED, involving clear and transparent information-sharing about available medical history, radiologic results, and history gathered.

A debrief was also recommended for ED staff and involved medical providers to discuss medical care delivery, elements of any resuscitation performed, and patient outcomes.

Most importantly, following this MDT debriefing, a purposeful conclusion of care or transition time for the family/caregivers was recommended. The MDT members should outline what to expect next from the medicolegal, investigative perspective, timelines for results of outstanding medical or investigative procedures, and identification of an MDT partner families could contact with questions or needs that may arise in the future. These needs may be related to ongoing bereavement support, funeral arrangements, school/employment absences, and any other self-identified concern that requires supportive intervention.

DISCUSSION The majority of SUID occur at home, frequently after the infant was placed to sleep, and the specific manner and cause of death are often unknown at the time of medical professional assessment in the ED.1,3 Because of possible contribution of underlying health issues, infectious disease, or abuse or neglect to the SUID presentation, and a need to ensure the ongoing health and safety of surviving siblings and other family members in the home and larger community, a conservative, collaborative, trauma informed approach that expeditiously involves MDT partners to facilitate a comprehensive medicolegal death investigation is warranted.

Procedural guidance and key considerations for hospitals involve establishment of protocols to coordinate communication with families and investigating agencies, education of medical staff and other relevant hospital personnel about the jurisdiction’s medicolegal death investigation approach, state statutes and local regulations regarding notification of deaths, hospitalrelated policies and procedures, and establishment of local protocols at the discretion of the ME and hospital that provide the family the opportunity to interact with their loved one, while respecting medicolegal investigative constraints, following death pronouncement.1 Section 906 of Title 16 of the Delaware Code15 requires the use of a multidisciplinary team response for any child abuse or

neglect report involving death, serious physical injury, physical injury, human trafficking of a child, torture, or sexual abuse. The statute requires a CPS investigation for the death of a child three years of age or younger that appears to be sudden, unexpected, and unexplained. The state is also required to implement a memorandum of understanding among agencies and entities to ensure that the state conducts a multidisciplinary response to such cases. In 2017, the Memorandum of Understanding for the Multidisciplinary Response to Child Abuse and Neglect was implemented.16 The following language is in the Memorandum of Understanding: • In nearly all child death cases, the body will be transported to the hospital. In cases where the death is suspicious and the child is pronounced at the hospital, parents and caregivers will not be permitted to touch the body. However, parents and caregivers may be permitted to touch the body with supervision by LE, in consultation with ME, in cases where there is a sudden unexpected infant death (i.e., sudden infant death syndrome (SIDS), unknown cause, and accidental suffocation in bed). For cases in which the child is pronounced and remains on scene, LE will preserve the body and maintain the scene, not allowing anyone to touch the body until the ME assumes responsibility.

• Photographs must be taken to document the number and size of the injuries to the child; scale of injury should be documented in photograph. These photographs will be taken as part of the medical examination process if the child has been transported to a medical facility. This does not preclude LE and ME from taking photographs as needed for investigative purposes.

• If life supporting mechanisms were utilized, then LE will consider video documentation of these efforts to include the explanation by the medical provider.

• The ME will conduct a post-mortem examination of the child in all unexpected and unexplained death cases. LE and DOJ will be contacted prior to the post-mortem examination to allow for observation.

A post-mortem computed tomography (CT) scan at designated children’s hospitals may occur prior to the post-mortem examination. In cases where there are surviving siblings or other children in the household, the ME will request an expedited CT scan…will discuss findings from imaging, the post-mortem examination, SUIDI Form, doll re-enactment, and relevant information obtained from the interviews to ensure that team members are fully aware of all relevant case information.15

Table 3. Hospital-Based Comprehensive Documentation in Sudden and Unexpected Infant Death Assessments Action

Responsible Party

Dislodgement/movement of lines/equipment during evidence collection/imaging

Hospital staff

History provided by family, siblings/household contacts

Pastoral Care, Child Life, Hospital staff

Communication with Gift of Life

Hospital staff

Disposition of body determination (transferred to hospital morgue, Medical Examiner’s office, or funeral home)

Hospital Social Worker, Law Enforcement

18 Delaware Journal of Public Health - May 2022

The Nemours ED setting must approach SUID cases in adherence with relevant state statutes and MDT protocols.

Revisions to the existing SUID response process in the Nemours ED setting highlighted the following key lessons.

First, the expert think tank identified critical MDT collaborators for SUID cases involving ME, CPS, LE, and ED medical professionals including the attending physician, social worker, and forensic nurse examiner. Second, it was understood that the ME had the authority to restrict contact with the deceased infant and must be consulted to understand these parameters before any postmortem care or preparations could take place. Third, delivery of postmortem health care must be comprehensively documented in the medical record.

Development of the protocol also allowed exploration of more challenging issues, including need for standardized referrals to investigative agencies for medicolegal death investigation initiation and/or tension around more restrictive parameters sometimes established by the ME after death pronouncement.

Additionally, the think tank identified and debunked perceptions by participating MDT members that families would feel unduly emotionally burdened by involvement in the resuscitative process; rather, medical literature suggests otherwise.12 Investigating agencies had incorrectly perceived that observing the resuscitation or death of an infant would result in negative emotional outcomes and increased trauma for the caregiver/family member. Finally, also explored was confusion around consent for various medical and postmortem interventions (like radiologic imaging or lab testing) and organ donation, with strong recommendation for continued collaborative decision-making across sectors in partnership with involved family members.13 Although the above protocol was structured as a step-wise approach, the MDT think tank acknowledged that each component operates across a continuum of care delivery in the ED setting and may occur simultaneously or in a varied approach that is unique to the needs of the child and family, harnessing a trauma informed, family-centered approach. The MDT identified a need to balance investigative needs with family needs, which rarely provoke conflict but may potentiate stress in an inherently stressful circumstance. The MDT think tank determined this was best accomplished through collaborative communication among MDT members and with involved family members, engaging in purposeful efforts to keep the family at the forefront of the process through traumainformed participation.

PUBLIC HEALTH IMPLICATIONS Family needs after SUID are extremely complex, and facilitating a family-centered approach that is compassionate and trauma informed, while respecting investigative standards, provides the best opportunity for improved outcomes for families suffering profound losses.1 Collaboration among necessary MDT partners is best accomplished when preexisting protocols are in place that have been developed and implemented with multi-stakeholder input, and health care institutions should explore and refine policies and procedures to ensure medicolegal death investigations involving SUID are approached with sensitivity, compassion, and minimal family distress.

LIMITATIONS At the local level at Nemours Children’s Health, Delaware, impact of the revised process on families grieving SUID is unknown, as the family experience pre- and post-process implementation was not specifically assessed. Consideration should also be given to assessing MDT experience with the implementation of such protocols in future study.

CONCLUSION Implementation of a family-centered, ED-based protocol standardizing the approach to SUID can effectively support medicolegal death investigative procedures while prioritizing trauma informed, supportive, sensitive ED care for grieving families.

Dr. Deutsch may be contacted at Stephanie.deutsch@nemours.org

ACKNOWLEDGEMENTS Thank you to Rosalie Morales of the Office of the Child Advocate and Dr. Gary Lincoln Collins, Chief Medical Examiner of the Delaware Department of Safety and Homeland Security, Division of Forensic Science for their assistance.

REFERENCES 1. Palusci, V. J., Devinksy, O., Drake, S. A., Kay, A. J., Landi, K., Bowen, E., & Crandall, L. G. (2019). Family needs and follow up care after the sudden, unexpected death of a child. In: Bundock, E., & Corey, T. (eds.): Unexplained pediatric deaths: investigation, certification and family needs. The SUDC Foundation: Roseland, NJ, USA. 2. Garstang, J., Watson, D., Pease, A., Ellis, C., Blair, P. S., & Fleming, P. (2021, September). Improving engagement with services to prevent Sudden Unexpected Death in Infancy (SUDI) in families with children at risk of significant harm: A systematic review of evidence. Child: Care, Health and Development, 47(5), 713–731. https://doi.org/10.1111/cch.12875 3. Palusci, V. J., Kay, A. J., Batra, E., Moon, R. Y., Corey, T. S., Andrew, T., & Graham, M., & the Council on Child Abuse and Neglect, & the Section on Child Death Review and Prevention, & the Task Force on Sudden Infant Death Syndrome, & the NATIONAL ASSOCIATION OF MEDICAL EXAMINERS. (2019, September). Identifying child abuse fatalities during infancy. Pediatrics, 144(3), e20192076. https://doi.org/10.1542/peds.2019-2076 4. O’Malley, P. J., Barata, I. A., Snow, S. K., Shook, J. E., Ackerman, A. D., Chun, T. H., . . . Brecher, D., & the American Academy of Pediatrics Committee on Pediatric Emergency Medicine, & the American College of Emergency Physicians Pediatric Emergency Medicine Committee, & the Emergency Nurses Association Pediatric Committee. (2014, July). Death of a child in the emergency department. Pediatrics, 134(1), 198–201. https://doi.org/10.1542/peds.2014-1245 5. U.S. Department of Health & Human Services. (2020). Child Maltreatment, 2020. Retrieved from https://www.acf.hhs.gov/cb/report/child-maltreatment-2020 6. Rudd, R. A., & D’Andrea, L. M. (2013). Professional support requirements and grief interventions for parents bereaved by an unexplained death at different time periods in the grief process. International Journal of Emergency Mental Health, 15(1), 51–68. https://pubmed.ncbi.nlm.nih.gov/24187887 19

7. Royal College of Pathologists and Royal College of Pediatric and Child Health. (2016). Sudden unexpected death in infancy and childhood: multi-agency guidelines for care and investigation, 2nd ed. Royal College of Pathologists: London, England, UK. 8. Sidebotham, P. (2010, February). Do we need a new definition for SIDS? Commentary on ‘Sudden Unexpected Death in Infancy and the Dilemma of Defining the Sudden Infant Death Syndrome’ by Henry Krous. Current Pediatric Reviews, 6(1), 13–14. https://doi.org/10.2174/157339610791317287 9. National Sudden Infant Death Syndrome/Infant Death Resource Center. (n.d.). Responding to a sudden, unexpected infant death: the professional’s role. Retrieved from: https://www.ncemch.org/suid-sids/documents/SIDRC/ProfessionalRole.pdf 10. Shapiro-Mendoza, C. (2007). Sudden unexplained infant deaths: introduction. In: CDC: Sudden unexpected infant death investigation: a systematic training program for the professional infant death investigation specialist. CDC: Atlanta, GA, USA. 11. Su, X., Xu, B., Liang, H., Olsen, J., Yuan, W., Cnattingius, S., . . . Li, J. (2015, September 24). Prenatal maternal bereavement and risk of eating disorders in infants and toddlers: A population-based cohort study. BMC Psychiatry, 15, 229. https://doi.org/10.1186/s12888-015-0612-9

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12. Joyner, B. L., Jr. (2018, May 1). Does family presence in the trauma bay help or hinder care? AMA Journal of Ethics, 20(5), 507–512. https://doi.org/10.1001/journalofethics.2018.20.5.sect1-1805 13. Deutsch, S. A., Teeple, E., Dickerman, M., Macaulay, J., & Collins, G. (2020, September). For victims of fatal child abuse, who has the right to consent to organ donation? Pediatrics, 146(3), e20200662. https://doi.org/10.1542/peds.2020-0662 14. Lindberg, D. M., Shapiro, R. A., Laskey, A. L., Pallin, D. J., Blood, E. A., & Berger, R. P., & the ExSTRA Investigators.

(2012, August). Prevalence of abusive injuries in siblings and household contacts of physically abused children. Pediatrics, 130(2), 193–201. https://doi.org/10.1542/peds.2012-0085 15. Reports and investigations of abuse and neglect. 16 Del. C. §906 (1997). Retrieved from: https://delcode.delaware.gov/title16/c009/sc01/index.html 16. Child Protection Accountability Commission. (2017).

State of Delaware memorandum of understanding for the multidisciplinary response to child abuse and neglect.

Retrieved from: https://courts.delaware.gov/childadvocate/cpac/cpac_reports.aspx

HIGHLIGHTS FROM

The

NATION’S HEALTH A P U B L I C AT I O N O F T H E A M E R I C A N P U B L I C H E A LT H A S S O C I AT I O N

May 2022 The Nation’s Health headlines Online-only news from The Nation’s Health newspaper Stories of note include: Public health asks: How can we strengthen public trust? — Faltering trust endangers health, lives Mark Barna Surge of legislation against LGBTQ youth threatens health: Measures censor lessons, discussions Kim Krisberg Survey: High US health care costs harm minorities during pandemic Michal Ruprecht State health insurance exchanges open enrollment after disasters: Colorado, California part of new trend Mark Barna Report: Climate-driven weather to take toll on global health Michal Ruprecht ECO Bookworms Club shares books with classrooms: Free books for teachers, librarians by request from APHA Aaron Warnick Emory students use photography to express public health issues Aaron Warnick Newsmakers: May 2022 Michal Ruprecht Resources: May 2022 Michal Ruprecht 21

Multidisciplinary Team Approach to Addressing Child Sexual Abuse at Nemours Children’s Health, Delaware Allison T. Dovi, Ph.D. Nemours Children’s Health, Delaware

Allan De Jong, M.D., F.A.A.P. Nemours Children’s Health, Delaware

Jennifer L. Macaulay, M.S.W. Nemours Children’s Health, Delaware

Randall E. Williams, M.P.A. Chief Executive Officer, Children’s Advocacy Center (CAC) of Delaware

Andrea Repine, A.P.R.N. Nemours Children’s Health, Delaware

Stephanie Anne Deutsch, M.D., M.S., F.A.A.P. Nemours Children’s Health, Delaware

ABSTRACT In 2019, 4.4 million referrals of maltreatment were made that affected approximately 7.9 million children. It was estimated that 9.3% of the referrals were related to child sexual abuse (CSA). To prevent negative psychosocial and health-related outcomes associated with CSA, CSA survivors often participate in a forensic interview, medical and behavioral health assessments, and behavioral health treatment while navigating other life disruptions or changing family dynamics precipitated by the CSA (e.g., change in custody or household, lack of contact with preparator, etc.). The assessment and treatment of pediatric survivors of CSA by multidisciplinary teams (MDT) can enhance families’ engagement and participation with the legal process, medical evaluation, and behavioral health services.

This paper explores the Nemours Children’s Health, Delaware MDT’s approach to assessing and treating CSA, explores benefits and barriers associated with the current model, and discusses public health implications of a MDT approach to addressing CSA.

INTRODUCTION Child sexual abuse (CSA) is a global public health concern and a serious issue in pediatric medicine. Studies have reported associations between CSA and many negative psychosocial and health-related outcomes, including development of behavioral issues (e.g., posttraumatic stress disorder (PTSD), depression, suicidality) and physical health morbidities (e.g., smoking cigarettes, sexually transmitted diseases, premature death) particularly if CSA-related concerns are untreated or unaddressed.1–5 Given these negative associations and estimated rates of CSA affecting 1% to 35% of children,6 it is critical to develop systematic frameworks that support the early identification and provision of evidence-based treatment for CSA survivors to potentially mitigate negative long-term effects of abuse victimization.

THE MULTIDISCIPLINARY TEAM (MDT) APPROACH TO TREATING CHILD SEXUAL ABUSE Investigations of CSA necessitate coordination of various multidisciplinary team (MDT) members including law enforcement, child protective services, medical and behavioral health professionals, legal professionals and victim advocates, often based at a Children’s Advocacy Center (CAC), to increase access to community-based medical and behavioral healthcare services, improve continuity of care for children and families, and reduce duplicative services.7 In addition to agency-specific roles, MDT members provide needed education to families about the benefits of medical and behavioral healthcare services and advocate to ensure a family is successfully connected with evidence-based treatment to mitigate any long-term impact of CSA for the survivor. For example, the Delaware (DE) 22 Delaware Journal of Public Health - May 2022

Department of Services for Children, Youth, and Their Families (DSCYF) and law enforcement professionals often complete family assessments which may recognize service needs, and frequently connect families with agency-specific victim advocates if a need for additional support is identified. At the local level, the partnership between Nemours Children’s Health DE medical and behavioral healthcare services and the CAC of DE serves this goal by directly providing family-centered/trauma-informed services for the CSA survivor and their family. In addition to medical and behavioral health trauma services, Nemours Children’s Health, DE provides pediatric primary and specialty care for more than 100 pediatric specialties in Delaware, New Jersey, and Pennsylvania, which enables trauma providers to make appropriate referrals to other specialties (e.g., psychiatry, adolescent medicine, gastroenterology, etc.) as needed. In this brief report, we aim to provide an overview of the collaboration between Nemours Children’s Health and multi-agency partners that delivers trauma-informed care to CSA survivors.

APPROACH TO ASSESSING AND TREATING CHILD SEXUAL ABUSE AT THE LOCAL LEVEL IN DELAWARE Once an allegation of CSA has been made, the child-victim is referred by local law enforcement, child protective services (i.e., DSCYF), or the DE Department of Justice to the CAC for a forensic interview (FI). The agency that refers the child-victim, or CSA survivor, for the forensic interview depends on the survivor’s age and the status of the survivor’s relationship with the alleged perpetrator(s) (See Figures 1 & 2). Intrafamilial CSA, or that involving a family/household family in a caretaking capacity, necessitates involvement of DSCYF, whereas extrafamilial CSA may involve only law enforcement investigators. Forensic DOI: 10.32481/djph.2022.05.004

interviewing, a means of gathering factual information from a victim or witness about abuse for use in a legal setting in a legally defensible and developmentally appropriate manner, is frequently essential to the conduction of CSA investigations, as the survivor and alleged perpetrator may be the only people who know details of what really happened.8,9 Interviews are conducted by individuals who are skilled in child development, linguistics, civil and criminal offenses, memory, and suggestibility using a nationally recognized and approved forensic interview process. These FIs, which are performed in a safe, child-friendly, neutral setting, provide a unique opportunity for the survivor to share specific details regarding their abuse experience that may impact investigation and prosecutorial trajectory and the safety of other children and adolescents around them (such as through the identification of other abuse survivors and/or perpetrators).

Figure 1. Referral for Forensic Interview, Survivor Age < 12 Years

*A survivor may disclose abuse in the medical or mental health setting, that then results in notification of child protective services and/or law enforcement.

Figure 2. Referral for Forensic Interview, Survivor Age > 12 Years

Beyond disclosures with legal or safety significance, participation in a FI importantly provides CAC professionals an opportunity to engage CSA survivors and their families in longitudinal access to community-based services to promote long-term coping and psychosocial functioning for symptoms related to CSA psychological trauma. The CAC employees, specifically the Family Resource Advocate (FRA), perform a comprehensive family needs assessment during initial contact with the caregiver of a survivor of CSA. This comprehensive family needs assessment permits the MDT to tailor referrals to appropriate services (social, medical, or behavioral health-based) for the family and CSA survivor during post-FI debriefings. Through completion of a checklist, the FRA may identify essential needs (clothing, food, housing, transportation, utilities, or energy assistance), social needs (childcare, custody, legal assistance, employment, or workforce training, educational resources, legal assistance) or other child or family health and safety-based needs (e.g., dental/oral care, family planning, prenatal care, insurance, or child development-related issues).

Through a unique, geographical co-location at the Nemours Children’s Hospital Wilmington-based facility, the New Castle County CAC-based FRA frequently provides a “warm-handoff,” or a brief face-to-face transfer of services, to Nemours medical and behavioral health professionals when identifying survivor or caregiver needs in addition to referrals to other community-based programs. The “warm-handoff ” permits the Nemours medical or behavioral health professional to further assess symptoms of significant concern (e.g., suicidal ideation, depression, etc.) or schedule a follow up visit with the family. External to the co-located site in Wilmington, two operational, southernbased Delaware CACs collaborate with medical and behavioral health professionals both at Nemours and across the state via telephone, teleconference, or electronically to ensure expedited, comprehensive communication of survivor and family needs irrespective of geographic location.

Survivors of CSA may receive medical care through the Nemours Children at Risk Evaluation (CARE) Program which offers nonacute medical examinations similar to the regular well-child visit a child has had with a pediatrician, assessing the child’s physical health from head-to-toe. This examination often includes an ano-genital assessment to identify any injuries or infection related to the CSA experience or address any medical concerns the survivor or family may have. The examination may also include lab and radiology tests depending on the reason the child has been referred for a forensic examination. Photodocumentation may be performed during the examination for a variety of reasons to assist in medical management of the child survivor and for documentation of injuries for medico-legal, forensic purposes.

Parents and caregivers are encouraged to dually participate in the examination and be present throughout care. A CSA survivor under the age of 12 must be accompanied by an adult chaperone during the examination; if the survivor is 12 years of age or older, he or she may choose to have a support person (family member, friend, or advocate) in the room during the exam, but there will always be an accompanying chaperone.

*A survivor may disclose abuse in the medical or mental health setting, that then results in notification of child protective services and/or law enforcement.

Undergoing a medical examination may be a stressful time for a CSA survivor and caregiver. Care is taken to discuss the exam before it is completed to prepare the survivor and their caregiver in advance of any interventions. It is important that the survivor 23

and their caregiver(s) have the opportunity to ask questions and express any concerns they might have. During the assessment, the survivor and accompanying caregiver or support person may be asked about medical and behavioral symptoms, such as pain, discomfort, difficulty sleeping, changes in appetite, changes in school performance, self-injurious behaviors and suicidal ideation. Identification of emergent medical or behavioral symptoms may warrant referral to the Nemours emergency department for crisis intervention, based on casespecific circumstances. Utilizing a trauma-informed approach, the CARE Program medical professionals explain every part of the examination before and as it is performed. They also seek feedback during the process about how the survivor is feeling to minimize anxiety and answer any questions.

At the conclusion of the appointment, the medical professional reviews the findings from the examination and any results of testing available during a post-exam debriefing and call with any outstanding results. The outcome of the visits and testing results are discussed with the parent/legal guardian and the survivor within the context of patient confidentiality considerations and their developmental stage. Referrals to counseling, supportive services or other subspecialty medical professionals may be made if needed, based on case-dependent circumstances, the findings from the examination, psychological distress reported during the visit, or parent- or youth-reported interest in additional services.

The healthcare professional also maintains contact with the MDT regarding the specific needs of the child CSA survivor and family.

Once a referral is placed by the CARE team or a handoff complete, families are connected to a behavioral health professional with specialized trauma training. Of note, families are also able to access behavioral health services for trauma at Nemours Children’s Hospital DE through a self-referral, a referral from a Nemours healthcare professional, or a direct referral from the CAC. Every CSA survivor between the ages of three and 21, and their family, must complete a trauma consultation at the Trauma and Resiliency Clinic located in Nemours’ Division of Behavioral Health to identify whether trauma services offered best fit the family’s presenting concerns before they are placed on therapy waitlists.

Trauma Consultation. The trauma consultation occurs over two appointments, typically 75-90 minutes in length, and is conducted by a behavioral health clinician with specialized trauma training. This consultation is provided in person at Nemours Children’s Health DE or via a HIPAA compliant virtual platform. This consultation is divided into two parts: information gathering and a formal assessment of posttraumatic stress symptoms (PTSS). The clinician begins and ends the trauma consultation with the CSA survivor and their caregiver to orient the family to the process and to emphasize the importance of a family-based approach to addressing PTSS. However, during the information gathering portion of the trauma consultation process, the caregiver and the CSA survivor meet with the clinician independently for much of the appointment to ensure both parties have privacy and can independently express their thoughts and feelings about the allegations of sexual abuse freely.

It is also common for individuals to fear judgement from family members or may be protective of loved ones’ feelings, which may result in underreporting of CSA details and associated symptomatology; therefore, gathering information about the 24 Delaware Journal of Public Health - May 2022

CSA survivor’s experience independently of the caregiver helps mitigate underreporting. The goals of the trauma consultation are multifaceted and include: • Gathering information about the CSA and any other potentially traumatic events the family has experienced, • Ensuring that the CSA survivor is safe, • Assessing suicide and homicide risk, • Determining whether any additional mandated reporting is needed, • Confirming with the caregiver that the CSA survivor has completed the forensic interview before any questions about the allegations are asked of the CSA survivor, and • Briefly gathering more information about the family’s concerns surrounding the CSA survivor’s emotional and behavioral concerns.

Information about the status of the investigation is also gathered at this first appointment to determine when the CSA survivor should be clinically evaluated. For example, for CSA survivors who have not completed their forensic interview, questions about the allegation or how the CSA survivor is adjusting to the allegation are not asked. Instead, an additional appointment may be scheduled after the CSA survivor’s scheduled forensic interview.

The second portion of the trauma consultation includes a formal assessment of caregiver- and CSA survivor-reported PTSS, as well as other presenting concerns (e.g., depression, anxiety, problematic sexual behavior, oppositional behavior, substance use). The formal assessment includes one broadband measure and one trauma screening. The Behavior Assessment System for Children, 3rd Edition (BASC-3)10 is administered to the caregiver and age-appropriate CSA survivor to provide information about the child’s presenting behavioral and emotional concerns. The Child and Adolescent Trauma Screening, Version 2.0 (CATS 2.0)11 is also administered to both the caregiver and/or the CSA survivor, independently, to assess whether any other potentially traumatic events (PTEs) have occurred, and to assist in determining whether the CSA survivor’s adjustment to the allegations of abuse is normative, indicative of posttraumatic stress, or indicative of other behavioral health concerns. The CATS 2.0 is administered to the caregiver and CSA survivor independently to explore both parties’ perception of the traumatic event(s) and its aftermath, which may play an important role in treatment. The CATS 2.0 produces a total symptom score that is used to identify whether a survivor is experiencing clinically relevant levels of posttraumatic stress symptoms. Of note, a recent meta-analysis found that only 15.9% of youth who were exposed to a PTE developed posttraumatic stress disorder.12 Given that CSA survivors with elevated PTSS are more likely to have positive treatment outcomes if connected with trauma-focused, evidence-based treatments,13 such as Trauma-Focused Cognitive Behavioral Therapy (TFCBT),14 identifying elevated PTSS via a trauma symptom screening like the CATS 2.0 is helpful in identifying CSA survivor

and families who would benefit from trauma-focused, evidencebased treatments. For the CSA survivor who appears to be adjusting well (i.e., not clinically elevated PTSS, many protective factors), clinicians may share psychoeducation with families about how they can continue to enhance the CSA survivor’s protective factors, as well as how to recognize when treatment may be needed. Conversely, for CSA survivors who are not endorsing PTSS but are presenting with other symptoms that have seemingly been exacerbated by the CSA or another traumatic event identified during the administration of the CATS 2.0, clinicians may offer treatment referrals for other evidence-based interventions—such as Cognitive Behavioral Therapy, Exposure and Response Prevention, or Dialectical Behavioral Therapy— that may be a better fit with the CSA survivor’s presenting concerns. Before finalizing recommendations and referrals for families, a brief risk assessment is also conducted to ensure that the CSA survivor is safe to be placed on a treatment waitlist.

Feedback regarding PTSS scores and treatment recommendations are provided to the CSA survivor and their caregivers. Time is spent answering questions about treatment recommendations as well as providing relevant psychoeducation and brief parenting skills that may be help the CSA survivor’s adjustment.

Trauma Treatment. After the Trauma Consultation is completed, families who are referred for trauma treatment through Nemours are placed on the waitlist. The Trauma and Resiliency Clinic offers two trauma-specific interventions, TF-CBT and Cognitive Processing Therapy (CPT), and two trauma-informed evidencebased intervention, Parent-Child Interaction Therapy (PCIT) and Body Safety (i.e., an abbreviated version of TF-CBT). Risk assessments, such as the “Ask Suicide-Screening Questions” (ASQ)15 and the Columbia-Suicide Severity Rating Scale (C-SSRS),16 are administered to ensure that families are safe to be placed on a treatment waitlist. Once CSA survivor and their family complete treatment, symptom progress is monitored via re-administration of the BASC-3 and CATS 2.0. At this time, a clinician may make additional referrals (e.g., further testing to assess other areas of concerns, psychotropic intervention) as necessary.

Booster Sessions and Additional Referrals to Consider. Once the CSA survivor and their family complete treatment, they are welcome to return for booster sessions as needed until they are no longer eligible for services as a patient at Nemours. These booster sessions are often limited to less than five sessions total, often due to the clinical needs of the families, and may serve many purposes, such as to reassess new symptoms of concern, review skills to help the CSA survivor regulate emotions related to court testimony, engage in additional cognitive processing work, or review skills in the wake of an additional PTE.

IMPLICATIONS OF THE NEMOURS CHILDREN’S HEALTH, DELAWARE MDT’S APPROACH TO ASSESSING AND TREATING CHILD SEXUAL ABUSE The co-location of the Wilmington-based Nemours CARE Program and Trauma and Resiliency Clinic with the New Castle County-based CAC streamlines services aimed to support those who have experienced CSA and encourages efficient information sharing to improve the social and emotional outcomes of CSA

survivors and families. Although the appointments may occur at different points in time, families experience the forensic interview, medical examination, trauma consultation, and trauma therapy in the same building. Families who complete the trauma consultation but are not exhibiting significant PTSS may be referred to clinicians in the community if the CSA survivor is experiencing other symptoms of emotional and/or behavioral distress unrelated to the CSA. This may minimize the stress often experienced by families who must obtain multiple services by various providers at different locations. The co-location of services also provides continuity of care between the medical and psychological healthcare professionals as they are able reference documentation in the medical record, which often helps reduce the number of times families must repeat their trauma histories.

This access also allows for professionals from the medical and behavioral health disciplines to prepare for the family’s visit more effectively. For example, behavioral observations indicative of low mood made during the medical examination may prompt the behavioral health professional to administer an additional depression screening that is not currently part of the Trauma Consultation’s standard protocol. It is also for the CSA survivor and their family, who are experiencing a significant amount of distress, and may unintentionally forget to mention important events or concerns. Therefore, allowing medical and behavioral health professionals to have access to information gathered during the respective appointments may provide a more comprehensive clinical picture of the family. Creating a comprehensive clinical picture of a family is important in selecting an appropriate behavioral health intervention for the survivor and their family.

AN IMPERFECT PROCESS Although many of CSA cases will complete the forensic interview first, before the family is referred for a medical examination or trauma consultation, this is not always the case; it is not a unidirectional process. For example, families may self-refer a CSA survivor for a trauma consultation before they complete a forensic interview, and speaking with the CSA survivor about allegations of CSA before they complete the forensic interview could interfere with the investigation. This example highlights the importance of clinicians clarifying what aspects of the investigation, assessment, and treatment process have been completed at the start of the visit, as well as emphasizes the value of being able to access records across teams and highlights the benefits of warm handoffs. Although in ideal practice, the team strives to do warm handoffs, the precise estimate of cases that do not follow this trajectory is unknown at this time. Another limitation to the model is that this is one piece of the CAC’s larger MDT; therefore, the youth and their family may interact with many other systems unknown to Nemours which may result in the duplication of services, confusion for the family, and a greater opportunity for children to be lost to follow-up care. Statewide initiatives to improve communication across systems that interact with CSA survivors may improve the likelihood of families successfully connecting with and completing treatment.

PUBLIC HEALTH IMPLICATIONS Nemours remains committed to the MDT response to child abuse and neglect in DE and is involved in the various statewide efforts to streamline the investigation, assessment, and treatment of CSA. 25

Under the leadership of The Child Protection Accountability Commission (CPAC) Committee on the Investigation, Prosecution, and Treatment of CSA, co-chaired by attorneys Haley King, Esq. and Jennifer Donahue, Esq., the MDT partners remain dedicated to improving the multidisciplinary response to CSA through the facilitation of various working groups to identify system weaknesses and strengths in the investigation, prosecution, assessment, and treatment of CSA. Through committee work, MDT members have identified that availability and accessibility of behavioral health services for CSA survivors in DE remains an issue of public health concern. Besides identified local shortages, there is a broader national shortage of behavioral health clinicians, especially those who have specialized training in assessing PTSS and providing evidence-based trauma services.

This national shortage may be the result of a lack of opportunity to participate in specialized, evidence-based trauma training due to cost, availability of trainings, and appropriate supervision and consultation after training is completed. Another contributing factor to the growing shortage of behavioral health professionals is secondary traumatic stress, vicarious traumatization, and worker burnout. These are distinctly different processes that practitioners and management need to differentiate, even though they are often similar in presentation.17 The behavioral health professional shortage has frequently compelled long wait times prior to assessment and treatment initiation that may cause families to disengage from the pursuit of behavioral health treatment services. Noted also were gaps in trauma-focused services that address the diverse needs of traumatized families and survivors, such as youth with neurodevelopmental disorders, those who are multilingual, and individuals who reside in rural geographic regions of the state. In an ideal model, all three operational CAC’s across the state would be co-located with medical and behavioral health professionals to facilitate a “warm-handoff ” process to ensure continuity of care for CSA survivors and their families; current barriers to co-location replication include financial and staff constraints, and a paucity of medical and mental health professionals skilled in the evaluation and management of CSA across the state. Despite these barriers, Nemours and CACbased collaborators from the Wilmington location continue to comprehensively serve CSA survivors living in southern DE through creative navigation of transportation and other logistical supports that ensure the northern geographic location of the medical facility is not prohibitive.

Enhancing caregiver engagement in treatment also emerges as a priority. Therefore, coordinated follow-up efforts, such as through assignment of a longitudinal victim advocate to the CSA survivor and their family, may better ensure that families are able to participate in therapeutic services. How best to provide caregivers with anticipatory guidance about the PTSS presents in affected CSA survivors, the difference between a natural reaction to a stressor and PTSS, and destigmatizing abnormal stress-related symptoms to ensure caregivers develop skills to proactively address concerning symptoms remain best-practice issues under review by CPAC committee members. Lastly, providing information to caregivers about evidence-based trauma treatments is necessary to ensure that families are established with effective services that meet their unique needs.

Dr. Dovi may be contacted at allison.dovi@nemours.org 26 Delaware Journal of Public Health - May 2022

ACKNOWLEDGMENTS We would like to thank Pauline Corso, Senior Vice President and Chief Operating Officer at Nemours Children’s Health, Delaware Valley for her assistance with editing this manuscript.

REFERENCES 1. Brown, D. W., Anda, R. F., Tiemeier, H., Felitti, V. J., Edwards, V. J., Croft, J. B., & Giles, W. H. (2009, November). Adverse childhood experiences and the risk of premature mortality.

American Journal of Preventive Medicine, 37(5), 389–396. https://doi.org/10.1016/j.amepre.2009.06.021 2. Dube, S. R., Felitti, V. J., Dong, M., Giles, W. H., & Anda, R. F. (2003, September). The impact of adverse childhood experiences on health problems: Evidence from four birth cohorts dating back to 1900. Preventive Medicine, 37(3), 268–277. https://doi.org/10.1016/S0091-7435(03)00123-3 3. Hailes, H. P., Yu, R., Danese, A., & Fazel, S. (2019, October).

Long-term outcomes of childhood sexual abuse: An umbrella review. The Lancet. Psychiatry, 6(10), 830–839. https://doi.org/10.1016/S2215-0366(19)30286-X 4. Pérez-Fuentes, G., Olfson, M., Villegas, L., Morcillo, C., Wang, S., & Blanco, C. (2013, January). Prevalence and correlates of child sexual abuse: A national study. Comprehensive Psychiatry, 54(1), 16–27. https://doi.org/10.1016/j.comppsych.2012.05.010 5. Scoglio, A. A. J., Kraus, S. W., Saczynski, J., Jooma, S., & Molnar, B. E. (2021, January). Systematic review of risk and protective factors for revictimization after child sexual abuse.

Trauma, Violence & Abuse, 22(1), 41–53. https://doi.org/10.1177/1524838018823274 6. Child Advocacy Center Foundation. (2022). Sexual Abuse.

Retrieved from: https://cac-foundation.org/sexual-abuse/ 7. Jones, L. M., Cross, T. P., Walsh, W. A., & Simone, M. (2005, July). Criminal investigations of child abuse: The research behind “best practices”. Trauma, Violence & Abuse, 6(3), 254–268. https://doi.org/10.1177/1524838005277440 8. Mart, E. G. (2010). Common errors in the assessment of allegations of child sexual abuse.

The Journal of Psychiatry & Law, 38(3), 325–343. https://doi.org/10.1177/009318531003800306 9. Newlin, C., Steele, L. C., Chamberlin, A., Anderson, J., Kenniston, J., Russell, A., . . . Vaughan-Eden, V. (2015).

Child forensic interviewing: Best practices (pp. 1-20). US Department of Justice, Office of Justice Programs, Office of Juvenile Justice and Delinquency Prevention. Retrieved from https://www.ojjdp.gov/pubs/248749.pdf 10. Reynolds, C. R., & Kamphaus, R. W. (2015). Behavior assessment system for children–Third Edition (BASC-3).

Bloomington, MN: Pearson.

11. Sachser, C., Berliner, L., Holt, T., Jensen, T. K., Jungbluth, N., Risch, E., . . . Goldbeck, L. (2017, March 1). International development and psychometric properties of the Child and Adolescent Trauma Screen (CATS). Journal of Affective Disorders, 210, 189–195. https://doi.org/10.1016/j.jad.2016.12.040

12. Alisic, E., Zalta, A. K., van Wesel, F., Larsen, S. E., Hafstad, G. S., Hassanpour, K., & Smid, G. E. (2014). Rates of posttraumatic stress disorder in trauma-exposed children and adolescents: Meta-analysis. Br J Psychiatry, 204(5), 335–340. https://doi.org/10.1192/bjp.bp.113.131227 13. Keeshin, B., Byrne, K., Thorn, B., & Shepard, L. (2020, September 5). Screening for trauma in pediatric primary care.

Current Psychiatry Reports, 22(11), 60. https://doi.org/10.1007/s11920-020-01183-y 14. Deblinger, E., Mannarino, A. P., Cohen, J. A., Runyon, M. K., & Heflin, A. H. (2015). Child sexual abuse: A primer for treating children, adolescents, and their nonoffending parents.

Oxford University Press.

DHF

15. Horowitz, L. M., Bridge, J. A., Teach, S. J., Ballard, E., Klima, J., Rosenstein, D. L., . . . Pao, M. (2012, December). Ask Suicide-Screening Questions (ASQ): A brief instrument for the pediatric emergency department. Archives of Pediatrics & Adolescent Medicine, 166(12), 1170–1176. https://doi.org/10.1001/archpediatrics.2012.1276 16. Posner, K., Brent, D., Lucas, C., Gould, M., Stanley, B., Brown, G., . . . Mann, J. (2008). Columbia-suicide severity rating scale (C-SSRS). New York, NY: Columbia University Medical Center, 10.

17. Canfield, J. (2005). Secondary traumatization, burnout, and vicarious traumatization: A review of the literature as it relates to therapists who treat trauma. Smith College Studies in Social Work, 75(2), 81–101. https://doi.org/10.1300/J497v75n02_06

Delaware Health Force

Coming in July 2022

Where data becomes intelligence, and intelligence informs decision-making.

27

2022 State Report

Delaware

28 Delaware Journal of Public Health - May 2022

County Health Rankings 2022

2022 County Health Rankings for the 3 Ranked Counties in Delaware

County Kent

County 3

3

New Castle

County 1

1

Sussex

2

2

For more information on how these ranks are calculated, view the technical notes at the end of this report and visit www.countyhealthrankings.org

Stay Up-To-Date with County Health Rankings & Roadmaps For the latest updates on Rankings, What Works for Health, Action Learning Guides, and more visit

www.countyhealthrankings.org See what we’re featuring on our webinar series, what communities are doing to improve health, and how you can get involved!

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County Health Rankings 2022

County Health Rankings & Roadmaps (CHR&R) brings actionable data, evidence, guidance, and stories to diverse leaders and residents so people and communities can be healthier. The University of Wisconsin Population Health Institute created CHR&R for communities across the nation, with funding from the Robert Wood Johnson Foundation.

What are the County Health Rankings?

The County Health Rankings Model

The Rankings help us understand what influences how long and how well we live. They provide measures of the current overall health (health outcomes) of each county in all 50 states and the District of Columbia. Rankings data include a variety of measures, such as high school graduation rates, access to nutritious foods, and the percent of children living in poverty, all of which impact the future health of communities (health factors).

The County Health Rankings Model illustrates a broad vision for health. The model shows that policies and programs at the local, state, and federal levels play an important role in shaping health factors that in turn, influence a community’s health outcomes.

Health factors represent things that, if modified, can improve length and quality of life. They are predictors of how healthy our communities can be in the future. The four health factor areas in the model include Health Behaviors, Clinical Care, Social & Economic Factors, and Physical Environment.

Health outcomes represent how healthy a county is right now. They reflect the physical and mental well-being of residents through measures representing the length and quality of life typically experienced in the community.

We believe in a future where everyone has opportunities to be healthy and to thrive. Many factors impact how long and how well we live. Our data show how these factors shape community conditions, while highlighting the stark differences in health that stem from injustices and barriers to opportunity. Use our resources to take action toward better health for all.

Communities use the Rankings to build support for local health improvement initiatives by engaging many sectors including public health, health care, business, policymakers, and local residents.

30 Delaware Journal of Public Health - May 2022

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County Health Rankings 2022

Growing Healthy Places Means Ensuring Opportunities for All Communities thrive when all people can be healthy in their neighborhoods, schools, and workplaces. CHR&R brings actionable data and strategies to communities working to ensure that healthy places are available to all. Pages 5 and 6 of this report highlight how health outcomes and health factors differ by place within Delaware. On page 7, we outline how economic security – or the ability of individuals, households, and communities to meet basic needs with dignity – is important to health. We call attention to childcare cost burden as a barrier to economic security and health.

Growing Community Power to Improve Health Equity The Take Action to Improve Health section of the CHR&R website helps communities find tools and guidance to take action, select evidence-informed strategies, and make lasting changes. Take Action to Improve Health is a hub for information to help improve a community’s health and foster health equity. Find resources including: • •

What Works for Health, a searchable menu of evidence-informed strategies.

Action Learning Guides, self-directed learning modules that combine guidance, tools, and reflection activities.

Using Data to Improve Health Equity Data show a persistent pattern across the country in barriers to opportunity for people with lower incomes and for people of color. Differences in the opportunities available to different groups of people are related to unfair policies and practices.

Our progress toward health equity will be measured by how health disparities change over time. Visit www.countyhealthrankings.org to learn more about: 1. Health outcome and factor measures for your state and county.

2. Measures with data available by race and ethnicity to illuminate differences in opportunities for health.

3. Additional data resources for Delaware that provide information about health and opportunity by age group, gender, and zip code.

What Has Been Done Can Be Undone Achieving health equity means eliminating unjust and avoidable differences in access and opportunity. What can communities do to tackle unfair differences in how long and how well people live? Check out new strategies at What Works for Health that can address past harms and create conditions for thriving communities for everyone.

Many communities are mobilizing to harness the collective power of residents, organizations, and policymakers. They are working together to address past and present policies that cause harm and are ensuring the growth of healthy places for all. To learn about these efforts, visit countyhealthrankings.org.

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County Health Rankings 2022

What are Health Outcomes?

We measure length and quality of life to understand the health outcomes among counties in Delaware.

Length of Life

Quality of Life

Premature death

Self-reported health status

(years of potential life lost before age 75)

Percent of low birthweight newborns

How Do Counties Rank for Health Outcomes?

The green map shows Delaware’s health outcome rankings by county. In this map, less color intensity indicates better health outcomes.

Detailed information on the measures and their associated weights is available toward the end of this report. Learn about how we calculate health outcome ranks at www.countyhealthrankings.org.

What Do Differences Between Ranks Mean?

Counties are ordered by the health outcome rank, with a top-ranked county (rank = 1) having the best health outcome score. Ranks are good for sparking conversations, but they do not show differences in health within counties or describe the magnitude of difference in community health experienced between ranks. The chart next to the map shows the spread of health outcome scores (ranks) for each county (green circles) in Delaware.

This graphic shows the size of the gaps between ranked counties. The background colors correspond to the map legend.

32 Delaware Journal of Public Health - May 2022

Figure 1. Health outcome ranks (map) and underlying health outcome scores (chart)

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County Health Rankings 2022

What are Health Factors?

Health factors represent community conditions that we can change to improve health and opportunity, such as access to quality education, living wage jobs, quality clinical care, nutritious foods, green spaces, and secure and affordable housing.

We measure four health factor areas.

Health Behaviors Tobacco use Diet & exercise

Social and Economic Factors

Clinical Care

Education

Access to care

Employment & income

Alcohol & drug use Sexual activity

Family & social support

Quality of care

Community safety

Physical Environment Air & water quality Housing & transit

How Do Counties Rank for Health Factors?

The blue map shows Delaware’s health factor rankings by county. In this map, less color intensity indicates better health factors.

Detailed information on the measures and their associated weights is available toward the end of this report. You can also learn about how we calculate health factor ranks at www.countyhealthrankings.org.

What Do Differences Between Ranks Mean?

Counties are ordered by the health factor rank, with a top-ranked county (rank = 1) having the best health factor score. The chart next to the map shows the spread of health factor scores (ranks) for each ranked county (blue circles) in Delaware. This graphic shows the size of the gaps between ranked counties. The background colors correspond to the map legend.

Figure 2. Health factor ranks (map) and underlying health factor scores (chart)

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County Health Rankings 2022

Economic Security is Key to Thriving Communities Economic security enables families to cover basic needs such as housing, education, childcare, food, and medical care.

Each of these needs has demonstrated ties to health. However, economic security is not equally accessible to all people.

When a single household expense consumes the majority of a paycheck, it becomes difficult to meet competing needs and can force households into tough decisions like choosing between quality childcare, paying rent, and purchasing nutritious food. Individuals, households, and communities deserve the opportunity to meet basic needs with dignity.

Advancing a just recovery from the COVID-19 pandemic, and the layered impacts of racism and economic exclusion requires intentional action to ensure all people and places have what they need to thrive. Check out policies and programs that can be implemented in your community at What Works for Health.

Childcare Cost Burden in Delaware and the U.S. Childcare cost burden measures the percentage of household income needed to pay for childcare. When childcare is affordable and accessible, it can support parents’ and guardians’ ability to participate in paid work and can provide lifelong benefits to children. The U.S. Department of Health and Human Services’ benchmark suggests childcare is no longer affordable if it exceeds 7% of a household’s income. This measure of childcare cost burden reflects the experience of a household with two children.

Childcare Cost Burden in Delaware Counties The childcare cost burden among counties in Delaware ranges from 20% to 24%.

In Context • Similar levels of childcare cost burden exist across all levels of urbanization.

• Median household income varies by race and ethnicity across Delaware counties ranging between $48,591 for American Indian & Alaska Native households to $96,191 for Asian households. These income disparities demonstrate how economic security is not equally accessible to all people living in Delaware.

Childcare Cost Burden Across the U.S.

Figure 3. Childcare cost burden in Delaware by county

The typical cost burden of childcare among counties in the U.S. is about 25% of household income – meaning a quarter of every dollar earned goes to paying for childcare. Families in every state experience a childcare cost higher than the 7% federal benchmark of affordability.

The childcare cost burden in Delaware is 24%.

Figure 4. Childcare cost burden in the U.S. by state Want to learn more? Visit our State Reports page at www.countyhealthrankings.org to interact with the data.

34 Delaware Journal of Public Health - May 2022

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County Health Rankings 2022

2022 County Health Rankings: National and Delaware State Values for Ranked Measures Measure HEALTH OUTCOMES Premature death* Poor or fair health Poor physical health days Poor mental health days Low birthweight* HEALTH FACTORS HEALTH BEHAVIORS Adult smoking Adult obesity Food environment index Physical inactivity Access to exercise opportunities Excessive drinking Alcohol-impaired driving deaths Sexually transmitted infections Teen births* CLINICAL CARE Uninsured Primary care physicians Dentists Mental health providers Preventable hospital stays*

Description

DE DE Minimum Maximum

US

DE

Years of potential life lost before age 75 per 100,000 population (age-adjusted).

Percentage of adults reporting fair or poor health (age-adjusted).

Average number of physically unhealthy days reported in past 30 days (age-adjusted).

Average number of mentally unhealthy days reported in past 30 days (age-adjusted).

Percentage of live births with low birthweight (< 2,500 grams).

7,300 17% 3.9 4.5 8%

8,100 18% 3.8 4.6 9%

8,100 17% 3.7 4.3 8%

8,600 20% 4.3 4.8 9%

Percentage of adults who are current smokers (age-adjusted).

Percentage of the adult population (age 18 and older) that reports a body mass index (BMI) greater than or equal to 30 kg/m2 (age-adjusted).

Index of factors that contribute to a healthy food environment, from 0 (worst) to 10 (best).

Percentage of adults age 18 and over reporting no leisure-time physical activity (ageadjusted).

Percentage of population with adequate access to locations for physical activity.

16% 32%

16% 34%

15% 33%

19% 41%

7.8 26%

7.5 25%

7.8 27%

8.2 31%

80%

80%

51%

94%

Percentage of adults reporting binge or heavy drinking (age-adjusted).

Percentage of driving deaths with alcohol involvement.

20% 27%

20% 25%

18% 23%

20% 28%

Number of newly diagnosed chlamydia cases per 100,000 population.

551.0

602.2

447.4

783.2

19

18

14

29

7% 2,150:1 4,390:1 490:1 4,009

10% 1,090:1 1,740:1 270:1 5,370

Number of births per 1,000 female population ages 15-19.

Percentage of population under age 65 without health insurance.

Ratio of population to primary care physicians.

Ratio of population to dentists.

Ratio of population to mental health providers.

Rate of hospital stays for ambulatory-care sensitive conditions per 100,000 Medicare enrollees.

Mammography screening* Percentage of female Medicare enrollees ages 65-74 that received an annual mammography screening.

Flu vaccinations* Percentage of fee-for-service (FFS) Medicare enrollees that had an annual flu vaccination.

SOCIAL & ECONOMIC FACTORS High school completion Percentage of adults ages 25 and over with a high school diploma or equivalent.

Some college Percentage of adults ages 25-44 with some post-secondary education.

Unemployment Percentage of population ages 16 and older unemployed but seeking work.

Children in poverty* Percentage of people under age 18 in poverty.

Income inequality Ratio of household income at the 80th percentile to income at the 20th percentile.

Children in single-parent Percentage of children that live in a household headed by a single parent. households Social associations Number of membership associations per 10,000 population.

Violent crime Number of reported violent crime offenses per 100,000 population.

Injury deaths* Number of deaths due to injury per 100,000 population.

PHYSICAL ENVIRONMENT Air pollution - particulate Average daily density of fine particulate matter in micrograms per cubic meter (PM2.5). matter Drinking water violations+ Indicator of the presence of health-related drinking water violations. 'Yes' indicates the presence of a violation, 'No' indicates no violation.

Severe housing problems Percentage of households with at least 1 of 4 housing problems: overcrowding, high housing costs, lack of kitchen facilities, or lack of plumbing facilities.

Driving alone to work* Percentage of the workforce that drives alone to work.

Long commute - driving Among workers who commute in their car alone, the percentage that commute more than alone 30 minutes.

11% 8% 1,310:1 1,320:1 1,400:1 2,190:1 350:1 340:1 3,767 4,495 43%

51%

49%

52%

48%

56%

54%

56%

89% 67% 8.1% 16% 4.9 25%

91% 62% 7.8% 15% 4.4 29%

88% 55% 7.5% 14% 4.1 27%

92% 65% 8.6% 17% 4.6 34%

9.2 386 76

10.3 499 87

8.9 406 77

10.7 551 92

7.5

7.5

6.7

8.6

N/A

N/A

N/A

N/A

17%

15%

14%

16%

75% 37%

79% 35%

77% 33%

82% 38%

*Indicates subgroup data by race and ethnicity is available; +Not available in all states

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35

County Health Rankings 2022

2022 County Health Rankings: Ranked Measure Sources and Years of Data Measure HEALTH OUTCOMES Length of Life Quality of Life

HEALTH FACTORS HEALTH BEHAVIORS Tobacco Use Diet and Exercise

Alcohol and Drug Use Sexual Activity

Weight Source

Premature death* Poor or fair healthⱡ Poor physical health daysⱡ Poor mental health daysⱡ Low birthweight*

50% 10% 10% 10% 20%

National Center for Health Statistics - Mortality Files Behavioral Risk Factor Surveillance System Behavioral Risk Factor Surveillance System Behavioral Risk Factor Surveillance System National Center for Health Statistics - Natality files

Adult smokingⱡ Adult obesityⱡ Food environment index

10% 5% 2%

Physical inactivityⱡ Access to exercise opportunities Excessive drinkingⱡ Alcohol-impaired driving deaths Sexually transmitted infections

2% 1% 2.5% 2.5% 2.5%

Teen births*

2.5%

Behavioral Risk Factor Surveillance System Behavioral Risk Factor Surveillance System USDA Food Environment Atlas, Map the Meal Gap from Feeding America Behavioral Risk Factor Surveillance System Business Analyst, ESRI, YMCA & US Census Tigerline Files Behavioral Risk Factor Surveillance System Fatality Analysis Reporting System National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention National Center for Health Statistics - Natality files

5% 3% 1% 1% 5% 2.5% 2.5%

Small Area Health Insurance Estimates Area Health Resource File/American Medical Association Area Health Resource File/National Provider Identification file CMS, National Provider Identification Mapping Medicare Disparities Tool Mapping Medicare Disparities Tool Mapping Medicare Disparities Tool

5% 5% 10% 7.5% 2.5% 2.5% 2.5% 2.5% 2.5%

American Community Survey, 5-year estimates American Community Survey, 5-year estimates Bureau of Labor Statistics Small Area Income and Poverty Estimates American Community Survey, 5-year estimates American Community Survey, 5-year estimates County Business Patterns Uniform Crime Reporting - FBI National Center for Health Statistics - Mortality Files

2.5% 2.5% 2% 2% 1%

Environmental Public Health Tracking Network Safe Drinking Water Information System Comprehensive Housing Affordability Strategy (CHAS) data American Community Survey, 5-year estimates American Community Survey, 5-year estimates

CLINICAL CARE Access to Care

Uninsured Primary care physicians Dentists Mental health providers Quality of Care Preventable hospital stays* Mammography screening* Flu vaccinations* SOCIAL & ECONOMIC FACTORS Education High school completion Some college Employment Unemployment Income Children in poverty* Income inequality Family and Social Support Children in single-parent households Social associations Community Safety Violent crime Injury deaths* PHYSICAL ENVIRONMENT Air and Water Quality Air pollution - particulate matter Drinking water violations+ Housing and Transit Severe housing problems Driving alone to work* Long commute - driving alone

*Indicates subgroup data by race and ethnicity is available; +Not available in all states; ⱡ2018 data for New Jersey.

36 Delaware Journal of Public Health - May 2022

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Years of Data 2018-2020 2019 2019 2019 2014-2020

2019 2019 2019 2019 2010 & 2021 2019 2016-2020 2019 2014-2020 2019 2019 2020 2021 2019 2019 2019 2016-2020 2016-2020 2020 2020 2016-2020 2016-2020 2019 2014 & 2016 2016-2020 2018 2020 2014-2018 2016-2020 2016-2020

County Health Rankings 2022

2022 County Health Rankings: Additional Measure Sources and Years of Data HEALTH OUTCOMES Length of Life

Quality of Life

HEALTH FACTORS HEALTH BEHAVIORS Diet and Exercise Alcohol and Drug Use Other Health Behaviors CLINICAL CARE Access to Care

Measure

Source

COVID-19 age-adjusted mortality Life expectancy* Premature age-adjusted mortality* Child mortality* Infant mortality* Frequent physical distress ⱡ Frequent mental distress ⱡ Diabetes prevalence ⱡ HIV prevalence+

National Center for Health Statistics - Mortality Files National Center for Health Statistics - Mortality Files National Center for Health Statistics - Mortality Files National Center for Health Statistics - Mortality Files National Center for Health Statistics - Mortality Files Behavioral Risk Factor Surveillance System Behavioral Risk Factor Surveillance System Behavioral Risk Factor Surveillance System National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention

2020 2018-2020 2018-2020 2017-2020 2014-2020 2019 2019 2019 2019

Food insecurity Limited access to healthy foods Drug overdose deaths* Motor vehicle crash deaths* Insufficient sleep

Map the Meal Gap USDA Food Environment Atlas National Center for Health Statistics - Mortality Files National Center for Health Statistics - Mortality Files Behavioral Risk Factor Surveillance System

2019 2019 2018-2020 2014-2020 2018

Uninsured adults Uninsured children Other primary care providers SOCIAL & ECONOMIC FACTORS Education High school graduation+ Disconnected youth Reading scores*+ Math scores*+ School segregation School funding adequacy+ Income Gender pay gap Median household income* Living wage Children eligible for free or reduced price lunch+ Family and Social Support Residential segregation - Black/White Residential segregation - non-White/White Childcare cost burden

Community Safety

Childcare centers Homicides* Suicides* Firearm fatalities* Juvenile arrests+

Small Area Health Insurance Estimates Small Area Health Insurance Estimates CMS, National Provider Identification

Years of Data

2019 2019 2021

EDFacts American Community Survey, 5-year estimates Stanford Education Data Archive Stanford Education Data Archive National Center for Education Statistics School Finance Indicators Database American Community Survey, 5-year estimates Small Area Income and Poverty Estimates The Living Wage Calculator National Center for Education Statistics

2018-2019 2016-2020 2018 2018 2020-2021 2019 2016-2020 2020 2021 2019-2020

American Community Survey, 5-year estimates

2016-2020

American Community Survey, 5-year estimates The Living Wage Calculator, Small Area Income and Poverty Estimates Homeland Infrastructure Foundation-Level Data (HIFLD) National Center for Health Statistics - Mortality Files National Center for Health Statistics - Mortality Files National Center for Health Statistics - Mortality Files Easy Access to State and County Juvenile Court Case Counts

PHYSICAL ENVIRONMENT Housing and Transit Traffic volume

EJSCREEN: Environmental Justice Screening and Mapping Tool Homeownership American Community Survey, 5-year estimates Severe housing cost burden American Community Survey, 5-year estimates Broadband access American Community Survey, 5-year estimates + *Indicates subgroup data by race and ethnicity is available; Not available in all states; ⱡ2018 data for New Jersey.

2016-2020 2021 & 2020 2021 2014-2020 2016-2020 2016-2020 2019

2019 2016-2020 2016-2020 2016-2020

See additional contextual demographic information and measures online at www.countyhealthrankings.org Page 10 | www.countyhealthrankings.org

37

County Health Rankings 2022

Glossary of Terms

Glossary of Terms, Technical Notes, and FAQs

Health equity: Assurance of conditions for optimal health for all people. Achieving health equity requires valuing all individuals and populations equally, recognizing and rectifying historical injustice, and providing resources according to need.

Health inequity: Differences in health factors or outcomes that are systematic, avoidable, unnecessary, unfair, and unjust.

Health disparities: The numerical or statistical differences in health outcomes, such as mortality rate differences. Reducing and ultimately eliminating disparities in health and its determinants of health is how we measure progress toward health equity.

Technical Notes •

•

Figures 1 and 2 depict each county as a single, semi-transparent circle. Counties with very similar values are displayed as overlapping circles having greater color saturation. Similarly, circles representing states may be overlapping in Figure 4.

The state and national values for childcare cost burden represent the median of counties within the state and nation, respectively.

FAQs

How does CHR&R select evidence-informed solutions?

Evidence-informed solutions are supported by robust studies or reflect recommendations made by experts. To learn more about our evidence analysis methods, visit What Works for Health.

How does CHR&R rank counties?

To calculate the ranks, we first standardize each of the measures using z-scores. Z-scores allow us to combine multiple measures because the measures are now on the same scale. The ranks are then calculated based on weighted sums of the measure z-scores within each state to create an aggregate z-score. The county with the best aggregate z-score (healthiest) gets a rank of #1 for that state. The aggregate z-scores are graphed next to the maps for health outcomes and health factors on pages 5 and 6 to show the distribution of the values that contribute to the rank. To see more detailed information on rank calculations please visit Our Methods section in Explore Health Rankings at:countyhealthrankings.org.

How did the 7% benchmark for childcare affordability originate?

The Department of Health and Human Services published a 2016 update to rules and regulations for the Child Care and Development Fund (CCDF) program, which helps cover childcare costs for children from low-income households. The updated rules established a federal benchmark for an enrolled family’s childcare co-payments not to be considered affordable if costs exceed 7% of household income. The benchmark has since been applied outside of the context of the CCDF program to indicate that low- and middle-income families should not spend more than 7% of their income on childcare for it to be considered affordable.

How does CHR&R define county levels of urbanization?

We define levels of urbanization as: Rural (non-metropolitan counties with less than 50,000 people); Smaller Metro (counties within a metropolitan statistical area (MSA) with between 50,000 and 1 million people); Large Suburban Metro (non-central fringe counties within an MSA with more than 1 million people); Large Urban Metro (central urban core counties within an MSA with more than 1 million people).

How does CHR&R define racial and ethnic groups?

We recognize that “race” or “ethnicity” are social categories. Society may identify individuals based on their physical appearance or perceived cultural ancestry, as a way of characterizing individuals' value. These categories are not based on biology or genetics. A strong and growing body of empirical research provides support for the fact that genetic factors are not responsible for racial differences in health factors and very rarely for health outcomes.

We are bound by data collection and categorization of race and ethnicity according to the U.S. Census Bureau definitions, in adherence with the 1997 Office of Management and Budget standards. Our analyses also do not capture those reporting more than one race, of “some other race”, or who do not report their race. This categorization can mask variation within racial and ethnic groups and can hide historical context that underlies health differences.

How does CHR&R define gender?

We recognize that while the terms “gender” and “sex” are often used interchangeably, they do not represent the same concept. Sex is generally assigned at birth based on observed anatomy, while gender is a social construct wherein certain tendencies or behaviors are assigned by society to labels of masculine or feminine. We know that neither gender nor sex are binary constructs and that people living intersectional identities (e.g., transgender women) experience compounding power differentials, which are not captured in a binary delineation between men and women.

38 Delaware Journal of Public Health - May 2022

Page 11 | www.countyhealthrankings.org

County Health Rankings 2022

Credits Report Authors: Christine Muganda, PhD Jess Hoffelder, MPH Hannah Olson-Williams Keith Gennuso, PhD Marjory Givens, PhD, MSPH Sheri Johnson, PhD Research Assistance: Jennifer Robinson Matthew Rodock, MPH Anne Roubal, PhD

Ganhua Lu, PhD Molly Burdine Eunice Park, MIS

Elizabeth Blomberg, PhD Nicholas Schmuhl, PhD Suryadewi Nugraheni, MD, MA, PhD

With key contributions from: Michael Stevenson, MPH Lindsay Garber, MPA Beth Silver, MCM Cathy Vos and the entire County Health Rankings & Roadmaps Team Data collaborations : • The Centers for Disease Control and Prevention •

Dr. Amy Glasmeier, PhD and The Living Wage Calculator at the Massachusetts Institute of Technology

Communications & website support: • •

Burness Forum One

This work is made possible with support from the Robert Wood Johnson Foundation.

Recommended citation: University of Wisconsin Population Health Institute. County Health Rankings Delaware State Report 2022.

Talk to a Team Member: Have questions about your data?

Need help finding an evidence-informed strategy?

Looking for more information on how to take action?

CHR&R team members are available to help you navigate the many resources we have available to support you on your journey to create healthy, equitable communities.

To contact us, please go to www.countyhealthrankings.org/contact-us. We’re here to help!

University of Wisconsin Population Health Institute, County Health Rankings & Roadmaps 610 Walnut St, #524, Madison, WI 53726 | (608) 265-8240 | info@countyhealthrankings.org Page 12 | www.countyhealthrankings.org

39

Actions Against Racism: Bringing Together Trauma-Informed Practices, Social-Emotional Learning, and Racial Socialization to Combat Racism in Schools Danielle R. Hatchimonji, Ph.D. Nemours Children’s Health Kira Branch, Psy.D. Nemours Children’s Health, Sidney Kimmel Medical College, Thomas Jefferson University Danika Perry, Psy.D. Nemours Children’s Health, Sidney Kimmel Medical College, Thomas Jefferson University Tia N. Barnes, Ph.D. University of Delaware

ABSTRACT Racism is a social determinant of health with dire consequences for the health, education, and mental health of students of color. Thus, there is an urgent need to develop and test evidence-based strategies to combat racism in schools. In response to this need, our team has developed a multi-tiered school-based intervention to build capacity for combatting racism in educators, students, and families. The “Actions Against Racism” intervention synthesizes three evidence-based practices: trauma-informed practices, social-emotional learning (SEL), and racial socialization. The multiple tiers of intervention aim to cultivate skills for combatting individual and structural racism in educators, families, and students across the school ecology. In this paper, we present the rationale for this intervention and provide an overview of the “Actions Against Racism” components

INTRODUCTION Racism is a social determinant of health, negatively impacting education, physical, and mental health outcomes of students of color.1 Experiences of racial discrimination are associated with poorer mental health2 and physical health3 for children and adolescents of color, with impacts lasting through adulthood.4 In schools, students of color are disciplined more harshly,5 are more likely to be identified as needing special education services,6 less likely to be identified as needing gifted services,7 and less likely to have access to a quality education.8 The COVID-19 pandemic has caused further disproportionate harm to students of color and disconnected students from mental health and school support services.9 Thus, there is an urgent need for evidence-based strategies to address racism in schools toward promoting the social, emotional, and behavioral wellness of all children. In response to this need, we have developed “Actions Against Racism,” a multi-tiered school-based intervention to build capacity for combatting racism in educators, students, and families. The intervention is innovative because it brings together three evidence-based practices—trauma-informed practices, social-emotional learning (SEL), and racial socialization—to cultivate skills for combatting racism in individuals from diverse backgrounds. In this paper, we present the rationale for this intervention and provide an overview of the “Actions Against Racism” components.

40 Delaware Journal of Public Health - May 2022

THE URGENCY OF COMBATTING RACISM IN EDUCATION Racism operates at structural and individual levels to create and maintain inequity in education, health, and mental health.1 At the structural level, racism is produced and reproduced by laws, rules, and practices that are sanctioned and implemented by various levels of government and embedded in the economic system and in cultural and societal norms.10 Over hundreds of years, structural racism has organized the structure of American society by race, resulting in unequal access to resources and opportunities.11 At the individual interpersonal level, racial microaggressions cause psychological harm to students of color.12 Experiences of microaggressions, overt discrimination, and other forms of racial maltreatment are associated with anxiety, stress, and trauma symptoms.13 Racial trauma, specifically, is a traumatic response to accumulated exposure to race-based stress.14 Racial stress and trauma are thought to contribute to racial mental health disparities, such as higher rates of post-traumatic stress disorder (PTSD) for Black and African Americans compared to other racial groups.15 Thus, there is an urgent need to combat racism at both individual and structural levels. Yet, despite the unequivocal dire effects of racism, most efforts to address racial inequity focus on isolated indicators of structural racism (e.g., achievement gap), rather than identifying racism itself as the root cause of inequity.16 At the same time, the disproportionate harm of COVID-19 on communities of color and the highly visible DOI: 10.32481/djph.2022.05.005

killings of people of color have changed public consciousness and discourse about challenging racism. Researchers and practitioners are at an inflection point that allows for a reconceptualization of what can be done to combat racism in schools.

EXISTING PROMISING PRACTICES TO COMBAT RACISM IN SCHOOLS Currently, schools employ multiple, often disconnected, strategies to address racial inequity.17 Few of these efforts aim to cultivate actionable skills for combatting racism directly.18 Although there are no evidence-based interventions that directly target racism in schools, three distinct practices have shown promise for promoting mental health in the context of racial stress and trauma: trauma-informed practices, social-emotional learning (SEL), and racial socialization. For students and staff impacted by racial stress and trauma, trauma-focused interventions offer specific strategies to support coping and healing.19 SEL practices build student and educator competencies that are essential for combatting racism, like assertive communication, empathy, and emotion regulation.20 Racial socialization can increase awareness about messages related to culture and racism, increase student and educator competence in having discussions about these topics, and create cultural pride and unity in the school setting.18 Bringing together trauma-informed intervention, SEL, and racial socialization to build skills for combatting racism can create schools where educators, students, and families are more confident about discussing race and are prepared to disrupt racism at individual and structural levels.

Trauma-Informed Practices

Although trauma-informed interventions are rarely designed to specifically address racism or racial stress and trauma, the trauma-informed lens is useful because it guides practitioners to view students who demonstrate challenging behaviors with compassion and to provide them opportunities to heal.21 School-based trauma-informed programs have been created over the past two decades in response to growing recognition of the harmful effects of toxic stress, trauma, and adversity on child development.22 Trauma-informed approaches emphasize strengthening existing supports and building skills for coping in the face of ongoing or previous exposure to trauma or adversity.19 Trauma-informed approaches include classroom and school-wide approaches to support students with trauma histories. Schoolwide approaches serve students with a range of social, emotional, or behavioral needs through multiple tiers of intervention.21 Specific psychological treatments for post-traumatic stress symptoms also fall broadly under the trauma-informed practices umbrella (e.g., Cognitive Behavioral Intervention for Trauma in Schools).23 These individual and group-based interventions have demonstrated some effectiveness in addressing trauma symptoms.19 Unfortunately, as currently implemented, traumainformed practices often pathologize Black and Brown youth for their responses to unjust conditions created and maintained by structural racism.24 There is a need to leverage the strengths of trauma-informed practices to specifically support coping and healing from racial stress and trauma, while simultaneously addressing the pathologizing of Black and Brown youth and working to dismantle structural racism.

Social-Emotional Learning (SEL)

SEL approaches provide a whole school structure for systematically and explicitly supporting the development of social-emotional skills and positive relationships. SEL skills allow students to “integrate cognition, affect, and behaviors, to achieve specified social tasks and positive developmental outcomes.”25 Competencies in the social-emotional domain support positive mental health20 and promote a positive school climate.26 SEL initiatives often include explicit instruction by classroom teachers through manualized programs. Meta-analytic findings suggest that these programs lead to gains in social-emotional skills, mental health, and academic achievement.20,27 However, these interventions have not been adequately examined from the perspective of race/ethnicity, socioeconomic, disability, and sexual and gender identity considerations.28 In recent years, the SEL field has introduced the concept of “transformative SEL” which speaks to the potential of SEL to ameliorate the educational, social, and economic inequities resulting from structural racism.29 A key approach to transformative SEL is incorporating culturally responsive practices. However, as with many curricula, the expectation remains that teachers will proactively incorporate culturally responsive practices. Particularly for White teachers (a majority of the teaching workforce), integrating culturally responsive pedagogy into SEL requires significant support.30 The transformative SEL approach has the potential to support efforts to combat racism by building key skills for identity exploration, cultural humility, collaborative problem-solving, and multicultural competence. There is a need to support educators, parents, and students in building these social-emotional skills to empower them in identifying, disrupting, and dismantling racism within the education system.

Racial Socialization

Racial socialization, or messages about race and racism, can promote adaptive social, emotional, and academic functioning for children of color.31 Racial socialization is most often studied in the context of parents teaching children about culture, race, and identity, and preparing children to deal with racism. Racial socialization by parents in families of color supports positive mental health32 and academic functioning.33 Coping responses supported by racial socialization are unique from general coping strategies, thereby necessitating attention to racial socialization, particularly for students of color.31 In contrast to parents and families of color, White teachers and parents are less likely to engage in racial socialization practices that promote disruption of racism.34 Thus, schools aiming to combat racism must specifically build racial socialization skills in White members of the school community. In doing so, schools will be able to increase constructive interracial interactions and promote constructive racial socialization in the school environment.18 Infusing racial socialization practices into social-emotional learning (SEL) and trauma-informed practices holds great potential for building educator skills to combat racism in their classrooms and school communities.

ACTIONS AGAINST RACISM The Actions Against Racism intervention was originally conceived as a parent-child group intervention by Kira Branch and colleagues35 at Nemours Children’s Health after the events surrounding the murder of George Floyd in May 2020. It was 41

developed to address an urgent need to provide skills for coping, healing, and disrupting and dismantling racism. The adaptation of “Actions Against Racism” to the school context began in Spring 2021 in partnership with educators throughout Delaware. The school-based adaptation of Actions Against Racism incorporates evidence-based practices from racial socialization research,36 trauma-focused cognitive behavior therapy,37 and transformative social-emotional learning.29 Actions Against Racism builds capacity for combatting racism in K-8 schools through three universal (Tier 1) components (school staff trainings, caregiver workshops, classroom conversations) and a small group component for students with social, emotional, or behavioral concerns (Tier 2/3).

1.

School staff trainings. Promotes racial socialization as well as recognizing and combatting racial bias in staff-staff, staff-student, and student-student interactions (Seven 90-minute workshops).

2.

Caregiver workshops. Promotes caregiver racial socialization skills (Seven 90-minute workshops).

3.

Universal classroom. Classroom conversations to promote constructive dialogue around racism and build inclusive and responsive classroom and school climate (At least weekly as part of existing classroom conversation structures).

4.

Small group. Students build coping and action plans for experiencing or witnessing racism (Fourteen 40-minute sessions).

All four components target five actions broadly relevant to adults and young people from all backgrounds: Talking about Racism, Recognizing Racism, Disrupting Racism, Coping with Racism, and Healing from/Repairing Harm from Racism.

The series of workshops or group sessions culminate in either individual action plans (caregiver/school staff) or group projects (small group/classroom) to act against racism. The student social action projects use a problem-based learning approach to combat racism at the structural level. Table 1 summarizes how racial socialization skills, trauma-informed practices, and SEL skills align with the five actions against racism.

Table 1. Actions Against Racism Theoretical Underpinnings Actions Against Racism

Developmental Framework for Trauma-Informed Carea

SEL Skill (CASEL 5 frameworkb)

Racial Socialization Skill

Action 1: Talking about Racism

Trauma Aware Awareness of prevalence of trauma and need for trauma -informed care

Identity Reflection (Self-Awareness)

Racial & Cultural Pride

Perspective Taking (Social Awareness)

Understanding Harm from Racism

Active Listening (Relationship Skills)

Cultural Humility

Verbal and nonverbal communication (Social Awareness)

Reading Racial Situations

Self-Reflection (Self-Awareness)

Recognizing own bias

Assertive Communication (Relationship Skills)

Disarming microaggressions

Social Problem Solving (Responsible Decision Making)

Building and Empowering Upstander Community

Trauma Responsive Changes in behaviors and practices to be more traumainformed

Emotion Identification (Self-Awareness)

Impact of racism on self

Emotion Regulation (Self-Management)

Social, emotional, behavioral, and cognitive coping strategies

Trauma Informed Continuous improvement and leadership to be trauma-informed

Goal setting and planning (Responsible decision making)

Strengthening Identity as Upstander/Leader/Ally

Social Problem solving (Responsible decision making)

Fostering Collective Healing, Repair, and Growth

Ethical Decision Making (Responsible decision making)

Advocating for Change

Action 2: Recognizing Racism

Action 3: Disrupting Racism

Action 4: Coping with Racism

Action 5: Healing and Repairing Harm from Racism

Trauma Aware Explain and advocate for traumainformed care

Trauma Sensitive Create readiness for change

Note. a: Family Services Cabinet Council, 202038 b: CASEL (2020)39 42 Delaware Journal of Public Health - May 2022

THEORY OF CHANGE Through five target “Actions,” the intervention builds socialemotional and behavioral skills for addressing racism in teachers, caregivers, and staff of all racial/ethnic backgrounds (Figure 1). Through the small group intervention component, students develop active problem solving and coping skills that lead to improvements in mental health and distress related to racism. Cultivating the five actions through the three universal components of the intervention (staff, caregivers, classroom) aims to increase staff and caregiver confidence in engaging in racial socialization practices and support a more inclusive school racial climate across staff, caregivers, and students. In turn, these changes in racial school climate will support the social, emotional, and behavioral functioning of all students, including those with specific concerns. Ultimately, the long-term impact of the intervention is expected to manifest in improvements in academic functioning for all students and reduction in racial disparities in mental health and education outcomes.

Unique Features of Actions Against Racism

The simultaneous focus on healing while also building skills and practicing actions against racism sets this intervention apart from other school-based interventions. In addition, the intervention materials are designed for all racial/ethnic groups and ability levels, which is particularly useful for the school environment. Many interventions related to racism emphasize the African American experience or have only been tested on

African American youth.36 Thus, the fact that Actions Against Racism addresses the varied needs of students, caregivers, and staff from diverse backgrounds with one intervention will help build a more cohesive classroom and school climate. The modifications available for ability levels is also a unique and valuable feature. The Actions Against Racism intervention was developed by pediatric clinical psychologists who routinely treat a wide range of psychological disorders seen in schools, including autism, intellectual disability, ADHD, disruptive behavior disorders, anxiety, and depression. Intervention materials include adaptations for simplifying content and using concrete learning strategies to meet the needs of a range of learners.

Next Steps

The Actions Against Racism intervention is in early stages of development and refinement. Over the next few years, we expect to further refine the intervention in partnership with schools and families throughout Delaware. After refining, piloting, and testing each intervention component, we anticipate conducting larger scale trials and ultimately training and disseminating throughout Delaware and beyond.

CONCLUSION In the wake of COVID-19’s disruptions to our schools and communities we are well-positioned to re-evaluate and facilitate necessary changes to support equitable education, physical, and mental health outcomes for all students. Without acceptable

Figure 1. Actions Against Racism Intervention Model

43

and feasible strategies to change the ongoing harm from racism, schools will perpetuate racism with dire impacts on students of color’s physical and mental health. Moreover, educators without sufficient awareness, knowledge, or skills will promote race-based harm at a micro and macro level, perpetuating the school-toprison pipeline and overcriminalization of unmanaged social, emotional, and behavioral health needs.

Pulling from the positive aspects of existing interventions, we have created and are in the process of testing the Actions Against Racism intervention for use in Delaware and beyond. This intervention will support school communities in: 1. Recognizing the harm of racism and racial stress/ trauma; 2. Building transformative social-emotional competencies using culturally responsive pedagogy while recognizing that members of privileged groups may need significant support in engaging in this process; 3. Uplifting historically marginalized voices and empowering the school community to co-create caring and inclusive schools; and 4. Working together to take anti-racist action through service learning, problem-based learning, and social action projects for classrooms, after school groups, and whole school and district communities.

We look forward to the continued evolution of this work as we partner with administratoes, educators, parents, and students to support equitable outcomes in Delaware schools and beyond.

Dr. Hatchimonji may be contacted at: Danielle.hatchimonji@nemours.org.

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27. Taylor, R. D., Oberle, E., Durlak, J. A., & Weissberg, R. P. (2017, July). Promoting positive youth development through school-based social and emotional learning interventions: A meta-analysis of follow-up effects. Child Development, 88(4), 1156–1171. https://doi.org/10.1111/cdev.12864 28. Rowe, H. L., & Trickett, E. J. (2018). Student diversity representation and reporting in universal school-based social and emotional learning programs: Implications for generalizability. Educational Psychology Review, 30, 559–583. https://doi.org/10.1007/s10648-017-9425-3

34. Abaied, J. L., & Perry, S. P. (2021, July). Socialization of racial ideology by White parents. Cultural Diversity & Ethnic Minority Psychology, 27(3), 431–440. https://doi.org/10.1037/cdp0000454 35. Branch, K.S., Perry, D.S., Hatchimonji, D.R., Hoffman, M., Marchante-Hoffman, A., Gramszlo, C., …, Hessel, E. (2021).

Actions Against Racism Curriculum. [Print].

36. Anderson, R. E., & Stevenson, H. C. (2019, January).

RECASTing racial stress and trauma: Theorizing the healing potential of racial socialization in families. The American Psychologist, 74(1), 63–75. https://doi.org/10.1037/amp0000392 37. Metzger, I. W., Anderson, R. E., Are, F., & Ritchwood, T. (2021, February). Healing interpersonal and racial trauma: Integrating racial socialization into trauma-focused cognitive behavioral therapy for African American youth. Child Maltreatment, 26(1), 17–27. https://doi.org/10.1177/1077559520921457 38. Family Services Cabinet Council (FSCC). (2019). Delaware Developmental Framework for Trauma-Informed Care. https://governor.delaware.gov/wp-content/uploads/sites/24/2019/02/ Delaware-Developmental-Framework-FSCC.pdf 39. Collaborative for Academic, Social, and Emotional Learning (CASEL). (2020). CASEL SEL Framework. https://casel.s3.us-east-2.amazonaws.com/CASEL-SELFramework-11.2020.pdf

29. Jagers, R. J., Rivas-Drake, D., & Williams, B. (2019).

Transformative social and emotional learning (SEL): Toward SEL in service of educational equity and excellence.

Educational Psychologist, 54(3), 162–184. https://doi.org/10.1080/00461520.2019.1623032 30. Barnes, T. N., & McCallops, K. (2019). Perceptions of culturally responsive pedagogy in teaching SEL. Journal for Multicultural Education, 13(1), 70–81. https://doi.org/10.1108/JME-07-2017-0044 45

The DPH Bulletin

From the Delaware Division of Public Health

May 2022

DHMIC presents 2022 Kitty Esterly, MD Health Equity Champion Awards Before a 360-person audience, the Delaware Healthy Mother and Infant Consortium (DHMIC) presented the 2022 Kitty Esterly, MD Health Equity Champion Awards during its 16th summit, held virtually on April 26. Dr. Esterly, a pediatrician who specialized in neonatal care, provided quality health care to all people, especially vulnerable populations.

Westside Family Healthcare and Planned Parenthood of Delaware tied as the 2022 organization champions.

Westside Family Healthcare ensures that patients have access to affordable housing, job placement, healthy food, clothing, and other necessities.

Westside offered patients rapid on-site COVID-19 testing and critical postpartum and infant wraparound services for families facing unemployment and other hardships. Westside raised private and state funds to deliver boxes of diapers, pack-n-plays, car seats, sleep sacks, infant hygiene items, breastfeeding pumps, and breastfeeding supplies to support moms most in need. To reduce unnecessary visits, Westside launched a remote prenatal blood pressure monitoring program.

Planned Parenthood of Delaware (PPD) ensures that the community can access quality, affordable health care and information to protect their health.

PPD strives to improve health outcomes by increasing access to prenatal care and reducing rates of unintended pregnancy and sexually transmitted infections. Their new Seaford clinic provides reproductive health care services. In an atmosphere of diversity, equity, and inclusion, PPD clinicians ensure that patients receive needed services, that wishes are addressed, and that patient concerns are at the center of every health care visit.

State Representative Melissa Minor-Brown, a staunch advocate for vulnerable women and children, received the individual champion award.

Her policy agenda addresses disparities for Black and Indigenous People of Color. Representative Minor-Brown removes barriers and galvanizes stakeholders in various sectors, such as legislating for an extended postpartum period and including doulas as an integral part of the health care delivery team. She works on the DHMIC’s Social Determinants of Health Committee to address issues such as housing for homeless pregnant women.

46 Delaware Journal of Public Health - May 2022

Lieutenant Governor Bethany Hall-Long organized a COVID-19 Remembrance Memorial Ceremony, held May 3 at the Jesse Cooper Building in Dover. A pink dogwood tree honors mission essential personnel, COVID-19 survivors, and the 2,919 people who have died from COVID-19. From left: the Rev. Carol E. Harris, Director of Pastoral Care, Bayhealth; Governor John Carney; Division of Public Health Director Dr. Karyl Rattay; Lieutenant Governor Hall-Long; Charonda Johnson of COVID Survivors for Change; and Rosie Davis of Yellow Heart Memorial.

Visit de.gov/covidmemorial to submit the names of loved ones lost to COVID-19, those living with long-haul symptoms, and those who worked tirelessly throughout the pandemic.

Photo by Sean Dooley.

Delaware infant mortality data Delaware’s infant mortality rate fell from 9.3 deaths per 1,000 live births in 2004 to 7.2 deaths per 1,000 live births in 2019, a 22.6 percent drop.

In Delaware in 2019, the infant mortality rate in the City of Wilmington was 14.8 deaths per 1,000 live births, compared to 6.5 deaths per 1,000 live births in the balance of New Castle County; 6.9 deaths per 1,000 live births in Kent County; and 6.0 deaths per 1,000 live births in Sussex County.

In Delaware in 2019, the Black rate of 12.5 deaths per 1,000 live births is three times as high as the White rate of 4.2 deaths per 1,000 live births; the Hispanic rate is two times as high as the White rate.

Visit https://dethrives.com/ for more information.

Source: DPH Vital Statistics (2019)

RespondDE announces Outstanding County Volunteers for 2022 The Division of Public Health’s Emergency Medical Services and Preparedness Section manages RespondDE, a statewide volunteer corps of medical and non-medical professionals who are trained to respond to local public health emergencies and promote health education. In 2021, 785 RespondDE volunteers gave over 4,377 hours to assist DPH’s COVID-19 response, for an estimated economic impact of $133,000.

“Your training and skills expand the reach of the Division of Public Health, especially during the ongoing COVID efforts,” DPH Director Dr. Karyl Rattay told the volunteers.

During an April 27 appreciation event RespondDE honored three of its 1,700 volunteers:

Marion Osborne, RN

Erin Fink, RN

Marion Osborne, RN, New Castle County RespondDE Volunteer of the Year – Osborne has been a RespondDE volunteer since March 2017. In 2021, she assisted with COVID-19 testing and vaccination Points of Distribution (PODs) and Food Bank First Aid Stations.

Erin Fink, RN, Kent County RespondDE Volunteer of the Year – Fink has been a RespondDE volunteer since January 2021. In 2021, she assisted with COVID-19 testing and vaccinations and volunteers multiple times weekly, providing student COVID-19 testing at the University of Delaware.

Christopher Miller, RN, Sussex County RespondDE Volunteer of the Year – Miller has been a RespondDE volunteer since May 2020. In 2021, he assisted with COVID-19 testing and vaccination PODs, Food Bank First Aid Stations, and other opportunities.

Christopher Miller, RN

For more information, visit respondde.org. To contact RespondDE or request volunteers at your event, send an email to respondde@delaware.gov or call 302-223-2939.

The DPH Bulletin – May 2022

RespondDE COVID-19 response, Delaware, 2021 volunteers hours Estimated economic impact:

$133,000

Vaccine distribution events Test kit assembly • Data entry

Thank you Source: RespondDE, 2022

Stay one step ahead of COVID-19

Delaware’s seven-day average of new positive COVID-19 cases rose to 157.1, a 94.0 increase, between March 25, 2022 and April 22, 2022, according to the Division of Public Health (DPH).

The Centers for Disease Control and Prevention reported 991,439 deaths due to COVID-19 in the United States as of May 2, 2022.

Stay one step ahead of COVID-19 with these tips: • Get vaccinated and boosted when eligible.

Vaccines are readily available. Find a vaccination site at de.gov/getmyvaccine.

• Stay home when you are sick.

• Get tested if you have symptoms, as some mirror those of flu and seasonal allergies. Find a testing location or where to get a home test kit at de.gov/gettested.

• If you test positive, check with your health care provider to determine if you should get treatment.

• Mask up in crowded indoor spaces with poor ventilation and if you have a weakened immune system or live with someone who does.

• Everyone age 2 years and older is encouraged to wear a well-fitting mask or respirator when on public transportation.

For the latest COVID-19 data trends, visit https://coronavirus.delaware.gov/.

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Outdoor workers risk getting skin cancer

Skin cancer is a serious risk for outdoor workers, according to the Centers for Disease Control and Prevention. Farmers, construction and road crews, and other outdoor workers are exposed to damaging ultraviolet (UV) rays that could lead to skin cancer. If you work outdoors or care about someone who does, remember and share these key points: 1. Skin cancer is serious. According to the most recent data available for Delaware, melanoma, the most serious form of skin cancer, accounts for 2 percent of cancer deaths in the state, with 63 percent of those deaths occurring in men. Limiting outdoor exposure is so important that the U.S. Occupational and Safety Health Administration (OSHA) requires employers to minimize workers’ sun risk by providing shade on the job and allowing breaks for sunscreen application.

2. “Protect and check” is a winning combination.

Shield your skin from head to toe by wearing longsleeved shirts and long pants and wide-brimmed hats to cover your head, face, neck, and ears.

Wear sunglasses that block 99 percent or more of UV light. Use a water-resistant sunscreen with UVA and UVB protection and a broad-spectrum Sun Protective Factor (SPF) of 30 or higher. If you wear cosmetics, choose a high SPF/broad spectrum label.

Check your skin regularly for new growths and moles and changes in mole shape and color.

Contact a dermatologist immediately if anything unusual appears.

3. It can take years for skin cancer to develop.

Many adults are diagnosed with skin cancer that started when they were younger. No matter what your age, protect yourself every day, even if you feel and look fine.

Sun safety toolkits specific to schools, camps, and employers are available at DPH’s Sun Safety website: https://www.protectyourskinde.com/.

Women and girls: prioritize physical and mental health

National Women’s Health Week (May 8-14, 2022) reminds women and girls to prioritize their health.

Women and girls who are caregivers, have chronic illnesses or disabilities, and are lesbian, bisexual, and transgender are at greater risk for poor physical and mental health, according to the Centers for Disease Control and Prevention and the U.S. Department of Health and Human Services’ Office on Women’s Health. Take the following steps to prevent disease and detect problems early: 1. Catch up on your exams and screenings, such as a pap test for cervical cancer and breast cancer screenings. Visit HealthyDelaware.org to contact a Nurse Navigator for assistance in scheduling cancer screenings.

2. Learn the basics of healthier eating habits.

Maintain weight with a healthy and balanced eating plan; if planning pregnancy, take folic acid daily to help prevent major birth defects; and limit alcohol to one drink or less daily.

3. Get and stay active. Physical activity has many health benefits, including lowering your risk of heart disease.

4. Prioritize your mental health. Get enough sleep, be smoke free, unwind with enjoyable activities, and connect with others. Find services at the Delaware Department of Health and Social Services’ Division of Substance Abuse and Mental Health. If you are overwhelmed with sadness, anxiety, or depression, or feel like you want to harm yourself or others, visit https://www.suicidehotlines.com/delaware.html or call: Kent/Sussex Mobile Crisis Unit: 1-800-345-6785 Mobile Crisis Intervention Service New Castle: 302-577-2484 or toll-free: 1-800-652-2929.

Individuals struggling with a substance disorder can visit http://www.HelpisHereDE.com or call the Delaware Hope Line at 833-9-HOPEDE. Seek help for domestic violence and intimate partner violence from the Delaware Coalition Against Domestic Violence at these 24-hour hotlines: New Castle County: 302-762-6110 Kent and Sussex counties: 302-422-8058 Abriendo Puertas: 302-745-9874.

The DPH Bulletin – May 2022 48 Delaware Journal of Public Health - May 2022

Page 3 of 4

Research suggests Mediterranean Dietary Plan reduces chronic disease

Four of the top five leading causes of death in Delaware are chronic diseases, according to the Division of Public Health. Chronic diseases progress slowly and persist for a long time.

Examples are cancer, diabetes, Alzheimer’s, cardiovascular diseases, and chronic lower respiratory diseases. At the center of many strategies for managing chronic disease are nutritional and/or dietary interventions, physical activity, and healthy lifestyle changes.

Getting a comprehensive dilated eye exam can save your sight May is Healthy Vision Month and a good time to make an appointment for a comprehensive dilated eye exam to detect eye diseases early – before they cause vision loss and when they are easier to treat.

Diabetic retinopathy, glaucoma, age-related macular degeneration, and glaucoma can be detected with a comprehensive dilated eye exam. It is a simple and usually painless test.

The eye care professional uses eye drops to view the inside of the eye. The drops dilate (widen) the pupil, which is the opening in the center of the iris, the colored part of the eye. Once dilated, each eye is examined using a special magnifying lens that provides a clear view of important tissues at the back of the eye, including the retina and the optic nerve, which connects the retina to the brain.

The Centers for Disease Control and Prevention (CDC) recommends a dilated eye exam every year for people with diabetic retinopathy, the leading cause of blindness in American adults. The CDC recommends a dilated eye exam every two years for Black Americans 40 years and over, individuals over age 60, especially Mexican Americans; and people with a family history of glaucoma.

Improving nutrition and a healthy diet are critically important to manage chronic disease. According to The Dietary Guidelines for Americans, 2020-2025, one healthy dietary option is the Mediterranean Diet, based on the traditional meals of Italy, Greece, and other countries bordering the Mediterranean Sea. Research suggests that this healthy dietary plan can help prevent heart disease and stroke and reduce risk factors such as obesity, diabetes, high cholesterol, and high blood pressure.

The Mediterranean dietary plan features plant-based foods like whole grains, vegetables, beans, fruits, herbs, and spices. Fish, seafood, dairy, and poultry are eaten in moderation (up to twice weekly), and red meat only occasionally. Olive oil replaces butter as the main source of fat. Other healthy fats come from nuts and seeds, and from fatty fish like sardines, tuna, and salmon. If dessert is served, it is usually fresh fruit.

Visit Healthy Delaware’s Healthy Lifestyles Map at https://www.healthydelaware.org to find local produce at farmers’ markets and farm stands.

Those seeking physical activity options can also use the Healthy Lifestyles Map to find nearby fitness centers and parks.

The National Eye Institute recommends asking a friend or family member to drive you home from the eye appointment, since your vision may be blurry for a few hours. Bring your sunglasses because your eyes will be temporarily sensitive to light.

For more information, talk to your eye care provider and visit the CDC or the National Eye Institute.

The DPH Bulletin – May 2022

Page 4 of 4 49

Accommodating Developmental Disabilities in the Social Determinants of Health: A Brief Inquiry into the Applicability of Metrics to the Lives of Individuals with Developmental Disabilities in Delaware Ankita Mohan and Jody A. Roberts, Ph.D. Delaware Division of Developmental Disabilities Services

ABSTRACT This commentary outlines the methods and findings of a preliminary study examining the fitness of the Social Determinants of Health in their current conceptualizations for accommodating the specific and general experiences of individuals with developmental disabilities and suggests recommendations for both additional research and policy interventions. The study is based on research conducted with individuals with intellectual and developmental disabilities living in Delaware and other stakeholders working in this community. There is currently extensive literature concerning the validity and importance of including the social determinants of health in healthcare decision-making, but very little research exists around the intersection of developmental disabilities and these determinants. This commentary provides additional detail and added emphasis to calls previously made in this Journal to align social determinants with developmental disabilities and the importance of considering the SDOH in policy measures aimed at supporting this population. The ultimate aim of the work presented here is to explore how the State’s interest in putting the SDOH to work generally can be aligned to accommodate the needs and interests of individuals with I/DD and to identify future research and policy interventions in support of these efforts.

BACKGROUND The Social Determinants of Health

The connection between health equity and the social determinants of health has been demonstrated through multiple studies. The U.S Department of Health and Human Services (HHS), in its report, Healthy People 2020, defines the social determinants of health (SDOH) as “conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.” The five key determinants include: economic stability, education, social and community context, health and healthcare, and neighborhood and built environment.1 A study by the World Health Organization (WHO) Commission on Social Determinants of Health (CSDH) found that the social determinants of health contribute (individually and collectively) to many of the health inequities present within countries. A 2010 WHO article compiled and summarized 13 separate studies to analyze the impact of the social determinants on public health programs. The studies found that among other impacts, the SDOH influenced the prevalence of cardiovascular disease, health and nutrition of children, food safety, unintended pregnancy and pregnancy outcomes, and violence and unintentional injury.2

The Developmental Disability Community

For individuals with developmental disabilities, maintaining good health is essential in order to reduce the effect of “impairment on 50 Delaware Journal of Public Health - May 2022

functioning and participation.”3 However, the IDD community is exposed to many barriers to health including a lack of prepared health providers, scarce access to high quality medical care, and a lack of inclusion of people with IDDs in public health efforts.4 Additionally, people with acquired physical disabilities such as Polio, Rheumatoid Arthritis, and stroke are more likely to acquire a greater number of chronic diseases.5 This increased possibility emphasizes the importance of access to adequate health care, in general, and an appreciation for how social determinants of health create or exacerbate these conditions within the population of individuals with IDD. However, the IDD community is not typically discussed in SDOH literature. In the latest report by the CSDH, the word “women” is mentioned 337 times, “gender” 237 times, “the poor” 75 times, “indigenous people” 37 times, “disabled people” 1 time, and “people with disabilities” 3 times.6 Healthy People 2020 maintains an objective of “disability and health,” and commits to “[e]xpanding the knowledge base and raising awareness about determinants of health for individuals with disabilities by increasing: 1. the inclusion of individuals with disabilities in public health data collection efforts across the lifespan; 2. the inclusion of individuals with disabilities in health promotion activities; and 3. the expansion of disability and health training opportunities for public health and health care professionals.”1 DOI: 10.32481/djph.2022.05.006

There is an acknowledged lack of data already present regarding the application of the SDOH to the general assessment of health within the IDD community. However, we found no studies assessing the fitness of application of the SDOH as generally understood and measured to individuals with IDD. Our brief survey, outlined below, is an attempt at taking that first step in assessment and an exploration of what might need to be modified in our general understanding of social determinants of health in order to make them of use – for both policy and clinical practice – supporting individuals with IDD.

METHODOLOGY This project employed a mixed-methods approach to data collection using content gathered from a series of semi-structured interviews (see Appendix A) to inform and shape the structure of a survey distributed to a broader audience of stakeholders receiving services from Delaware’s Division of Developmental Disabilities Services (DDDS). Methods were structured in this way to allow for a quick, scalable snapshot of the broad intersection of the social determinants with experiences of those living with intellectual and/or developmental disabilities while providing an opportunity for future refinement and focus on select areas of interest.

Both interviews and surveys focused on fitness of current conceptions of the Social Determinants of Health and not on health outcomes associated with those determinants. That is, while there is an acknowledged lack of data examining the social determinants of health and their application to individuals with disabilities, we instead have stepped back to ask whether the language and metrics used to substantiate the determinants themselves adequately accommodate the lived experiences of individuals with developmental disabilities in the first place. The goal of this specific research was to study the tool itself to examine its applicability to our targeted population. The findings of this research are descriptive level data that do not draw the connection between the determinants and health outcomes, but instead provide perspective on the language and metrics used.

Part A: Semi-Structured Interviews The semi-structured interviews were conducted with the goal of obtaining experience with and reaction to standard metrics commonly used in each of the five main categories of social determinants. Interviews were conducted through video calls with eight individuals occupying at least one of the following three categories: an individual with an intellectual or developmental disability, a parent of a child with an I/DD, or a professional with experience working with individuals with intellectual and/or developmental disabilities. Interviewees were asked a few short introductory questions before being introduced to the social determinants. Interviewees were asked to draw on personal and professional experiences to reflect on the adequacy of measures used to evaluate the social determinants and to provide feedback for making them more inclusive of their experiences.

The interviews were then transcribed, and thematic analysis was conducted with the goal of identifying the most prevalent responses and connections to ideas behind those responses.

Part B: Survey From the analysis of our semi-structured interviews, we generated a short twenty question survey to be distributed among active DDDS service recipients. The survey was sent to all DDDS service recipients with cases managed by the Columbus Organization and yielded 171 responses. The survey was designed to collect data in three scales. First, a Likert scale was used to assess what indicators within each determinant were of importance. Participants were then asked to rank-order priorities within each SDOH category, indicating the most important priority within each determinant.

Finally, respondents were asked to rank order SDOH categories with regards to immediate needs and priorities for access to a healthy life. The survey also included questions that gauged awareness of SDOH focused initiatives, such as free financial literacy courses.

RESULTS Part A: Semi-Structured Interview Figure 1 presents the responses from the semi-structured interview. Each response that is bolded signifies that it was a repeated response, and the parenthesis next to each bolded issue expresses the number of times a response was repeated.

Part A of the survey identified key issues and underlying causes that are the strongest indicators of the five determinants for the developmental disability community. Figure 2 indicates the most frequently identified priorities and the frequency of responses.

Part B: Survey Part B surveyed 171 individuals receiving services from DDDS and identified the order of key issues and underlying causes that are important to the developmental disabilities community when considering the five key determinants.

I. Economic stability 1. Access to employment or vocational training 2. Registration with state-based services 3. Accommodations in employment II. Education 1. Utilization and quality of IEPs 2. Access to alternate degrees 3. Access to accommodations in higher education III. Social and Community Context 1. Access to appropriate communication 2. Support of community 3. Involvement in community IV. Health and Healthcare 1. Access to quality medical care 2. Plain language medical literature 3. Behavioral supports V. Neighborhood and Built Environment 1. Affordable, accessible housing 2. Affordable, readily available transportation 3. Comfort in law enforcement interactions.

51

Figure 1. SDOH, Key Issues (Identified by HHS), and Proposed Key Issues

Figure 2. Top Indicators for Determinants by Frequency of Responses

Figure 3. Percent of Respondents who Indicated Top Priority

52 Delaware Journal of Public Health - May 2022

Health Literate Care Model A Universal Precautions Approach

The respondents were then asked to rank the determinants according to what they felt was a top priority for indicating their health outcomes. Respondents could indicate more than one determinant as a top priority. Figure 3 depicts the ranking of determinants based on respondents’ top priority.

A small number of additional questions regarding awareness of resources to address some of these priorities were also asked.

When asked about S.T.A.N.D., abuse training in DE, only 18% were aware of this resource. When asked about awareness of financial literacy courses through DE Money School, 30% knew about this service.

To learn more about the Health Literate Care Model — including tips and tools that will help you implement it— visit health.gov.

7

Figure 4. The Health Literate Care Model

Health Literate Systems Organization of Health Care

Community Partners

Delivery system design

Resources and Policies

Health information systems Self-management support Shared decision making

Strategies for Health Literate Organizations Apply improvement methods Improve verbal interaction Improve written communication

POLICY OPTIONS, OPPORTUNITIES, & FURTHER RESEARCH Additional research is needed to systematically understand what role the social determinants of health can and should have in accounting for the health and livelihoods of individuals with intellectual and developmental disabilities, and what additions or modifications would need to be made to those determinants to make them applicable and inclusive of this population. Based on this preliminary work, however, there is plenty of data to suggest at least a few immediate, trackable policy interventions that can be made.

Policy Options – Short-Term

1. Resources available to the developmental disability community regarding education, economic stability, community, health, and environment should be easy to access and easy to navigate.

Through the semi-structured interviews conducted, it was found that while many programs in place aim to address the inequities in the SDOH for the developmental disability community, often they are not known because of the lack of accessible advertisement or display of these resources. Further, in the surveys, it was found that many people were not aware of free, community-based initiatives such as free financial literacy classes. In the survey, individuals indicated that they would like help finding a job. Comments like these provide an opportunity for resource creation, such as an inclusive employers list.

Through improving how programs and recourses are marketed and advertised to individuals, the full potential of the programs increases.

2. Access to plain language medical literature and opportunities to improve health literacy are critical for ensuring equal access to healthcare. The State and Delaware-based healthcare communities must come together to remove these barriers.

In the semi-structured interview portion of the study, access to plain language medical literature was flagged as a priority.

Further, during the survey, it was ranked either number one or number two in health and healthcare by over 53% of respondents.

Providing plain language medical literature is a short-term goal that can be implemented in healthcare settings such as clinics, doctors’ offices, and hospitals. This could also mean ensuring that language or ability to read are not barriers in understanding medical options. The U.S. Department of Health and Human Services (HHS) maintains a health literacy webpage that provides tools that can be utilized to improve the usability of different health tools.

Further, the HHS Health Literate Care Model (figure 4) should be implemented in Delaware healthcare settings to ensure that health literacy is a central value in DE.7

Link to supportive systems Engage patients as partners in care and improvement efforts

Productive Interactions Informed, Health Literate, Activated Patient and Family

Prepared, Proactive, Health Literate Health Care Team

Improved Outcomes See: Koh, H.; Brach, C.; Harris, L.M.; and Parchman, M.L. (2013) “A Proposed ‘Health Literate Care Model Would Constitute A Systems Approach to Improving Patients’ Engagement in Care.” Health Affairs. No. 2 (357-367).

The goals of the Health Literate Care Model are: • Approach all patients as if they are at risk of not understanding health information; • Employ a range of strategies for clear communication; • Confirm that patients understand what providers are saying7 Ultimately, the Health Literate Care Model outlines the standard of approaching all patients if they may not understand their health conditions or how to manage them. Following this, subsequent confirmation that patients understand is required.

This model would create a systemic plan for addressing health literacy.

Policy Options – Long-Term

Delaware-based medical providers should have consistent access to quality continuing education opportunities specific to IDD health and healthcare.

In both the semi-structured interviews and the mass survey, “access to quality medical providers, familiar with developmental disabilities” ranked as a priority. Further, the disparities in physician knowledge around disabilities was demonstrated through a study by Lisa Iezzoni et al. who found that 35.8% of physicians knew little or nothing about their legal responsibilities under the Americans with Disabilities Act and 68.4% felt that they would be at risk for ADA lawsuits.8 To ensure that physicians and health professionals are well versed to treat vulnerable communities, it is important that medical professionals continue learning about developmental disability health. By creating a CME requirement of developmental disability health, the population with disabilities will be provided with the best health treatment possible.

The Medical Society of Delaware (MDS) provides accreditation and training events for medical professionals in Delaware.9 There should be a partnership formed with MDS to ensure that medical trainings relating to disability health are incorporated into MDS resources.

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Further Research

6. Wolbring, G. (2011, July-August). People with disabilities and social determinants of health discourses. Can J Public Health, 102(4), 317–319. https://doi.org/10.1007/BF03404058

Through the literature review, it was found that there is a lack of evidence-based research surrounding the effectiveness of policy interventions on the SDOH. This data collection and policy recommendation serves as a blueprint for further policymaking and policy tracking around the SDOH and disabilities. Producing evidence-based research, specifically targeted at the indicators within the health and healthcare and education determinants, would provide a sound foundation of data that is centered on producing equitable health outcomes. By producing this type of research, the importance and validity of policy in this area will be demonstrated, allowing for the inclusion of the social determinants of health in decision-making.

7. U.S. Department of Health and Human Services. (n.d.). Health literate care model. https://health.gov/our-work/nationalhealth-initiatives/health-literacy/health-literate-care-model

More evidence-based research should be conducted on the current policy efforts aimed at addressing issues related to the Social Determinants of Health.

Dr. Roberts may be contacted at jody.roberts@delaware.gov

REFERENCES 1. Healthy People. 2020. (n.d.) Disability and health. https://www.healthypeople.gov/2020/topics-objectives/topic/ disability-and-health 2. World Health Organization. (1970, Jan 1). Equity, Social Determinants and public health programmes. World Health Organization. https://apps.who.int/iris/handle/10665/44289 3. Abdullah, N., Horner-Johnson, W., Drum, C. E., Krahn, G. L., Staples, E., Weisser, J., & Hammond, L. (2004). Healthy lifestyles for people with disabilities. Californian Journal of Health Promotion, 2(SI), 42–54.

4. Anderson, L. L., Humphries, K., McDermott, S., Marks, B., Sisirak, J., & Larson, S. (2013, October). The state of the science of health and wellness for adults with intellectual and developmental disabilities. Intellectual and Developmental Disabilities, 51(5), 385–398. https://doi.org/10.1352/1934-9556-51.5.385 5. Campbell, M. L., Sheets, D., & Strong, P. S. (1999). Secondary health conditions among middle-aged individuals with chronic physical disabilities: Implications for unmet needs for services. Assist Technol, 11(2), 105–122. https://doi.org/10.1080/10400435.1999.10131995

8. Iezzoni, L. I., Rao, S. R., Ressalam, J., Bolcic-Jankovic, D., Agaronnik, N. D., Lagu, T., . . . Campbell, E. G. (2022, January). US physicians’ knowledge about the Americans with disabilities act and accommodation of patients with disability.

Health Aff (Millwood), 41(1), 96–104. https://doi.org/10.1377/hlthaff.2021.01136 9. Medical Society of Delaware. (n.d.). CME. https://www.medicalsocietyofdelaware.org/delaware/ CMMSD/CME/CMMSD/Nav_Items/CME.aspx

APPENDIX A SEMI-STRUCTURED INTERVIEW GUIDE DDDS Semi-Structured Interview Survey Part 1: Background Questions 1. What is your relationship with the IDD community? ☐ Expert

☐ Parent

☐ Individual with IDD

2. How long have you had this relationship? _________ years

_________ months

3. Are you familiar with the Social Determinants of Health? ☐ yes

☐ no

*Share figure 5 on the screen*

Figure 5. Measures of SDOH Figure 5. Measures of SDOH DETERMINANT

MEASURE

Economic Stability

- Poverty - Employment - Food Insecurity - Housing Instability

Education

Social and Community Context

- High School Graduation

- Social Cohesion

- Access to Healthcare

- Enrollment in Higher Education

- Civic Participation

- Access to Primary Care

- Language and Literacy

- Discrimination

- Health Literacy

- Early Childhood Education and Development

- Incarceration

https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-health/interventions-resources 54 Delaware Journal of Public Health - May 2022

Health and Healthcare

Neighborhood and Built Environment - Access to Foods that Support Healthy Eating Patterns - Quality of Housing - Crime and Violence - Environmental Conditions

Read the following aloud: To provide a general definition, I will read the U.S. Department of Health and Human Services, Healthy People definition.

Healthy People defines the Social Determinants of Health as “ the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.”

SDOH can be grouped into 5 domains: Economic Stability, Education, Social and Community Context, Health and Healthcare, and Neighborhood and Built Environment.

Healthy People identify that the goal of SDOH is “ to establish policies that positively influence social and economic conditions and those that support changes in individual behavior, we can improve health for large numbers of people in ways that can be sustained over time. Improving the conditions in which we live, learn, work, and play and the quality of our relationships will create a healthier population, society, and workforce.”

Do you have questions about the role of the social determinants of health before we move forward?

Read the following aloud: This chart has the 5 key determinants along with key issues that Healthy People have identified as representative of the determinants. I will go through the chart section by section and following each section, I will ask a few follow up questions.

Do you have any questions before we move on?

For economic stability, the issues identified were poverty, employment, food insecurity, and housing stability.

1.

In your opinion, what if any determinants or measures shown here are not inclusive of the IDD community?

2.

What if any measures or determinants should be added to accurately include the IDD community? For example, when thinking about employers, maybe inclusive employers should be added.

For education, high school graduation, enrollment in higher education, language and literacy, and early childhood education and development were identified.

1.

In your opinion, what if any determinants or measures shown here are not inclusive of the IDD community? For example, high school graduation may not be applicable to everyone.

2.

What if any measures or determinants should be added to accurately include the IDD community? For example, alternative diplomas may need to be added to education to accurately include the IDD population.

For social and community context, the issues identified were social cohesion, civic participation, discrimination, and incarceration.

1.

In your opinion, what if any determinants or measures shown here are not inclusive of the IDD community?

2.

What if any measures or determinants should be added to accurately include the IDD community? For example, maybe community support should be added?

For health and healthcare, access to healthcare, access to primary care, and health literacy were identified.

1.

In your opinion, what if any determinants or measures shown here are not inclusive of the IDD community?

2.

What if any measures or determinants should be added to accurately include the IDD community? For example, access to behavioral services?

Finally, the issues identified for neighborhood and built environment were access to foods that support healthy eating patterns, quality of housing, crime and violence, and environmental conditions.

1.

In your opinion, what if any determinants or measures shown here are not inclusive of the IDD community? For example, it might be important to note that many of these key issues are drastically different for people living in residential communities and those living alone.

2.

What if any measures or determinants should be added to accurately include the IDD community?

3.

Do you have any additional comments you would like to share?

55

Domestic Violence: A Public Health Problem Requires a Public Health Solution Erin Ridout, M.S.W., M.P.H. Domestic Violence & Community Health Program Manager, Delaware Coalition Against Domestic Violence

THE PROBLEM Domestic violence (DV) is a prevalent and pervasive public health issue that has enormous health, well-being, and economic impacts. Domestic violence is when one person in a relationship perpetrates a pattern of coercive or assaultive behaviors over another. The abuser uses physical violence, sexual violence, threats, emotional abuse and/or financial manipulation to harm and control their partner. Noting that domestic and sexual violence are chronically underreported, “about 1 in 4 women and nearly 1 in 10 men have experienced contact sexual violence, physical violence, and/or stalking by an intimate partner during their lifetime.”1 Domestic violence impacts individuals across all demographic lines, impacting people regardless of age, race, religion, ethnicity, culture, socioeconomic class, education level, gender, and sexuality. That said, women of color, members of the LGBTQ+ community, and those living in poverty are disproportionately impacted.

Domestic violence results in disparate health outcomes for survivors and their families in the areas of chronic disease, mental health, substance use, and reproductive health. In addition to physical injuries, domestic violence can result in chronic pain, headaches, fatigue, immune, endocrine and gastrointestinal disorders, as well increased risk of irritable bowel syndrome and diabetes.2 Domestic violence survivors are three times more likely to have a mental health condition; six times more likely to become dependent on drugs or alcohol, and twice as likely to smoke, become obese, and practice sexual risk behaviors, increasing risk for STIs, including HIV.2 The health, well-being, and social impacts of domestic violence have only been exacerbated by the COVID-19 pandemic, resulting in an increase in severity and complexity of the safety, health, and social needs of survivors.

THE NEED Domestic violence has long been treated as a criminal justice issue to be handled by law enforcement and the courts. This traditional approach contains systemic barriers for many survivors, and there have been increasing calls from survivors and advocates alike to “develop responses to gender violence that do not depend on a sexist, racist, classist, and homophobic criminal justice system.”3 For many victims of domestic violence, the first source of help will not be law enforcement, but rather their healthcare provider. Victims of domestic violence who may be too frightened to involve the police or the courts because of retribution by their abuser, or systemic barriers, may seek assistance and counseling through their doctor. This creates an opportunity for an additional access point for survivors to connect to domestic violence resources and support.

Whether survivors seek support from their health care team or other care provider, it is imperative that the response be trauma56 Delaware Journal of Public Health - May 2022

informed. Trauma-informed care “is an intentional approach to understanding and interacting with people who have or may be experiencing trauma.”4 For domestic violence survivors, this care includes treating the survivor as the expert on their experience and supporting their decision-making, and being survivorcentered. Survivor-centered care aligns with the healthcare community’s commitment to patient-centered care.

It is also important that domestic violence response, referral, and support services are equitably accessible. Survivors from historically marginalized communities often face additional barriers in accessing care and support – barriers around the language of services, the location of services, time limitations on duration of service engagement, and documentation status requirements.

PROMISING SOLUTION The Domestic Violence – Community Health Worker Project (DV-CHW Project) is a collaborative effort among the Delaware Coalition Against Domestic Violence (DCADV), CHILD, Inc., ChristianaCare, Westside Family Healthcare, and St. Francis Hospital. DCADV serves as the project lead, guiding this public health response to domestic violence. The DV-CHW Project provides life-saving services and care coordination to victims of domestic violence and crucial training and resources to health care teams.

The unique service delivery model of the DV-CHW Project combines the trauma-informed, survivor-centered work of domestic violence advocates with the community-based, culturally competent, and accessible work of Community Health Workers (CHWs). This innovative approach creates services that address the complex safety, health, and social needs of domestic violence survivors and their families.

Project partner CHILD Inc. employs three full-time DV-CHWs who meet with survivors wherever they feel safe and comfortable.

The DV-CHW team is mobile and committed to the accessibility of their services, going to survivors’ homes, libraries, health clinics, coffee shops, workplaces, stores, and an ever-expanding list of other convenient locations. Two of the three DV-CHWs are bilingual in Spanish and English. Critical to their services and survivor engagement, the DV-CHW Project utilizes flex funds— flexible financial assistance—to meet the tangible and urgent needs of survivors. Understanding that survivors cannot focus on their health or safety if their children are hungry or their lights are about to be shut off, these flex funds target survivors’ social determinants of health needs, with the top categories of spending being basic needs, housing, children’s needs, transportation, and physical health.

DCADV also provides free practice area-specific trainings to health care teams around trauma-informed, evidence-based domestic violence screening and referral, along with a wide DOI: 10.32481/djph.2022.05.007

variety of domestic violence resource materials in multiple languages. These trainings and resources seek to strengthen the frequency and efficacy of health care-based domestic violence screenings and referrals, targeting the low rates of screening among health care providers.5,6

ensures that vulnerable and underserved individuals receive services that are accessible, equitable, and culturally specific.

CHW certification and reimbursement is an important public health approach to reducing the health inequities Delaware’s most vulnerable communities face.

THE IMPACT

To learn more about DCADV, the DV-CHW Project, or domestic violence resources, please visit dcadv.org.

The DV-CHWs have been serving survivors in New Castle County since February 2019. Through regular communication and a trauma-informed approach, the DV-CHWs build supportive connections focused on long-term safety and health.

Survivors stay engaged with their DV-CHW for an average of ten months, connecting multiple times a month, often for long periods of time.7 The DV-CHWs complete a health and social needs screening, ensure the survivor is connected to healthcare, engage in safety planning that includes both immediate protections and a long-term plan, and assist with addressing barriers to health and safety. On average, the team currently serves almost 90 survivors a month.7 As the DV-CHW pilot became a critical and innovative program, it became clear that the level of engagement needed to support survivors’ safety, health, and social needs was high. Formal evaluation of the DV-CHW program by the University of Delaware (UD) revealed that, in a large part, it is the meaningful and authentic relationship between the survivor and DVCHW itself that is paramount to the survivors’ feelings of safety and well-being.8 UD noted that in qualitative interviews with survivors, they described the wide variety of services the DV-CHW program provides and the impact on their overall well-being by way of increased social and emotional support, increases in their knowledge of and connection to community resources, and reduced financial stress.8,9 Using trauma-informed relationship building and emotional support, the DV-CHWs increase the survivors’ perceptions of safety and comfort accessing services, including healthcare services.

In addition to the positive impacts on well-being, recent further evaluation by UD revealed that survivors engaged with the DVCHWs report reduction in poor health, as measured by Healthy Days core questions of the Centers for Disease Control and Prevention (CDC) asked at intake and throughout engagement.10 Notably, the reduction in poor physical and mental health days increases the longer the survivor engages with the DV-CHWs.10

NEXT STEPS

Meeting the complex safety, health, and social needs of survivors of domestic violence requires trauma-informed, survivorcentered services that are accessible to underserved communities.

DCADV’s Domestic Violence – Community Health Worker Project is a shift from the traditional criminal justice approach to a trauma-informed public health approach. The commitment, passion, and flexibility of CHILD, Inc.’s DV-CHWs is incredible and the impact on survivors’ health and well-being is promising.

The DV-CHW Project currently serves survivors in New Castle County and, like many other innovative approaches, relies on grant funding. As DCADV looks to secure the funding needed to expand statewide, sustainable funding is critical. DCADV is one of many organizations collaborating with the newly formed Community Health Worker Association of Delaware, recognizing the importance of community-based, trauma-informed approaches, exemplified by CHWs. The CHW service model

ACKNOWLEDGEMENTS DCADV would like to recognize the incredible work the DVCHWs do every day to support survivors and their families.

DCADV is grateful to the DV-CHW Project’s current funders: the Longwood Foundation, Highmark’s BluePrints for the Community, ChristianaCare, the Delaware Division of Public Health’s Healthy Women Healthy Baby mini-grant, and HRSA/ PHMC’s My Vaccine Counts. DCADV would also like to recognize the outstanding partnership that exists with the University of Delaware’s Drs. Lessard and Fleury-Steiner and Sarah Williams Leng.

REFERENCES 1. Smith, S. G., Zhang, X., Basile, K. C., Merrick, M. T., Wang, J., Kresnow, M., & Chen, J. (2018). The National Intimate Partner and Sexual Violence Survey (NISVS): 2015 data brief—Updated release. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention.

2. John Snow, Inc. (n.d.). The impact of domestic violence on health. [Infographic] https://www.jsi.com/resource/the-impact-of-domestic-violence-on-health/ 3. INCITE! (2001). Statement on gender violence and the prison industrial complex. https://incite-national.org/incite-critical-resistance-statement/ 4. Trauma Matters Delaware. (n.d.). What is trauma-informed care? https://traumamattersdelaware.org/what-is-trauma-informed-care/ 5. Sharples, L., Nguyen, C., Singh, B., & Lin, S. (2018, October).

Intimate partner violence screening in a primary care system.

Fam Med, 50(9), 702–705. https://doi.org/10.22454/FamMed.2018.311843 6. Waalen, J., Goodwin, M. M., Spitz, A. M., Petersen, R., & Saltzman, L. E. (2000, November). Screening for intimate partner violence by health care providers. Barriers and interventions. American Journal of Preventive Medicine, 19(4), 230–237. https://doi.org/10.1016/S0749-3797(00)00229-4 7. Delaware Coalition Against Domestic Violence. (2022).

DCADV’s Domestic Violence-Community Health Worker Project service data summary [unpublished data report].

8. Leng, S.W. & Lessard, L. (2022). Delaware Coalition Against Domestic Violence Community Health Advocate program trimonthly assessment: Qualitative findings. [unpublished data report].

9. Lessard, L., Sabina, C., Fleury-Steiner, R. (2021). Evaluation of the Delaware Coalition Against Domestic Violence Community Health Worker program: Short report. [unpublished data report].

10. Leng, S.W., Lessard, L. (2022). Delaware Coalition Against Domestic Violence Community Health Worker trimonthly assessment: Quantitative findings. [unpublished data report].

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www.fic.nih.gov www.fic.nih.gov www.fic.nih.gov

GLOBAL GLOBAL HEALTH GLOBAL HEALTH M AT TERS HEALTH M AT TERS M AT TERS

Inside this issue Inside this issue Fogarty Fellow Ivan Segawa Inside this issue investigates nurse-led PrEP Fogarty Fellow Ivan Segawa

MAR/APR 2022

Fogarty Fellow Ivan Segawa delivery in Uganda…page investigates nurse-led PrEP 4

MAR/APR 2022 MAR/APR 2022

investigates nurse-led PrEP delivery in Uganda…page 4

FOGARTY INTERNATIONAL CENTER • NATIONAL INSTITUTES OF HEALTH • DEPARTMENT OF HEALTH AND HUMAN SERVICES

delivery in Uganda…page 61 4

FOGARTY INTERNATIONAL CENTER • NATIONAL INSTITUTES OF HEALTH • DEPARTMENT OF HEALTH AND HUMAN SERVICES

CUGH 2022 examines corruption, anti-science movement CUGH 2022 examines corruption, anti-science movement CUGH 2022 examines corruption, anti-science movement FOGARTY INTERNATIONAL CENTER • NATIONAL INSTITUTES OF HEALTH • DEPARTMENT OF HEALTH AND HUMAN SERVICES

What would health look like everyone counted?

It isSocial Justice” The theme of the 2022 conference was if “Healthy People, Healthy Planet, time to weave ubuntu into our pursuit of health equity, The theme of the 2022 conference was “Healthy People, Healthy Planet, Social Justice” What would health look like if everyone counted?

It than is said Madonsela, who feels hopeful.

“Today is better time towould weave ubuntu into pursuit ofcounted? health equity, What health look like if everyone It is yesterday when it comes toour health equity and social justice.” said Madonsela, who feels hopeful.

“Today is better than time toproblems weave ubuntu into“Africa our pursuit of health equity, While still exist, is becoming more than just yesterday when it comes health equity social justice.” said Madonsela, who feelsto hopeful.

“Today is better than a market where everyone else dumps theirand health outputs.

While problems still exist, “Africa is becoming more than just yesterday when comes to health equity and social justice.”

It’s becoming anitequal partner.” a market where everyone else dumps their health outputs.

While problems still exist, “Africa is becoming more than just It’s becoming aneveryone equal partner.” a market where else dumps their health outputs.

Global security at risk It’s becoming an equaldedicated partner.” a plenary session to The 2022 conference Global security atLaundering, risk “Corruption, Money Governance and Global The 2022 conference dedicated a plenary session to Global security at risk Security.” The COVID-19 response, including lockdowns, “Corruption, Money Laundering, Governance and Global The 2022 conference dedicated a plenary sessionon to . . . continued p. 2 Security.”

The COVID-19 response, including lockdowns, “Corruption, Money Laundering, Governance and Global .continued continued on p.page 2 .. ...including on next Security.” The COVID-19 response, lockdowns, . . . continued on p. 2

President Joseph Biden signed into law the Consolidated Appropriations Act, 2022 in March which provides budget President signed into law Consolidated increases Joseph for bothBiden NIH and Fogarty.

NIHthe received $45 Appropriations Act, 2022 in March which provides budget President Joseph Biden into law the2021.

Consolidated billion, a $2.2 billion risesigned from Fiscal Year Fogarty increases for both NIH and NIH received Appropriations Act,million, 2022 in March which provides$45 budget was allocated $87 aFogarty.

3.4% rise. billion, a $2.2 billion rise from Fiscal Year 2021.

Fogarty increases for both NIH and Fogarty. NIH received $45 was allocated million, a 3.4% rise. billion, a $2.2 $87 billion rise from Fiscal Year 2021. Fogarty was allocated $87 million, a 3.4% rise.

The measure also included $20 million to study the mental health effects of COVID-19, $700 million for global health The measure also included $20 million to study the mental security to USAID, and $1 billion for HHS' Advanced health effects of COVID-19, $700 million for global The measure also included $20 million to study thehealth mental Research Projects Agency for Health (ARPA-H ) initiative. security to USAID, and $1 billion for HHS' Advanced health effects of COVID-19, $700 million for global health Fiscal Year 2022 began on Oct. 1, 2021.

Research Health (ARPA-H ) initiative. security toProjects USAID,Agency and $1for billion for HHS' Advanced Fiscal Year 2022 began on Oct. 1, 2021.

Research Projects Agency for Health (ARPA-H ) initiative.

Fiscal Year 2022 began on Oct. 1, 2021.

The theme of the 2022 conference was “Healthy People, Healthy Planet, Social Justice”

NIH, Fogarty see budget increases for Fiscal Year 2022 NIH, Fogarty see budget increases for Fiscal Year 2022 NIH, Fogarty see budget increases for Fiscal Year 2022

Rethinking the scientific diaspora

FOCUS FOCUS FOCUS 58 Delaware Journal of Public Health - May 2022

• Diaspora scientists focus on capacity building in sub-Saharan Africa Rethinking the scientific diaspora • Using home-grown knowledge to advance health in Suriname • Rethinking scientists the scientific focus on diaspora building in sub-Saharan • Diaspora Building research capacity incapacity East Africa with the One Health Africa Initiative • Using home-grown knowledge to advance health in Suriname Africa • Diaspora scientists focus on capacity building in sub-Saharan Read on 63-66 Read more onpages pages 6–9 • research capacity in East Africa with theMore One Health Initiative • Building Using home-grown knowledge to advance health in Suriname • Building research capacity in East Africa with the more One Health Initiative Read on pages 6–9 Read more on pages 6 – 9

CourtesyCourtesy of CUGH Courtesy of CUGH of CUGH

Ubuntu, the African concept of humanity, includes the philosophy of “health is wealth,” explained Thuli N. Madonsela, Ubuntu, the African concept of humanity,ofincludes the philkeynote speaker at the 2022 Consortium Universities osophy ofthe “health is wealth,” explained Thuli N. Madonsela, Ubuntu, African concept of humanity, includes the philfor Global Health (CUGH) conference.

Madonsela added: keynote speaker at the 2022 Consortium of Universities osophy ofhas “health is wealth,” explained Thuli N. “nothing evidenced this truism so vividly in Madonsela, our lifetime for Global Healthat (CUGH) conference.

Madonsela added: keynote speaker the 2022 Consortium of of Universities as the COVID-19 pandemic.”

As the wealth health became “nothing has evidenced this truism so vividly in our lifetime forreality Global (CUGH) conference.

Madonsela added: a forHealth everyone, “it was inconceivable that the dark side as the COVID-19 As theso wealth ofin health became “nothing hasin evidenced truism vividly our lifetime of humanity thepandemic.” formthis of the scourge of corruption” would a for everyone, “it was inconceivable that the dark side asreality the“its COVID-19 pandemic.”

As the wealth of health became show sordid face…yet it did,” said Madonsela. of humanity in the form of the scourge of corruption” would a reality for everyone, “it was inconceivable that the dark side show “its sordid face…yet did,” said Madonsela. of humanity in the form ofit the scourge of corruption” would This year’s annual CUGH conference, dedicated to “Healthy show “its sordid face…yet it did,” said Madonsela.

People, Healthy Planet, Social Justice,” hosted more than This annual CUGH conference, dedicated to “Healthy 2,000year’s scientists and students representing a range of People, Healthy Planet, Social Justice,” hosted more than This year’s CUGH disciplines conference,who dedicated to “Healthy medical andannual non-medical addressed some of 2,000 scientists and students representing a range of People, Healthy Planet, Socialfaced Justice,” hosted more than the most pressing challenges by the world. medical and non-medical disciplines who addressed 2,000 scientists and students representing a range ofsome of the most pressing challenges faced by the world. medical and scourge non-medical disciplines who addressed some of Pandemic the most pressing facedofby the world. connected Corruption tips thechallenges scales in favor the politically Pandemic scourge and the wealthy, noted Madonsela, recalling the looting Corruption the scales in favor of nations the politically connected Pandemic scourge of pandemictips resources in developing and the and the wealthy, noted Madonsela, recalling the looting Corruption tips the scalespricing in favor the politically connected hoarding and exorbitant of of vaccines, tests, and of pandemic developing nations andlooting the side and the wealthy, noted in Madonsela, recalling the treatments inresources developed nations.

“An unexplored ugly hoarding andresources exorbitant of vaccines, tests, andhow pandemic inpricing developing and was the of this competition-driven response tonations COVID-19 treatments in developed nations.

“An unexplored ugly hoarding and exorbitant pricing vaccines, tests, andside African indigenous systems and of solutions were dismissed,” of this competition-driven response to COVID-19 was treatments in developed nations. unexplored ugly how side added Madonsela, chair of Social “An Justice at Stellenbosch African indigenous systems and solutions were dismissed,” of this competition-driven response to COVID-19 was how University, South Africa. Neglect of indigenous knowledge added Madonsela, chair of Social Justice Stellenbosch African indigenous systems and solutions were dismissed,” and health resource asymmetries exist farat beyond the scope University, South Africa.

Neglect of indigenous knowledge added Madonsela, chair of Social Justice at Stellenbosch of the pandemic. One-size-fits-all policies persist despite and health asymmetries exist far beyond the scope University, South Africa.

Neglect of indigenous knowledge their failureresource to meet the needs of many. of the pandemic.

One-size-fits-all policies persist despite and health resource asymmetries exist far beyond the scope their to meet the needs of many. of thefailure pandemic.

One-size-fits-all policies persist despite their failure to meet the needs of many.

MARCH/APRIL 2022

CUGH 2022 examines corruption, anti-science movement from previous .. .. ..continued continued from p.1 page led to the rise of totalitarianism, said co-founder of Transparency International Frank Vogl: “The pandemic has had a negative impact on democracy in every region in the world.” Corruption is “universal” and not confined to low and middle-income countries, he noted. In the same session, Olusoji Adeyi, a former director at the World Bank Group, said higher resource nations “codify their corruption.” To rectify corruption, high income country governments need to rework banking laws and expose corruption through transparency, while developing countries need to promote accountability using checks and balances.

Colonial mindset & anti-science movement AFREhealth hosted a satellite session focused on decolonizing global health post-pandemic, a topic covered heavily in this year’s conference. The session’s keynote speaker, Dr. Jimmy Volmink of Stellenbosch University, argued, “The most egregious shortcoming of the global response to COVID-19 was the lack of solidarity between nations in the face of a common threat.” He later added, “The colonial perspective of global health needs reconceptualization to move towards a more equitable future.”

Deputy director of Fogarty, Dr. Peter Kilmarx, presented findings from the AFREhealth CUGH research subcommittee, which he co-chairs. They highlighted increased collaboration in multi-country studies, the impact of COVID-19 on vulnerable populations in Africa, and vaccine hesitancy as one area for future work. The group also discussed using metrics to help make Fogarty’s capacity-building projects in LMICs more equitable and effective.

In a satellite session focused on the anti-science movement, panelists addressed growing mistrust of public health authorities and anti-vaccine sentiments. Renowned virologist Dr. Peter Hotez reminded the group that ‘antiscience’ has been a leading cause of preventable death in the United States throughout the pandemic.

Dr. Maureen Lichtveld, an epidemiologist and dean at the University of Pittsburgh School of Public Health whose work centers around environmental health, said, “This mistrust in science is not a new phenomenon to environmental health. The pandemic has simply amplified it.”

NCI’s Cancer Research Symposium This year also marked the 10th anniversary of the Symposium on Global Cancer Research hosted by the

2

National Cancer Institute (NCI). The 3-day satellite session included an Early Career Investigator Day in addition to the symposium, “New Models for Global Cancer Research, Training, and Control.” Dr. Satish Gopal, director of NCI’s Center for Global Health, opened and closed the symposium with a remembrance of the late global health leader, Dr. Paul Farmer. Quoting him, he said “The idea that some lives matter less is the root of all that is wrong with the world.”

Fogarty Fellows & Scholars In the annual Fogarty Fellows and Scholars session, recent fellows presented projects in various disciplines.

Keenan Withers, a psychiatry resident at UCLA, presented on factors impacting PrEP adherence among men in Vietnam with a history of recreational drug use. “The Fogarty fellowship is unique as it allows you to have mentors at every level of your project.” Other presentations included adapting trauma neuroimaging paradigms in South Africa; identifying resources for children with neurodevelopment disorders in Ghana; Zambia-based studies on the correlation between gender, HIV, and hypertension; and a project on the prevalence of cervical and breast cancers and HIV in aging patients in Latin America.

Implementation science in LMICs Rachel Sturke, deputy director of Fogarty’s Center for Global Health Studies, moderated a session centered on the role of implementation science in evidence-based interventions in LMICs. The panel included leaders from public sector health systems, academia, and funding agencies. “Investments in training local researchers and governments will continue to be a key mechanism to decolonize global health,” said panelist Anita Zaidi of the Bill and Melinda Gates Foundation. She later added, “we must fund the entire ecosystem to see the result in capacity-building projects, not just the end goal.”

To end the conference, Dr. Joseph Kolars, incoming CUGH chair, shared his thoughts on the “important, compelling, and frankly daunting” work ahead: “We've got climate and environmental crises. We have political systems that are giving way to conflict … So many of us have been struggling to overcome the COVID pandemic, where the problems of equity have really been illuminated.” He called for community, dialogue, connection, and shared commitment to the common good. “We’ve all gotten much more in touch with the need to have a decolonizing mindset … we can do this despite some of the clouds overhead.”

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MARCH/APRIL MARCH/APRIL 2022 2022 MARCH/APRIL MARCH/APRIL 2022 2022

H3Africa H3Africaachievements achievements H3Africa H3Africaachievements achievements endure endurebeyond beyonditsitsend end endure endurebeyond beyonditsitsend end

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Recent Recent headline headline scientists scientists Flash Flash forward forward to to 2022.

2022.

H3Africa H3Africa has has funded funded 51 51 projects projects from from H3Africa H3Africa include include Dr.Dr. Charles Charles Rotimi, Rotimi, a driving a driving force force and and spawned spawned a consortium a consortium with with multiple multiple sites—primary sites—primary from from H3Africa H3Africa include include Dr. Dr. Charles Charles Rotimi, Rotimi, a driving a driving force force and and spawned spawned a consortium a consortium with with multiple multiple sites—primary sites—primary behind behind H3Africa and and now now scientific scientific director director at at NHGRI; NHGRI; Dr.Dr. sites, sites, lablab sites, sites, collection collection sites, sites, and and analysis analysis sites sites allall using using behind behind H3Africa H3Africa and and now now scientific scientific director director at at NHGRI; NHGRI; Dr.Dr. sites, sites, lab lab sites, sites, collection collection sites, sites, and and analysis analysis sites sites all all using using Ambroise Ambroise Wonkam, Wonkam, one one of of the the program’s program’s PIs, PIs, world-renown world-renown common common protocols protocols and and capabilities—in capabilities—in different different countries countries Ambroise Ambroise Wonkam, Wonkam, one one of of the the program’s program’s PIs, PIs, world-renown world-renown common common protocols protocols and and capabilities—in capabilities—in different different countries countries geneticist geneticist and and sickle sickle cell cell disease disease expert, expert, and and recently recently across across the the continent. continent.

The The H3Africa H3Africa Consortium Consortium comprises comprises geneticist and and sickle sickle cell disease disease expert, expert, and and recently recently across across the the continent. continent.

The The H3Africa H3Africa Consortium Consortium comprises comprises appointed appointed director director of cell of the the Department Department of of Genetic Genetic Medicine Medicine 500 500 members members and and 445 445 trainees trainees in in more more than than 3030 countries. countries. geneticist appointed appointed director director of of the the Department Department of of Genetic Genetic Medicine Medicine 500 500 members members and and 445 445 trainees trainees in in more more than than 30 30 countries. countries. and the the McKusick-Nathans McKusick-Nathans Institute Institute of of Genetic Genetic Medicine Medicine Notable Notable achievements achievements include include 100,338 100,338 participants participants recruited recruited and and and the the McKusick-Nathans McKusick-Nathans Institute Institute of of Genetic Genetic Medicine Medicine Notable Notable achievements achievements include include 100,338 100,338 participants participants recruited recruited Johns Johns Hopkins; Hopkins; and and Dr.Dr. Christian Christian Happi, Happi, also also anan forfor studies, studies, 50,000 50,000 samples samples genotyped, genotyped, 2626 core core phenotypes phenotypes at at at Johns Johns Hopkins; Hopkins; and and Dr. Dr. Christian Christian Happi, Happi, also also anan forfor for for studies, studies, 50,000 50,000 samples samples genotyped, genotyped, 26 26 core core phenotypes phenotypes H3Africa H3Africa PI, PI, director director of of the the African African Center Center of of Excellence Excellence identified, identified, 2,062 2,062 workshops/meetings workshops/meetings held, held, and and nearly nearly 700 700 at H3Africa H3Africa PI, PI, director director of of the the African African Center Center of of Excellence Excellence forfor identified, identified, 2,062 2,062 workshops/meetings workshops/meetings held, held, and and nearly nearly 700 700 Genomics Genomics of of Infectious Infectious Diseases Diseases at at Redeemer's Redeemer's University University papers papers published. published.

Genomics Genomics of of Infectious Infectious Diseases Diseases at at Redeemer's Redeemer's University University papers papers published. published. in in Nigeria Nigeria and and the the first first African African scientist scientist to to sequence sequence anan in Nigeria Nigeria and and the the first first African African scientist scientist to to sequence sequence anwe’re an African African SARS-CoV-2 SARS-CoV-2 genome. genome.

“One “One of of the the outcomes outcomes we’re InIn addition addition to to standing standing upup computing computing infrastructure infrastructure across across in African African SARS-CoV-2 SARS-CoV-2 genome. genome.

“One “One of of the the outcomes outcomes we’re we’re In In addition addition to to standing standing up up computing computing infrastructure infrastructure across across most most proud proud of of is is the the highly-trained highly-trained workforce workforce that that has has the the continent, continent, the the consortium consortium created created three three regional regional most proud proud of of isacross is the the highly-trained highly-trained workforce workforce that that has has the the continent, continent, the the consortium consortium created created three three regional regional been been developed developed across Africa Africa with with cutting-edge cutting-edge skills skills in in biorepositories—in biorepositories—in Nigeria, Nigeria, Uganda, Uganda, and and South South Africa—that Africa—that most been been developed developed across across Africa Africa with with cutting-edge cutting-edge skills skills in in biorepositories—in biorepositories—in Nigeria, Nigeria, Uganda, Uganda, and and South South Africa—that Africa—that genomics genomics research research and and analysis analysis plus plus responsible responsible sample sample share share common common methodologies methodologies and and house house DNA DNA samples. samples. genomics genomics research research and and analysis analysis plus plus responsible responsible sample sample share share common common methodologies methodologies and and house house DNA DNA samples. samples. and data data management,” management,” said said Troyer.

Troyer.

One One of of the the most most requested requested datasets datasets is is from from a whole-genome a whole-genome and and and data data management,” management,” said said Troyer.

Troyer.

One One of of the the most most requested requested datasets datasets is is from from a whole-genome a whole-genome sequencing sequencing analyses analyses of of 426 426 individuals individuals comprising comprising 5050 sequencing sequencing analyses analyses of of 426 426 individuals individuals comprising comprising 50 50 AsAs H3Africa H3Africa nears nears conclusion, conclusion, the the original original aims aims of of the the ethnolinguistic ethnolinguistic groups groups (including (including previously previously unsampled unsampled As As H3Africa H3Africa nears nears conclusion, conclusion, the the original original aims aims of of the the ethnolinguistic ethnolinguistic groups groups (including (including previously previously unsampled unsampled program—to program—to identify identify genetic genetic and and non-genetic non-genetic factors factors populations). populations).

The The research research team team on on this this project project uncovered uncovered program—to program—to identify identify genetic genetic and and non-genetic non-genetic factors factors populations). populations).

The The research research team team on on this this project project uncovered uncovered that that contribute contribute to to diseases diseases and and individual individual responses responses more more than than three three million million previously previously unknown unknown variants, variants, contribute contribute towhile to diseases diseases and and individual individual responses responses more more than than three million million previously previously unknown unknown variants, variants, to that to medications medications while increasing increasing collaboration collaboration between between described described in in athree Nature a Nature article, article, “High-depth “High-depth African African genomes genomes that to to medications medications while while increasing increasing collaboration collaboration between between described described in in a Nature a Nature article, article, “High-depth “High-depth African African genomes genomes African African researchers—have researchers—have largely largely been been met. met.

While While there there inform inform human human migration migration and and health.” health.”

Resources Resources and and African African researchers—have researchers—have largely largely been been met. met.

While While there there inform inform human human migration migration and and health.” health.”

Resources Resources and and have been been delays delays due due to to COVID-19, COVID-19, productivity productivity past past the the archives archives from from H3Africa H3Africa studies studies are are accessible accessible to to researchers researchers have have have been been delays delays due due to to COVID-19, COVID-19, productivity productivity past past the the archives archives from from H3Africa H3Africa studies studies are are accessible accessible to to researchers researchers designated designated end end of of the the program program and and no-cost-extensions no-cost-extensions viavia H3ABionet.

H3ABionet. designated designated end end of of the the program program and and no-cost-extensions no-cost-extensions viavia H3ABionet.

H3ABionet. are are expected. expected.

Overall Overall sustainability sustainability is is also also anticipated. anticipated. are are expected. expected.

Overall Overall sustainability sustainability is is also also anticipated. anticipated.

H3Africa H3Africa investigators investigators are are now now contributing contributing to to other other NIH NIH H3Africa H3Africa working working groups, groups, which which established established policies policies and and H3Africa H3Africa investigators investigators are are now now contributing contributing to to other other NIH NIH H3Africa H3Africa working working groups, groups, which which established established policies policies and and programs, including including NHGRI's NHGRI's Polygenic Polygenic RIsk RIsk MEthods MEthods guidelines guidelines forfor member member scientists, scientists, had had a particularly a particularly strong strong programs, programs, programs, including including NHGRI's NHGRI's Polygenic Polygenic RIsk RIsk MEthods MEthods guidelines guidelines for for member member scientists, scientists, had had a particularly a particularly strong strong in in Diverse Diverse populations populations (PRIMED) (PRIMED) Consortium Consortium and and the the impact. impact.

"In"In some some cases, cases, these these guidelines guidelines forfor genomic genomic in Diverse Diverse populations populations (PRIMED) (PRIMED) Consortium Consortium and and the the impact. impact.

"In "In some some cases, cases, these these guidelines guidelines forfor genomic genomic Common Common Fund's Fund's Harnessing Harnessing Data Data Science Science forfor Health Health research, research, consent, consent, community community engagement, engagement, and and feedback feedback of of in Common Common Fund's Fund's Harnessing Harnessing Data Data Science Science for for Health Health research, research, consent, consent, community community engagement, engagement, and and feedback feedback of of Discovery and and Innovations Innovations in in Africa Africa program program (DS-I (DS-I Africa), Africa), findings findings have have informed informed oror been been adapted adapted forfor national national policies policies Discovery and and Innovations Innovations in in Africa Africa program program (DS-I (DS-I Africa), Africa), findings findings have have informed informed orTroyer. or been been adapted adapted foralso for national national policies policies Discovery asDiscovery as well well asas obtaining obtaining research research grants grants through through NIH NIH and and within within Africa,” Africa,” explained explained Troyer.

H3Africa H3Africa also developed developed as as well well as as obtaining obtaining research research grants grants through through NIH NIH and and within within Africa,” Africa,” explained explained Troyer.

Troyer.

H3Africa H3Africa also also developed developed other international international funders. funders. research research tools tools and and products products available available to to scientists, scientists, including including other other international international funders. funders. research research tools tools and and products available available totagging to scientists, scientists, including including other a genotyping a genotyping array array forproducts for capturing capturing and and tagging African African a genotyping a genotyping array array for for capturing capturing and and tagging tagging African African variation. variation.

RESOURCES RESOURCES variation. variation.

33 RESOURCES RESOURCES https://bit.ly/H3Africa https://bit.ly/H3Africa 33 https://bit.ly/H3Africa https://bit.ly/H3Africa 60 Delaware Journal of Public Health - May 2022 DOI:

PPPRRROOOFFFII ILLLEEE Fogarty FogartyFellow FellowIvan IvanSegawa Segawa Fogarty Fellow Ivan Segawa investigates investigates investigatesnurse-led nurse-led nurse-ledPrEP PrEP PrEP delivery delivery deliveryin ininUganda Uganda Uganda One in four new HIV infections in sub-Saharan Africa One in four new HIV infections in sub-Saharan Africa One One in in four four new new HIV HIV infections infections in in sub-Saharan sub-Saharan Africa Africa occurs among adolescent girls and young women (AGYW) occurs among adolescent girls and young women (AGYW) occurs occurs among girls and and young young women women (AGYW) (AGYW) aged 15among to 24. adolescent Inadolescent Uganda,girls 270 new infections occur every aged 15 to 24.

In Uganda, 270 new infections occur every aged aged 15 15 to to 24.

24.

InIn Uganda, Uganda, 270 new new infections infections occur occur every every week within this age group.270 Researcher Ivan Segawa week within this age group.

Researcher Ivan Segawa week week within within this age age group. group.

Researcher Researcher Ivan Ivan Segawa Segawa observed thethis increased vulnerability to HIV for AGYM. observed the increased vulnerability to HIV for AGYM. observed observed the the increased increased vulnerability vulnerability to to HIV HIV forfor AGYM. AGYM. “They have limited access to HIV services plus they are “They have limited access to HIV services plus they are “They “They have have limited limited access access to to HIV HIV services services plus plus are are young, their partners are older, and so often it they is they their young, their partners are older, and so often it is their young, young, their their partners partners are are older, older, and so so often often it is it is their their partners who decide whether to and use HIV prevention partners who decide whether to use HIV prevention partners partners who decide decide whether whether to to use use HIV HIV prevention prevention methods orwho not.” methods or not.” methods methods oror not.” not.”

In Uganda, pre-exposure prophylaxis (PrEP) is generally In Uganda, pre-exposure prophylaxis (PrEP) is generally InIn Uganda, Uganda, pre-exposure pre-exposure prophylaxis prophylaxis (PrEP) (PrEP) is is generally generally delivered through HIV clinics, which many people find delivered through HIV clinics, which many people find delivered delivered through through HIV HIV clinics, clinics, which which many many people find find unappealing due to stigma surrounding thepeople virus. unappealing due to stigma surrounding the virus. unappealing unappealing due to to stigma stigma surrounding surrounding the the virus. virus.

Segawa’s pilotdue study evaluates a health delivery model Segawa’s pilot study evaluates health delivery model Segawa’s Segawa’s pilot pilot study study evaluates evaluates a health aa health delivery delivery model model that integrates oral PrEP into family planning clinics, that integrates oral PrEP into family planning clinics, that that integrates integrates oral oral PrEP PrEP into into family family planning planning clinics, clinics, where nurses can take the lead in offering effective HIV where nurses can take the lead in offering effective HIV where where nurses nurses can can take take the the lead lead inclinics, in offering offering effective effective HIV HIV prevention to AGYW. Unlike HIV family planning prevention to AGYW. Unlike HIV clinics, family planning prevention prevention to to AGYW. AGYW. Unlike Unlike HIV clinics, clinics, family family planning planning clinics are frequent stops forHIV women seeking birth control. clinics are frequent stops for women seeking birth control. clinics clinics are are frequent stops stops forfor women women seeking birth birth control. control.

Their staff of frequent experienced sexual and seeking reproductive health Their staff of experienced sexual and reproductive health Their Their staff staff of of experienced experienced sexual sexual and reproductive reproductive health health nurse providers are familiar facesand to many AGYW patients nurse providers are familiar faces to many AGYW patients nurse nurse providers providers are are familiar familiar faces faces toidentify to many many AGYW AGYW patients patients and thus strategically positioned to those who may and thus strategically positioned to identify those who may and and thus strategically strategically positioned to to identify identify those those who who may may be atthus high risk for HIV.positioned be at high risk for HIV. bebe at at high high risk risk forfor HIV. HIV. “This study, which is co-funded by the National Institute “This study, which is co-funded by the National Institute “This “This study, study, which which is(NINR), is co-funded co-funded by the the National National Institute Institute of Nursing Research can by inform task-shifting of Nursing Research (NINR), can inform task-shifting of of Nursing Nursing Research Research (NINR), (NINR), can can inform inform task-shifting task-shiftingrun initiatives that have already seen nurses successfully initiatives that have already seen nurses successfully run initiatives initiatives have have already already seen seen nurses nurses successfully successfully run run HIV clinicsthat inthat our settings,” said Segawa, whose education HIV clinics in our settings,” said Segawa, whose education HIV HIV clinics clinics in in our our settings,” settings,” said said Segawa, Segawa, whose whose education education spans pharmaceutical science, clinical epidemiology, and spans pharmaceutical science, clinical epidemiology, and spans spans pharmaceutical pharmaceutical science, clinical clinical epidemiology, epidemiology, biostatistics.

“Yet otherscience, health professionals also haveand aand biostatistics.

“Yet other health professionals also have biostatistics. biostatistics.

“Yet other other health health professionals professionals also also have role to play in“Yet increasing access to HIV services.”

Inhave thea aa role to play in increasing access to HIV services.”

In the role role tofor to play play in in increasing increasing access access to to HIV HIV services.” services.”

InIn the the U.S., example, pharmacies provide vaccinations and U.S., for example, pharmacies provide vaccinations and U.S., U.S., for for example, example, pharmacies pharmacies provide provide vaccinations and and other services, he noted.

Pharmacies invaccinations Uganda might other services, he noted.

Pharmacies in Uganda might other other services, services, hehe noted. noted.

Pharmacies Pharmacies in in Uganda Uganda might might conduct HIV testing or deliver PrEP helping to alleviate conduct HIV testing or deliver PrEP helping to alleviate conduct conduct HIV HIV testing testing oror deliver deliver PrEP helping helping to to alleviate alleviate the burden on physicians who PrEP might then focus on severe the burden on physicians who might then focus on severe the the burden burden on physicians physicians who who might might then then focus focus onon severe severe cases.

“But on the challenges we faced were with privacy and cases.

“But the challenges we faced were with privacy and cases. cases.

“But the the challenges challenges we faced faced were were with with privacy privacy and and we are “But still navigating this we landscape,” explained Segawa. we are still navigating this landscape,” explained Segawa. wewe are are still still navigating this this landscape,” explained Segawa.

Segawa.

Research isnavigating also needed to landscape,” evaluate theexplained value of new Research is also needed to evaluate the value of new Research Research is is also also needed needed to evaluate evaluate the the value value of of new new delivery methods for HIVto services outside traditional HIV delivery methods for HIV services outside traditional HIV delivery delivery methods methods HIV HIV services services outside outside traditional traditional HIV HIV clinics, he said. forfor clinics, he said. clinics, clinics, hehe said. said.

Segawa and his team have completed enrolling patients Segawa and his team have completed enrolling patients Segawa Segawa and and hishis team team have have completed completed enrolling patients patients for his fellowship project.

The nurses, enrolling who trained for for his fellowship project.

The nurses, who trained for forfor his his fellowship fellowship project. project.

The The nurses, nurses, who who trained trained for for four weeks with Segawa’s team, are now delivering PrEP four weeks with Segawa’s team, are now delivering PrEP four four weeks weeks with with Segawa’s Segawa’s team, team, are are now now delivering delivering PrEP PrEP

4 4 44

Ivan Segawa, BPharm, MScEnd Ivan Ivan Segawa, Segawa, BPharm, BPharm, MScEnd MScEnd

Fogarty Fellow: 2021-2022 Fogarty Fellow: 2021-2022 2021-2022 Fogarty Fogarty Fellow: Fellow: 2021-2022 US Institution: University of Washington US Institution: University of Washington Washington USUS Institution: Institution: University University of of Washington Foreign Institutions: Global Health Uganda; College of Health Sciences, Foreign Institutions: Global Health Uganda; College of Health Health Sciences, Foreign Foreign Institutions: Institutions: Global Global Health Health Uganda; Uganda; College College of of Health Sciences, Sciences, Makerere University, Uganda Makerere University, Uganda Makerere Makerere University, University, Uganda Uganda Research interest: Nurse-Led PrEP Delivery for Adolescent Girls and Research interest: Nurse-Led Nurse-Led PrEP Delivery for Adolescent Girls and Research Research interest: interest: Nurse-Led PrEP PrEP Delivery Delivery forfor Adolescent Adolescent Girls Girls and and Young Women in Uganda Young Women in Uganda Uganda Young Young Women Women in in Uganda

while fulfilling their traditional responsibilities at the while fulfilling their traditional responsibilities at the while while fulfilling fulfilling their their traditional traditional responsibilities responsibilities at at the the clinic.

“Initially, of course, the nurses had no prior clinic.

“Initially, of course, the nurses had no prior clinic. clinic.

“Initially, “Initially, of course, course, the the nurses nurses had had nono prior prior training in PrEP,ofso we explored many topics, including training in PrEP, so we explored many topics, including training training in in PrEP, PrEP, soso wewe explored many many topics, including counseling.

Sometimes weexplored felt like this topics, was tooincluding much counseling.

Sometimes we felt like this was too much counseling. counseling.

Sometimes Sometimes wewe felt felt like like this this was was tootoo much much for them. But we told them, ‘pick up what you can, for them.

But we told them, ‘pick up what you can, forfor them. them.

But But wewe told told them, them, ‘pick ‘pick upup what what you you can, can, and we will keep coming back,’” said Segawa.

He hopes and we will keep coming back,’” said Segawa.

He hopes and and wewe will will keep keep coming coming back,’” back,’” said said Segawa.

Segawa.

HeHe hopes hopes his research will provide enough evidence to make this his research will provide enough evidence to make this hishis research research will provide provide enough enough evidence evidence to to make make this this model of HIV will prevention care sustainable. model of HIV prevention care sustainable. model model of of HIV HIV prevention prevention care care sustainable. sustainable.

Throughout his fellowship, Segawa has acquired Throughout his fellowship, Segawa has acquired Throughout Throughout hishis fellowship, fellowship, Segawa Segawa has has acquired acquired new skills, like manuscript writing and constructing new skills, like manuscript writing and constructing new new skills, skills, like like manuscript manuscript writing constructing constructing quantitative methodologies.

“Iwriting usedand toand think manuscript quantitative methodologies.

“II used used to think manuscript quantitative quantitative methodologies.

“I “I used to to think think manuscript manuscript writing is formethodologies. the end. But now know you can work writing is for the end.

But now I know you can work writing writing is is for for the the end. end.

But But now now Idata.” know I know you you can can work work on drafts, even while collecting He also believed on drafts, even while collecting data.”

He also believed onon drafts, drafts, even even while while collecting collecting data.”

HeHe also also believed believed science was about clinics, labs, data.” writing, and computers science was about clinics, labs, writing, and computers science science was about about clinics, clinics, labs, labs, writing, writing, and and computers computers until he was discovered project management.

“If you are until he discovered project management.

“If you are until until heto he discovered discovered project project management. management.

“If“If you you are are not up speed on managing human resources and not up to speed on managing human resources and not not upup tothat’s to speed speed onon managing managing human resources and and finances something thathuman can setresources you back,” said finances that’s something that can set you back,” said finances finances that’s that’s something something that that can can setset you you back,” back,” said said Segawa.

Segawa.

Segawa.

Segawa.

Another important aspect of his training has been Another important aspect of his training has been Another Another important important aspect aspect of of hishis training training has has been been the weekly competency meetings, where he learns the weekly competency meetings, where he learns the the weekly weekly competency competency meetings, where hehe learns learns about mentorship and Kmeetings, grants.

“Iwhere hope to apply for about mentorship and K grants. grants.

“I hope hope to apply for about about mentorship mentorship and K K grants.

“I “I hope to to apply apply forfor a K43 grant withinand the next two years using the data a K43 grant within the next two years using the data K43 a K43 grant grant within within the the next next two two years years using using the the data data Ia will have generated from my Fogarty study and will have generated from my Fogarty study and I will II will have have generated generated from from mymy Fogarty Fogarty study and and master’s degree.

In the meantime, I amstudy seeking small master’s degree.

In the meantime, am seeking small master’s master’s degree.

In In the the meantime, meantime, I am II am seeking seeking small grants to degree. answer more research questions in thesmall field grants to answer more research questions in the field grants grants to to answer answer more more research research questions questions in in the the field field of HIV prevention.”

A Ph.D. and academic career of HIV prevention.”

A Ph.D. and academic career of of HIV HIV prevention.” prevention.”

A Ph.D. A Ph.D. and and academic academic career feel “inevitable” to Segawa, steps along thecareer road to feel “inevitable” to Segawa, steps along the road to feel feel “inevitable” “inevitable” to to Segawa, Segawa, steps steps along along the the road road to to becoming an independent researcher.

To those hoping becoming an independent researcher.

To those hoping becoming becoming anaan independent independent researcher. researcher.

ToTo those those hoping to apply for Fogarty grant, he advises: “Read ahoping lot of to apply for Fogarty grant, he advises: “Read lot of to to apply apply for for ayour Fogarty aa Fogarty hehe advises: advises: “Read “Read lot aa lot of of literature in areagrant, togrant, identify gaps that willaincrease literature in your area to identify gaps that will increase literature literature in your your area area toAnything to identify identify gaps that that will will increase increase the noveltyinof your idea. isgaps possible, just the novelty of your idea.

Anything is possible, just the the novelty novelty of of your your idea. idea.

Anything Anything is is possible, possible, just just believe in yourself.” believe in yourself.” believe believe in in yourself.” yourself.”

RESOURCES RESOURCES RESOURCES RESOURCES https://bit.ly/IvanSegawa https://bit.ly/IvanSegawa https://bit.ly/IvanSegawa https://bit.ly/IvanSegawa

61

Q A Q& &A

ROBER T S AMUEL S, MBCHB, MSCI ROBER T S AMUEL S, MBCHB, MSCI T scientist S AMUEL MBCHB, MSCI Dr. Robert Samuels isROBER a physician at theS, Kenema Government Hospital (KGH) in Sierra Leone.

Dr. Samuels a physician scientist at the Kenema Government (KGH) in Sierra Leone.

AfterRobert completing hisismedical training, he studied the impact of hepatitisHospital B on Ebola survivors and Lassa Dr. Robert Samuels is a physician scientist at the Kenema Government Hospital (KGH) in Sierra Leone.

After completing his medical training, he studied the impact of hepatitis B on Ebola survivors and Lassa fever patients. He did a one-year fellowship with the Vanderbilt Vaccine Research Program, serving After completing his medical training, he studied the impact of hepatitis B on Ebola survivors and Lassa fever patients. assistant He did aon one-year fellowship with Vanderbilt Vaccine serving as a research the Moderna phase III the COVID-19 vaccine trial.Research CurrentlyProgram, he is completing fever patients. He did a one-year fellowship with the Vanderbilt Vaccine Research Program, serving as research assistant on the Moderna phase III COVID-19 is completing an aevaluation of the prevalence of influenza and respiratory vaccine syncytialtrial. virusCurrently (RSV) in he children under 2 as a research assistant on the Moderna phase III COVID-19 vaccine trial. Currently he is completing an evaluationatofKGH. the prevalence of influenza and respiratory syncytial virus (RSV) in children under 2 hospitalized an evaluation of the prevalence of influenza and respiratory syncytial virus (RSV) in children under 2 hospitalized at KGH. hospitalized at KGH.

Tell us about your current Fogarty project Most patients signs andproject symptoms Tell us aboutwith yourrespiratory current Fogarty Tell us about your current Fogarty project are treated for bacterial pneumonia without laboratory Most patients with respiratory signs and symptoms

Most patients with respiratory signs without and symptoms confirmation. can lead to problems.

Patients blindly are treated forThis bacterial pneumonia laboratory are treated for bacterial pneumonia without laboratory given antibiotics have a high probability of developing confirmation. This can lead to problems. Patients blindly confirmation.

This can problems.

Patients blindly resistance.

If we give antibiotics to patients who don’t given antibiotics have alead hightoprobability of developing given antibiotics have a high probability of developing need them, we deprive patients who do need them.

Also, resistance. If we give antibiotics to patients who don’t resistance.

If we give antibiotics to patients who don’t an incorrect diagnosis sometimes leads to longer hospital need them, we deprive patients who do need them. Also, need them, we deprive patients who do need them.

Also, stays with higher risk of nosocomial infections (infections an incorrect diagnosis sometimes leads to longer hospital an incorrect diagnosis sometimes leads to longer hospital originating in the risk hospital). stays with higher of nosocomial infections (infections stays with higher of nosocomial infections (infections originating in the risk hospital).

My study aims to understand originating in the hospital). the true burden and seasonal of RSV and the influenza amongand the My study variation aims to understand true burden My study aims to understand the true burden and youngest children in our region.

If the data shows seasonal variation of RSV and influenza among thehigh seasonal of our RSV and influenza among the numbers of RSV and flu infections, that justifies the need youngest variation children in region.

If the data shows high youngest children in our region.

If the data shows high for rapid diagnostic tests.

These tests would help us make numbers of RSV and flu infections, that justifies the need numbers of RSV and flu infections, that justifies need correct —tests. lowering both hospital admissions for rapiddiagnoses diagnostic These tests would helpthe us make for rapid diagnostic tests.

These tests would help us make and antibiotic misuse — while also improving our district correct diagnoses — lowering both hospital admissions correct diagnoses — lowering admissions labs.

We’ve collected samples from 503 participants and antibiotic misuse — whileboth also hospital improving our district and antibiotic misuse — while also improving our district find notsamples only RSV and503 flu but other labs.expect We’veto collected from participants labs.expect We’veto collected samples from participants respiratory viruses: human rhinovirus, and find not only RSV and503 flu parainfluenza, but other and expect to find not only RSV andcoronaviruses. flu parainfluenza, but other In the metapneumovirus, adenovirus and respiratory viruses: human rhinovirus, respiratory human rhinovirus, parainfluenza, end, I hope viruses: this data informs diagnosis and treatment metapneumovirus, adenovirus and coronaviruses.

In the metapneumovirus, adenovirus and for coronaviruses.

In the policies andthis provides a foundation long-term viral end, I hope data informs diagnosis and treatment end, I hope data informs diagnosis and treatment surveillance. policies andthis provides a foundation for long-term viral policies and provides a foundation for long-term viral surveillance. surveillance.

What skills did you acquire as a Fogarty trainee?

I acquired skills mentoring, projects, and What skills didfor you acquire managing as a Fogarty trainee?

What skills didfor you acquire managing as aThe Fogarty trainee? proposals and publications.

Vanderbilt Iwriting acquired skills mentoring, projects, and I acquired skills for mentoring, managing projects, and Vaccine Research Center gave me hands-on experience writing proposals and publications.

The Vanderbilt writing the proposals and publications.

The involved Vanderbilt during Moderna vaccine trial. was in preVaccine Research Center gave me Ihands-on experience Vaccine Research Center gave me Ihands-on experience and post-vaccination assessments of participants, during the Moderna vaccine trial. was involved inand pre-I during thepart Moderna trial. I of was involved in pre-I also took in the vaccine decision-making processes, including and post-vaccination assessments participants, and and post-vaccination assessments of participants, and I organizing parts trial. Through collaborations and also took part in of thethe decision-making processes, including also took part in of thethe decision-making processes, including networking, I developed partnerships researchers organizing parts trial.

Through with collaborations and organizing parts the trial.

Through collaborations and from the U.S. andofother countries.

I also helped networking, I developed partnerships with researchers networking, I developed partnerships with researchers Vanderbilt University medical students onhelped research from the U.S. and other countries.

I also from the U.S. and other countries.

I alsoon helped proposals and projects related to Sierra Leone.

Fogarty Vanderbilt University medical students research Vanderbilt University medical students on research has not only helped me but also my colleagues and Sierra proposals and projects related to Sierra Leone. Fogarty proposals and projects related to Sierra Leone.

Fogarty Leone. has not only helped me but also my colleagues and Sierra has not only helped me but also my colleagues and Sierra Leone.

Leone.

How can Sierra Leone improve health care?

First, to develop human health resources.

How we canneed Sierra Leoneour improve care?

How canneed Sierra Leoneour improve care?

First, we to develop human health resources.

First, we need to develop our human resources.

62 Delaware Journal of Public Health - May 2022

Currently, we have epidemiologists, often specialized, but we need broader base of clinical andspecialized, public Currently, wea have epidemiologists, often Currently, we have epidemiologists, often specialized, health scientists.

We need to develop scientific teams but we need a broader base of clinical and public but we need a broader base of clinical and public —biostatisticians, clinical trial experts, bioethicists, health scientists. We need to develop scientific teamslab health scientists.

We need to develop scientific technicians, and all the other occupations that teams makelab —biostatisticians, clinical trial experts, bioethicists, —biostatisticians, clinical trial experts, bioethicists, research possible.

We also need people educated to lab technicians, and all the other occupations that make technicians, and all the other occupations that make practice clinical specialties at the Masters’ level or research possible. We also need people educated tohigher research possible.

We also need people educated tohigher instead the level of certificates and short courses. practice of clinical specialties at the Masters’ level or practice clinical specialties at the Masters’ level or higher Another priority is infrastructure: Building new research instead of the level of certificates and short courses. instead of the level of certificates and short courses. centers with electronic records while strengthening Another priority is infrastructure: Building new research Another priority is infrastructure: Building new old ones.

These centers need anwhile established dataresearch centers with electronic records strengthening centers with electronic records strengthening management system that extends through hospitals old ones.

These centers need anwhile established data oldthat ones.

These centers need an established data so the flow of data is uniform.

Right now, most of management system that extends through hospitals management system that extends hospitals our datathe is flow paper-based most through of our lab capacity so that of data isand uniform.

Right now, most of so that the of data isand uniform.

Right now, most and infrastructure is based inmost the city.

We need to of our data is flow paper-based of our lab capacity our data is paper-based andin most ofaour lab capacity decentralize labs and equip them higher level and infrastructure is based theto city.

We need to so that and infrastructure iscultures based theother city.

We need to so district labs can and specialized tests. decentralize labs do and equip in them to a higher level that decentralize labs do and equip them to a higher level so that district labs can cultures and other specialized tests.

Finally, we need to create mentorship that district labs can do cultures and otherprograms specialized tests. start in the undergrad years and moveprograms into postgrad.

Finally, we need to create mentorship that I Finally, wegreatly need to create mentorship programs that I benefited from my mentors.

Aside from personal start in the undergrad years and move into postgrad. start in the undergrad years and move into postgrad. development, an established program can also help I benefited greatly from my mentors.

Aside from personal benefited greatly from my mentors.

Aside a community or develop because it from leads to development, an region established program can also personal help development, an region established program also help publications influence and informcan local policies. a communitythat or develop because it leads to a communitythat or region develop it leads to publications influence and because inform local policies. publications that influence and inform local policies.

What’s ahead?

First on my list is to complete my research project — What’s ahead?

What’s ahead? after we finish the samples, I will project write and First on my listanalyzing is to complete my research — First on my list is to complete my research project — prepare manuscript forthe publication. been after we afinish analyzing samples, I’ve I willalso write and after we finish analyzing the samples, I will write and training anurses in datafor management KGH. prepare manuscript publication.atI’ve alsoMy been prepare anurses manuscript publication. also been intention is to roll data training toatI’ve the entire hospital. training in out datafor management KGH. My nurses in out data management KGH. My hospital.

Itraining have coordinated the data renovation of to aatdata office in the intention is to roll training the entire intention is to roll data the ward without plans oftraining extending thisentire to thehospital. entire Ipediatric have coordinated the renovation of to a data office in the I have coordinated the renovation a data office the hospital.

Finally, I’m working on a of study of to preexisting pediatric ward with plans of extending this the in entire pediatric Finally, ward with extending this the this entire COVID-19 immunity with of plans clinical trials hospital.

I’mplans working onfor a study of to preexisting hospital.

Finally, I’m with working on a study of trials preexisting year.

In 2023, I hope to secure scholarships for a this Ph.D. COVID-19 immunity plans for clinical COVID-19 immunity plansscholarships for clinical a trials in clinical immunology.

Finally, developing robust year.

In 2023, I hope with to secure for a this Ph.D. year.

In 2023, I hope to secure scholarships for a Ph.D. mentorship program for Sierra Leone is a goal I hope to in clinical immunology. Finally, developing a robust in clinical immunology.

Finally, developing a robust accomplish in the next several years. mentorship program for Sierra Leone is a goal I hope to mentorship program forseveral Sierra years.

Leone is a goal I hope to accomplish in the next accomplish in the next several years.

RESOURCES RESOURCES https://bit.ly/RobertSamuelsRSV RESOURCES https://bit.ly/RobertSamuelsRSV https://bit.ly/RobertSamuelsRSV

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FOCUS FOCUS

Rethinking the scientific diaspora Rethinking the scientific diaspora

TT

exponentially faster, build training and infrastructure, and pursue work that addresses the public health issues in that exponentially faster, build training and infrastructure, and country. pursue work that addresses the public health issues in that country.

Dr. Wondwossen Gebreyes, a professor of molecular epidemiology and executive director of Global Health and Global Dr. Wondwossen Gebreyes, aOne professor molecularatepidemHealthofPrograms Ohio iology and executive director State of Global Health Global University, and started his One Health at Ohio career in hisPrograms native Ethiopia.

State University, started Knowing the culture and his having career in his native Ethiopia. colleagues there has helped Knowing the culture and having him immensely in working with colleagues there has helped other East African countries him in working with as heimmensely leads capacity-building other East African projects there. “It iscountries much as he leads easier whencapacity-building you know the projects there.

“It is much culture, how people think, and easier when you know thework what sort of mechanisms culture, howsetting.” people think, and best in that what sort of mechanisms work best in thattosetting.”

According a 2014 World Photo courtesy Photo courtesy of NHGRI of NHGRI

he concept of “brain drain” from low- and middleincome countries (LMICs) has been getting a rehe concept ofin“brain lowand convermiddleassessment recentdrain” years.from As the global income countries (LMICs) has been getting a resation has shifted focus to health equity and decolonizaassessment in recent years.

As the global convertion, many in scientific diasporas are now leading the sation has for shifted to health equity and movement morefocus equitable partnerships indecolonizaLMICs, tion, many in scientific diasporas are now leading the benefiting both U.S. and movement for more equitable partnerships in LMICs, LMIC institutions. benefiting both U.S. and LMIC institutions.

Fogarty’s 2009 publica-

tion, “The Globalization Fogarty’s publicaof Health 2009 Research: tion, “The Globalization Harnessing the Scienof Health Research: tific Diaspora,” outlined Harnessing theand Scienthe challenges tific Diaspora,” outlined opportunities many the challenges and diaspora scientists opportunities many face in their countries diaspora of origin. scientists Some of the face in theirthat countries challenges persist of origin.

Some of the today include lack challenges persist Bank report, “A Decade of of access tothat baseline According to ain2014 World today include lack Development Sub-Saharan research infrastructure Bank report, “A Decade of of access to baseline African Science, Technology, and limited administraAs the global conversation has shifted focus to health equity and decolonization, Development in Sub-Saharan research infrastructure Engineering & Mathematics tive and local governmany in scientific diasporas are now leading the movement for more equitable African Science, Technology, and administrapartnerships.

Research,” diaspora scientists mentlimited support.

Add As the global conversation has shifted focus to health equity and decolonization, Engineering & Mathematics tive and local governmany in scientific diasporas are now leading the movement for more equitable who return to their country of in security issues, partnerships.

Research,” diaspora scientists ment support.

Addand political origin in East and sub-Saharan Africa significantly increase economic policies, instability. These issues can who return to their country of in security issues, the citation impact of the work done there. make pursuing research in some LMICs unattractive. origin in East and sub-Saharan Africa significantly increase economic policies, and political instability. These issues can the citation impact of the make work done there. make pursuing research in some LMICs unattractive.

While diaspora scientists up less than 4% of the Many of Fogarty’s scholars, fellows, and grantees are part of diaspora communities in the West, often holding Many Fogarty’s positions scholars, in fellows, and grantees are seniorof leadership government or universities, part of diaspora communities in the West, often holding seemingly proving the point that brain drain is real. senior leadership positions in government or their universities, However, many diaspora scientists return to country of seemingly proving the point that brain drain is real.enable origin at some time or another. Such homecomings However, many diaspora scientists return to their country of what some call “brain circulation.” origin at some time or another. Such homecomings enable what some call Ogedegbe, “brain circulation.”

Dr. Olugbenga a professor at NYU Langone and Fogarty advisory board member, is originally from Nigeria Dr. a professor at NYU Langone andOlugbenga has led twoOgedegbe, separate capacity-building projects in and West Fogarty advisory board member, is originally from Nigeria Africa. He says, “the tension between brain drain and giving and separate projects in West backhas canled be two difficult, but capacity-building it is reassuring that diaspora Africa.

He says, “the tension between brain drain and giving scientists often give back to their home country.” back can be difficult, but it is reassuring that diaspora scientists often give unique back to perspective their home and country.”

Diaspora scientists’ connection to their country of origin allow them to reach the talent there Diaspora scientists’ unique perspective and connection to their country of origin allow them to reach the talent there

research base in that region, the impact of their research, While make lessother thanresearchers 4% of the cite which diaspora measuresscientists the number of up times research base in that region, the impact of their research, their work, is between 4% and 27% higher than that of the which measures the number of times other researchers cite average researcher in East and sub-Saharan Africa. their work, is between 4% and 27% higher than that of the average East andpublication sub-Saharan Africa.

In the 13researcher years sinceinFogarty’s on harnessing the scientific diaspora, research on diaspora scientists’ direct In the 13 Fogarty’s publication on harnessing impact onyears their since country of origin is still lacking.

A recent study the scientific diaspora, research on diaspora scientists’ direct led by researchers at the University of Washington and the impact on their country of origin is still lacking.

A recent study University of California, Los Angeles found that the literature led by researchers at theengagement University of and them the on the topic of diaspora isWashington limited, leaving University of California, Los Angeles found that the literature unable to measure the true impact of this “brain circulation.” on the topic of diaspora engagement is limited, them That said, diaspora scientists have proven to beleaving an essential unable to measure the true impact of this “brain circulation.” resource in the field of global health research and play a That said, scientists have proven to be an essential pivotal rolediaspora in creating truly equitable partnerships between resource in the field of global health research the U.S. and LMIC institutions in the future. and play a pivotal role in creating truly equitable partnerships between the U.S. and LMIC institutions in the future.

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Resources: https://bit.ly/ScientificDiaspora

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Resources: https://bit.ly/ScientificDiaspora 63

FOCUS ON AFRICAN SCIENTISTS IN THE DIASPORA FOCUS ON COVID AWARDS

Diaspora influence on research in subSaharan Africa

A contributing factor to this growth has been the influence of diaspora scientists. Dr. Olugbenga Ogedegbe is the Chief of the Division of Health & Behavior and Director of the Center for Healthful Behavior Change in the Department of Population Health at New York University’s School of Medicine. He is also a member of Fogarty's advisory board. He says, “Looking at the data between 2002 to 2012, 79% of the research coming out Africa is led by the U.S. and the majority of those driving that work are diaspora scientists.”

Diaspora scientists bring a unique perspective to the U.S. institutions they work in, connecting with colleagues and potential study participants in their country of origin more quickly and with more understanding than other scientists. Dr. Fred Ssewamala, a professor and associate dean at Washington University, says, “One of the biggest added benefits an African scientist brings is lived experience. Being from Uganda and doing most of my work there, I understand the environment, and I can pose relevant questions and apply methodologies that work for the communities we engage with.”

This background gives diaspora scientists the ability to mentor up-and-coming researchers in their countries of origin. “Many researchers seek guidance from diaspora scientists on becoming a productive scientist despite being from a lower-income country,” said Ssewamala. “Having diaspora scientists in leadership positions is important because it shows these scientists it is within their reach.”

However, those who left a lower-income country to study and work in the U.S. or other high-income countries find the balance between “brain drain” and “brain circulation” —or the collaboration of diaspora scientists with those in their country of origin—challenging. They know that while their careers benefited from relocating, the research capacity in their home country may have suffered.

64 Delaware Journal of Public Health - May 2022

Researchers from the University of Rwanda at a research administration and grants management workshop in Kigali. The Fogarty-funded project focuses on enhancing HIV research training capacity.

Photo courtesy of Adebola Adedimeji

The migration of experienced scientists and medical professionals from sub-Saharan Africa since the 1980s has led to gaps in education and research capacity.

In 2022, the pace of migration has slowed; in fact, researchers in sub-Saharan Africa have more than doubled their research production since 2002.

With this in mind, many diaspora scientists in global health work on projects intended to give back and build research capacity within their country or region of origin. Dr. Adebola Adedimeji, division head and research associate professor at Albert Einstein College, is currently a principal investigator on a Fogartyfunded project in Rwanda focused on enhancing HIV research training capacity. “Being in the U.S. has allowed me to tap into the available expertise and resources to advance our research in sub-Saharan Africa.”

Dr. Ogedegbe has been the principal investigator since 2018 on a Fogarty-funded project that aims to strengthen research ethics capacity in Ghana by offering a master’s degree in bioethics from NYU to 24 fellows in Ghana and developing a sustainable bioethics program at the University of Ghana.

Dr. Ssewamala is a co-principal investigator on several NIH-funded training programs that focus on training early-career researchers committed to careers in child behavioral health. Among them is the Fogarty Global Fellows and Scholars program at Washington University, now called LAUNCH, which fosters the next generation of global health scientists by providing training early at established biomedical and behavioral research institutions and project sites across subSaharan Africa.

Projects like these are just the beginning of what many hope to see for the future in decolonizing global health.

“We cannot rely on a one-size-fits-all strategy for capacity building,” said Adedimeji. With life expectancy in sub-Saharan Africa still much lower than that of the rest of the world, mainly due to the burden of chronic disease, building this base of scientists and researchers is critical. “Fogarty’s continued support for capacity building initiatives across sub-Saharan Africa has been extremely valuable, but we still have a lot of ground to cover.”

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FOCUS ON AFRICAN SCIENTISTS IN THE DIASPORA

Using home-grown knowledge to advance health in Suriname

Lichtveld’s Surinamese background brings a unique perspective to the field of environmental and global health.

As a part of the UJMT Fogarty Global Health Fellowship, Lichtveld developed the first project of its kind in the Caribbean. “With Fogarty funding, we put together an environmental epidemiology cohort study that brought together 1,200 pregnant moms and ultimately babies who are now three to four years old,” said Lichtveld. “For the first time, we were conducting this research in a country where things like cultural and geographic differences had never been considered.”

The study focused on studying the effect of neurotoxins on the health of babies in Suriname, looking for any indications of the impact of the exposure on their brain development. As a result, they collected more than 15,000 biospecimen samples, making it the largest biospecimen bank in Suriname, an invaluable resource for future research in that area. “The return on investment from this Fogarty funding has been phenomenal, and it is important work that I hope we can continue.” Lichtveld hopes to build off this project, looking at the opposite end of the spectrum, studying the effect of neurotoxins on generations of women, from grandmothers to their grandchildren.

An accomplishment Lichtveld is most proud of came out of Fogarty’s GEOhealth program. She and her colleagues developed a fully hybrid master of science/public health degree program at the University of Suriname, specifically designed to address important local health problems while keeping scientists in country. Since its inception, four cohorts have graduated from the program, and seven

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Dr. Maureen Lichtveld (right) mentored Fogarty Scholars while developing an environmental epidemiology cohort study in Suriname.

Photo courtesy of Maureen Lichtveld

Suriname is one of the most ethnically and culturally diverse countries in the Western Hemisphere, making for a unique population to study. At just 23 years old, Dr. Maureen Lichtveld began her career working with communities living in the Amazon rainforest in her home country, a small Caribbean nation on the northern coast of South America. While in the Amazon doing clinical work, Lichtveld realized many of the health issues plaguing its small communities could be linked back to the toxins in the environment. This realization was the beginning of what would be a life-long career in environmental healt2h research. Today, she is a renowned epidemiologist and Dean of the University of Pittsburg’s School of Medicine.

students have moved on to their Ph.D.’s, focusing their research on environmental epidemiology.

Lichtveld’s role as a diaspora scientist and a woman in science has influenced her from the beginning of her career. “When my mother passed away, one of the things that I promised her I would do is grow women leaders in the field,” said Lichtveld. “Women in leadership, especially in low- and middle-income countries, have tremendous benefits often using a multi-disciplinary and holistic approach in their work.”

Dr. Cecilia Alcala, a mentee of Dr. Lichtveld, is currently a post-doctoral fellow at the Department of Environmental Medicine and Public Health at the Icahn School of Medicine at Mount Sinai. She credits her time working with Dr. Lichtveld for helping her establish a career in global environmental health research. “Seeing Suriname from the perspective of a diaspora scientist like Dr. Lichtveld and understanding the perspective of the researchers who worked alongside us in Suriname gave us a well-rounded experience and allowed us to connect on a deeper level with the cohort,” said Alcala. “The research we did during my global health fellowship was something the community and the government needed in order to pursue different interventions and policies. Understanding that impact was a stepping-stone for me to see that this is what I want to do for the rest of my life.”

Another mentee of Dr. Lichtveld’s, Anisma Gokoel, a researcher at the Academic Hospital Paramaribo in Suriname, began working with her on the Caribbean Consortium for Research in Environmental and Occupational Health (CCREOH)-MeKiTamara project in Suriname in 2016. She says, “Dr. Lichtveld has been an inspiration for me, not only to advance my career but also to give back to my country of origin.”

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FOCUS ON AFRICAN SCIENTISTS IN THE DIASPORA FOCUS ON AFRICAN SCIENTISTS IN THE DIASPORA

Building research capacity in East Africa Building research capacity in East Africa effectively conduct research on zoonotic diseases and Dr. Wondwossen Gebreyes began his research career as a veterinarian in Ethiopia in the early 1990s, where he says, “I was raising chickens to support my education.”

Dr. Wondwossen Gebreyes began his research career as He migrated toin the U.S. in in 1995.

His first job there? a veterinarian Ethiopia the early 1990s, where he Working as araising parking attendant at NIH, an that says, “I was chickens to support myagency education.” would ultimately play a significant role in job his there? future He migrated to the U.S. in 1995. His first career.

Working as a parking attendant at NIH, an agency that would ultimately play a significant role in his future career.

“I remember working at different parts of the NIH campus in the late 1990s, mainly across from building 31, the main working office space for institute and their “I remember at different partsdirectors of the NIH staff,” said Gebreyes. campus in the late 1990s, mainly across from building 31, the main office space for institute directors and their staff,” said Gebreyes.

“ Making progress in a short period is much easier in aculture short period is much when youprogress know the and how peopleeasier think “ Making when you there. know the culture and how peopleandthink and work Establishing partnerships

and there.

Establishing partnerships and beingwork taken seriously on a political level happens

” so much faster. ”

being taken seriously on a political level happens so much faster.

66 Delaware Journal of Public Health - May 2022

fellowship in rotavirus, tuberculosis,for The project’s next phasesalmonellosis, offers more opportunities and research.

Gebreyes hopes thoseleishmaniasis pursuing a master’s degree via aalso predoctoral to strengthen collaborations between veterinarians, fellowship in rotavirus, salmonellosis, tuberculosis, physicians, and environmental health scientists and leishmaniasis research. Gebreyes also hopesin East Africa to collaborations address zoonotic diseases.

Gebreyes to strengthen between veterinarians, says, “Fogarty’s training and scientists capacity building physicians, and research environmental health in programs been instrumental in this Gebreyes region, and East Africahave to address zoonotic diseases. the impact is so research clear. We training are all so grateful for building their says, “Fogarty’s and capacity support.” programs have been instrumental in this region, and the impact is so clear. We are all so grateful for their support.”

Gebreyes, right, visit fellows at Sokoine University in Tanzania. He received the NIH Gold medallion in 2019 and was elected to the National Academy of Medicine in 2021.

Gebreyes, right, visit fellows at Sokoine University in Tanzania. He received the NIH Gold medallion in 2019 and was elected to the National Academy of Medicine in 2021.

Photo courtesy Photo of courtesy Wondwossen of Wondwossen GebreyesGebreyes

Dr. Gebreyes, who was born in Ethiopia, received his degree in veterinary medicine from Addis Ababa University in 1990.

At the time, the country was still in Dr. Gebreyes, who was born in Ethiopia, received the midst of civil war that beganfrom in 1974. the official his degree inaveterinary medicine AddisBy Ababa end of the war, experts estimate thatcountry at leastwas 1 million University in 1990.

At the time, the still in people hadofdied duewar to famine and in combat As a the midst a civil that began 1974. violence.

By the official veterinarian, heexperts practiced in the that ruralatareas end of the war, estimate leastof1 Ethiopia, million “I saw firsthand the devastating effects thatviolence. infectious people had died due to famine and combat As a diseases, parasites and antimicrobial can have veterinarian, he practiced in the rural resistance areas of Ethiopia, on these communities.”

“I saw firsthand the devastating effects that infectious diseases, parasites and antimicrobial resistance can have on theseafter communities.”

Shortly moving to the U.S., he was accepted into a Ph.D. program at North Carolina State University eventually joining thetofaculty.

Now Ohio State, he is a Shortly after moving the U.S., heat was accepted into Hazel C.program Youngberg Distinguished in molecular a Ph.D. at North Carolina Professor State University epidemiology and the director of the Global eventually joining the executive faculty. Now at Ohio State, he is a One Initiative.

This initiative works toinimprove HazelHealth C. Youngberg Distinguished Professor molecular the health of communities, builddirector capacity public epidemiology and the executive of among the Global health professionals, learning One Health Initiative. and Thisprovide initiative works opportunities to improve for faculty, and staff around the among world. public the students, health of communities, build capacity health professionals, and provide learning opportunities for students, faculty, and staff around the world.

Since 2010, Dr. Gebreyes has led a Fogarty-funded project establishing sustainable research and training capacity for foodborne pathogen in East African Since 2010, Dr. Gebreyes has ledresearch a Fogarty-funded academic institutions.

The ultimate goal ofand thistraining program project establishing sustainable research is to build critical mass of capable scientists that can capacity fora foodborne pathogen research in East African academic institutions. The ultimate goal of this program is to build a critical mass of capable scientists that can

implement prevention and control systems. effectively conduct research on zoonotic diseases and To date, this program has four laboratories implement prevention and established control systems. in East African universities, trained 28 Ph.D. fellows, more than 40program laboratory andlaboratories established To date, this hastechnologists, established four a of highuniversities, quality, ethical research in aras such inculture East African trained 28 Ph.D. fellows, as molecular “This Fogarty project has more than 40epidemiology. laboratory technologists, and established allowed bring something unique to the region. a cultureusoftohigh quality, ethical research in aras such Most studentsepidemiology. in this area are taught through a didactic as molecular “This Fogarty project has curriculum, it issomething not often unique that youtoare to allowed us toand bring theable region. integrate a research and training program,” said Most students in thisproject area are taught through a didactic Gebreyes. ”Ifand we had this that training in the curriculum, it is to notdooften you program are able to U.S., we would have project only been to train a fraction of integrate a research andable training program,” said students we training have been able to in dothe here Gebreyes.compared ”If we hadtotowhat do this program in thewe region with theonly Fogarty U.S., would have beensystem.” able to train a fraction of students compared to what we have been able to do here in the aregion with Fogartydiaspora system.” here in the U.S. Being part of thethe Ethiopian has opened many doors for Gebreyes’ work in East Africa over last of 12the years.

“Making progress in ainshort period Beingthe a part Ethiopian diaspora here the U.S. is much easier when youfor know the culture howAfrica has opened many doors Gebreyes’ work and in East people andyears. work “Making there. Establishing over thethink last 12 progress inpartnerships a short period and being takenwhen seriously on a political level happens is much easier you know the culture and how so much faster, a huge added value to a project people think andwhich work is there.

Establishing partnerships like and this.” being taken seriously on a political level happens so much faster, which is offers a hugemore added value to a project The project’s next phase opportunities for like this.” those pursuing a master’s degree via a predoctoral

OPINION OPINION

By Dr. Roger I. Glass, Director, Fogarty International Center

By Dr. Roger I. Glass, Director, Fogarty International Center

Health Health disparities disparities research research offers offers lessons lessons for for US, US, LMICs LMICs There is a regrettable truth about There iscare a regrettable truth about health and medical advances: healthdocare medical advances: They notand benefit all people equally.

Theyresults do notare benefit all disparities people equally.

The health The results are health disparities (HD)— preventable differences in (HD)— preventable differences wellness and medical outcomesinthat wellness and medical outcomes that adversely affect certain populations adversely affect The certain populations but not others. health inequities butsee notin others.

Themiddlehealth inequities we low- and income in of lowmiddleincome countries as well aswe in see some ourand own impoverished countries as have well as in some of our owntoimpoverished populations been strongly linked social populations have been strongly to social determinants.

Evidence of HD islinked not only visible in determinants.

Evidence HD is statistics, not only visible in life access to care but also inofhealth such as access to care but also in health statistics, such as and life expectancy at birth, under-5 mortality in children, expectancy at birth, under-5 mortality in children, and maternal deaths. maternal deaths.

Naturally, Fogarty aims to reverse this by funding Naturally,that Fogarty aims the to reverse thisofby funding research examines influence environments, research that examines influence of environments, social determinants, andthe other underlying mechanisms sociallead determinants, and underlying mechanisms that to differences inother medical and health outcomes. that what lead to medicalin and health outcomes.

And wedifferences learn frominresearch LMICs may open our And what learn from research in LMICs may open our eyes to thewe same problems at home. eyes to the same problems at home.

Across our portfolio of grants, Fogarty supports Across ourtoportfolio of grants, Fogarty supports programs train researchers that study HD and social programs to train that at study and social determinants.

Ourresearchers program based Moi HD University determinants. program based at Moi University in Kenya aims Our to develop data science leaders who in Kenya aimstotocapture developand data sciencedata leaders who are equipped analyze on social are equipped to anddesign analyze dataeffective on social determinants of capture health and more determinants for of health and design more effective interventions communicable and noncommunicable interventions for communicable and noncommunicable diseases.

In Cameroon and South Africa, researchers diseases.

In Cameroon South Africa, Sciences researchers at the African Institute and for Mathematical at Cameroon the Africanand Institute for Mathematical Sciences in the University of Cape Town are in Cameroon and the University Cape Townassociated are examining health disparities withofrisk factors examining health disparities with riskdisparities, factors associated with surgical disease linked to social such as with of surgical disease linked to social disparities, suchand as cost care and access to transportation, to discover cost of care and access to transportation, to discover and address these compounding issues. address these compounding issues.

A South American program trains Quechua-speaking A South American program Quechua-speaking indigenous researchers fromtrains Argentina, Bolivia, Peru, indigenous researchers from Argentina, Bolivia, Peru, and Paraguay at the Universidad de Buenos Aires and andUniversidad Paraguay atPeruana the Universidad deHeredia, Buenos where Aires and the Cayetano they the Universidad Peruana Cayetano Heredia, where learn epidemiology, genetics, and neuroimaging so they that learncan epidemiology, genetics, and neuroimaging that they develop a greater understanding of the so major they can develop a greater understanding of the major psychiatric disorders in their own populations. psychiatric disorders in their own populations.

10 10

Finally, in our Malaysian program, researchers are Finally, in our Malaysian program, researchers developing an artificial intelligence-based mobileare health developingintervention an artificial to intelligence-based mobile health (mHealth) increase HIV testing among (mHealth) intervention increase HIV worse testinghealth among men who have sex withto men who have men who have sex with men who have health outcomes due to the discrimination andworse stigma they outcomes due to investments the discrimination and stigma they face.

All Fogarty attempt to support equity face. AllinFogarty investments attempt to support issues global health, but we want and need to equity do issues in global health, but we want and need to do more. more.

We’ve seen that, among U.S. researchers, those who We’ve seen that, among U.S. researchers, those who are minorities show a special interest in research of are minorities show a special interestthe in research HD, so we believe that if we increase diversity of our HD, so wewe believe that if we increase the diversity of our grantees, can improve health throughout the world. grantees, weif can improvepreviously health throughout the world.

In essence, we include disadvantaged In essence, not if weonly include previously disadvantaged individuals as research partners but also as individuals not only research partners as to research leaders, theas benefits of our work but will also extend research leaders, the benefits of ourThis work willrequires extend to neglected populations everywhere. plan neglected populations everywhere. planthese requires a greater understanding of how we This can put a greater understanding of this how end, we can put these strategies into practice. To Fogarty and the strategies intoissue practice.

To thisfor end, Fogarty and theon NIH will soon a Request Information (RFI) NIH will soon issue a Request Information onin approaches NIH might take to for promote greater(RFI) equity approaches might within take tolowpromote greater equity global healthNIH research and middleincomein global health research within low- and middle- income countries. countries.

The RFI is an open invitation… to you. Please take The time RFI is open invitation… to you.

Please take the toan express your ideas about ways we could the time to the express your ideas about ways we could encourage expansion and ensure the quality of encourage the expansion and ensure theand quality of global research collaborations including among global research collaborations including and among scientists and institutions in low resource settings. scientists and institutions low resource settings.

We welcome comments on in current NIH practices that We welcome comments NIH practices thatbe might be revised as wellon ascurrent new practices that could might be revised as well as new practices thatincould be implemented.

Beyond this, we are interested hearing implemented. this, we are interested in hearing your thoughts Beyond on: inclusive community researchyour thoughts on: inclusive community researchengagement strategies; mutually beneficial data and engagement strategies; mutually beneficialaccess; data and material sharing approaches; publication material and sharing approaches; publication access; training career development; joint leadership training and career development; joint leadership strategies; and research priority setting. strategies; and research priority setting.

We anticipate receiving many practical and beneficial We anticipate receiving practical beneficial ideas from global healthmany researchers at and all levels of ideas career. from global health at all levelsus of their I thank you researchers in advance for helping their career.

I thank advance for helping us improve Fogarty andyou the in NIH by responding to this improve Fogarty and the NIH byideas. responding to all this forthcoming RFI with your best It's time forthcoming RFI withfrom yourthe best ideas.

It'sand timescience all humanity benefitted hard work we humanity benefitted from the hard work and science we do together. do together.

RESOURCES RESOURCES https://bit.ly/HealthDisparitiesResearch https://bit.ly/HealthDisparitiesResearch 67

PEOPLE NCI Director Steps Down

Global HEALTH Briefs CGHS launches case study collection

Dr. Norman “Ned” Sharpless stepped down from his role as Director of the National Cancer Institute, a position he has held since 2017. During his tenure, Sharpless oversaw the development of NCI’s Childhood Cancer Data Initiative and the Experimental Therapeutics Program and briefly served as the FDA’s Acting Director. NCI’s Deputy Director, Dr. Douglas Lowy, will serve as acting NCI director effective April 30.

Fogarty’s Center for Global Health Studies (CGHS), in collaboration with the Cincinnati Children’s Hospital Medical Center and the National Cancer Institute (NCI), has developed a collection of case studies documenting examples of rigorous implementation research in low- and middleincome countries (LMICs).

Full collection: https://bit.ly/ImpliSciCaseStudies

Gerberding Named Chief Executive Officer of FNIH

2021 G-Finder report released

The foundation for the National Institutes of Health has named Dr. Julie Gerberding as their Chief Executive Officer, a role she will assume on May 16th. Previously, Gerberding served as the 15th director of the CDC and currently serves as Chief patient officer and executive vice president, Population Health & Sustainability at Merck.

Panjabi joins National Security Council In March, Dr. Raj Panjabi assumed his role as National Security Council senior director for global health security and biodefense.

Prior to this, Panjabi served as the global health malaria coordinator at USAID and co-founder and CEO of Last Mile Health, a nonprofit that aims to develop community health care systems globally.

NIBIB Director named to National Academy National Institute of Biomedical Imaging and Bioengineering (NIBIB) Director Dr. Bruce Tromberg will be inducted as a fellow to the National Academy of Inventors (NAI) in June. The NAI fellows program highlights those who have created or facilitated inventions that have made a tangible impact on quality of life, economic development, and societal welfare.

Mayanja-Kizza honored at CUGH 2022 Dr. Harriet Mayanja-Kizza, HIV researcher, former Dean of Makerere Medical School in Uganda, and former Fogarty Fellow, was one of two recipients of the 2022 CUGH Distinguished Leader Award honoring individuals who have made exceptional contributions to the advancement of global health worldwide.

McKee confirmed for top USAID Position The Senate confirmed Erin McKee as the Assistant Administrator for Europe and Eurasia on March 24th. McKee previously served as the Ambassador to Papua New Guinea, Solomon Islands, and Vanuatu at the Department of State since 2019. Before her state department appointment, McKee served for over 24 years at USAID in various roles.

68 Delaware Journal of Public Health - May 2022

The 2021 G-Finder Report on global investment in neglected disease R&D breaks down funding by disease, platform, and funder type (government, private sector, philanthropic). While neglected disease R&D dipped just 4% from 2019’s nearrecord, the pandemic adversely impacted clinical trials funding which saw a 10% decrease.

Full report: https://www.policycuresresearch.org/ analysis/

African CDC releases vaccine framework

The African CDC published the Partnerships for African Vaccine Manufacturing (PAVM) Framework for Action in March. The framework documents the current vaccine manufacturing environment in Africa and recommends eight programs to grow and scale vaccine development and manufacturing over the next two decades.

Framework download: https://bit.ly/AfricanVaccines

WHO announces health facilities database WHO announced its new Global Health Facilities Database (GHFD) initiative meant to locate and provide access to healthcare services for populations worldwide. The initiative aims to consolidate the master lists of local and regional health facilities into one standardized database.

Website: https://www.who.int/data/GIS/GHFD

USAID tracks COVID-19’s impact on LMICs

USAID released its second landscape analysis of first- and second-order impacts of COVID-19 on low- and middle-income countries. While not exhaustive, the analysis intends to provide a highlevel synthesis of some of the major storylines of 2021, leveraging the best available data to understand the pandemic’s most significant global impacts.

Full report: https://bit.ly/USAID_COVID_Impact

11

MARCH/APRIL 2022

Funding Opportunity Announcement

Deadline

Details

International Bioethics Research Training Program D43 Clinical Trials Optional R25 Clinical Trials Not Allowed

Jun 7, 2022

http://bit.ly/BioethicsTraining

Chronic, Noncommunicable Diseases and Disorders Research Training D43 Clinical Trials Optional

Jul 13, 2022

https://bit.ly/NCD_ResearchTraining

Global Infectious Diseases (GID) Research Training Program D43 Clinical Trials Optional

Aug 3, 2022

https://bit.ly/InfectiousDiseasesResearch

Emerging Global Leader K43 Independent Clinical Trials Required K43 Independent Clinical Trials Not Allowed

Nov 3, 2022

http://bit.ly/E_Lead

For more information, visit www.fic.nih.gov/funding

Global Health Matters

World Report data aids entrepreneurship in Africa

March/April 2022 Volume 21, No. 2 ISSN: 1938-5935 Fogarty International Center National Institutes of Health Department of Health and Human Services

Writer/editor: Mariah Felipe Mariah.Felipe@nih.gov Writer/editor: Susan Scutti Susan.Scutti@nih.gov Digital analyst: Merrijoy Vicente Merrijoy.Vicente@nih.gov Designer: Carla Conway

All text produced in Global Health Matters is in the public domain and may be reprinted. Please credit Fogarty International Center. Images must be cleared for use with the individual source, as indicated.

SUBSCRIBE: www.fic.nih.gov/subscribe

World Report allows quick access to data about global research investments.

Image courtesy of the NIH World Report

Managing editor: Judy Coan-Stevens Judith.Coan-Stevens@nih.gov

When helping startups in healthcare and life sciences technology in Africa, Dr. Robert Karanja often turns to World Report (WR) for insight. “Our work in global health innovation is integrated in a global value chain of ideas and finance. Thus, the ability to see the flow of funding and the areas of research receiving funding is great intel that informs our strategy and operations,” Dr. Karanja explained. Dr. Karanja is co-founder of Villgro Africa, an early-stage business incubator and investor that seeks to support startups with a global social impact focus in the African region.

Public tools such as WR help entrepreneurs like Dr. Karanja see where research funding is going. It also helps him identify experts in medical and scientific areas, such as screening infants for pneumonia. A search on WR reveals over 1,000 pneumonia research projects underway at 720 organizations in 61 countries. Dr. Karanja added, “A tool that could link [patents to PubMed] would be very useful. Understanding a patent’s nuances informs a startup’s freedom to operate.” NIH’s Office of Portfolio Analysis will consider this feedback as it develops the next version of World Report, part of a portfolio analysis tool suite to be released this summer.

R E SOURCE Explore World Report here: https://worldreport.nih.gov 69

Promoting Burnout Prevention Through a Socio-Ecological Lens Amy D. Habeger, Ph.D., L.C.S.W. Associate Professor, Social Work, Delaware State University Tana D.J. Connell, Ph.D., L.M.S.W. Assistant Professor, Social Work, Delaware State University Rona L. Harris, M.H.S., L.B.S.W. Opioid Outreach Specialist, NCALL Research, Inc. Chanda Jackson, D.S.W. FSCC Projects Director, Delaware Department Health and Social Services

ABSTRACT There has been increased attention on the role of indirect trauma and the need for burnout prevention for behavioral health workers. Though frontline workers traditionally serve high needs and vulnerable populations, pandemic challenges have involved service delivery pivots to meet social distancing and safety guidelines, and have resulted in staff shortages and increased caseloads, increased use of maladaptive coping skills such as substance use, and increased mental health concerns within the workforce. Secondary traumatic stress and vicarious trauma within the workforce have often been linked with increased feelings of burnout. A socioecological model can provide a multilevel framework for addressing burnout and increasing resiliency among frontline workers. This article discusses recommendations for preventing burnout on an individual, interpersonal, organizational, community, and societal level. Prevention interventions include increasing training, mentorship, peer support, supervision, organizational culture, and interdisciplinary licensure efforts.

INTRODUCTION There has been increased attention on the role of indirect trauma and the need for burnout prevention for behavioral health workers. Though frontline workers traditionally serve high needs and vulnerable populations, pandemic challenges have involved service delivery pivots to meet social distancing and safety guidelines, and have resulted in staff shortages and increased caseloads, increased use of maladaptive coping skills such as substance use, and increased mental health concerns within the workforce. Secondary traumatic stress and vicarious trauma within the workforce have often been linked with increased feelings of burnout.1 Some studies have predicted clinician burnout at more than 50%.2 For example, it has been found that social workers have higher levels of stress and burnout when compared to other occupational groups due to the nature of the practice and the work environment.3 Some studies have also predicted over 50% of physicians and 30% of nurses experience burnout.4 Historically, burned-out workers leave the workforce at higher rates than their colleagues experiencing compassion satisfaction. Burned-out workers frequently do not deliver highvalue empathetic services which can lead to poor service quality and shortages in service availability.

INDIRECT TRAUMA Secondary traumatic stress and vicarious trauma are forms of indirect trauma, which occur as a result of continuous exposure to victims of trauma and violence, and typically are occupationally related.5 While both vicarious and secondary trauma leads to burnout, they can be distinguished by how they impact the worker. Vicarious traumatization represents a philosophical change in the worker’s viewpoint based on traumatic events and 70 Delaware Journal of Public Health - May 2022

stories shared by clients. On the other hand, secondary traumatic stress describes the emotional and mental state of the worker after hearing about a client’s trauma experience. Frequently processing personal tragedies and trauma with clients, the chronic nature and complexity of client problems, resistant clients, and the vulnerability of the populations served are all work environment factors that increase burnout risk.1 Some workers may report intrusive negative thoughts or use defense mechanisms such as avoidance of certain clients associated with negative or traumatic situations.6 Throughout this article, the close linkages between secondary traumatic stress, vicarious trauma, and burnout are assumed, and though distinctions exist between these terms, the impact on the workforce is similar, and the terms have been explored to inform this model.

SIGNS OF BURNOUT The outcome of secondary traumatic stress and vicarious trauma is frequently seen through the symptoms of burnout. Burnout has been conceptualized as a psychological syndrome emerging as a prolonged response to chronic interpersonal job stressors.

Signs of burnout include exhaustion, depersonalization, and reduced personal accomplishment.7 Exhaustion includes feelings of cynicism and job detachment, wearing out, loss of energy, depletion, and fatigue. Depersonalization includes negative or inappropriate attitudes towards clients, irritability, loss of idealism, and withdrawal. The third concept, reduced personal accomplishment, includes reduced productivity, low morale, and an inability to cope. Burnout symptoms result in a negative outlook towards self and others.8 The significance and impact of burnout are far-reaching as it relates to workforce retention and work-life challenges.

DOI: 10.32481/djph.2022.05.008

CASE STUDIES Some examples of workers experiencing burnout as an outcome of indirect trauma in the workplace include Sara and Monica. Sara is a new nurse at a methadone clinic. She is excited about her work and the population she is serving. However, Sara quickly finds that her coworkers speak negatively about their clients, and one encouraged her to show less enthusiasm about client change as he has seen minimal improvement in his caseload. Sara begins to dread going to work and finds that she has begun to have shorter interactions with her clients to avoid hearing about their triggers and setbacks in their recovery journey.

Monica has been a rural mental health therapist for nineteen years, and she has seen many policy shifts over the years. Since the beginning of the pandemic, her agency has decreased in size by forty percent due to coworker retirements and resignations. Her caseload has increased significantly, and she struggled throughout the pandemic due to her need to transition to telehealth sessions, her agency’s expectation that all therapists will maintain a full schedule from home, and supervising her son’s virtual learning during school closures. She has struggled to manage her self-care and balance her roles as a worker, a mother, and a wife. Though Monica used to greatly enjoy her job, she has begun to dread getting up to start her day, and has found herself snapping at her son and her partner. She has found herself using more sick time for her own coping and mental health and has found herself becoming more easily frustrated with her clients and co-workers.

The Socio-ecological Model for Burnout Prevention (see Figure 1) proposes several interdependent and interactional factors, including individual, relationship, organizational, community, and societal factors, that can reduce burnout. The model is designed to identify opportunities to reduce burnout by promoting both individual and environmental factors as strategies to create a comprehensive system of support to address burnout.

It addresses the importance of evidence-based interventions directed at changing individual, interpersonal, organizational, community, and societal factors that can increase resiliency. The first level of the model represents biological (e.g., age and sex) and personal belief systems (e.g., self-efficacy) that influence individual actions.14 McLeroy and colleagues15 describe examples of individual-level factors as demographics, educational status, self-concept, and developmental history of the individual. This level of the social-ecological model focuses on promoting changes to attitudes, beliefs, and behaviors that would increase positive personal factors to prevent burnout. Individual interventions for burnout prevention focus on areas such as training, mentorship, mindfulness practice, self-care, and achieving a work-life balance.

Figure 1. The Social Ecological Model for Burnout Prevention

Case Study Analysis

As demonstrated by Sara and Monica, the impact of burnout is wide-reaching due to reduced productivity and impaired work quality, increased personal conflict, and disruption of job tasks and service delivery.4 Burnout undermines the care and professional attention given to clients,9 and impacts therapeutic relationships, which can negatively impact recovery outcomes.10 Burnout has an impact on clients, the work environment, and coworkers,11 with an impact that also expands into interpersonal relationships outside of the work environment.12 There are multiple types of interventions that could be used to decrease burnout and promote resiliency in the cases of Sara and Monica.

Increased training and education, a strong support system to brainstorm healthy ways to cope with workplace stress, increased community awareness of workforce burnout, advocating for opportunities for educational attainment, and the creation of consortiums designed to improve the life experiences of rural workers would assist with preventing burnout.

SOCIO-ECOLOGICAL MODEL A multilevel framework can provide solutions for addressing burnout and increasing resiliency among frontline workers.

Ecological models, first described by Urie Bronfenbrenner,13 assume that one’s external environment influences functioning.

The ecological environment is conceived as a set of nested structures, each inside the other, in which an individual is conceptualized at the center of the interconnected systems. The social-ecological model extends the work of Bronfenbrenner to recognize levels of influence related to the well-being of one’s physical and mental health. The social-ecological model proposes that it is necessary to intervene across multiple systems to protect individuals from experiencing the impact of burnout and secondary traumatic stress.14

Interpersonal relationships are designed to create change within social relationships and refer to one’s close social networks, such as friends and family members, who might influence a person’s beliefs and behaviors. Burnout prevention strategies at the interpersonal level aim to build strong connections with others.

The organizational or institutional level of the socio-ecological model focuses on ways in which organizations can support a culture and work environment that prevent burnout. Burnout prevention efforts at this level should emphasize strengthening education, training, and connections with the workforce that can lead to early identification of employees at high risk of burnout and compassion fatigue. The community level is designed to impact the relationship that a person has with neighborhood structures such as schools, churches, workplaces, etc.16 Improving the physical and social atmosphere of community settings 71

includes creating positive norms and standards that promote safe and healthy community settings; empowering community groups to advocate for change; and increasing access and availability of services.14,16 The societal level refers to the cultural context in which individuals reside including socioeconomic status, values, and ethnicities of others in the surrounding environment. Societal level influences are a product of social and cultural norms that allow individuals to maintain ineffective methods for coping with stress.14 Strategies to prevent burnout at this level include efforts to strengthen financial, educational, and social policies that influence burnout.

Given that burnout is determined by several interactive factors, the socio-ecological systems theory appropriately conceptualizes how environmental factors can affect a person’s quality of life.

The literature on prevention intervention strategies of each level of the socio-ecological model is discussed below to provide a comprehensive strategy for preventing burnout.

Individual Level Interventions

Training Intervention. Increased awareness of the signs and impact of burnout is an essential prevention tool for burnout in the workforce, as are regular burnout screenings.1 The Maslach Burnout Inventory was developed in 1986 and is the most utilized burnout screening instrument. This instrument could be used by an agency longitudinally to measure change in each staff person and to inform needed support interventions. Regularly scheduled burnout intervention training will normalize the burnout continuum, from compassion satisfaction to compassion fatigue, and encourage self-awareness and self-care within the workforce. A variety of trainings from the literature are summarized in Table 1.

Table 1. Burnout Trainings Types of Trainings Reviewed Acceptance and Commitment Therapy techniques • Aspects of ACT to decrease burnout in addiction counselors.10 Education • Series of 3, ninety-minute education sessions focused on compassion fatigue, vicarious trauma, selfcare, compassion satisfaction, quality of life, and resilience.17 Mindfulness • Mindfulness Based Wellness and Resilience (MBWR)brief mindfulness focused intervention for primary care team to promote resilience and prevent burnout of professionals, participants perceived benefits from the training.18 • Online Mind-Body Skills Training (MBST) Modules.

Focused on the promotion of resilience, mindfulness, and empathy. Participants included nurses, dieticians, physicians, clinical trainees, health researchers, and social workers. Positive results were found in all three areas of focus.19

The training model utilized by an agency should be responsive to the workforce at that agency in logistical consideration of modality, length, duration, and frequency. The burnout training model developed by an agency should not increase the stress on the workforce in such areas as extensive time away from work, 72 Delaware Journal of Public Health - May 2022

travel, vaccine hesitancy, etc. Given the current landscape of the workforce, and the increased comfort with virtual platforms, a virtual training or hybrid training model may best meet the needs of all training stakeholders. Additionally, multiple types of activities should be included within the intervention, such as: • Education on burnout, • Health promotion education and practices, • Collegial socialization, • Team building activities within work units, • Self-care planning, • Experiential practice of activities related to mindfulness Lastly, it is essential to build on and promote existing resources.

Handouts may be provided on existing free and low-cost resources such as mindfulness apps, guided imagery downloads, white noise downloads and apps, mood and stress trackers, and existing toolkits, etc.

Evaluations of the effectiveness of the training intervention should be completed, and possible variables and measurement tools may include resilience (Brief Resilience Scale), burnout (Maslach Burnout Inventory), perceived stress (Perceived Stress Scale), compassion satisfaction and the effects of secondary trauma (Professional Quality of Life Scale- Version 5).

Mindfulness Practice. Positive mental health refers to a state of wellbeing without the presence of psychopathology.20 Mindfulness practice supports positive mental health through decreasing perceived stress and increasing psychological wellbeing.

Mindfulness techniques can be incorporated into trainings, self-care practices, mentorship activities, supervisory practice, or adapted as a philosophical guiding principal for organizational culture.

Self-Care. Research supports that some of the best ways to mitigate burnout are increasing awareness of the signs and symptoms of burnout, creating a self-care routine,21 and maintaining a work-life balance.22 Table 2 provides details on selfcare recommendations from the literature.

Table 2. Self-Care Recommendations Self-Care Recommendations Taking breaks, maintaining a sustainable and manageable workload, developing healthy job-related relationships, and developing healthy habits such as exercising, eating right, and getting enough sleep.7 Self-awareness, balance, flexibility, physical health, social supports, spirituality, utilization of leisure time, taking breaks as needed, using time management skills, engaging in sleep hygiene techniques, maintaining a balanced diet and engaging in physical activity, and developing a strong social support system.22 Create a self-care routine.21 Practice self-care and increase professional supports.23 Slowing down and breaking large projects into manageable tasks.24

Interpersonal Level Interventions

Building strong interpersonal relationships among work colleagues, supervisors, and peer relationships can improve personal well-being and assist with creating a healthier work environment.7 Mentorship. One way to buffer psychological distress is through increased positive social support and connections.25 Peer support is one important facet of burnout prevention26 and can be achieved through mentorship relationships.

Mentorship is associated with lower levels of burnout for emerging professionals.27 Mentorship provides the opportunity to build on, and extend, the effects of individual training interventions. It fosters relationships and connections between mentors and mentees within, or between agencies. Support of formal mentorship relationships and activities demonstrates an organizational culture supportive of staff needs. Mentorship may include regularly scheduled meetings, social activities, avenues for virtual connections, and support of professional goals.

Peer Relationships. Positive relationships with colleagues and job engagement have been shown to mitigate burnout risk.7 Opportunities should be promoted to encourage strong peer relationships. These opportunities will vary based on the organizational setting, and types of services provided. For some organizations, peer relationships can be promoted through social opportunities with colleagues such as team building activities and staff appreciation events. Organizations should generate internal discussions with employees on valuable ways to support peer engagement.

Supervision Techniques. Supervisors need proper training to recognize the risks of job stressors. Supervision is an organizational component which follows three major factors: commanding, guiding, and controlling.28 This distinctive professional activity provides training and professional development to guide the functioning of hired staff. Supervision also involves creating aspects of understanding, interaction, expectations, and confidence in self, as well as providing restorative support to lessen tension and pressure between staff in the organization.28 To promote successful supervision outcomes within organizations, the supervisor should receive continuous training, education, and awareness. New methodologies for supervision practice can be established through opportunities for supervisor reflection on their work routine, client, and staff engagement.29 Though there are a variety of supervision models and activities, depending upon discipline, Table 3 provides an overview of social work supervision domains and suggested activities for each to support burnout prevention and decrease occupational vicarious trauma.

Organizational Level Influence

Organizations and their leaders play a significant role in preventing burnout and increasing job satisfaction among employees. Further, interventions at both the worker and administrator level should focus on preventing burnout in the workforce.31 Organizations have a responsibility to continually measure burnout risk in their staff, recruit and retain staff with protective factors against burnout, provide regular trainings to increase awareness and skills, and continually work towards creating and maintaining an agency culture that supports compassion satisfaction.

Measurement of Compassion Fatigue and Burnout. According to Kumar, regular burnout screenings can be a crucial step in raising awareness as well as offering help to affected staff.1 Kumar identified screening signal areas as affective, cognitive, behavioral, and motivational. Affective signals include irritability, oversensitivity, reduced emotional empathy with clients, and an increase in anger. Cognitive signals include cynical perceptions of clients, a pessimistic view of clients, and providing derogatory labels of clients. Behavioral signals include violent outbursts, irritability towards clients, interpersonal conflicts, social isolation, and mechanical responses to clients. Motivational signals include decreased interest and a lack of respect for clients.

Staffing and Training. Existing workplace and workload stress can lead to poor training of new staff members and agency staff not adequately prepared to handle job related stressors.32 As workers choose to leave agencies, either as a result of burnout or other reasons, the workload burden increases for those staff who remain,10 and becomes more difficult to manage.33 Workers with a high number of cases often have little opportunity to rest, recover and restore balance, all of which decrease service quality.7 Service delivery is further disrupted by insufficient recognition or reward of the existing workforce which is associated with feelings of inefficacy and devaluation.7 Organizational Culture. Attachment security is linked with lower levels of burnout and compassion fatigue, which is an important consideration for recruitment, training, and supervision.34 Communication pipelines to report concerns related to compassion fatigue or burnout are essential within the organizational setting.21 Burnout preventative measures in organizational cultures include ongoing supervisory support, encouragement of coworker relationships and support, and the promotion of self-care activities.35 Organizations fostering a culture of acceptance and support of the high levels of stress associated with the helping professions will be more supportive of their workforce, and strategies to continue to support the workforce are essential for recruitment and retention of a resilient workforce.

Table 3. Supervision Domains and Relevant Activities Supervision Type and Description30

Activities

Administrative: Management & organizational policy

Assess for burnout, review agency policies on service delivery standards

Educational: Clinical, professional development & ethics

Encouraging continuing education on stress management and vicarious trauma

Supportive: Trust-building, nurturing & encouragement

Building professional identity and promoting self-care practices 73

Community & Societal Level

The health of the frontline workforce can be improved by focusing on collaborative efforts among community groups and industries.

Advocating for macro-level policy and systematic change can encourage workers from diverse fields such as medicine, nursing, psychology, social work, public health, etc. to bring burnout prevention to the forefront of national conversations regarding licensing and educational accreditation standards.

Interdisciplinary Licensing Efforts. As burnout continues to increase among members of helping professions, so does the need for community efforts to advocate for policy and communitylevel changes. Many professions such as social work have specific licensing requirements to maintain the standards and values of the profession. One policy change to assist with burnout prevention is the need for national licensure boards to mandate training on burnout prevention and self-care in their licensure renewal cycles.36 This idea is consistent with continuing education and professional development as a means to help workers stay current on best practices in the field. Burnout training modules should be available to all members of the frontline workforce to promote a widespread recognition of burnout prevention as an essential part of continuing education. Burnout prevention is a necessary element of educational training for the frontline workforce, which accrediting bodies should mandate into their curriculums.36 A successful advocacy campaign for the integration of burnout training at the community level should be communitycentered, empowering, and involve multiple partnerships with various community groups.16 Access to Training. Current burnout trainings are particular to each discipline. However, the causes and symptoms of burnout among workers exist for many of the same reasons because compassion fatigue and vicarious trauma occur across disciplines.

Rather than create burnout trainings specific to disciplines, trainings at the administrative, supervisory, and staff levels might be more appropriate to help workers recognize and respond to burnout and increase access and the availability of burnout prevention trainings. A key outcome of burnout prevention training across agencies is creating an organizational and community culture supportive of burnout prevention which can increase compassion satisfaction.

Funding. Consistent with most policy-level changes, securing funding and buy-in from community members and leaders are necessary. Raising awareness about burnout can not only help prevent and manage it,1 but also bring it to the forefront of researchers and policy-makers. Funding for burnout can create interdisciplinary opportunities for workers and those interested in facilitating burnout trainings to complete research related to burnout prevention.

CONCLUSION A socio-ecological framework provides a basis for understanding the etiology of burnout and developing prevention and intervention practices for individuals, peers, organizations, communities, and society. Secondary traumatic stress and vicarious trauma have become prevalent conditions amongst professions that need to have continuous interventions and training implemented in the workplace. Both the future and the current behavioral health workforce across disciplines (e.g., medical, nursing, psychology, social work, public health) can benefit from understanding and implementation of burnout prevention strategies. While agencies have a responsibility to 74 Delaware Journal of Public Health - May 2022

recruit and retain competent staff who are prepared to meet the functional requirements of their positions, organizations also have the responsibility to continue to support their staff to meet the day-to-day workplace demands, both physically and psychologically. This can be achieved through the use of a multi-level framework and include robust training, continuing education opportunities, regular supportive supervision sessions, assistance in attaining needed resources for service delivery, promotion of inter-collegial relationships in the workplace setting, and rewards for outstanding service delivery.

Dr. Habeger may be contacted at ahabeger@desu.edu.

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14. Krug, E. G., Dahlberg, L. L., Mercy, J. A., Zwi, A. B., & Lozano, R. (2002). World report on violence and health. World Health Organization, Geneva. http://apps.who.int/iris/bitstream/handle/10665/42495/9241545615_eng.pdf 15. McLeroy, K. R., Steckler, A., & Bibeau, D. (Eds.). (1988). The social ecology of health promotion interventions. Health Education Quarterly, 15(4), 351–377. https://doi.org/10.1177/109019818801500401 16. Golden, S. D., & Earp, J. A. (2012, June). Social ecological approaches to individuals and their contexts: Twenty years of health education & behavior health promotion interventions.

Health Educ Behav, 39(3), 364–372. https://doi.org/10.1177/1090198111418634 17. Klein, C. J., Riggenbach-Hays, J. J., Sollenberger, L. M., Harney, D. M., & McGarvey, J. S. (2018, June). Quality of life and compassion satisfaction in clinicians: A pilot intervention study for reducing compassion fatigue. The American Journal of Hospice & Palliative Care, 35(6), 882–888. https://doi.org/10.1177/1049909117740848 18. Colgan, D. D., Christopher, M., Bowen, S., Brems, C., Hunsinger, M., Tucker, B., & Dapolonia, E. (2019, July 1).

Mindfulness-based Wellness and Resilience intervention among interdisciplinary primary care teams: A mixedmethods feasibility and acceptability trial. Prim Health Care Res Dev, 20(e91), e91. https://doi.org/10.1017/S1463423619000173 19. Kemper, K. J., & Khirallah, M. (2015, October). Acute effects of online mind-body skills training on resilience, mindfulness, and empathy. Journal of Evidence-Based Complementary & Alternative Medicine, 20(4), 247–253. https://doi.org/10.1177/2156587215575816 20. Keyes, C. L. (2005, June). Mental illness and/or mental health?

Investigating axioms of the complete state model of health.

Journal of Consulting and Clinical Psychology, 73(3), 539–548. https://doi.org/10.1037/0022-006X.73.3.539 21. Clay, R. (2020). Are you experiencing compassion fatigue? https://www.apa.org/topics/covid-19/compassion-fatigue# 22. Posluns, K., & Gall, T. L. (2020). Dear mental health practitioner, take care of yourselves: A literature review on self-care. International Journal for the Advancement of Counseling, 42(1), 1–20. https://doi.org/10.1007/s10447-019-09382-w 23. Otto, A. K., Pietschmann, J., Appelles, L. M., Bebenek, M., Bischoff, L. L., Hildebrand, C., . . . Wollesen, B. (2020, October 6). Physical activity and health promotion for nursing staff in elderly care: A study protocol for a randomised controlled trial. BMJ Open, 10(10), e038202. https://doi.org/10.1136/bmjopen-2020-038202

25. Benight, C. (2004). Collective efficacy following a series of natural disasters. Anxiety, Stress, and Coping, 17(4), 401–420. https://doi.org/10.1080/10615800512331328768

27. Perumalswami, C. R., Takenoshita, S., Tanabe, A., Kanda, R., Hiraike, H., Okinaga, H., . . . Nomura, K. (2020, June 3).

Workplace resources, mentorship, and burnout in early career physician-scientists: A cross sectional study in Japan. BMC Medical Education, 20(1), 178. https://doi.org/10.1186/s12909-020-02072-x 28. Lee, S., Denniston, C., Edouard, V., Palermo, C., Pope, K., Sutton, K., . . . Rees, C. (2019, June 1). Supervision training interventions in the health and human services: Realist synthesis protocol. BMJ Open, 9(5), e025777. https://doi.org/10.1136/bmjopen-2018-025777 29. Substance Abuse and Mental Health Services Administration.

(2014). Trauma-informed care in behavioral health services.

U.S. Department of Health and Human Services. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK207201/pdf/Bookshelf_ NBK207201.pdf 30. National Association of Social Workers. (n.d.). Best practice standards in social work supervision. Retrieved from https://www.socialworkers.org/LinkClick. aspx?fileticket=GBrLbl4BuwI%3D&portalid= 31. Broome, K. M., Knight, D. K., Edwards, J. R., & Flynn, P. M. (2009, September). Leadership, burnout, and job satisfaction in outpatient drug-free treatment programs. Journal of Substance Abuse Treatment, 37(2), 160–170. https://doi.org/10.1016/j.jsat.2008.12.002 32. Miele, G., & Rutkowski, B. (2019, Oct). Addressing compassion fatigue in the context of service delivery [Virtual conference workshop]. The 16th Annual Integrated Care Conference, Universal City, CA. 33. Wacek, B. (2017). Factors which put social workers at a greater risk for burnout. https://sophia.stkate.edu/cgi/viewcontent. cgi?article=1806&context=msw_papers 34. West, A. (2015). Associations among attachment style, burnout, and compassion fatigue in health and human service workers: A systematic review. Journal of Human Behavior in the Social Environment, 25(6), 571–590. https://doi.org/10.1080/10911359.2014.988321 35. Oser, C. B., Biebel, E. P., Pullen, E., & Harp, K. L. (2013, January-March). Causes, consequences, and prevention of burnout among substance abuse treatment counselors: A rural versus urban comparison. Journal of Psychoactive Drugs, 45(1), 17–27. https://doi.org/10.1080/02791072.2013.763558 36. Kreitzer, M. J., & Klatt, M. (2017, February). Educational innovations to foster resilience in the health professions.

Medical Teacher, 39(2), 153–159. https://doi.org/10.1080/0142159X.2016.1248917

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Disclosure of a Dementia Diagnosis: Minimizing Medical Trauma James M. Ellison, M.D., M.P.H. Geriatric Psychiatrist, Swank Foundation Endowed Chair in Memory Care and Geriatrics, ChristianaCare Sehba Husain-Krautter, M.D., Ph.D. Zucker Hillside Hospital, Litwin-Zucker Research Center for the Study of Alzheimers Disease, Feinstein Institute for Medical Research

CASE REPORT Ms. D., a retired secretary, was 65 years old when she sought assessment for “memory impairment” in a memory disorders clinic. She and her husband attributed recent memory lapses to the low dose lithium carbonate she had taken for many years following a manic episode in her 30’s. Her neurological and physical examinations and laboratory studies—including lithium level—were unremarkable. Although she scored 27/30 on the Mini Mental Status examination,1 her behavior suggested more significant cognitive compromise. She was repeating questions and she displayed difficulty recalling recent events. She acknowledged some confusion about directions when driving.

Although advised to have an MRI and neuropsychological testing, she declined these tests for fear they would show her “in a bad light.” Her cognitive symptoms were provisionally ascribed to lithium toxicity.

Lithium discontinuation was followed by increasing difficulty performing customary household tasks and engaging in her usual activities. Two years after her initial assessment, she agreed to further evaluation. At age 67, her Montreal Cognitive Assessment2 score was 7/30 and neuropsychological testing demonstrated significant cognitive impairment. Her brain MRI showed involutional changes including parenchymal volume loss and chronic white matter microvascular ischemic changes.

FDG-PET scan demonstrated regional hypometabolic changes consistent with a diagnosis of Alzheimer’s Disease.

When told that her cognitive symptoms most likely represented Alzheimer’s dementia, Ms. D. reacted with immediate shock and terror. Over several days she slipped into a deep depression accompanied by delusions of persecution, which necessitated inpatient psychiatric care. In lucid moments, she was able to discuss how traumatized she felt by the disclosure of her Alzheimer’s disease diagnosis, a condition she could not name without bursting into tears. Her impaired memory limited the value of psychotherapy, but her depressive symptoms resolved gradually when she was treated with antidepressant and antipsychotic medications. Subsequently, having observed her devastated response to the discussion of her diagnosis, her family and care providers learned to avoid mention of dementia or Alzheimer’s disease in her presence. Her husband, designated as decision-maker, was able to discuss the management of her Major Neurocognitive Disorder with her clinicians in order to facilitate appropriate treatment interventions.

DISCUSSION While symptoms such as pain, fever, vomiting, or bleeding often prompt a quick search for evaluation and treatment, many people react differently to cognitive symptoms. Memory loss in particular and cognitive impairment in general are among the 76 Delaware Journal of Public Health - May 2022

symptoms most feared by older adults. Because the diagnosis of dementia (formally termed Major Neurocognitive Disorder) is widely understood as a progressive condition without available disease-modifying treatments, evaluation may be avoided by individuals who observe changes in themselves. Friends and family members, too, may disregard or minimize the cognitive changes they observe in a loved one. Discussion even of the possibility of Alzheimer’s disease or other neurodegenerative disorders can be extremely upsetting to a patient.

Nonetheless, there are valid reasons to identify and address cognitive symptoms even at an early stage. Recognition of the earliest clinical manifestations of cognitive decline, diagnosed as Mild Neurocognitive Disorder, permits an affected individual and caregivers to understand and learn about functional changes they have most likely already observed. Early detection allows an affected individual to participate fully and effectively in plans for the future, including decisions regarding health care options, finances, residential arrangements, and needs for various kinds of assistance. In the presence of mild cognitive changes, lifestyle interventions affecting disease management, physical activity and nutrition may delay or mitigate further cognitive decline. Once cognitive faculties are more significantly compromised, detection and diagnosis of impairment becomes a necessary aspect of protecting the rights and safety of an affected individual.3 The psychoanalyst and teacher Elvin Semrad famously formulated the importance of helping a patient to “acknowledge, bear, and put in perspective” their suffering.4 Cognitively impaired individuals, however, are uniquely impaired in their ability to hear, understand, and process a disturbing and potentially traumatic diagnosis. Acknowledgment may be intermittent and unstable. Diminished short term memory creates an impediment to the reflective contemplation which supports the integration of disturbing information. Changes in language and insight may further undermine comprehension of a diagnosis and prognosis. Social cognition can be affected even at an early stage of cognitive decline, interfering with collaborative discussion and planning for the future.5 A previous history of anxiety or mood disorder can create even greater difficulty for an individual coping with a new, serious diagnosis.

Medical trauma, which can include the “psychological traumas that result from medical diagnosis and/or medical intervention,” is a recognized potential consequence of diagnosis disclosure which can induce symptoms similar to those of Post-Traumatic Stress Disorder.6,7 Yet, the medical ethical principle of “respect for persons” implies that patients have a right to know their diagnoses.8 The 21st Century Cures Act, furthermore, stipulates that patient electronic health information be made available to patients without delay and at no cost.9 Furthermore, a recent pilot study showed that the impact of the dementia diagnosis DOI: 10.32481/djph.2022.05.009

was lower on individuals who had accessed support and referral services available to them as compared to those who had not.10 Yet many providers are reluctant to discuss a dementia diagnosis explicitly, despite evidence that the majority of patients referred to a memory clinic preferred full diagnostic disclosure.11 Some of this reluctance, of course, comes from experience with patients like Ms. D, who have found disclosure unbearable and traumatic.

In the pressured and complex practice of clinical care, how can clinicians fulfill their duty of diagnosis disclosure to patients, respecting their right to know and learn about their diagnosis without inducing harmful psychological trauma? Dr. Rob Buckman, who crusaded to improve the disclosure process for patients diagnosed with cancer, addressed this dilemma in 1992 in an influential book entitled How to Break Bad News: A Guide for Health Care Professionals. He outlined a systematic approach for breaking stressful news. The six steps, summarized in the acronym SPIKES, are: Setting up the interview, assessing the patient’s Perception, obtaining the patient’s Invitation, giving Knowledge and information to the patient, assessing the patient’s Emotions with empathic responses, and strategy and Summary.12 A recent review of the art of disclosing a dementia diagnosis offers some additional clinical guidance focused on the needs of persons with dementia.13 Roca and colleagues point out that the presence of memory impairment may require the disclosure discussion to include, with patient’s consent, the presence of trusted family members or other caregivers. The patient’s readiness for information and ability to understand the implications of a neurocognitive diagnosis must be assessed. A brief appointment may not provide sufficient time to address the inevitable questions. Repeated visits, if appropriate, will reinforce the difficult message, which includes prognosis for emergence and progress of both cognitive and behavioral symptoms. Written materials can serve to emphasize the key points of discussion. A clear plan for additional diagnostic testing, referrals, symptom management and follow up should be reviewed with patient and caregivers. Many people with dementia fear above all their loss of independence and the prospect of abandonment. Open discussion of these fears can be reassuring, A special concern faced by persons with dementia is the traumatic effect of unnecessary redisclosure of their diagnosis.

Caregivers and surrogate decision-makers must know the relevant medical information, and they often benefit from coaching about management of the behavioral issues that arise during dementia’s progression. The affected patient who is unable to absorb and process the news of a dementia diagnosis and expected developments, however, need not be continuously re-traumatized. In the absence of an ability to work through and accept a dementia diagnosis, it is reasonable for caregivers to discuss cognitive difficulties euphemistically. “Memory lapses,” “memory slips,” “having a bad day,” and “brain aging” are ways in which clinicians can acknowledge difficulty without invoking a specific diagnosis. Such terms offer an opportunity to avoid inflicting unnecessary pain. Keeping in mind that many essential personality features of a person with cognitive impairment persist well into the course of a progressive illness can help clinicians and caregivers to preserve an empathic, honest, and minimally traumatic relationship with the affected patient.

REFERENCES 1. Folstein, M. F., Folstein, S. E., & McHugh, P. R. (1975, November). “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician.

Journal of Psychiatric Research, 12(3), 189–198. https://doi.org/10.1016/0022-3956(75)90026-6 2. Nasreddine, Z. S., Phillips, N. A., Bédirian, V., Charbonneau, S., Whitehead, V., Collin, I., . . . Chertkow, H. (2005, April).

The Montreal Cognitive Assessment, MoCA: A brief screening tool for mild cognitive impairment. Journal of the American Geriatrics Society, 53(4), 695–699. https://doi.org/10.1111/j.1532-5415.2005.53221.x 3. Bejenaru, A., & Ellison, J. M. (2021, November). Medicolegal implications of mild neurocognitive disorder. Journal of Geriatric Psychiatry and Neurology, 34(6), 513–527. https://doi.org/10.1177/0891988720957092 4. Ghaemi, N. (2013, Jul 9). Existential psychopharmacology. A tribute to Dr. Jacob Katzow. Psychology Today. Retrieved from https://www.psychologytoday.com/us/blog/mood-swings/201307/ existential-psychopharmacology-tribute-dr-jacob-katzow 5. Ellison, J. M. (2021, July). Getting interpersonal: Unmasking the value of social cognition assessment in older adults. Am J Geriatr Psychiatry, 29(7), 643–644. https://doi.org/10.1016/j.jagp.2020.12.002 6. Janssen, J. S. Medical trauma. (n.d.). Social Work Today Medical Trauma. Retrieved from https://www.socialworktoday.com/news/enews_0416_1.shtml 7. Hall, M. F., & Hall, S. E. (2013). When treatment becomes trauma: Defining, preventing, and transforming medical trauma. Ideas and Research You Can Use: VISTAS 2013.

Retrieved from https://www.counseling.org/docs/default-source/ vistas/when-treatment-becomes-trauma-defining-preventing-.pdf 8. US Government. (1978). The Belmont report: ethical principles and guidelines for the protection of human subjects of biomedical and behavioral research. U.S. Government Printing Office, Bethesda, MD. https://www.hhs.gov/ohrp/ regulations-and-policy/belmont-report/index.html 9. 21st Century Cures Act, HR 34 (ENR) 114 U.S.C. (2016). https://www.govinfo.gov/app/details/BILLS-114hr34enr 10. Dunham, A., Mellor, D., Rand, E., McCabe, M., & Lewis, M. (2020, November). Impact of disclosure of a dementia diagnosis on uptake of support services: A pilot study exploring a post-traumatic stress approach. Dementia (London), 19(8), 2658–2670. https://doi.org/10.1177/1471301219844659 11. van den Dungen, P., van Kuijk, L., van Marwijk, H., van der Wouden, J., Moll van Charante, E., van der Horst, H., & van Hout, H. (2014, October). Preferences regarding disclosure of a diagnosis of dementia: A systematic review. International Psychogeriatrics, 26(10), 1603–1618. https://doi.org/10.1017/S1041610214000969 12. Buckman, R. (1992). How to break bad news: a guide for health care professionals. Johns Hopkins University Press.

13. Roca, R. P., Lehmann, S. W., Kyomen, H. H., & Ellison, J. M. (2022, Mar 24). The science, ethics, and art of disclosing a dementia diagnosis. Psychiatric Times. Retrieved from: https:// www.psychiatrictimes.com/view/the-science-ethics-and-art-ofdisclosing-a-dementia-diagnosis 77

Trauma-Related Dissociation and the Dissociative Disorders: Neglected Symptoms with Severe Public Health Consequences Stacey M. Boyer, Psy.D. Director, Psychology Services, Outpatient and Embedded Behavioral Health, ChristianaCare Jennifer E. Caplan, M.A. Widener University Institute for Graduate Clinical Psychology Lisa K. Edwards, M.A. Widener University Institute for Graduate Clinical Psychology

ABSTRACT Trauma-related dissociation is a major public health risk warranting the attention of the healthcare professions.

Severe dissociative pathology or dissociative disorders (DDs) are more prevalent than some commonly assessed psychiatric disorders (e.g., Bipolar Disorder, Obsessive Compulsive Disorder, Schizophrenia), yet are often underrecognized and undertreated, despite being associated with significant disability and chronic medical issues, among many other severe and costly public health consequences. In fact, people living with DDs spend an average of 5 to 12.4 years actively engaged in treatment before receiving an accurate diagnosis. Detection and treatment of trauma-related dissociation and DDs leads to a myriad of positive outcomes including improved quality of life, treatment outcomes, reduction in health and social risks, decreased healthcare utilization and costs (25-64% reduction), and significant economic advantages for society. It is imperative that healthcare professionals are trained in recognizing, assessing, and treating dissociation in service of preventing the discussed public health consequences. This article provides a comprehensive review of the important public health implications resulting from often neglected or untreated trauma-related dissociation and DDs while offering a summary of assessment methods, treatments, and resources to empower individuals and healthcare professionals to effect change.

INTRODUCTION Trauma is a widespread public health risk of grave proportions.

It can be defined as a high impact stressor that overwhelms the individual’s ability to cope and disrupts their relationship with self and others. There are many different types of traumas, including one-time events that involve actual or threatened serious injury or death, sexual violence, or chronic and repetitive experiences of abuse, neglect, marginalization, homelessness, and disrupted attachment relationships. The World Health Organization’s (WHO) World Mental Health (WMH) Surveys found that 70% of individuals across the globe reported exposure to at least one traumatic event,1 indicating that trauma is ubiquitous and highly prevalent. Within the United States (U.S.), the vast majority (89.7%) of adults have experienced at least one traumatic event according to Diagnostic and Statistical Manual of Mental Disorders-V-TR (DSM-V-TR) criteria, suggesting that the prevalence of trauma exposure in the U.S. may be even higher than that of the global average.2 The largest studies to date investigating the prevalence and lasting effects of childhood trauma exposure in the U.S. revealed that about three out of every five U.S. adults experienced at least one traumatic event in childhood, and about one out of every four U.S. adults experienced three or more.3 The more trauma exposure in childhood, the greater the rates of chronic disease, suicide attempts, mental illness, substance misuse, disability, shortened 78 Delaware Journal of Public Health - May 2022

life expectancy, and healthcare utilization costs.3 A myriad of studies examining these effects indicate that trauma-related dissociation, a common yet widely unrecognized symptom of trauma, mediates this relationship among trauma exposure, post-traumatic stress disorder (PTSD), and many health and social risks.4,5 Dissociation is an often “hidden and neglected” public health issue warranting the attention of the healthcare professions (p.1).6

ETIOLOGY, PREVALENCE, AND CLINICAL FEATURES OF DISSOCIATION AND DISSOCIATIVE DISORDERS Etiology of Dissociation and Dissociative Disorders

There is a robust correlation between dissociative symptoms and exposure to trauma, particularly early childhood trauma and disruptions in attachment and caregiving. Dissociation can be defined as disconnections between thoughts, feelings, behaviors, sensations, and other mental processes that would normally be connected. It is a human phenomenon, experienced by all to varying degrees on a continuum ranging from benign to problematic. On one end of the continuum are experiences of daydreaming, “highway hypnosis,” or absorption and flow wherein the individual’s mental energy is focused on a particular task while other thoughts or perceptions fade into the background. These dissociative experiences are often benign and under the individual’s control.

DOI: 10.32481/djph.2022.05.010

On the other end of the continuum are trauma-related dissociative phenomena that, while adaptive in some ways, can become entrenched over time and impair overall functioning.

In the face of overwhelming traumatic experience, dissociation can offer a psychic escape when there is no physical escape. For example, it is not uncommon for survivors of rape to report experiencing themselves as being outside of their body (i.e. depersonalization) during the assault. Individuals may also have thoughts and feelings that appear disconnected (e.g.: “Logically, I know that the trauma was not my fault, but I feel that it was my badness that caused it”). Over time, and particularly in the context of repeated trauma during childhood, the use of dissociation can become a rigid and automatic response to stress that disrupts “the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior” (p. 329).7 While in some ways adaptive for trauma survivors, severe trauma-related dissociative symptoms can interfere with almost all aspects of functioning and lead to a diagnosis of a DD.

Prevalence and Clinical Features of Dissociative Disorders

The DSM-V-TR identifies the following (DDs): depersonalization/derealization disorder, dissociative amnesia, dissociative identity disorder, unspecified dissociative disorder, and other specified dissociative disorder. Depersonalization/ derealization disorder is characterized by persistent feelings of detachment from one’s body or experiences (e.g.: feeling as though things are unreal or a dream). Dissociative amnesia is characterized by gaps in autobiographical memory beyond normal forgetting, that may range from one experience to several years. Dissociative identity disorder (DID), the most severe dissociative disorder, includes both persistent depersonalization/derealization and dissociative amnesia as well as the presence of distinct self-states with unique attributes or experiences. People with DID may experience disremembered behaviors; trance states; fugues; fluctuations in skills, habits, or knowledge; voice hearing; negative hallucinations; analgesia; unexplained somatoform symptoms; abrupt or significant changes in mood; and intrusive thoughts,

feelings, behaviors, or urges that do not feel like one’s own (passive influence). Similar presentations that do not meet full criteria for DID may be captured by diagnoses of either unspecified DD or other-specified DD. Many epidemiological studies have explored the prevalence of DDs. Lifetime prevalence of DDs ranges from approximately 9 to 18%.6 This wide prevalence range is attributable to differences in special populations or clinical/non-clinical settings and exceptionally limited clinician training in the assessment of dissociative symptoms that results in misdiagnosis. Across inpatient and outpatient clinical samples, the prevalence of DDs is up to 46%.8 Figure 1 summarizes the DSM-V-TR 12-month U.S. prevalence rates of the five DDs as compared to other common psychiatric disorders.7 Of note, because DDs are often the result of chronic and repetitive trauma beginning in early childhood, the vast majority of people with DDs also experience comorbid PTSD.

Prevalence and Clinical Features of PTSD Dissociative Subtype

In 2013, the American Psychiatric Association added a dissociative subtype to the PTSD diagnosis that is characterized by persistent symptoms of depersonalization and derealization.

The 12-month U.S. prevalence for PTSD generally is 4.7%.7 In the WHO’s World Mental Health Surveys of 16 countries, 14.4% of individuals with PTSD met criteria for this dissociative subtype.9

Neurobiology of Dissociation

Neuroimaging studies demonstrate fascinating structural and functional brain alterations among individuals with DDs that are similar and yet distinct from PTSD. These findings are enhancing understandings of the unique presentations and treatment needs of these individuals. Lotfinia, Soorgi, Mertens, and Daniels offers a thorough review of the research in this area, including structural MRI, resting fMRI, and task-related fMRI studies by diagnostic group (PTSD, Borderline Personality Disorder, Depersonalization/Derealization Disorder, and DID).10 Researchers have attempted to replicate the brain activation patterns using professional actors of varying levels of fantasyproneness who are trained to feign dissociative symptoms, but the actors were unsuccessful in duplicating these unique patterns.11

Figure 1: United States 12-Month Prevalence Rates of Dissociative Disorders Compared to Other Common Psychiatric Disorders

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PUBLIC HEALTH IMPLICATIONS OF UNTREATED DDS Implications of Misdiagnosis or Lack of Access to Non-Specialty Treatment Trauma-related dissociation and DDs not only significantly impact the individual’s experience, but they also play a central role in the pathway from trauma exposure to adverse and costly public health outcomes. Figure 2 provides a summary of these outcomes. Unfortunately, few clinicians have training on how to assess for and identify DDs, and their lack of training exacerbates skepticism and diagnostic errors.12 As a result, people living with DDs, particularly DID, spend an average of 5 to 12.4 years actively engaged in treatment with six or more clinicians before receiving a correct diagnosis, all the while experiencing worsening symptoms and increasing functional impairment throughout that time.8,13,14 Even after finding a clinician, patients with DID often have a difficult time sustaining treatment due to poor responses from their provider (i.e., skepticism, being disrespected by their clinician, or assumptions that treatment is no longer necessary).12,13,15 For many, accurate diagnosis and specialty treatment can be a matter of life or death. These widespread barriers in access to appropriate assessment, diagnosis, and treatment for DDs lead to adverse outcomes with significant public health implications.

Figure 2: Public Health Issues Associated with Dissociative Disorders

care, and occupational functioning.18 In relationships, they may also experience understandable fears of being harmed and may have patterns of withdrawal due to trauma-related shame.19 Additionally, those with comorbid dissociation and substance use disorders demonstrate higher severity of substance dependence than those without dissociation. Dissociation is generally correlated with increased symptom severity across diagnoses and higher psychiatric relapse rates that can be disabling in the absence of accurate diagnosis and treatment.

Poorer Physical Health and Chronic Medical Issues

Dissociation and trauma are both linked to poor physical health outcomes through multidirectional pathways that connect the three.8,18 Broadly, trauma and dissociation impact the responsivity of catecholamine system, HPA axis, and immune system. The effect on these systems increases risk of diabetes, cardiovascular issues, and inflammation, while also decreasing the individual’s threshold for pain.18,20 Individuals who experience trauma-related dissociation are likely to experience somatic symptoms.21 Studies have shown that individuals who have higher rates of various types of chronic pain are also likely to report dissociation.22 Adults and children who experience psychogenic non-epileptic seizures (PNES) also have higher rates of dissociation.23 Unaddressed trauma-related dissociation or DDs can also negatively impact treatment and medication adherence or pharmacological response.18,24

Engagement with Social Services

Individuals with DDs have higher rates of social service utilization due to the additional impairments and needs associated with medical illness, disability, and other consequences of dissociation.25 The health and social risks and impairments associated with untreated DDs may compound and produce a domino effect wherein individuals with DDs experience a progressive decline in functioning, resulting in increased engagement in costly social services. Thus, in addition to increased healthcare costs, DDs may also be associated with increased non-healthcare costs. This may include direct nonhealthcare costs, such as those connected to special education, disability programs or pension, child welfare programs, judicial involvement, transportation expenses, and resources to combat housing instability, as well as indirect nonhealthcare costs, including those associated with fatality, lack of productivity, and lost wages for individuals with DDs or their loved ones who may be servings as their caregivers.25

Increased Likelihood of Revictimization

Disability and Impaired Functioning The often-significant delays in diagnosis and limited access to specialty DD treatment lead to increased symptom severity, decreased quality of life, and disability.16,17 In one sample, 60% of people with DDs described themselves as disabled, with difficulty functioning across multiple domains.13 Without access to appropriate treatment, people with DDs may struggle with activities of daily living (e.g., self-care), engagement in medical 80 Delaware Journal of Public Health - May 2022

Dissociative symptoms are also strongly linked to higher rates of revictimization, including sexual assault and intimate partner violence.26 Several researchers have investigated the pathway through which dissociation predicts revictimization. Although dissociation is adaptive and protective in the face of inescapable trauma, persistent use of dissociation often interferes with the individual’s ability to process cues of danger and discern threatening from non-threatening information by keeping this information outside of awareness.27 By hindering the process by which one would detect a safety risk, dissociation may prevent individuals from employing self-protective behaviors (e.g., such as fleeing from an unsafe situation) and ultimately lead to greater risk of further victimization among individuals with DDs.

Increased Suicidal Ideation and Self-Injurious Behaviors

There is robust evidence linking DDs, self-injurious behaviors (SIBs), suicidal ideation (SI), and history of multiple suicide attempts. Higher levels of dissociation are associated with greater severity of SI (e.g., increased frequency, having a suicide plan) and increased likelihood of suicide attempts. In fact, over 70% of outpatients diagnosed with DID have attempted suicide at least once and people often require multiple hospitalizations.7 DDs are an independent risk factor for multiple suicide attempts, even when controlling for other variables such as age, gender, personality disorders, PTSD, or substance abuse.28 The presence of a DD is a greater predictor of suicide risk than SI, depression, or PTSD.29 Similarly, dissociation also strongly predicts engagement in SIBs and is an independent risk factor for them, even when controlling for variables such as age, gender, education, sexual abuse, physical abuse, personality disorders, substance use, and PTSD.4,28 The vast majority of DD patients (92.31%) report only partial awareness of precipitants to their SIBs.15 SIBs may be precipitated by trauma triggers, emotion dysregulation, stress, psychiatric or physical health problems, dissociative experiences, or limited or less helpful coping skills. They may serve the function of stopping uncomfortable dissociation (i.e., grounding) or inducing dissociation to numb or regulate emotions, but they often have significant negative consequences including scarring, hospitalization, and strong feelings of shame.

Increased Hospitalization and Healthcare Costs

People with DDs are higher utilizers of healthcare and social services than other diagnostic groups. In a study of children in the child welfare system, dissociation was the key predictor of rapid need for psychiatric hospitalization.30 Approximately 48% of adults with DDs report experiencing hospitalizations, with 68% noting <5 hospitalizations.13 Şar et al. noted a prevalence of DDs in emergency psychiatric admissions to be 34.9% in one sample.6 Macy compared acute care utilization rates among Massachusetts Medicaid patients diagnosed with DID, PTSD, major depressive disorder (MDD), panic disorder, and bipolar disorder.31 Patients with DID demonstrated the highest utilization rates of any diagnostic group and the most expensive hospitalizations at $2,300 per patient, compared to $300 or less for other diagnostic groups. In another sample that compared healthcare spending among patients with DDs, MDD, psychosis, or bipolar disorders, those with DDs demonstrated higher indices of healthcare spending, suicide, self-injury, emergency consultations, and psychotropic drug use.32 Langeland et al. conducted a systematic review of studies concerning the economic burden of DDs, which summarized the significant direct healthcare costs for psychiatric or medical emergency care, hospitalizations, community care, and medications.25 They found that appropriate diagnosis and access to specialty treatment for DDs significantly reduces costs (e.g., by 25% to 64%) by decreasing treatment length (e.g.: from 10 to 4 years), emergency care services, and hospitalizations. Myrick et al. demonstrated similar findings with significant reductions in both inpatient and outpatient costs when people with DDs were able to access treatment.33 Accurate diagnosis and treatment not only greatly reduces healthcare costs, but also offers life-altering, and potentially life-saving, implications for people with DDs.

ASSESSMENT AND TREATMENT Assessment

Assessing and diagnosing DDs can be a challenging feat, as symptoms are often trauma-related and shrouded in shame.

Moreover, healthcare professionals rarely receive any training on DDs and instead rely on film and media portrayals that are often inaccurate, fantasized, and dramatic, leading them to miss the far more common subtle presentations. Validated clinical interviews and measures can be helpful in accurately identifying and differentiating DDs from other psychiatric disorders or from feigning or malingering. Specifically, there are two semi-structured clinical interviews that can yield DD diagnoses and an Office Mental Status Exam for Dissociation for adults34 or children and adolescents.30 Numerous selfreport measures exist for dissociation, including one measure that has been researched in over 1,000 studies: the Dissociative Experiences Scale-II (DES-II).35 An adolescent version of this also exists, as well as Child Dissociative Checklist.36 Many clinicians assessing adults also use multiscale dissociation measures, performance-based tests, or non-dissociation specific broadband measures or malingering measures, for which normative data exists to differentiate true from simulated DID. Brand and Loewenstein offer a brief summary of the Loewenstein mental status exam for dissociation and useful screening or assessment measures.34

Treatment While some people have expressed concern that treating dissociation or DDs will exacerbate symptoms, research demonstrates the opposite: those patients who are able to access specialty treatment experience significant symptom reduction,37,38 decreased rates of self-harm and hospitalization,33,38 decreased rates of revictimization, decreased substance use,38 reduced inpatient and outpatient costs over time, reduced treatment length,25 and improved social, emotional, and occupational functioning.33,37,38 Without specialty treatment that targets dissociation, dissociative symptoms not only persist, but worsen.15 This is also true for dissociative children and adolescents, as untreated dissociation puts the aging child at risk for the development of more severe impairments in functioning over time due to worsening symptoms.30 Identifying and addressing trauma-related dissociation or DDs in childhood and adolescence, closer to the onset of symptoms, improves treatment outcomes and can prevent a lifetime of hardship and disability as well as the broader public health consequences discussed above. In short, specialty treatment for adults or children with DDs exists and works (see Figure 3).

Randomized controlled trials (RCTs) supporting many evidenced-based trauma treatment models, such as Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT), have unfortunately often excluded individuals with DDs. However, an RCT is currently being conducted to examine treatment outcomes of a manualized treatment for complex trauma and DDs. The Treatment of Patients with Dissociative Disorders (TOPDD) Studies are currently 81

Figure 3: Summary of Treatment Outcomes from Specialty Treatment for Dissociative Disorders

the largest body of research concerning the most effective interventions for DDs. The TOPDD Studies are comprised of naturalistic studies with DD experts and patients, efficacy studies of a web-based educational program for DD patients and their treatment providers, and expert surveys about DD treatment interventions.

Research and expert consensus suggest that the primary treatment for DDs is psychotherapy, with psychiatric medication as a potential helpful adjunctive treatment. Evidence-based guidelines exist to help clinicians facilitate effective specialty treatment for both children/adolescents and adults by the International Society for the Study of Trauma and Dissociation (ISSTD).39,40 Psychotherapy is typically conducted one to three times weekly over the course of several years for adults (M=6 years for DID).40 Children and adolescents may experience results more quickly. Treatments are often psychodynamic, but may integrate other modalities such as Cognitive Behavioral Therapy (CBT), Dialectical Behavior Therapy (DBT), hypnosis, Internal Family Systems (IFS), Eye-Movement Desensitization and Reprocessing (EMDR), and sensorimotor psychotherapy.40 All effective psychotherapy treatments for DDs utilize the tri-phasic trauma therapy approach as outlined by ISSTD (2011)40 and Brand et al.,38 including a prolonged period of focus on building a strong therapeutic alliance, establishing safety, stabilization, and symptom reduction (Phase I), followed by trauma processing and mourning (Phase II), and then integration and rehabilitation (Phase III).

CONCLUSION Dissociation is a human phenomenon experienced by all.

Trauma survivors experience higher rates of dissociation and may utilize it as an escape when there is no physical escape 82 Delaware Journal of Public Health - May 2022

from trauma. When dissociative symptoms become a pattern or entrenched, they can negatively impact many domains of functioning in a person’s life and warrant a DD diagnosis. DDs are far more prevalent than most clinicians recognize. In fact, they are more prevalent than numerous psychiatric disorders commonly encountered in clinical settings. Across inpatient and outpatient clinical samples, the prevalence of DDs is up to 46%.8 Despite their prevalence, clinicians typically receive no training on the assessment or treatment of DDs. As a result, people living DDs are often not believed, misunderstood, misdiagnosed, and undertreated for 5 to 12.4 years. When unable to access adequate diagnosis or treatment, the individual and public health implications are undeniable, with individuals experiencing increased functional impairment across domains, disability, health issues, risk of revictimization, self-injurious behaviors, suicidal ideation, frequent hospitalizations, and utilization of health and social services. To prevent these outcomes, it is imperative that clinicians are trained to assess, recognize, and treat dissociative symptom patterns that have historically been overlooked or disbelieved.

Validated screening instruments, that are available to the public at no cost, as well as formal assessment measures and clinical interviews are very helpful in early and accurate identification of DDs. Effective, evidence-based treatments for DDs also exist and can produce life-altering results, even after one year of treatment (e.g., significant reduction in SIBs, SI, hospitalizations, reduced treatment length). By training healthcare professionals on trauma-informed care as well as how to screen, assess, and treat trauma-related dissociation and DDs, we can not only substantially decrease economic and social burdens, but also spare these marginalized individuals further pain, suffering, and debilitation.

RESOURCES ◆ Treatment of Patients with Dissociative Disorders: topddstudy.com ◆ International Society for the Study of Trauma and Dissociation: isst-d.org ◆ International Society for Traumatic Stress Studies: istss.org ◆ National Alliance on Mental Illness—Dissociative Disorders: nami.org/Learn-More/Mental-HealthConditions/Dissociative-Disorders ◆ Trauma Disorders Program at Sheppard Pratt: sheppardpratt.org/care-finder/the-trauma-disordersprogram ◆ Harvard McLean Dissociative Disorders and Trauma Inpatient Program: https://www.mcleanhospital.org/ treatment/trauma-inpatient ◆ An Infinite Mind®: aninfinitemind.com

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The epidemiology of traumatic event exposure worldwide: results from the World Mental Health Survey Consortium. https://doi.org/10.1017/S0033291715001981 2. Kilpatrick, D. G., Resnick, H. S., Milanak, M. E., Miller, M. W., Keyes, K. M., & Friedman, M. J. (2013, October).

National estimates of exposure to traumatic events and PTSD prevalence using DSM-IV and DSM-5 criteria. Journal of Traumatic Stress, 26(5), 537–547. https://doi.org/10.1002/jts.21848 3. Centers for Disease Control and Prevention & Kaiser Permanente. (2016). The ACE study survey data [Unpublished Data]. Atlanta, Georgia: Centers for Disease Control and Prevention. https://www.cdc.gov/violenceprevention/aces/about.html 4. Franzke, I., Wabnitz, P., & Catani, C. (2015). Dissociation as a mediator of the relationship between childhood trauma and nonsuicidal self-injury in females: A path analytic approach. J Trauma Dissociation, 16(3), 286–302. https://doi.org/10.1080/15299732.2015.989646 5. Kratzer, L., Heinz, P., Pfitzer, F., Padberg, F., Jobst, A., & Schennach, R. (2018). Mindfulness and pathological dissociation fully mediate the association of childhood abuse and PTSD symptomatology. European Journal of Trauma & Dissociation, 2(1), 5–10. https://doi.org/10.1016/j.ejtd.2017.06.004 6. Sar, V. (2011). Epidemiology of dissociative disorders: An overview. Epidemiology Research International, 2011, 1–8. https://doi.org/10.1155/2011/404538 7. Diagnostic and statistical manual of mental disorders (2022).

(Fifth edition, text revision ed.). American Psychiatric Association Publishing.

8. Loewenstein, R. J. (2018, September). Dissociation debates: Everything you know is wrong. Dialogues in Clinical Neuroscience, 20(3), 229–242. https://doi.org/10.31887/DCNS.2018.20.3/rloewenstein

9. Stein, D. J., Koenen, K. C., Friedman, M. J., Hill, E., McLaughlin, K. A., Petukhova, M., . . . Kessler, R. C. (2013, February 15). Dissociation in posttraumatic stress disorder: Evidence from the world mental health surveys. Biological Psychiatry, 73(4), 302–312. https://doi.org/10.1016/j.biopsych.2012.08.022 10. Lotfinia, S., Soorgi, Z., Mertens, Y., & Daniels, J. (2020, September). Structural and functional brain alterations in psychiatric patients with dissociative experiences: A systematic review of magnetic resonance imaging studies.

Journal of Psychiatric Research, 128, 5–15. https://doi.org/10.1016/j.jpsychires.2020.05.006 11. Reinders, A. A., Willemsen, A. T., Vissia, E. M., Vos, H. P. J., den Boer, J. A., & Nijenhuis, E. R. S. (2016, June). The psychobiology of authentic and simulated dissociative personality states: The full monty. The Journal of Nervous and Mental Disease, 204(6), 445–457. https://doi.org/10.1097/NMD.0000000000000522 12. Brand, B. L. (2016). The necessity of clinical training in trauma and dissociation. Journal of Depression & Anxiety (Los Angeles, Calif.), 5(4). https://doi.org/10.4172/2167-1044.1000251 13. Leonard, D., Brann, S., & Tiller, J. (2005, October).

Dissociative disorders: Pathways to diagnosis, clinician attitudes and their impact. The Australian and New Zealand Journal of Psychiatry, 39(10), 940–946. https://doi.org/10.1080/j.1440-1614.2005.01700.x 14. Leonard, D., & Tiller, J. (2016, February). Dissociative identity disorder (DID) in clinical practice - what you don’t see may hurt you. Australas Psychiatry, 24(1), 39–41. https://doi.org/10.1177/1039856215604481 15. Nester, M. S., Hawkins, S. L., & Brand, B. L. (2022, February 17). Barriers to accessing and continuing mental health treatment among individuals with dissociative symptoms.

European Journal of Psychotraumatology, 13(1), 2031594. https://doi.org/10.1080/20008198.2022.2031594 16. Spiegel, D., Loewenstein, R. J., Lewis-Fernández, R., Sar, V., Simeon, D., Vermetten, E., . . . Dell, P. F. (2011, December 21).

Dissociative disorders in DSM-5. Depression and Anxiety, 28(12), E17–E45. https://doi.org/10.1002/da.20923 17. Mueller-Pfeiffer, C., Rufibach, K., Perron, N., Wyss, D., Kuenzler, C., Prezewowsky, C., . . . Rufer, M. (2012, December 30). Global functioning and disability in dissociative disorders.

Psychiatry Research, 200(2-3), 475–481. https://doi.org/10.1016/j.psychres.2012.04.028 18. Kendall-Tackett, K., & Klest, B. (2009). Causal mechanisms and multidirectional pathways between trauma, dissociation, and health. J Trauma Dissociation, 10(2), 129–134. https://doi.org/10.1080/15299730802624510 19. Dorahy, M. J., Corry, M., Shannon, M., Webb, K., McDermott, B., Ryan, M., & Dyer, K. F. W. (2013, May). Complex trauma and intimate relationships: The impact of shame, guilt and dissociation. Journal of Affective Disorders, 147(1-3), 72–79. https://doi.org/10.1016/j.jad.2012.10.010 83

20. Powers, A., Mekawi, Y., Fickenwirth, M., Nugent, N. R., Dixon, H. D., Minton, S., . . . Gillespie, C. F. (2021, October). Emotion dysregulation and dissociation contribute to decreased heart rate variability to an acute psychosocial stressor in traumaexposed Black women. Journal of Psychiatric Research, 142, 125–131. https://doi.org/10.1016/j.jpsychires.2021.07.032 21. Scioli-Salter, E. R., Johnides, B. D., Mitchell, K. S., Smith, B. N., Resick, P. A., & Rasmusson, A. M. (2016, September).

Depression and dissociation as predictors of physical health symptoms among female rape survivors with posttraumatic stress disorder. Psychol Trauma, 8(5), 585–591. https://doi.org/10.1037/tra0000135 22. Duckworth, M., Iezzi, T., Archibald, Y., Haertlein, P., & Klinck, A. (2000). Dissociation and posttraumatic stress symptoms in patients with chronic pain. International Journal of Rehabilitation and Health, 5(2), 129–139. https://doi.org/10.1023/A:1012958206465 23. Sawchuk, T., Buchhalter, J., & Senft, B. (2020, December).

Psychogenic non-epileptic seizures in children psychophysiology & dissociative characteristics. Psychiatry Research, 294, 113544. https://doi.org/10.1016/j.psychres.2020.113544 24. Keuroghlian, A. S., Kamen, C. S., Neri, E., Lee, S., Liu, R., & Gore-Felton, C. (2011, July). Trauma, dissociation, and antiretroviral adherence among persons living with HIV/ AIDS. Journal of Psychiatric Research, 45(7), 942–948. https://doi.org/10.1016/j.jpsychires.2011.05.003 25. Langeland, W., Jepsen, E. K. K., Brand, B. L., Kleven, L., Loewenstein, R. J., Putnam, F. W., . . . Heir, T. (2020, October).

The economic burden of dissociative disorders: A qualitative systematic review of empirical studies. Psychol Trauma, 12(7), 730–738. https://doi.org/10.1037/tra0000556 26. Zamir, O., Szepsenwol, O., Englund, M. M., & Simpson, J. A. (2018, May). The role of dissociation in revictimization across the lifespan: A 32-year prospective study. Child Abuse & Neglect, 79, 144–153. https://doi.org/10.1016/j.chiabu.2018.02.001 27. Zamir, O., & Lavee, Y. (2015). Emotional awareness and breaking the cycle of revictimization. Journal of Family Violence, 30(6), 675–684. https://doi.org/10.1007/s10896-015-9711-0 28. Foote, B., Smolin, Y., Neft, D. I., & Lipschitz, D. (2008, January). Dissociative disorders and suicidality in psychiatric outpatients. The Journal of Nervous and Mental Disease, 196(1), 29–36. https://doi.org/10.1097/NMD.0b013e31815fa4e7 29. Kessler, R. C., Warner, C. H., Ivany, C., Petukhova, M. V., Rose, S., Bromet, E. J., . . . Ursano, R. J., & the Army STARRS Collaborators. (2015, January). Predicting suicides after psychiatric hospitalization in US Army soldiers: The Army Study To Assess Risk and rEsilience in Servicemembers (Army STARRS). JAMA Psychiatry, 72(1), 49–57. https://doi.org/10.1001/jamapsychiatry.2014.1754

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30. Silberg, J. L. (2021). The Child Survivor. Taylor and Francis.

31. Macy, R. D. (2002). On the epidemiology of posttraumatic stress disorder: Period prevalence rates and acute service utilization rates among Massachusetts Medicaid program enrollees: 1993–1996. Available from Dissertations & Theses Europe Full Text: Social Sciences https://search.proquest.com/docview/276318300 32. Gonzalez Vazquez, A. I., Seijo Ameneiros, N., Díaz Del Valle, J. C., Lopez Fernandez, E., & Santed Germán, M. A. (2020, December). Revisiting the concept of severe mental illness: Severity indicators and healthcare spending in psychotic, depressive and dissociative disorders. Journal of Mental Health (Abingdon, England), 29(6), 670–676. https://doi.org/10.1080/09638237.2017.1340615 33. Myrick, A. C., Webermann, A. R., Langeland, W., Putnam, F. W., & Brand, B. L. (2017, September 19). Treatment of dissociative disorders and reported changes in inpatient and outpatient cost estimates. European Journal of Psychotraumatology, 8(1), 1375829–11. https://doi.org/10.1080/20008198.2017.1375829 34. Brand, B., & Loewenstein, R. J. (2010). Dissociative disorders: An overview of assessment, phenomenology, and treatment.

The Psychiatric Times, 27(10), 62-69.

35. Bernstein, E. M. & Putnam, F. W. (1986). Development, reliability, and validity of a dissociation scale. The Journal of Nervous and Mental Disease, 174(Dec 86), 727-735.

36. Putnam, F. W., Helmers, K., & Trickett, P. K. (1993, NovemberDecember). Development, reliability, and validity of a child dissociation scale. Child Abuse & Neglect, 17(6), 731–741. https://doi.org/10.1016/S0145-2134(08)80004-X 37. Brand, B. L., Classen, C. C., McNary, S. W., & Zaveri, P. (2009, September). A review of dissociative disorders treatment studies. The Journal of Nervous and Mental Disease, 197(9), 646–654. https://doi.org/10.1097/NMD.0b013e3181b3afaa 38. Brand, B., & Loewenstein, R. J. (2013). Does Phasic Trauma Treatment Make Patients With Dissociative Identity Disorder Treatment More Dissociative? Informa UK Limited.

39. International Society for the Study of Dissociation. (2004).

Guidelines for the evaluation and treatment of dissociative symptoms in children and adolescents. Journal of Trauma & Dissociation, 5(3), 119–150. https://doi.org/10.1300/J229v05n03_09 40. International Society for the Study of Trauma and Dissociation. (2011). Guidelines for treating dissociative identity disorder in adults, third revision. J Trauma Dissociation, 12(2), 115–187. https://doi.org/10.1080/15299732.2011.537247

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Trauma: A Gateway to Substance Use Disorder Julia Lawes, M.S. Executive Director, Drug Overdose Fatality Review Commission, Delaware Department of Justice

Substance Use Disorder (SUD) has been proven, through years of research, to be tightly connected to experiences of trauma. Through our specific research and data here with the Delaware Drug Overdose Fatality Review Commission (DOFRC), we have seen that at least 37.4% of decedents experienced at least one traumatic event. This number only considers those that self-reported; it is more than likely an underrepresentation, since medical examinations and police intervention do not typically assess specifically for trauma. Alarmingly, of that 37.4% self-reported trauma, only 8.5% reportedly received any counseling.

Given the number of decedents with a history of trauma and their limited exposure to counseling services, we recognize the need to better address the lack of counseling services received. We recommended in our 2021 Annual Report that treatment providers should have better access to trauma specific training and education to expand access to trauma specific counseling services. Further analysis of practitioners’ and treatment providers’ current approach to trauma-affected SUD patients can help inform the implementation of trauma-specific approaches.

Trauma comes in many forms and is often individual-specific, but a common thread is that it appears to be one of the most prevalent gateways to SUD. Wayne Munchel, for the Children’s Mental Health Network, writes that, “People who experience four or more ACEs (Adverse Childhood Experiences) are 500% more likely to abuse alcohol. People who report five ACEs or more are seven to ten times more likely to report illicit drug abuse. A jaw-dropping data point indicates that individuals who survive six or more ACEs are 46 times more likely to be IV drug abusers than people who report no ACEs.”1 Witnessing an overdose is traumatic. We found that 15% of decedents in the DOFRC analysis had previously witnessed an overdose. Of those, none reported subsequent therapeutic intervention. In 2020, 447 fatal overdoses occurred; that number rose to 515 in 2021 for 962 fatal overdoses in two years.

That’s 962 specific instances of directly-inflicted trauma.

In our review of deaths from 2019, we found that 25.7% of decedents were discovered by their significant others, 19.3% by parents, and 11% by friends. These findings highlight that those closest to the deceased are often the ones who are also emotionally attached to them, indicating that they will experience significant grief. As Fleury-Steiner and Stout have noted, individuals facing this trauma in Delaware often do not have access to—or do not know of—resources for navigating their grief, and experience symptoms of Complicated Grief Disorder at higher levels than those who connect to help seeking resources.2 Providing these individuals with counseling, peer support, and support group resources at the time of death would assist in mitigating some of the harms experienced from losing a loved one to an overdose.

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Another traumatic event is sexual assault. A University of North Texas study found that 85.12% of a sample population experienced at least one traumatic event.

The study also found significant gender differences in that more women reported experiencing sexual abuse, and more men reported witnessing violence: Sexual assault history is associated with higher risk of problem drinking and drug use in women, yet little is known about mechanisms linking trauma histories in general to women’s drinking or drug use problems. This study examined how various types of trauma, substance use coping, and PTSD relate to past-year problem drinking and drug use in women who experienced sexual assault.

Data from a large, diverse sample of women who had experienced adult sexual assault were analyzed with structural equation modeling to test a theoretical model of the relationship between trauma types, substance use coping, PTSD symptoms, and past-year drinking and drug use. Results show that PTSD symptoms fully mediated the association between noninterpersonal trauma and the use of substances to cope. However, the association between both interpersonal trauma and child sexual abuse severity on substance use to cope was only partially mediated by PTSD symptoms. In turn, use of substances to cope fully mediated the relationship between PTSD and problem drug use as well as partially mediated the effect of PTSD on problem drinking. These results suggest that different trauma types and substance use coping may be important risk factors distinguishing sexually assaulted women who develop PTSD and problematic substance use from those who do not. Identifying women’s histories of different traumas may help to identify those at greater risk for substance use problems.3 Being unhoused or living in unstable housing can be traumatic. When something that most of the population is able to take for granted like housing is absent, it can be traumatic for that individual that is unhoused or living in unstable housing. DOFRC identified almost 40% of the decedents in our sample as unhoused or unstably housed. Our findings highlight significant differences between treatment history for those with stable housing compared to those without.

Notably, decedents with unstable housing were more likely to have sought treatment: 42.9% of individuals who had previously sought treatment had stable housing, compared to 57.1% of individuals who did not. A further evaluation DOI: 10.32481/djph.2022.05.011

highlighted significant differences in what type of treatment individuals with unstable housing accessed. Individuals with unstable housing were significantly more likely to attend outpatient programs, inpatient programs, counseling services, detoxification centers, and sober living programs. Prior research has noted the direct links between unstable housing and SUD, signifying two approaches to helping this unique population: Housing First (HF) models and Treatment First (TF) models. HF models focus on providing unstably housed individuals with safe and secure housing first and foremost, without tying residency to abstinence requirements, while TF models only provide individuals with housing if they maintain total abstinence and meet certain program requirements.

Research also makes clear to us that unaddressed and untreated trauma can spiderweb out from those traumatized into relationships with family, friends, children, colleagues, and the community as whole. Ray Flannery, Jr., PhD, Associate Clinical Professor of Psychology at Harvard Medical School speaks to this directly. He states that, “The victim may experience disruptions in the domains of reasonable mastery of the environment, caring attachments to others, and a sense of meaningful purpose in life as well as the symptoms associated with traumatic events, especially hypervigilance, exaggerated startle response, intrusive memories, and a desire to withdraw from routine activities.”4 While we do not have specific data around the number of non-fatal overdoses occurring in the communities, as some go unreported and without medical intervention, there is potential that it continues to have a ripple effect among hundreds of families annually.

Many individuals that experience trauma turn to drugs and alcohol to self-medicate. Many individuals that experience trauma are not equipped to process the trauma, nor do they know where to receive the help that they need. This is clear. It is on us now, to ensure we treat the individual specifically, rather than just their addiction.

Ms. Laws can be contacted at Julia.lawes@delaware.gov

REFERENCES 1. Munchel, W. (2017, Jul 9). Trauma is the gateway drug – an ACE’S informed approach to substance abuse treatment.

Children’s Mental Health Network. https://www.cmhnetwork.org/news/trauma-is-the-gateway-drugan-aces-informed-approach-to-substance-abuse-treatment/ 2. Fleury-Steiner, B., & Stout, J. (2019, Dec 17). What losing a loved one to an overdose says about the opioid epidemic in Delaware. The News Journal.

3. Ullman, S. E., Relyea, M., Peter-Hagene, L., & Vasquez, A. L. (2013, June). Trauma histories, substance use coping, PTSD, and problem substance use among sexual assault victims.

Addictive Behaviors, 38(6), 2219–2223. https://doi.org/10.1016/j.addbeh.2013.01.027 4. Flannery, R. B., Jr. (2001, July-August). The employee victim of violence: Recognizing the impact of untreated psychological trauma. American Journal of Alzheimer’s Disease and Other Dementias, 16(4), 230–233. https://doi.org/10.1177/153331750101600406

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A Call to Action for Delaware: Why Recruiting and Sustaining a Culturally and Linguistically Diverse Behavioral Health Workforce is Integral to Trauma-Sensitive Care Kathleen Seipel, L.C.S.W. Deputy Director, Amanecer Counseling and Resource Center

AMANECER’S “WHY” When Sister Theresa Elitz, OSF, LPCMH became a Licensed Bilingual Counselor, she had already worked for three decades as a nurse in Latin America. As a bilingual health care worker serving vulnerable patients with few resources, Sister Theresa was deeply acquainted with the intersections of poverty, discrimination, abuse, lack of access to care, and trauma rooted in oppression that too often had been passed from generation to generation for hundreds of years.

As a newly licensed bilingual counselor in Wilmington in 2003, Sister Theresa could count on one hand the number of other licensed bilingual clinicians available to serve the behavioral health needs of the rapidly growing Latin@ population in the State of Delaware and surrounding areas.

With this awareness, Sister Theresa approached the Franciscan Friars at St. Paul’s Parish and asked to use a room in the church rectory to offer counseling sessions to community members in need. Sister Theresa’s counseling education, language skills, and inspiration to serve, combined with a room at St. Paul’s rectory, and a shoebox for free-will donations provided a healing space for the first of what eventually became thousands of individuals and families who have been able to rebuild their lives with the support of clinical therapy after traumatic losses and behavioral health challenges.

In the year 2000, the Latin@ population in the state of Delaware was estimated to be 37,300 (4.9% of the total state population).1 In just over twenty years, the Latin@ population has grown to an estimated 96,000 (9.7% of the total state population).1 Multiple generations of families with roots in Puerto Rico, Mexico, Guatemala, the Dominican Republic, and other parts of Latin America now call Delaware home. A tapestry of grass-roots community groups, faith communities, nonprofits and private businesses have also grown from Delaware’s Latin@ community. Federally Qualified Health Centers (FQHCs), such as Westside Family Health and La Red, were established and grew to respond to the health care needs of the Latin@ population. Yet, in 2022, there are still enormous gaps in the capacity of institutions to respond to the needs of Delaware’s Latin@s. Although there are more Spanish-speaking behavioral health professionals in Delaware now than there were in 2003 when Sister Theresa started seeing clients in the St. Paul’s rectory (our most recent estimate in April 2022 puts this number at approximately 40), the state still has a long way to go to adequately serve its population in a culturally humble, linguistically appropriate, trauma-sensitive manner.

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The need to recruit and retain a well-trained, well-supported bilingual behavioral health workforce that is connected to and trusted by the community it serves is key to behavioral health access for Latin@s in Delaware, and is the reason why Amanecer Counseling and Resource Center has prioritized behavioral health workforce development as an essential program area in its mission “to see Latinos health grow and thrive, by providing behavioral health and resources that empower individuals and families.”

DELAWARE’S LATIN@ POPULATION AND SOCIAL DETERMINANTS OF HEALTH The health of Delaware’s Latin@ population is influenced by an intersection of multiple social determinants of health.

The population is subject to a disproportionately high degree of marginalization, which simultaneously increases stressors and decreases access to services. Latin@s in Delaware have been vulnerable to multiple adverse health outcomes due to many factors, including multi-generational family histories of complex trauma, poverty, exposure to community violence, and limited access to public benefits due to immigration and language accessibility issues.

Multigenerational Trauma

Many of those seeking services at Amanecer have survived crimes that have never been reported. Some have come to the United States as refugees fleeing war, community violence, torture, abuse, and deprivation of fundamental resources needed for survival. People we serve have often experienced multiple traumatic events during their lives, and have grown up in families and communities with multigenerational exposures to trauma. Many have “normalized” these experiences as part of their expected life course.

Poverty

Latin@s in Delaware experience higher rates of poverty than nonLatin@s. They live in communities with a higher concentration of poverty (22% with median income of $28,000 according to the 2019 US Census Bureau American Community Survey).2 In the Westside Wilmington “Hilltop” neighborhood in which Amanecer’s office is located, 50% of the population is Latin@.2 In this census tract, 64% of people live at or below 50-75% of the median family income (MFI) and 31% live at or below 30-50% of the area median income (AMI) poverty level.2

Exposure to Violence

Latin@s in Delaware are exposed to higher rates of violent crime. Gun violence has continued to rise in the state of Delaware and in the City of Wilmington. According to data DOI: 10.32481/djph.2022.05.012

gathered by the Delaware News Journal, there were 293 victims of shootings and 81 fatalities in the state of Delaware in 2021, almost double the number of victims from 2019 (189 shooting victims, 43 fatalities). Most of these shootings have taken place in Wilmington (152 victims, 39 fatalities), most in neighborhoods with high concentrations of poverty.3

Inaccessible Services

US political rhetoric, especially over the past few years, has often led to pervasive fear among Latin@ immigrants that impacts their ability to access government-sponsored supports. Lowincome immigrants without citizenship are not able to access public benefits for which they would otherwise qualify and are less likely to seek protection from law enforcement and other government authorities for fear they could be detained or deported. When immigration policy changes target those with a history of accessing public benefits, such as the “public charge” rule promoted by the Trump Administration, are announced, there is a chilling effect. This already vulnerable, underserved, and underinsured population is now less likely to access available social services due to fear that a record of applying for public benefits their family is eligible to receive could negatively impact a petition for immigration status.4 Another factor that limits accessibility to behavioral health treatment is access to health insurance. The 2018 Delaware Behavioral Risk Factor Survey (BRFS) revealed that – even with the expanded coverage of the Affordable Care Act (ACA) – 46.5 percent of Latin@ residents between the ages of 18 and 64 did not have any form of health care coverage or health insurance.5

THE CONNECTION BETWEEN LANGUAGE ACCESS AND TRAUMA-SENSITIVE CARE While all the social determinants mentioned above play a role in worsening health outcomes and limiting access to care for Latin@s in Delaware, Amanecer’s workforce development program focuses on addressing access to linguistically appropriate and culturally humble behavioral health care. What does language accessibility have to do with trauma-sensitive care? When individuals call Amanecer seeking information about services, it is often the first time they have spoken about the experiences that happened to them and the feelings they have about it.

Establishing a sense of trust is vital throughout the therapeutic alliance. A National Academy of State Health Policy article from December 2021 referenced a study that linked ethnic matches between clients and clinicians with improved working alliances in treatment with individuals with severe mental illness.6 In 2014, the Substance Abuse and Mental Health Services Administration (SAMHSA) named six key principles of a Trauma-Informed Approach to behavioral health care7: 1.

2.

3.

4.

5.

6.

Safety Trustworthiness and Transparency Peer Support Collaboration and Mutuality Empowerment, Voice, and Choice Cultural, Historical, and Gender Issues

The quality of communication between clinician and client directly impacts the ability of behavioral health providers to implement trauma-informed care in each of the above areas. However, linguistic competency alone is not enough

to establish a sense of safety and trustworthiness. This is where the importance of cultural humility comes in.

For a client to rediscover their voice and to heal, it must be established in interactions with professionals that the client is the expert in their own life – in what has happened to them, what has worked to help them, what has retraumatized them, what they believe may help them to heal.

Advocacy and support from trauma-informed, culturally humble and linguistically responsive professionals establishes the safety and trust that is necessary for survivors of trauma to build a greater sense of safety and stability for themselves and their families.

COVID-19 IMPACT The disproportionate impact of negative health outcomes on people of color during the COVID-19 pandemic has been welldocumented. National data from the Centers for Disease Control and Prevention (CDC) shows that the percentage of deaths of Hispanic/Latino, non-Hispanic Black, and non-Hispanic American Indian or Alaska Native people has consistently been higher than the proportion of these populations in the overall US population.8 In Delaware, the portion of Latin@ residents testing positive for COVID was higher than non-Latin@s almost every day during the early part of the pandemic.9 The CDC and others continue to gather data about the disparities in COVID-19 outcomes, and the reasons are clearly complex, overlapping, and linked to social determinants of health. Infection rates early in the pandemic were higher among those who lived in households with multiple generations of family members present and living under the same roof. Infection and serious illness rates were also higher among those who worked in employment, such as meat processing plants, which continued to operate in person without options for adequate distancing or remote work.9 Significantly, not only was race or ethnicity shown to be a factor in COVID-19 infection and mortality, but language proficiency was also a factor. A story from WBUR public radio in April 2021 reported that Brigham and Women’s Hospital in Boston had tracked that non-English speakers had a 35% greater chance of death than those with English proficiency early in the pandemic. Early data showed that, by attending to the social determinant of language accessibility in health care, the hospital was able to improve outcomes among those with limited English proficiency, and learn important lessons about the importance of communication as a factor in the quality of care.10 Another critical issue that has been laid bare throughout the pandemic is the effect of Secondary Traumatic Stress on the health care workforce. As more stress compounded on fewer providers, people began leaving health care jobs. This stress has taken a significant toll on bilingual health care workers. A Spanishspeaking client who worked as a nursing assistant in a longterm care facility throughout the early months of the pandemic witnessed multiple deaths at work, while at the same time feeling unable to talk with supervisors or other co-workers about the toll this experience was having on her because none of them spoke Spanish. The Health Resources and Services Administration (HRSA) Bureau of Health Workforce analysis highlighted how the combined issues of shortages in the behavioral health workforce and poor mental health and substance abuse indicators during pandemic increased the urgency for improved efforts to recruit and retain a diverse behavioral health workforce.6 89

EFFORTS TO IMPROVE BEHAVIORAL HEALTH WORKFORCE DIVERSITY ACROSS THE COUNTRY The HRSA analysis also showed that 83.5% of psychologists, 64.6% of counselors, and 60.6% of social workers are white, and the majority of health care providers who are people of color are employed in non-licensed positions with limited opportunities for career advancement.6 As the recognition of the link between accessible health care and diversity of the professional health care workforce has grown, so too have projects to address the need to recruit and retain professionals of color. Although there is a lot of research that still needs to be done in this area, learnings from these projects have highlighted key components of successful recruitment and retention efforts. In a July 2015 Report from the University of Washington Center for Health Workforce Studies, the following components were listed as promising strategies to recruit and retain racially and ethnically diverse graduate level students11: • Targeting recruitment with strategic outreach to underrepresented populations; • Holistic admissions processes that access an applicant’s unique personal experiences alongside traditional measures of academic achievement; • Financial assistance – strategies that reduce financial barriers in education and training; • Mentoring – providing social support and networking with other supportive professionals in the field; and • Career development opportunities including intensive field training and partnerships among institutions with students at varied levels of training.

An article published in June 2020 similarly stated that best practices to improve workforce diversity in health professions are: Academic Support, Financial Support, Social Support / Mentoring, and Intensive Training in a community-based curriculum.12

CALL TO ACTION Addressing the behavioral health needs of Delaware’s Latin@ population will require the collective involvement of community members, government leaders, and health care practitioners from all disciplines. In order to make behavioral health in Delaware more trauma-sensitive, culturally humble, and linguistically responsive, we need to consider the impact of social determinants of health on disparities of care and prioritize interdisciplinary collaboration, cultural and intellectual humility, and competency building in crosscultural communication and trauma-informed care.

Amanecer is part of an innovative collaboration with Nemours Behavioral Health, Delaware State University, and Jewish Family Services of Delaware to recruit, retain, and support more behavioral health clinicians of color through graduate education to licensure and beyond. The unifying factor that drew the leaders of these organizations together is a sense of urgency about building community-based behavioral health service accessibility. The consortium has considered efforts to advance legislative advocacy, training, and mentorship with the goal of recruiting, retaining, and supporting culturally humble, linguistically responsive, trauma-informed health care workers that are connected to and trusted by the community they serve throughout their careers.

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We invite you to be a part of this conversation. Are you a leader of an organization that educates clinical behavioral health professionals? Are you a leader of an organization that employs clinical behavioral health professionals? Are you a community leader in Delaware that recognizes the need to make culturally responsive, trauma-sensitive behavioral health care more accessible in your community? Are you a Spanish-speaking behavioral health professional (from licensed practitioners to undergraduate students and everyone in between) in Delaware? Please reach out to me at Kathleen@amanecerde.org

REFERENCES 1. US Census Bureau. (n.d.). Quick facts: Delaware. https://www.census.gov/quickfacts/DE 2. US Census Bureau. (n.d.). American Community Survey. https://www.census.gov/programs-surveys/acs 3. Delaware Online. (n.d.). Gun violence database. https://www.delawareonline.com/in-depth/news/2021/08/16/ delaware-gun-violence-database/5518513001/ 4. Friedman, A. S., & Venkataramani, A. S. (2021, July). Chilling effects: US immigration enforcement and health care seeking among Hispanic adults. Health Affairs (Project Hope), 40(7), 1056–1065. https://doi.org/10.1377/hlthaff.2020.02356 5. Delaware Division of Public Health. (n.d.). Prevalence of health care coverage among Delaware adults, 2018. https://www.dhss.delaware.gov/dph/dpc/healthinsurance2017.html 6. Antezzo, M., Manz, J., Mette, E., & Purington, K. (2021, Dec 13). State strategies to increase diversity in the behavioral health workforce. National Academy for State Health Policy. https://www.nashp.org/state-strategiesto-increase-diversity-in-the-behavioral-health-workforce/ 7. Substance Abuse and Mental Health Services Administration.

(2014, Jul). SAMHSA’s concept of trauma and guidance for a trauma-informed approach. https://ncsacw.acf.hhs.gov/userfiles/files/SAMHSA_Trauma.pdf 8. Centers for Disease Control and Prevention. (2020, Dec 10).

Disparities in deaths from COVID-19. https://www.cdc.gov/coronavirus/2019-ncov/community/ health-equity/racial-ethnic-disparities/disparities-deaths.html 9. My Healthy Community. (n.d.). Flipping the stats: a COVID-19 success story. https://myhealthycommunity.dhss.delaware.gov/stories/vaccination 10. Bebinger, M. (2021, Apr 23). The pandemic imperiled non-English speakers in a hospital. https://www. npr.org/sections/health-shots/2021/04/23/989928262/thepandemic-imperiled-non-english-speakers-in-a-hospital 11. Snyder, C. R., Stover, B., Skillman, S. M., & Frogner, B. K. (2015, Jul). Facilitating racial and ethnic diversity in the health workforce. University of Washington School of Medicine. https://depts.washington.edu/uwrhrc/ uploads/FINALREPORT_Facilitating%20Diversity%20 in%20the%20Health%20Workforce_7.8.2015.pdf 12. Wilbur, K., Snyder, C., Essary, A. C., Reddy, S., Will, K. K., & Saxon, M. (2020, June). Developing workforce diversity in the health professions: A social justice perspective. Health Profession Education, 6(2), 222– 229. https://doi.org/10.1016/j.hpe.2020.01.002

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A Trauma-Informed Life Christopher Moore Director, Community Education and Engagement, Office of Health Equity, ChristianaCare; Faculty, English Department, Delaware Technical and Community College Catherine Dukes, Ph.D., L.C.S.W. Private Practice Clinical Therapist

INTRODUCTION Pandemic. War. Inflation. Disparities. Inequities.

Social media. Bipartisan rancor. It’s likely one of the aforementioned items caused you to have a reaction. It’s possible it even activated an unpleasant response; and rest assured, you’re not alone. The triggers in the world around us are ever-present. For many individuals, they run in tandem with another list – of negative life experiences. When triggered, the response may be the same, or worse; and, as a society, we don’t do ourselves any favors or give ourselves much grace. We don’t always score high marks for being sensitive, empathetic, or kind. Of course, we say we do and act the opposite. Simply put, we don’t always walk the walk.

But what if the same practices we used to treat patients translated more intentionally in our personal lives. This type of approach would lead self-compassion, creating safety and connection. We are trained to provide this type of care in clinical, academic and community settings. What would it take to have a trauma-informed life?

TRAUMA IS PERVASIVE While most people have experienced some type of trauma in their lives, everyone has been through difficult events, experienced hurt and suffering, and survived losses. While many of us have experienced what is commonly described as “little t” trauma, most people have had at least one “big T” trauma. In any case, due to the statistics telling us that trauma is normative (meaning most people have experienced it) and that you won’t know who specifically has been through “Trauma,” it stands to reason that we commit to treating ourselves, our loved ones, our staff, our patients, and our community members with trauma-informed care.

TRAUMA-INFORMED PRACTICES What might it look like if we took some key tenets of traumainformed practices and intentionally infused them into our daily lives, building a more nurturing way of life? First, we’d start with safety: physical and psychological safety is imperative. This includes safety for yourself, and for others.

Could you build that into your life? Look at your work, school, home, community and relationships and approach with curiosity to ask yourself, is there anything I need to shift toward more safety?

Second, we’d look at trustworthiness: are you showing up and present in your life? Are you giving authenticity, with kindness, and expecting and advocating for the same? We believe these practices and values lead to trust and the third tenet: peer/social support and mutuality. What is the quality of your relationships? The should be far less transactional, and instead, rooted in respect, compassion and mutual 92 Delaware Journal of Public Health - May 2022

empowerment. The strength in these connections should support the safety of it, and the trusting quality it provides.

It’s also worth considering the powerful effects and reverberations of intersectionality and how we are impacted by racial, cultural, gender, disability, and historical issues; can we give ourselves grace? Expand our communities of support? Balance social justice work with nurturing relationships and experiences? These concepts are critical to a trauma-informed life.

THE TRAUMA-INFORMED LIFE So, what would our world look like if we employed traumainformed practices outside our working hours? What if this became standard operating procedures at home, in the express line at the market, or dealing with strangers in the comment section of Facebook? What if we all approached life the way we approached the patients, clients and individuals we serve? It wouldn’t even be that much of a stretch. We could create safe spaces for people to show up and be themselves. The safety of that space would likely help build trust, and lead to more transparent relationships.

We could collaborate in ways which feel rooted in love and respect, and free ourselves from the transactional nature of our society. We could intentionally empower others to use their voice and have the freedom and authority to make choices of how they want to live and who they want to be. We would do this with a rich respect for historical context, especially for those who have been systemically underrepresented, marginalized and oppressed. We would also give ourselves grace, with room to fail, learn, and grow.

The spirit of this might even lead to a robust movement of integrated self-care – the yield of which might just be the panacea our world needs right at this very moment.

We know it’s a long shot. But we write this coming from places where professional learning has impacted personal growth in each of our lives. And we know we are not alone.

We also know it’s not exactly ground-breaking. But look around. The world needs a reminder and we, the trained, must stand up and do what’s right by practicing what we preach. Don’t you think it’s time?

TL;DR 1. Most people have trauma; everyone has had significant difficult experiences.

2. The core concepts of trauma-informed practices go beyond professional practices.

3. Living a trauma-informed life leads to self-compassion, creating safety and connection.

Mr. Moore can be contacted at chmoore@christianacare.org.

DOI: 10.32481/djph.2022.05.013

THE POWER TO SAVE A LIFE With Narcan, you can turn an opioid overdose into a chance at recovery. Get it, learn how to use it, and always keep it close.

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SPOTLIGHT

Intervening with Opioid-Exposed Newborns: Modifying an Evidence-Based Parenting Intervention

Christiana Martin, M.A. Doctoral Candidate, Clinical Psychology, University of Delaware Hung-Wei Bernie Chen, M.A. University of Delaware

Mary Dozier, Ph.D. Unidel Amy Elizabeth du Pont Chair in Child Development, University of Delaware

ABSTRACT Background: Prenatal opioid exposure predisposes infants to adverse development of regulatory systems and jeopardizes their long-term health outcomes. While sensitive caregiving promotes healthy development of emotional and physiological regulation and may remediate risks associated with prenatal opioid exposure, mothers with opioid use disorder often experience unique challenges that make providing sensitive care difficult.

Rationale: Empirically tested early interventions, such as the Attachment and Biobehavioral Catch-up (ABC) intervention, can positively impact children’s development following adversity through promoting sensitive caregiving. ABC intervention targets correspond to those parenting behaviors that may be challenging for mothers with opioid use disorder (i.e., nurturing infants who may be difficult to soothe, responding sensitively to infants by following the child’s lead with delight, and avoiding intrusive/frightening behavior), and have positive impacts on child development and regulation. However, given the unique challenges for infants and mothers impacted by opioid use, some adaptations may strategically address those vulnerabilities and thereby maximize the potential benefits for this population. Methods: The present paper describes modifications made to the ABC intervention for use with pregnant mothers in treatment for opioid use disorder. This modified intervention is currently being examined via a large scale randomized clinical trial (RCT) at the University of Delaware, and a case study is presented here to highlight considerations for working with mothers and infants impacted by opioid use and to exemplify ways that modified ABC addresses the needs of this population.

THE NEED FOR SENSITIVE PARENTING From an evolutionary standpoint, humans are similar to other precocious animals, which are dependent on the parent’s help to regulate physiology, emotion, and behavior.1 However, humans have an elevated level and length of dependency on the caregiver’s input due to a protracted period of brain development,2 with evidence showing the most rapid growth occurring within the first few years of life.3 These earliest years, when infants and young children rely most heavily on the support and protection of their parents, are thereby foundational for their subsequent developmental trajectory.1 Parents are essential sources of children’s regulation for a myriad of processes, and the quality of caregiving experiences inform development of these systems. Sensitive and responsive caregiving, involving accurate interpretation of and prompt responsiveness to distress and non-distress, confers numerous advantages, including fostering development of later regulatory capacities.4 However, when parents fail to meet the needs of an infant (e.g., deprivation) or become a source of dysregulation (e.g., abuse), children are tasked with developing regulatory capacities on their own, with many children who experience early caregiving adversity showing negative impacts even as they mature into late adolescence and adulthood.5 Fortunately, children who experience these and other forms of early trauma demonstrate plasticity and have the capacity for resilience and recovery.6 Children who receive 94 Delaware Journal of Public Health - May 2022

early interventions that increase caregiving quality, or those who have exposure to positive life experiences, can develop efficient regulatory capacities despite early adversity.7 Indeed, decades of research in caring for vulnerable infants sheds light on the power of sensitive parenting to buffer the effects of adversity.

CHALLENGES TO SENSITIVE PARENTING Parents who experience significant hardships (e.g., economic disadvantage, traumatic stressors, untreated mental health problems, lack of social support) and prior adverse caregiving experiences are especially at risk for providing non-optimal caregiving experiences to their children,8 even though their children are especially in need of sensitive caregiving. They may display more frequent intrusive caregiving, with behaviors that are adult-centered and ignore child cues, behaviors that are overstimulating (e.g., vigorous tickling, jarringly rough handling of the child) or behaviors that are frightening to the child, all of which are inherently dysregulating to children.9 The exposure to non-optimal caregiving experiences hinders children’s development of regulatory capacities and often leads children to behave in avoidant (i.e., rejecting) or resistant (i.e., fussy and irritable) ways with their parents, resulting in parents’ beliefs that the child does not need them for support under either distressing or non-distressing circumstances.10 This further contributes to insensitive and unresponsive caregiving experiences.

DOI: Doi: 10.32481/djph.2022.05.014

THE UNIQUE CHALLENGE OF MATERNAL OPIOID USE Young children can face numerous forms of early adversity, but the recent rise in opioid use and dependence has resulted in an alarming increase in the number of children impacted by maternal opioid use. In Delaware, opioids were involved in 88% of overdose deaths in 2018,11 above the national average of 69%, while the incidence of Neonatal Abstinence Syndrome (NAS) was 23.2 per 1,000 live births, above the national rate of 6.8 per 1,000 births.12 Despite the well-established nature of the opioid epidemic, illicit opioids and controlled prescription drugs continue to be a serious concern, and provisional overdose data for 2020 suggests increases both in Delaware and nationally.13 The impacts of opioid use on children occur both through prenatal exposure of infants to opioids and through the effects of opioid use and addiction on the mother’s ability to parent.

Neonatal abstinence syndrome (NAS), which occurs when infants are exposed to opioids that cross the placental barrier during pregnancy, causes direct neurological impacts but also can disrupt caregiving through symptoms (e.g., high-pitched cry, irritability, difficulty sleeping and soothing)14 which may make it more difficult for mothers to read their infants’ cues and persist in providing nurturance when infants are distressed. Medication assisted treatment (MAT) is the goldstandard treatment option for pregnant women with opioid use disorder. This means that even infants whose mothers are stable and in treatment during their pregnancy are exposed to maintenance drugs such as methadone and buprenorphine, which can result in NAS. At the same time, mothers with opioid dependency have a number of contextual stressors and psychosocial factors in addition to physiological factors that can negatively impact their ability to provide high quality care to their infants.15 In Delaware, approximately one third of serious or fatal child abuse and neglect cases between 20142018 involved infants who had prenatal substance exposure, with 85% of cases occurring before the child was four months of age, indicating particularly high risk for very young children.16 Additionally, trauma disproportionally affects mothers with opioid use disorder, with trauma exposure and particularly interpersonal trauma found at high rates among those with opioid use disorder.17 These complex, bi-directional factors between mothers and their infants put infants at risk for a number of negative developmental outcomes.18

ENHANCING SENSITIVE PARENTING While there are several preventive programs available to enhance sensitive parenting among vulnerable infants, the Attachment and Biobehavioral Catch-up (ABC) intervention is unique in terms of its model parsimony and the large body of empirical research showing efficacy and effectiveness.19 ABC is a brief (10-session, 1-hour per week), strength-based, homevisiting parenting intervention designed to promote sensitive caregiving in three main behavioral targets: (a) nurturing the child when he or she is distressed, (b) responding sensitively when the child is not distressed (i.e., following his or her lead with delight), and (c) avoiding intrusive or frightening behavior. These intervention targets were identified based on empirical findings on the needs of children experiencing

adversity.20 Parent coaches trained in ABC conduct the sessions at the target family’s home, therefore increasing generalizability though practicing intervention targets in their natural environment.

ABC has been empirically tested in several randomized clinical trials (RCTs) across different vulnerable populations, including parent-child dyads with a history of child protective services (CPS) involvement,21 children living in poverty,22 children in Early Head Start,23 foster children,24 and internationally adopted children.25 Parents who received ABC have demonstrated greater parental sensitivity than the control group in both high-risk (e.g., low resources, CPS-involved)7 and low-risk (e.g., foster and adoptive parents with high resources)7,26 populations. Importantly, the improvement in parental sensitivity has been pinpointed as the mechanism of the downstream positive effects for children who receive the intervention. Specifically, following the intervention, infants who received ABC showed more normative diurnal cortisol production than the control group, with effects sustained at three-years post-intervention and in middle childhood (ages 8 to 10).7 Behaviorally, at both post-intervention and middle childhood follow-ups, children who received ABC were found to show better inhibitory control than children who received a control intervention.27 In a functional magnetic resonance imaging (fMRI) task where children were presented pictures of their parent and a stranger, children who received ABC showed greater activations than the control group when viewing their parents vs. a stranger in brain regions implicated in socio-emotional functioning.28 Furthermore, children who received ABC showed enhanced executive functioning,24 better autonomic nervous system regulation,29 improved emotion expression,30 greater language development,31 and altered DNA methylation32 when compared to children who received a control intervention. These empirical data demonstrate that intervening to improve outcomes for vulnerable children is possible, and that working to increase sensitive and responsive caregiving through the ABC approach is an effective method of doing so.

Given the unique risk to infants with prenatal opioid exposure and the ways in which sensitive parenting and the infantcaregiver relationship may mediate that risk,33 intervening early through targeting parenting behaviors appears to be both a crucial and viable approach for improving long terms child outcomes. The empirical support for the ABC intervention in other at-risk populations, including parents with substance use concerns34 provides strong theoretical backing for use of ABC with infants prenatally exposed to opioids. However, the unique needs of these infants and their mothers suggest adaptations to the ABC intervention that need to be validated by empirical research prior to wide dissemination to this population. In order to do so, we are now examining the efficacy of a modified form of ABC specifically adapted for pregnant women on MAT for opioid use disorder and their infants. This research on modified ABC (mABC) is being conducted at the University of Delaware through a RCT, and while robust conclusions will not be available until data collection concludes, current development and implementation of the intervention may shed light on treatment considerations for others currently working with this vulnerable population.

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MODIFIED ATTACHMENT AND BIOBEHAVIORAL CATCH-UP A number of modifications have been made to the ABC intervention (for a detailed description of the original intervention, see Coaching Parents of Vulnerable Infants: The Attachment and Biobehavioral Catch-Up Approach)19 while retaining the core targets and mechanisms of the intervention.

Consistent with ABC, mABC targets aim to increase parenting sensitivity, and are addressed through flexibly manualized content, illustrations of parenting behaviors using video clips (including videos of the parent and child from previous sessions), and “in-the-moment” comments that highlight parent behavior in real time. These in-the-moment comments, where parent coaches provide positive feedback by describing and labeling target behaviors as they occur, have been identified as the primary mechanism of parent behavior change,35 and occur across all sessions, taking priority over content delivery. With an average commenting rate of one comment per minute, parents are receiving concrete feedback on opportunities to engage in targeted behavior and praise for attempts to do so approximately 60 times per session. Only towards the end of the intervention are advanced comments utilized to gently reshape problematic behaviors through suggestions or questions to help parents reflect on their behavior. This positive, strengths-based approach is one way that parent coaches come alongside parents to support their parenting and counteract parenting-associated insecurity or resistance resulting from previous experiences with DFS or other professionals. Qualitatively, this is even more important for mothers in treatment for opioid use disorder, who report significant anxiety around their parenting and judgment from those in both healthcare and substance use treatment settings regarding the effects of their addiction on their child.

Beyond these foundational similarities, mABC seeks to address the unique needs of mothers in treatment for opioid use disorder. In ABC, the intervention may begin when the child is an infant (6-24 months) or a toddler (24-48 months), and continues for 10 consecutive weeks. In contrast, mABC begins earlier, starting with a prenatal session during the third trimester of pregnancy with a second session taking place as soon after delivery as possible. It then continues for 10 additional sessions spaced every 2-3 weeks and concludes when the infant is around seven months of age. This allows the parent coach to provide support during the particularly vulnerable peripartum period and address challenges specific to infants who may be experiencing NAS symptoms. Parent coaches can help prepare mothers in the prepartum and peripartum period to provide crucial nurturance to their very young infants who may be difficult to soothe or are easily overstimulated. As the intervention progresses, it addresses parenting behaviors that are developmentally appropriate and gives parents the opportunity to practice skills (like following the lead) that are relevant to the infant’s increasing abilities.

The structure of the prenatal session is the most unique compared to ABC, given that the infant is not yet born, and thus the only hands-on practice (and opportunity for in-the-moment commenting) is created using an infant simulator. The early postnatal session typically takes place at the hospital, rather than in the home as other sessions, and prioritizes relationship building 96 Delaware Journal of Public Health - May 2022

and supporting the mother during this potentially challenging time. The parent coach primarily reinforces content from the previous session and builds engagement through in-the-moment commenting. The content in the following sessions proceeds similarly to ABC, moving from nurturance to following the lead with delight and then to reducing intrusive and frightening behavior. However, newborns are less likely to be awake and have a smaller repertoire of behaviors than older infants. Thus, in earlier sessions, activities to elicit target behaviors and in-themoment commenting are adjusted to account for the infant’s developmental abilities. In-the-moment comments are expanded to include comments on “pre-nurturance” (i.e. approximations of nurturance in the absence of infant distress, such as cuddling as the baby sleeps) and “pre-following” (i.e. approximations of following the lead in the absence of clear cues, such as making eye contact with the baby). The last four sessions include time for mothers to explore and override their automatic styles of responding that arise from previous experiences (“voices from the past” that interfere with their parenting) and consolidate gains made across the intervention. Given the high rates of trauma in this population and potential for difficult recollections of their own childhood experiences, parent coaches respond supportively to disclosures of mothers’ histories while empowering them to make deliberate choices about how to parent their own children.

This maintains the intervention’s present-focused child emphasis while acknowledging the mother’s context.

CASE STUDY: MARISSA & TREVOR Marissa was a 33-year-old woman in her seventh month of pregnancy when she enrolled in mABC. She had two older children, both of whom lived with relatives through kinship care. At the time of enrollment, she was on MAT and living with her partner and his parents. However, she also used illicit and prescription opioids sporadically throughout her pregnancy, and after Trevor was born, she moved to a residential treatment facility. Her relapses and substance use led to her moving out or back into the home with her partner six times over the course of her participation in the study. After the second move, Trevor remained in the home with his father and paternal grandparents, while Marissa visited approximately twice weekly during periods when she was not living in the home.

At the start of the intervention, Marissa’s efforts to nurture Trevor when he was fussy tended to rely on using a pacifier or distracting him by shaking a rattle in front of his face. Her behaviors were often intrusive and overwhelming; beyond regularly putting toys close to his face, she also played with him by moving his limbs or leaning close and loudly pretending to “gobble him up.” Her parent coach made frequent in-the-moment comments whenever Marissa followed Trevor’s lead or nurtured him, and Marissa made rapid gains in both domains. However, her behavior continued to be intrusive or frightening at times, such as getting frustrated when Trevor was crying and raising her voice. As the parent coach moved with her into the “voices from the past” sessions, Marissa had developed enough trust to disclose some of her own abuse history to her parent coach.

She and Marissa discussed how frightening behaviors were the norm in Marissa’s family growing up, and how it can be easy to do what you saw your own parent doing. Marissa recognized that even though she may be automatically ready to yell, she

can take a step back and override that impulse in order to be the safe person she wants to be for her son. In the consolidation sessions, the parent coach focused on intrusive/frightening behaviors, making comments such as, “Wow, look at how you paused and took a breath in that moment where it would be so easy to get frustrated, it’s so impressive that you can do that for Trevor!” Marissa also connected strongly with the idea “If there was someone ten times bigger than you, how would you feel?” in relation to her manipulation of her baby’s body during intrusive play. By the final session, Marissa was actively inhibiting intrusive and overwhelming play behaviors in response to Trevor’s cues, and had reduced the frequency of frightening behaviors. She was also more likely to nurture him by picking him up when he cried rather than seeking a means to distract him.

CONCLUSION The RCT is ongoing, limiting conclusions that can be drawn about the efficacy of mABC with mothers and infants affected by opioid use. However, previous research and preliminary findings suggest that modifying ABC to meet the needs of pregnant mothers with opioid use disorder may be a targeted method of addressing the vulnerabilities of mothers and their infants. By intervening to support sensitive parenting behavior through an individualized and trauma-informed approach in a real-world setting, mothers are better equipped, despite other ongoing challenges, to meet the socioemotional needs of their infants during this crucial period of development. The impacts of intervening early include not only buffering the developmental and regulatory susceptibilities of the infant, but also the lasting experience for the mother of positive parenting support and a strengthened parent-child relationship.

Author Note

Names and some identifying details of the case study presented have been changed in order to protect the anonymity of our research participants.

Ms. Martin may be contacted at cmartin@udel.edu.

REFERENCES 1. Hofer, M. (2006). Psychobiological roots of early attachment.

Current Directions in Psychological Science, 15(2), 84–88. https://doi.org/10.1111/j.0963-7214.2006.00412.x 2. Tottenham, N. (2020, February 15). Early adversity and the neotenous human brain. Biological Psychiatry, 87(4), 350–358. https://doi.org/10.1016/j.biopsych.2019.06.018

5. Rudd, K. L., Alkon, A., & Yates, T. M. (2017, October 15). Prospective relations between intrusive parenting and child behavior problems: Differential moderation by parasympathetic nervous system regulation and child sex.

Physiology & Behavior, 180, 120–130. https://doi.org/10.1016/j.physbeh.2017.08.014 6. Ramey, C. T., Yeates, K. O., & Short, E. J. (1984, October). The plasticity of intellectual development: Insights from preventive intervention. Child Development, 55(5), 1913–1925. https://doi.org/10.2307/1129938 7. Garnett, M., Bernard, K., Hoye, J., Zajac, L., & Dozier, M. (2020, November). Parental sensitivity mediates the sustained effect of Attachment and Biobehavioral Catch-up on cortisol in middle childhood: A randomized clinical trial.

Psychoneuroendocrinology, 121, 104809. https://doi.org/10.1016/j.psyneuen.2020.104809 8. Lyons-Ruth, K., Connell, D. B., Zoll, D., & Stahl, J. (1987).

Infants at social risk: Relations among infant maltreatment, maternal behavior, and infant attachment behavior.

Developmental Psychology, 23(2), 223–232. https://doi.org/10.1037/0012-1649.23.2.223 9. Lyons-Ruth, K., & Jacobvitz, D. (1999). Attachment disorganization: Unresolved loss, relational violence, and lapses in behavioral and attentional strategies. In J. Cassidy, & P. R. Shaver (Eds.), Handbook of attachment: Theory, research, and clinical applications; handbook of attachment: Theory, research, and clinical applications (pp. 520-554, Chapter xvii).

The Guilford Press, New York, NY. 10. Stovall-McClough, K. C., & Dozier, M. (2004, Spring).

Forming attachments in foster care: Infant attachment behaviors during the first 2 months of placement.

Development and Psychopathology, 16(02), 253–271. https://doi.org/10.1017/S0954579404044505 11. NIDA. (2020, July 8). Delaware: Opioid-involved deaths and related harms. National Institutes of Health. Retrieved https://nida.nih.gov/drug-topics/opioids/opioid-summaries-by-state/ delaware-opioid-involved-deaths-related-harms 12. Healthcare Cost and Utilization Project (HCUP). (n.d.). Data use agreement for HCUP Fast Stats. NAS Among Newborn Hospitalizations - HCUP Fast Stats. Retrieved from https://www.hcup-us.ahrq.gov/faststats/nas/nasquery.jsp 13. National Center for Health Statistics. (2022, April 13).

Products - vital statistics rapid release - provisional drug overdose data. Centers for Disease Control and Prevention.

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3. Gogtay, N., Giedd, J. N., Lusk, L., Hayashi, K. M., Greenstein, D., Vaituzis, A. C., . . . Thompson, P. M. (2004, May 25).

Dynamic mapping of human cortical development during childhood through early adulthood. Proceedings of the National Academy of Sciences of the United States of America, 101(21), 8174–8179. https://doi.org/10.1073/pnas.0402680101

14. Weller, A. E., Crist, R. C., Reiner, B. C., Doyle, G. A., & Berrettini, W. H. (2021, March 1). Neonatal opioid withdrawal syndrome (NOWS): A transgenerational echo of the opioid crisis. Cold Spring Harbor Perspectives in Medicine, 11(3), a039669. https://doi.org/10.1101/cshperspect.a039669

4. Fox, S. E., Levitt, P., & Nelson, C. A., III. (2010, JanuaryFebruary). How the timing and quality of early experiences influence the development of brain architecture. Child Development, 81(1), 28–40. https://doi.org/10.1111/j.1467-8624.2009.01380.x

15. Jalali, M. S., Botticelli, M., Hwang, R. C., Koh, H. K., & McHugh, R. K. (2020, August 6). The opioid crisis: A contextual, social-ecological framework. Health Research Policy and Systems, 18(1), 87. https://doi.org/10.1186/s12961-020-00596-8 97

16. Deutsch, S. A., Donahue, J., Parker, T., Hossain, J., & De Jong, A. (2020). Factors associated with child-welfare involvement among prenatally substance-exposed infants. The Journal of Pediatrics, 222, 35e1–44e1.

17. Lawson, K. M., Back, S. E., Hartwell, K. J., Moran-Santa Maria, M., & Brady, K. T. (2013, March-April). A comparison of trauma profiles among individuals with prescription opioid, nicotine, or cocaine dependence. The American Journal on Addictions, 22(2), 127–131. https://doi.org/10.1111/j.1521-0391.2013.00319.x 18. Peisch, V., Sullivan, A. D., Breslend, N. L., Benoit, R., Sigmon, S. C., Forehand, …, Forehand, R. (2018). Parental opioid abuse: A review of child outcomes, parenting, and parenting interventions. Journal of Child and Family Studies, 27(7), 2082–2099. https://doi.org/10.1007/s10826-018-1061-0 19. Dozier, M., & Bernard, K. (2019). Coaching parents of vulnerable infants: The attachment and biobehavioral catch-up approach. The Guilford Press.

20. Bernard, K., Butzin-Dozier, Z., Rittenhouse, J., & Dozier, M. (2010, May). Cortisol production patterns in young children living with birth parents vs children placed in foster care following involvement of Child Protective Services. Archives of Pediatrics & Adolescent Medicine, 164(5), 438–443. https://doi.org/10.1001/archpediatrics.2010.54 21. Bernard, K., Dozier, M., Bick, J., Lewis-Morrarty, E., Lindhiem, O., & Carlson, E. (2012, March-April). Enhancing attachment organization among maltreated children: Results of a randomized clinical trial. Child Development, 83(2), 623–636. https://doi.org/10.1111/j.1467-8624.2011.01712.x 22. Perrone, L., Imrisek, S. D., Dash, A., Rodriguez, M., Monticciolo, E., & Bernard, K. (2021, August). Changing parental depression and sensitivity: Randomized clinical trial of ABC’s effectiveness in the community. Development and Psychopathology, 33(3), 1026–1040. https://doi.org/10.1017/S0954579420000310 23. Aparicio, E. M., Denmark, N., Berlin, L. J., & Jones Harden, B. (2016, September). First-generation Latina mothers’ experiences of supplementing home-based early head start with the attachment and biobehavioral catch-up program.

Infant Mental Health Journal, 37(5), 537–548. https://doi.org/10.1002/imhj.21586 24. Lind, T., Lee Raby, K., Caron, E. B., Roben, C. K., & Dozier, M. (2017, May). Enhancing executive functioning among toddlers in foster care with an attachment-based intervention. Development and Psychopathology, 29(2), 575–586. https://doi.org/10.1017/S0954579417000190 25. Yarger, H. A., Bernard, K., Caron, E. B., Wallin, A., & Dozier, M. (2020, May-June). Enhancing parenting quality for young children adopted internationally: Results of a randomized controlled trial. J Clin Child Adolesc Psychol, 49(3), 378–390. https://doi.org/10.1080/15374416.2018.1547972 26. Bick, J., & Dozier, M. (2013, March 1). The effectiveness of an attachment-based intervention in promoting foster mothers’ sensitivity toward foster infants. Infant Mental Health Journal, 34(2), 95–103. https://doi.org/10.1002/imhj.21373 98 Delaware Journal of Public Health - May 2022

27. Lind, T., Bernard, K., Yarger, H. A., & Dozier, M. (2020, March). Promoting compliance in children referred to child protective services: A randomized clinical trial. Child Development, 91(2), 563–576. https://doi.org/10.1111/cdev.13207 28. Valadez, E. A., Tottenham, N., Tabachnick, A. R., & Dozier, M. (2020, September 1). Early parenting intervention effects on brain responses to maternal cues among highrisk children. The American Journal of Psychiatry, 177(9), 818–826. https://doi.org/10.1176/appi.ajp.2020.20010011 29. Tabachnick, A. R., Raby, K. L., Goldstein, A., Zajac, L., & Dozier, M. (2019, April). Effects of an attachment-based intervention in infancy on children’s autonomic regulation during middle childhood. Biological Psychology, 143, 22–31. https://doi.org/10.1016/j.biopsycho.2019.01.006 30. Lind, T., Bernard, K., Ross, E., & Dozier, M. (2014, September). Intervention effects on negative affect of CPSreferred children: Results of a randomized clinical trial.

Child Abuse & Neglect, 38(9), 1459–1467. https://doi.org/10.1016/j.chiabu.2014.04.004 31. Raby, K. L., Freedman, E., Yarger, H. A., Lind, T., & Dozier, M. (2019, March). Enhancing the language development of toddlers in foster care by promoting foster parents’ sensitivity: Results from a randomized controlled trial.

Developmental Science, 22(2), e12753. https://doi.org/10.1111/desc.12753 32. Hoye, J. R., Cheishvili, D., Yarger, H. A., Roth, T. L., Szyf, M., & Dozier, M. (2020, October). Preliminary indications that the Attachment and Biobehavioral Catchup Intervention alters DNA methylation in maltreated children. Development and Psychopathology, 32(4), 1486–1494. https://doi.org/10.1017/S0954579419001421 33. Mirick, R. G., & Steenrod, S. A. (2016). Opioid use disorder, attachment, and parenting: Key concerns for practitioners. Child & Adolescent Social Work Journal, 33(6), 547–557. https://doi.org/10.1007/s10560-016-0449-1 34. Berlin, L. J., Shanahan, M., & Appleyard Carmody, K. (2014, January-February). Promoting supportive parenting in new mothers with substance-use problems: A pilot randomized trial of residential treatment plus an attachment-based parenting program. Infant Mental Health Journal, 35(1), 81–85. https://doi.org/10.1002/imhj.21427 35. Caron, E. B., Bernard, K., & Dozier, M. (2018). In vivo feedback predicts parent behavior change in the attachment and biobehavioral catch-up intervention.

Journal of Clinical Child and Adolescent Psychology, 47(sup1), S35–S46.

WASH YOUR HANDS Please wash your hands for at least 20 seconds. Use warm water and soap. Turn off the faucet with a paper towel if available.

Use hand sanitizer when you cannot wash your hands.

Thank you.

For more information please visit:

de.gov/coronavirus Updated 5/21/2021

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During each day of National Public Health Week, we focus on public health topics important to our communities, identify ways we can help and make a difference, and create the healthiest nation.

This year, as part of a cross-campus event set into motion during National Public Health Week 2021, the Delaware Academy of Medicine/Delaware Public Health Association teamed up with the Delaware Health Sciences Alliance, Delaware State University, the University of Delaware, and Wilmington University to hold a student poster competition.

All undergraduates, graduates, and medical residents in Delaware completing research projects or internships were invited to present a poster on the status of their projects.

These projects are presented in the following pages.

100 Delaware Journal of Public Health - May 2022

Identifying Health Topics for Elementary-Aged Children in Delaware 1

Kayla Morrell1, Denise Hughes2

Sidney Kimmel Medical College,

2

Nemours Children’s Hospital

Introduction

Results

Conclusions Conclusion

Health Literacy is the ability to understand health-related information to make educated decisions regarding an individual’s health. Low health literacy is associated with poorer health outcomes, especially for those of minority races and lower socioeconomic status. Early introduction to health information and healthy lifestyles can minimize poor health outcomes and limit extraneous healthcare costs.

Only 4% of the teachers were incorporating any type of health education.

Through the interviews, the need for a comprehensive health curriculum for elementary-aged students was highlighted. Because each individual class may have unique demands, the curriculum should be offered as a “build-your-own experience” allowing teachers the ability to choose what they believe will best support their classroom, while offering a set foundation.

The themes identified were as expected, with teachers providing additional emphasis on mental health and nutrition. However, teachers did identify some topics that would be more appropriate for specific age groups.

Currently, Delaware elementary schools are falling far short of their required 30 hours/year of health, family, and drug/alcohol education as required by the Delaware Department of Education (DDoE). Thus, these students are at risk of low health literacy and the associated outcomes.

Our goal was to work with elementary school teachers to determine the best way to incorporate health-related topics into their existing curriculum, as well as identify the topics that would best capture the students’ attention, while satisfying the requirements.

The themes identified were similar between schools and across grade levels, regardless of school demographics.

Methods

Finally, though teachers emphasized the importance of time management and a curriculum that does not require additional classroom time, they also recognized that students would greatly enjoy hands-on activities and experiments, thus the curriculum should aim to utilize time for subjects beyond English-Language Arts, such as math, science, art, and gym.

Schools were selected from across the state and had a range of demographics. Teachers from grades K-5 by paired grade level (K&1, 2&3, 4&5), as well as, Phys. Ed. Teachers, school counselors, and school nurses participated in a series of group interviews.

The interviews were conducted with the following questions as guidance: 1) Are you currently reaching the DDoE standards of 30 hours spent learning health-related topics? What health education, if any, are you offering in your classroom?

2) What topics relating to healthcare do you see a need for with your students?

3) What types of lessons would you best be able to incorporate into your existing curriculum?

After questions were posed one at a time, the interviews were driven by discussion amongst the teachers.

The resulting discussions were qualitatively analyzed by two independent interviewers and compared for validity.

Reading exercises to work on comprehension and grammar were suggested for all age groups. Passages can be created at each specific grade level and will merely replace the content of passages that are currently utilized, allowing for seamless integration.

Classrooms with on-site gardens were already having discussions regarding nutrition and healthy eating. However, for schools without the resources to maintain a garden, a dedicated health curriculum could help fill in the gaps.

Suggestions to incorporate the new curriculum varied slightly across grade levels but were similar between schools.

Future work will include development of lesson plans and classroom materials, then implementation within the school system and modification as needed.

All groups of teachers agreed that incorporating English-Language Arts passages on health-related topics would be the easiest to seamlessly fit into the existing curriculum and be adjustable to specific grade-levels.

References

Peer-to-peer teaching from older to younger students was also widely suggested.

Teachers endorsed hands-on experiments, especially to teach about how the body works, despite recognizing that it would take up additional classroom time and would be difficult to fit into an existing curricula without dedicated science time.

Baur C, Harris L, Squire E. The U.S. National Action Plan to Improve Health Literacy: A Model for Positive Organizational Change. Stud Health Technol Inform. 2017;240:186-202.

Berkman ND, Sheridan SL, Donahue KE, Halpern DJ, Crotty K. Low health literacy and health outcomes: an updated systematic review. Ann Intern Med. 2011 Jul 19,;155(2):97-107.

Hughes D, Maiden K. Navigating the Health Care System: An Adolescent Health Literacy Unit for High Schools. J Sch Health. 2018 05;88(5):341-9.

Korbey, Holly. "Is it time to drop “finding the main idea” and teach reading in a new way?" Edutopia. July 28, 2020. Web. Jan 27, 2021 <https://www.edutopia.org/article/ittime-drop-finding-main-idea-and-teach-reading-new-way>. https://www.doe.k12.de.us/domain/69

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Qualitative outcomes of Shining the Light on You An evidence-based program designed to improve the health and wellbeing of family child care providers

AMMO BAR One-on-one interviews with providers revealed four major themes: impact on provider health, impact on children and families, the importance of connecting with other providers, and suggestions for program improvement.

IMPACT ON PROVIDER HEALTH • Providers discussed experiencing improvement in areas such as nutrition, physical activity, sleep, and stress.

• “I’m sleeping more, I’m drinking more water, and I’m losing weight.”

• Many providers commented on the connections between all components of wellbeing and the importance of self-care.

• Providers who took advantage of the one-onone health coaching sessions enjoyed the extra time to receive support for setting health goals.

• “I feel like it has probably been the most beneficial part for me because [health coach] is actually helping me to set goals and follow up to make sure those things are happening.”

PRESENTER: Sarah Albrecht BACKGROUND • The early care and education workforce, and family child care providers in particular, face challenges to optimal wellbeing and mental and physical health.

• The family child care workforce is predominately lowincome women of color, placing them at a higher risk for chronic diseases.

• A large proportion of the workforce has overweight or obesity, and many experience high levels of stress.

• Poor provider wellbeing may contribute to lower classroom quality, increased conflict and negative reactions to children, and decreased job commitment.

• Poor provider wellbeing may also influence children’s social-emotional development.

• Few evidence-based interventions have been developed or feasibly implemented with this population to address these issues.

IMPACT ON CHILDREN AND FAMILIES • Providers described how participating positively influenced the ways they engage with the children and families they serve.

• “Because when you’re stressed and you feel like everything’s falling apart in the house, it’s really hard to be pleasant and want to, you know, sit and read books and enjoy time with the kids. So I do feel like it has put me in a better frame of mind, which makes me react to the children in a much better way.”

CONNECTING WITH OTHER PROVIDERS • Many providers discussed the importance of having the opportunity to share and feel connected with other FCC providers.

• “It let me know that I wasn’t the only one going through what I was going through and listening to the other providers, it made me feel as though, okay, I can get through this…”

Non-Cognitive Predictors of Student Success: SHINING THE LIGHT ON YOU A Predictive Validity Comparison Between Domestic and International Students

•

• •

•

Shining the Light on You is a 15-week virtual program that integrates evidence-based practices from the Health and Wellness Coaching field and Early Childhood Education sector.

Providers can also meet with a health coach one-onone for three individual coaching sessions.

Program topics include self-care, mindful eating, stress management, sleep, financial literacy, and physical activity.

Shining the Light on You is designed to help providers develop individual and group wellbeing goals, provide ongoing monitoring and support, and connect participants with existing community resources to meet goals.

METHODS 1. Two cohorts of Shining the Light on You were pilottested in Fall of 2020 and Spring of 2021, respectively (n=18).

2. Participants were recruited through Delaware Institute for Excellence in Early Childhood.

3. Measures include pre- and post-program surveys and a post-program interview.

4. Modified thematic analysis was conducted for each individual interview and illustrative quotes were identified for each theme (n=12).

5. Participants received a $25 gift card for participating in the interview.

SUGGESTIONS FOR PROGRAM IMPROVEMENT • The most commonly reported suggestion for program improvement was occasionally offering sessions in person when it becomes safe to do so.

• “If COVID was over, it would be so great to meet in a group. Not for the whole 10 weeks. I think virtual was great because sometimes after daycare I don’t want to go anywhere.”

• Many providers also requested to have the program qualify for professional development hours.

Offering an evidence-based wellbeing program for family child care providers can improve their quality of life and the ways they interact with children and families.

102 Delaware Journal of Public Health - May 2022

Laura Lessard, PhD, MPH Rena Hallam, PhD Sarah Albrecht, B.S., B.A. Eric Plautz, M.S. Kyma Belardo

Adaptation of a Comprehensive Food Farmacy Intervention to Promote Latinx Health Equity in the First State Mia Seibold, BS1, Michelle Axe, MS2, Jacqueline Ortiz, MS2, Claudia Angelica Reyes-Hull2, Erin Booker, LPC2, Alicia L. Salvatore, DrPH, MPH1,3 1. ChristianaCare Institute for Research on Equity and Community Health; 2. ChristianaCare Office of Health Equity; 3. Department of Human Development and Family Sciences, University of Delaware.

Introduction Background •Advancing health equity requires culturally-appropriate interventions that address patients’ social needs, including food insecurity.

•While food pharmacy and other Food as Medicine interventions are rapidly being adopted by health systems, few have been culturally-adapted for Latinx patients.

•In Delaware and nationally, Latinx patients experience high levels of food insecurity that impede the achievement of healthy weight and effective management of chronic conditions such as hypertension and diabetes.

• Food insecurity screening conducted with Latinx patients (N=220) by our health systems indicated that 57.9% were food insecure.

• Our recent Latinx COVID-19 Community Survey (N=117) revealed higher rates and dramatic increases since the COVID-19 pandemic: 76.9% were food insecure since pandemic versus 31.6% prior to the pandemic.

Objectives • Assess cultural and contextual factors shaping Latinx health • Identify appropriate foods and program elements to create a culturally-centered Delaware Food Farmacy intervention for Latinx patients.

Methods and Materials

Table 1. Participant Characteristics (N=39) Hispanic/Latinx

Discussion

100%

Ancestry/Country of origin Mexican/Mexican-American

38.5%

Puerto Rican

38.5%

Other

23.0%

Spanish-speaking

64.1%

ChristianaCare patient

86.0%

“A lot of Hispanic patients feel like they're not as important, especially if they have to use a translator or interpreter.”

Table 2. Cultural and contextual factors to consider, top themes (n=39) Themes Transportation

Access to reliable and affordable transportation may be less common.

Families rely on one vehicle or on public transport. Getting to and from appointments may difficult.

Financial Constraints

Perception that eating healthy will be significantly more expensive. Access to affordable and healthy foods difficult for those living in food desserts.

Spanish-speakers receive quality care because of Table 3. Baseline DASH Adherence, DElower FF patients (N=23)

• Latinx health system employees who participated in this formative research all emphasized the need for a culturallycentered Delaware Food Farmacy for Spanish-speaking and Latinx patients.

• Participants supported key intervention elements such as community health worker engagement and weekly homedelivery of food adequate for the entire family for 6 months.

• Additional adaptations included: – culturally-relevant foods, recipes, and cooking equipment; – family member inclusion in intervention activities; – changes to the program name and messaging – partnership with faith leaders and promotores to build trust with the health system and program.

Language Barriers

miscommunications and biases. Accessing care in Spanish is difficult.

Limitations

Food-related Culture

Culturally, there is a belief that eating more is healthy; smaller portions indicates someone is sick or unwell. Traditional food preparation is often unhealthy; changes take getting used to and may be viewed as less tasty.

•

Sample size was small; study is ongoing.

•

Conducted at one mid-Atlantic health system and may not be generalizable.

Building Trust

There is a lot of fear in the community. Many have had unfavorable experiences with health care. Engaging community health workers and community partners needed to build trust.

Table 3. Additional program elements, top themes (n=39) Themes Nutrition and Healthy Culinary Education

Create accessible and relevant educational experiences and materials.

Include content on serving sizes, utilizing measuring tools, and how to prepare cultural meals in healthier way.

Conclusions • Engagement of Latinx employees – who are also patients – will be critical to the development of a culturally-appropriate comprehensive food pharmacy intervention for primarily Spanish-speaking Latinx patients.

• Future research will evaluate the feasibility and impact of this program on patient’s dietary patterns and chronic disease outcomes.

Data Collection and Measures

Fitness Classes

Offer beginner-friendly workout classes.

• Study took place at ChristianaCare, a mid-Atlantic health system

Include Family

Allow family members to participate. Encourage them to be as involved as possible – program should benefit whole household.

• Qualitative interviews (n=13) and a group discussion (n=26) were conducted with health system employees who self-identified as Hispanic.

Incentivize ParticipationIncentivize attendance in classes for patients and their families.

Acknowledgments

• Polling was used in discussion group.

Table 4. Top food additions recommended (n=39)

Support provided by an Institutional Development Award (IDEA) from NIGMS/NIH grant number U54-GM104941 (PI: Hicks).

Data Analysis • Descriptive statistics used to analyze sociodemographic and food recommendation data • Qualitative coding was completed in Dedoose

Grains Vegetables Fruits Dairy Corn Tomatillo, Mango, lime, Queso tortillas, guava, yucca, sweet fresco, rice, Bimbo potato, corn, watermelon, queso bread, corn potato, jicama, melon, Oaxaca flakes yellow onion orange

Proteins Beans Nuts Spices Salmon, Lentils, Cilantro, cod, black Cashews, peppers, shrimp, beans, pistachios Italian tilapia, pinto beans seasoning tuna

For more information contact Dr. Alicia Salvatore Alicia.salvatore@christianacare.org

103

Closing the Gap: Promoting Access to Community Fitness Facilities for Adults with Intellectual Disability STUDENTS: Ashley Steinbrecher, BS, Cory Lucamato, Shannon Gibbons, Cora Firkin, BS, Olivia Inman ADVISORS: Iva Obrusnikova, PhD; Al Cavalier, PhD; Rick Suminski, PhD

INTRODUCTION • Adequate physical activity (PA) is critical for increasing overall health-related quality of life and delaying functional declines.

• Adults with ID have low PA levels and do not engage in health promotion activities.

• Although CFFs are critical in the promotion of exercise, numerous factors may limit exercise participation by adults with ID in CFFs. • It is essential to conduct qualitative studies with key stakeholders to develop exercise programs for adults with ID.

PURPOSE • To elicit perceptions of the psychosocial factors and outcomes that affect exercise behavior in a CFF from adults with ID. • The Social Cognitive Theory (SCT; Bandura, 1997) framed the study (see Figure 1).

Adults with intellectual disability need appropriate type and intensity of support in a community fitness facility to close the gap between their unique health-related needs and the demands of the environment.

OUTCOME EXPECTATIONS FOR ADULTS WITH ID BENEFITS • Is good for the body; • Promotes physical fitness, posture, alignment, balance, and overall health; • Increases energy/PA levels; • Promotes weight loss; • Promotes positive feelings; • Improves job/sports performance; • Promotes motivation and focus

FACILITATORS

METHODOLOGY • Design: A descriptive qualitative research design.

• Participants (PP): A convenience sample of 20 adults with ID, aged 18-45 years, 10 females, 13 with Down syndrome.

• Procedures: Participants were interviewed individually before and after participating in five guided exercise sessions consisting of treadmill, stationary bike, chest/leg press, stretching, curl-ups, and military press at the Western Family YMCA. • Data Analysis: Interviews were transcribed verbatim and coded by two independent investigators using directed content analysis.

104 Delaware Journal of Public Health - May 2022

• Adults with ID are in the correct position or have the skills, knowledge, focus, or ability to perform the exercise; • CFFs have specialized and easy-to-use equipment; • Adults with ID have the support, feel motivated, and use visual aid/entertainment; • Tasks/prescriptions are individualized (FITT-PV)

COSTS • No costs; • Cause injury, pain, physical harm, sore muscles, or exhaustion; • Make me fall off the equipment/machine; • Be unpleasant; • Make me sick or infected; • Make me sweat

CONCLUSION • Adults with ID perceived more benefits than costs to exercising in a CFF. Most of the benefits or costs were physical, followed by self-evaluative and social.

• Although adults with ID generally perceived no costs to exercising in a CFF, many were concerned it could lead to an injury or falling off the equipment.

• The psychosocial factors mostly were related to the individual, followed by the built environment and the task.

BARRIERS • Adults with ID lack the skills, knowledge, or ability to perform the exercise correctly or operate the equipment; • CFFs lack specialized and easy-to-use equipment; • Tasks/prescriptions are not individualized (FITT-PV) • Adults with ID lack motivation, have tight muscles or other health conditions

PSYCHOSOCIAL FACTORS

FUTURE RESEARCH • The elicited beliefs will be used to design: • A technology-supported exercise

self-efficacy scale for adults with ID,

• Exercise interventions for adults with ID, • Professional curricula to prepare personal

trainers and caregivers.

Domestic Violence and COVID-19- How did Workforce Burnout Impact Victim Services?

Sarah A. Wells, Ruth Fleury-Steiner, Susan L. Miller, Lauren C. Camphausen, Jennifer A. Horney

Objective To assess factors related to the public health emergency response to the COVID-19 pandemic (e.g., distancing, closures, stay-at-home orders) that impacted the provision of services to domestic violence survivors and victims Background Domestic Violence (DV) impacts 12 million victims each year in the U.S. A review from the National Commission on COVID-19 and Criminal Justice reported increases of 8.1% in DV since the pandemic’s onset¹. Advocates experienced increased strain as they provided services amidst impacts of the pandemic. This study assessed how public health emergency response impacted service provision.

Results Participants included Executive Directors from State & Territorial Domestic Violence Coalitions. To date, 20 Executive Directors have been interviewed, representing 7 of 8 National Network to End Domestic Violence (NNEDV) regions. Some main themes around workforce burnout impacting victim services emerged from the inductive coding of transcripts: 1 DV workforce turnover

Subjects, Methods & Analysis Contacts at each U.S. State and Territorial Domestic Violence Coalition were identified using the National Domestic Violence Coalition website². Key informant interviews were conducted with Executive Directors.

Transcripts of interviews were inductively coded to identify themes The interview guide and other materials were reviewed and approved by the University of Delaware IRB (1597257).

Conclusions COVID-19 restrictions have impacted the ability to administer services to DV victims in ways that are unique compared to a typical disaster or emergency.

A lesson learned from the pandemic response is that future emergency responses will require empowerment-based social services that are resilient to a variety of impacts of a disaster or public health emergency. Resilient services will need to be available to victims and survivors and to help protect the DV workforce from burnout. Themes identified in this study will be used to inform the development of an online survey of direct service providers and member programs in each state and the development of practitioner resources.

1.

2.

Jennings, W. G., Jemison, E., Kaukinen, C., Knaul, F. M., & Piquero, A. R. (2021). Domestic Violence During COVID-19- Evidence from a Systematic Review and Meta-Analysis . National Commission on COVID-19 and Criminal Justice.

National Coalition Against Domestic Violence- State Coalitions. National Coalition Against Domestic Violence. https://ncadv.org/state-coalitions

2

The COVID-19 pandemic created elevated levels of stress among the DV workforce, which led to increased feelings of fear and exhaustion. For some advocates, they dealt with the impacts of the pandemic both in their personal and professional lives, so the secondary trauma of working with victims led to higher levels of exhaustion. Limited access to appropriate PPE, due to lack of essential worker status, also left DV workers fearful of the workplace. For some workers, lack of available childcare for their children was a barrier to working during the pandemic, as well as limited hazard pay for employees risking their safety to be in shelters with victims.

DV workforce turnover’s impact on providing services The DV workforce turnover created barriers to providing services. With a limited staff, advocates were working longer shifts to keep shelter services running. With funding uncertainty from the pandemic, it was hard to hire more staff to replace those who were lost. Along with a lack of money to hire more staff, training advocates takes a lot of time and money, so service providers didn’t have the capacity to train.

Figure 1. U.S. States where Domestic Violence Coalition Executive Directors have completed key informant interviews

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From the Archives: The Healing Arts in History Sharon Folkenroth Hess, M.A. Historian & Archivist, Delaware Academy of Medicine/Delaware Public Health Association

On August 13, 1895, 27-year-old Sarah C. Crumlish was admitted to the Delaware State (psychiatric) Hospital at Farnhurst.

Her husband, John, had noticed the “first symptoms of insanity” two weeks earlier, though she “ had been steadily failing both physically and mentally” since the birth of their last child five years ago. She had not eaten well and complained of unspecified “uterine trouble.” Two months into her stay, a pelvic exam revealed Sarah had tears to the os uteri and cervix and a prolapsed uterus. She was released from Farnhurst on May 13, 1896, despite showing no improvement in her mental state. In October 1897, Sarah suffered two falls that left her unable to walk. The New Castle County Almshouse and Hospital transferred Sarah to the State Hospital, reporting that the patient was hysterical and used foul language. Like the first time she was admitted in 1895, her abdomen was “extremely large.” Doctors discovered her pregnancy on January 8, 1898, during an examination. Sarah Crumlish died delivering her stillborn son three weeks later (p., 378-379).1 In 1889, the New Castle County Trustees of the Poor facility to house insane persons expanded to serve the entire state under the new State Board of Trustees of the Insane. The original county facility was renamed the Delaware State Hospital two years later. The New Castle County Almshouse and Hospital (1884-1933) operated in Farnhurst on an adjoining plot.

Since the cause of many mental and behavioral health concerns was unknown, the psychiatric facility —commonly referred to as “Farnhurst’’—became a “catch-all” for a range of patients. In addition to treating schizophrenia, melancholia, and substance abuse disorders, doctors attended to patients with traumatic brain injuries, epilepsy, syphilis, age-related senility, and cognitive and physical disabilities. Unfortunately for many women, some gynecological or sexual health problems landed them in Farnhurst and similar facilities.

106 Delaware Journal of Public Health - May 2022

Thirty percent of women admitted between 1894 and 1920 had menopause, pregnancy, puberty, or “domestic troubles” listed as the cause of their stay. In Sarah Crumlish’s case, she suffered from “neurotic hypochondria” triggered by her pregnancy. Today we would hopefully recognize the influence of emotional and physical trauma of multiple unwanted pregnancies and abortive attempts. However, contemporary physicians attributed many psychiatric conditions to the harmful effect of having female reproductive organs. The Delaware Academy of Medicine Archives house an extensive collection of nineteenth and early twentieth books that explain the alleged connection between mental illness and the ‘weaker sex’ (see Figure 1).

Charles B. Penrose, M.D., Ph.D. (1862-1925), a professor of gynecology at the University of Pennsylvania and surgeon at the Gynecean Hospital of Philadelphia, wrote several editions of A Text-Book of Diseases of Women. In the 1900 revised third edition, Penrose claims that diseases peculiar to women occur more frequently in “civilized” women than in “barbarous” females or lower animals. Her increased liability is due to her poor physique, and her inferiority is tremendously increased during illness. He blames the imbalance on their improperly constrictive clothing, the delicate arrangement of her reproductive apparatus, venereal diseases, and neglect during menstruation. Likewise, the unnatural state of celibacy is a cause of disease. Without the relief of pregnancy and lactation, “unceasing menstrual congestions” result in uterine fibroid tumors and cirrhotic ovaries (p. 17-20).2 Alexander H. P. Leuf, M.D. (1861-1929) of Philadelphia, though better known for his pioneering work in sports medicine, authored a three-part series for The Medical Council on women’s health. The articles were collected and published as a single volume. In addition to warning physicians not to lose money to specialists by avoiding the “easy” practice of gynecology (p. 18), Leuf asserts that women are biologically prone to insanity.3 While pelvic health issues can cause mental disturbances in men, he argues:

“The female pelvis contains more, and its contents are subjected to greater strains and exactions. She is also more emotional and impressionable, and thus the more likely to yield remotely, or reflexively, to these greater and more frequent local disturbances. The female departments of the great insane asylums show a large proportion of tubal and ovarian disease” (p. 126-127)3

DOI: 10.32481/djph.2022.05.015

Leuf states that women are at the most significant risk for mental perturbation at the end of fertility. While puberty, pregnancy, menstruation, and lactation have rendered women incapable of governing themselves, resulting in anything from ill-tempered outbursts and scolding to “(often unjustifiable) murder,” menopause is more likely to “slip a cog in the machinery of the brain” (p. 306 & 311).3 The good doctor suggests that these nervous system diseases be remedied with sedatives, intra-pelvic massage (instructions on pages 140-142), and therapeutic bicycle rides with the proper saddle (p. 142-145).

In his 1897 treatise on menopause, Andrew F. Currier, A.B., M.D. (1851–1937) denies that the end of menstruation in itself is a cause of insanity, but instead increases the likeliness of mental health crises at a time when the mind is in “unstable equilibrium” (p. 217).4 He also asserts that menopause only appears in “highly bred, tenderly reared women of civilized life” and those who have experienced “an undue share of the ills and stings of life” (p. 12-13).4 The severity of a woman’s menopausal symptoms results from factors like race and climate (p. 37, 131-132).4 While it is easy to laugh at the missteps in medicine of yesteryear, we must contend with the attitudes they have ingrained in our health systems. The myth of female physiological inferiority has been debunked, and yet women continue to be treated through the lens of frailty. Conditions that are not immediately

diagnosable are often dismissed as mental health issues. Until women are considered reliable resources for reporting their experiences with their bodies, the problems of the past are not yet history.

After four years of dedication, anthropologist Dr. Katherine A. Dettwyler published a database and book that detailed the admission and clinical notes of nearly 3,000 patients admitted to Farnhurst between 1894 and 1920. Thanks to her remarkable efforts, stories like Sarah Crumlish’s will not be forgotten.

REFERENCES 1. Dettwyler, K. A. (2019). Remembering Farnhurst: Stories from the Delaware State Hospital. Outskirts Press.

2. Penrose, C. B. (1900). A Text-Book of Diseases of Women.

W.B. Saunders.

3. Leuf, A. H. P. (1902). Gynecology, Obstetrics, and Menopause.

Philadelphia Medical Council.

4. Currier, Andrew F. (1897). The Menopause: a consideration of the phenomena which occur to women at the close of the child-bearing period. D. Appleton & Co.

Figure 1. Examples of Some of the Collection in the Delaware Academy of Medicine Archives

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BEHAVIORAL HEALTH/TRAUMA INFORMED CARE RESOURCES Behavioral Health Amanecer Counseling and Resource Center http://www.amanecerde.org Behavioral Health Associates (New Castle County, DE) http://behavioralhealthassociatesde.com • Children • Adolescents • Adults

Brandywine Counseling and Communtiy Services (Statewide) http://www.brandywinecounseling.org • Individual Counseling • Group Counseling

Champions for Children’s Mental Health (Dover, DE) http://www.championsDE.org • Family peer support

CORAS Wellness & Behavioral Health (New Castle & Kent County, DE) http://www.coraswellness.org • Assessments • Individual and group therapy • Family therapy • Case management • HIV counseling • Medication Assisted Treatment • DUI Treatment

Delaware Behavioral Health, Inc (Newport, DE) https://www.delawarebehavioralhealth.org • Mental Health Therapy and Counseling • Medication Management

Dover Behavioral Health System (Dover, DE) https://doverbehavioral.com • Children, Adolescents, Adults, Military • Inpatient Treatment • Adolescent Partial Hospitalization • Substance Use Disorder Intensive Outpatient • Detoxification • Adult Partial Hospitalization • Assessment and Referrals

Nemours Children’s KidsCope https://www.nemours.org/services/behavioral-health-resources.html • Children & Adolescents • Attention Deficit Hyperactivity Disorder (ADHD) • Anxiety Disorders (Obsessive-Compulsive Disorder, Separation Anxiety, Panic Attacks, Selective Mutism, Social Anxiety) • Autism Spectrum Disorder • Depression & Mood Disorders (Bipolar Disorder, Seasonal Affective Disorder, Suicide, Self-Harm) • Eating Disorders (Anorexia Nervosa, Bulimia, Binge Eating, Body Dysmorphic Disorder, Compulsive Exercise) 108 Delaware Journal of Public Health - May 2022

BEHAVIORAL HEALTH/TRAUMA INFORMED CARE RESOURCES • Posttraumatic Stress Disorder • Tic Disorders, Tourette Syndrome

Sun Behavioral Delaware (Georgetown, DE) https://sunbehavioral.com/delaware/adult-mental-health-services • Adolescents • Adult Co-Occurring/Substance Use Disorder • Adult Mental Health Services • Adult Outpatient • Telehealth Services

State Services • Behavioral Health Consortium https://ltgov.delaware.gov/behavioral-health-consortium • Division of Prevention and Behavioral Health Services https://kids.delaware.gov/prevention-and-behavioral-health-services • Division of Substance Abuse and Mental Health (DSAMH) https://dhss.delaware.gov/dsamh • Mental Health Association in Delaware https://www.mhainde.org • Mental Health DE https://mentalhealthde.com • Project DelAWARE https://www.doe.k12.de.us/domain/588

Trauma Informed Care Delaware Mini Medical School (2022) • Trauma Informed Care https://www.youtube.com/watch?v=cCw9cl-d6ZA

Department of Education • Trauma-Informed Practices https://www.doe.k12.de.us/Page/4349

Division of Substance Abuse and Mental Health • Trauma Informed Care Training https://www.dhss.delaware.gov/dsamh/tic.html

Trauma Informed Delaware • Delaware Developmental Framework for Trauma-Informed Care https://governor.delaware.gov/wp-content/uploads/sites/24/2019/02/Delaware-Developmental-Framework-FSCC.pdf • From Trauma-Aware to Trauma-Informed https://traumainformedde.org/wp-content/uploads/2020/05/Trauma-BluePrint.pdf • State Progress Report and Action Plan 2019-2020 https://governor.delaware.gov/wp-content/uploads/sites/24/2019/11/DE-TIC-Progress-Report-and-Action-Plan.pdf

Trauma Matters Delaware https://traumamattersdelaware.org

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The American Public Health Association’s 2022 Annual Meeting 7 Expo 150 Years of Creating the Healthiest Nation: Leading the Path Toward Equity Boston | November 6-9, 2022 Make plans to gather with friends and colleagues from around the nation, and world, for four days of insightful presentations, engaging activities and face-toface networking. With more than 1,000 presentations, we’re covering nearly every public health topic. Plus, the 2022 Annual Meeting and Expo is the culmination of APHA’s 150th anniversary celebration, so we’ve got even more planned than normal for this exciting educational event.

Important reminder: The 2022 mid-term elections will be Tuesday, Nov. 8, so be sure to vote early.

Can’t travel? We’re hosting a digital version of APHA 2022 on Nov. 14-16. This will include access to recordings of more than 120 sessions from the Annual Meeting. Of course, the Featured and General Sessions are included, along with up to two sessions selected by each APHA Section. You’ll even be able to participate live in the

apha.org/annual-meeting 110 Delaware Journal of Public Health – - May May2022 2022

Index of Advertisers The DPH Bulletin - April 2022. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Delaware Division of Public Health The Nation's Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 American Public Health Association The DPH Bulletin - May 2022 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Delaware Division of Public Health Making the Decision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 Public Health Communications Collaborative APHA 2022 Annual Meeting and Expo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110 The American Public Health Association Submission Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 Delaware Journal of Public Health

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Delaware Journal of

Public Health

Submission Guidelines

updated April, 2020

About the Journal Established in 2015, The Delaware Journal of Public Health is a bi-monthly, peer-reviewed electronic publication, created by the Delaware Academy of Medicine/Delaware Public Health Association. The publication acts as a repository of news for the medical, dental, and public health communities, and is comprised of upcoming event announcements, past conference synopses, local resources, peer-reviewed content ranging from manuscripts and research papers to opinion editorials and personal interest pieces, relating to the public health sector. Each issue is largely devoted to an overarching theme or current issue in public health.

The content in the Journal is informed by the interest of our readers and contributors. If you have an event coming up, would like to contribute an Op-Ed, would like to share a job posting, or have a topic in public health you would like to see covered in an upcoming issue, please let us know.

If you are interested in submitting an article to the Delaware Journal of Public Health, or have any additional inquiries regarding the publication, please contact DJPH Deputy Editor Elizabeth Healy at ehealy@delamed.org, or the Executive Director of The Delaware Academy of Medicine and Delaware Public Health Association, Timothy Gibbs, at tgibbs@delamed.org

Information for Authors Submission Requirements The DJPH accepts a wide variety of submission formats including brief essays, opinion editorials pieces, research articles and findings, analytic essays, news pieces, historical pieces, images, advertisements pertaining to relevant, upcoming public health events, and presentation reviews. If there is an additional type of submission not previously mentioned that you would like to submit, please contact a staff member.

Cover Letters must address the following four article requirements: 1. A description of what the paper adds to current knowledge, in particular with respect to material previously published in DJPH, and if systematic reviews exist on the topic.

2. The public health importance of the paper.

3. One sentence summarizing the main message(s) of the paper, which may be used to disseminate the paper on social media.

The initial submission should be clean and complete, without edits or markups, and contain both the title and author(s) fulls name(s). Submissions should be 1.5 or 4. For individual or group randomized trials, provide the double spaced with a font size of 12. Initial submissions date of trial registration and the NCT number from must also contain a cover letter with concise text www.Clinicaltrials.gov or other approved registry. (maximum 150 words). Once completed, articles In the cover letter only, not in the paper. Do NOT should be submitted via email to Elizabeth Healy at include the trial registration or NCT number in the ehealy@delamed.org as an attachment. Graphics, images, abstract or the body of the manuscript during the info-graphics, tables, and charts, are welcome and initial submission. encouraged to be included in articles. Please ensure that all pieces are in their final format, and all edits and track All manuscripts must be submitted via email to Elizabeth Healy at ehealy@delamed.org. changes have been implemented prior to submission.

112 Delaware Journal of Public Health - May 2022

To view additional information for online submission requirements, please refer to the website for the Delaware Journal of Public Health: https://djph.org/sample-page/submit-an-article/.

Submission Length While there is no prescribed word length, full articles will generally be in the 2500-4000-word range, and editorials or brief reports will be in the 1500-2500-word range. If you have any questions regarding the length of a submission, or APA guidelines, please contact a staff member.

Copyright Opinions expressed by contributors and authors do not necessarily reflect the opinions of the DJPH or affiliated institutions of authors. Copying for uses other than personal reference or interest without the consent of the DJPH is prohibited. All material submitted alongside written work, including graphics, charts, tables, diagrams, etc., must be referenced properly in accordance with APA formatting.

Conflicts of Interest Any conflicts of interest, including political, financial, personal, or academic conflicts, must be declared prior to the submission of the article, or in conjunction with a submission. Conflicts of interest are any competing interests that may leave readers feeling misled or deceived, and/or alter their perception of subject matter. Declared conflicts of interest may be published alongside articles in the final electronic publication.

Additional Documents and Information for Authors Please Note: All authors and contributors are asked to submit a brief personal biography (3 sentences maximum) and a headshot along submissions. These will be published alongside final submissions in the final electronic publication. For pieces with multiple authors, these additional documents are requested for all contributors.

Abstracts Authors must submit a structured or unstructured abstract along with their article.

The word limit is 200 words, including headings. A title page should be submitted with this abstract as well.

Structured abstracts should employ 4-5 headings: Objectives (begins with “To…”) Methods Results Conclusions A fifth heading, Policy Implications, may be used if relevant to the article.

Trial Registration information is required for clinical trials and must be included in the final version abstract All abstracts should provide the dates(s) and location(s) of the study is applicable.

Note: There is no Background heading.

Nondiscriminatory Language Use of nondiscriminatory language is required in all DJPH submissions. The DJPH reserves the right to reject any submission found to be using sexist, racist, or heterosexist language, as well as unethical or defamatory statements.

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Thank you to our 2022 Annual Meeting Sponsors!

Delaware Academy of Medicine / DPHA 4765 Ogletown-Stanton Road Suite L10 Newark, DE 19713

www.delamed.org | www.djph.org Follow Us:

The Delaware Academy of Medicine is a private, nonprofit organization founded in 1930. Our mission is to enhance the well being of our community through medical education and the promotion ofpublic health. Our educational initiatives span the spectrum from consumer health education tocontinuing medical education conferences and symposia.

The Delaware Public Health Association was officially reborn at the 141st Annual Meeting of the American Public Health Association (AHPA) held in Boston, MA in November, 2013. At this meeting, affiliation of the DPHA was transferred to the Delaware Academy of Medicine officially on November 5, 2013 by action of the APHA Governing Council. The Delaware Academy of Medicine, who’s mission statement is “to promote the well-being of our community through education and the promotion of public health,” is honored to take on this responsibility in the First State.

ISSN 2639-6378