RISE: The Emerging Leaders Magazine Issue No. 01

MAY 2022 | ISSUE NO 01

The Emerging Leaders Public Health Magazine

BUILDING THE FUTURE OF PUBLIC HEALTH

"It gives me great hope, and confidence, to see these emerging leaders standing at the ready to help sustain and advance our movement."

Jason Vitello, MSW CPHA President

Cover artwork by Jeni Mitchell

TABLE OF CONTENTS 3

Editors

5

Letters from Leadership

FEATURED PIECES 7

Health Equity in Action: A Local LGBTQ+ Diabetes Prevention Pilot

12 RISE Public Health Crossword 13 Locating Autonomy within Women's Reproductive Health in Chiapas, Mexico 15 Community-Engaged Science for a Healthier Montbello 18 Colorado's Young People are Screaming for Help. It is Time to Stop Ignoring Them.

20 PhD or DrPH? How Program Reformation Can Create Expert Researchto-Policy Translators 23 COVID-19: The Effects on Frontline Healthcare Workers 27 The State Government's Moral Obligation to Address the Mental Health Crisis 32 Covid-19 Pandemic: War on a Mother's Mental Health?

34 The Shell Doesn't Fall Far 35 Connecting Classroom to the Field in a Healthcare Industry – Story of a Student from Peru 36 Implementing a Health Behavior Theory – Opinion and Personal Experience

OUTSTANDING EMERGING LEADER RECOGNITIONS 26 Outstanding Community Service 31 Outstanding CPHA Emerging Leader

CONTRIBUTORS AND REFERENCES 38 Authors and Artists 39 References

EDITORS Hannah Craig Hannah is a Master of Public Health student in the Environmental and Occupational Health Department at the Colorado School of Public Health. She received her bachelor's in Public Health and Environmental Studies from Tulane University in 2018. Her early career experiences have been in migration, food systems, and gender research; she has worked with an interdisciplinary team using big data approaches to food security research in Colombia and studied socioecological factors related to gender-based violence among refugee populations in Greece.

Recently, Hannah's interests are coalescing around the study of human-environment interactions and the roles that urban neighborhood environments can play in chronic disease prevention, including neighborhood walkability, access to green spaces, community gardens, and sustainable transportation. Hannah is an avid composter and amateur collage artist.

Chelsea Sobczak Chelsea Sobczak is a Research Services Senior Professional at the University of Colorado School of Medicine. She works across projects focused on increasing equitable access to care, and equipping practices to better support their patients in the Department of Family Medicine and the Practice Innovation Program. Chelsea received her bachelor’s in Dietetics with a minor in Global Health (2015), and after working as a nutrition practitioner, chose to focus on healthcare access and education by pursuing her Master of Public Health with a focus in Community and Behavioral Health (2017).

During her graduate studies, she worked with a local non-profit on a public health intervention designed to re-direct patients from unnecessary emergency department visits back to their patient-centered medical home, reducing costs and improving quality of care. She has since also worked in healthcare policy and finance consulting, and public health graduate student advising, before returning to public health interventions and research. She values using community engagement strategies to ensure collaboration with stakeholders and those affected by research interventions. In her spare time, Chelsea enjoys cooking or trying new restaurants, and hiking with her husband and dog.

Sami Wilson Sami is a first year MPH student in the Global Community and Behavioral Health concentration at CU Anschutz. For the last two and a half years, she has worked at Planned Parenthood of the Rocky Mountains in a patient-facing role in a health center and now in Learning and Development. She is passionate about promoting comprehensive sexual and reproductive health education so that individuals can make informed choices about their bodies.

Sami earned dual bachelor's degrees from University of California, Berkeley, in Environmental Health and English where she pursued extracurricular activities in both fields. She is interested in using her interdisciplinary background to draw connections across fields and topics within public health. In particular, she is interested in drawing connections between climate change and reproductive health.

Outside of work and school, you can find Sami hanging out at coffee shops, eating good vegan food, and enjoying outdoor activities.

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CONTRIBUTORS Samantha Bertomen Co-Founder of RISE Associate Director of Emerging Leaders

Samantha (she/her/hers) is the Community-Based Organizations Coordinator at TriCounty Health Department. Through this position, she builds community partnerships, manages funding, and provides resources to support long-term recovery from COVID-19. As a Master of Public Health student and Student Senator at the Colorado School of Public Health, Samantha represents her peers and assists in coordinating the university’s annual Emerging Leaders Conference. She serves on several Colorado Public Health Association committees, including the Public Health in the Rockies Conference Committee, the Communications and Membership Committee, and the Public Health Policy Committee.

Jeni Mitchell Marketing Coordinator

Jeni currently serves as Social and Digital Media Student Assistant for the Colorado School of Public Health in the Office Of Communications and Marketing. In her role, Jeni manages the school's Instagram account, supports in content creation, and website management. In her work, she aims to promote ColoradoSPH as an educational institution and leader in the public health space while also highlighting the school's events and current research.

Jeni earned her bachelor's degree in Food Science and Human Nutrition concentrating in Dietetics and Nutrition Management from Colorado State University in 2018. For the last three years, Jeni has been building her marketing skillset while working for a Colorado-based digital marketing agency focusing in marketing coordination, blog and podcast management, and event planning/organization. Jeni is currently pursuing her Master's in Public Health from the Colorado School of Public Health and is concentrating her studies in Community and Behavioral Health.

Lisa Peters

Co-Founder of RISE Director of Emerging Leaders Lisa is a team member at Centura Health! She works on the reimbursement team, helping Centura hospitals with Medicare, Medicaid, and Tricare cost reporting. She assists hospitals with Medicare bad debt and reimbursement analyses, wage index reviews, volume decline and geographic reclassification, and various low volume and disproportionate share hospital applications. Lisa is passionate to support Centura hospitals tackle their healthcare and reimbursement needs.

In her free time, Lisa loves serving the community. She has served four years on the Young Professionals Board of Boys Hope Girls Hope, raising over $300,000 for Colorado high school students who overcame a challenging or disadvantaged background.

Lisa is a 2019 graduate of Colorado Christian University, Denver, with bachelor’s degrees in Accounting and Business Administration. She is currently pursuing a Master of Public Health through Johns Hopkins Bloomberg School of Public Health and expects to graduate in 2024.

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CPHA Emerging Leaders Networking Event 2021

LETTERS FROM LEADERSHIP As we journey into the future of public health, we recognize the need to build strong leaders in order to create a public health movement. The last few years have placed public health professionals front and center to be scrutinized, leading to a high turnover in our field. It has never been a more important time to build up our public health leaders. This is one of the reasons we were inspired to create RISE Magazine.

Over the past year, emerging leaders in public health have stepped up across Colorado. Our goal in creating RISE Magazine is to highlight, encourage, and connect emerging leaders as you continue to rise in this field. You are an essential component of CPHA and the future of public health.

Most importantly, we want to remind you to have compassion for one another during this time. We have experienced a worldwide public health crisis together, and empathy is greatly needed. As you enjoy articles and pieces of art from your peers, we encourage you to take pride in one another’s work. We have pushed through adversity, and now we get to celebrate with each other.

Together we RISE! Lisa Peters & Samantha Bertomen Emerging leaders Committee, CPHA

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LETTERS FROM LEADERSHIP Greetings Colorado Public Health, I would like to welcome you all to the launch of CPHA’s Rise magazine. It couldn’t have come at a better time. Across the United States we are forced to contend with sustained anti-public health backlash, and organized efforts to undermine and disempower our efforts. We also continue to face down the challenges of a global pandemic, endemic racism, climate crisis, political polarization, anti-science, and misinformation and disinformation campaigns.

We have never needed a galvanized, unified, and mobilized public health more than right now. Luckily, in the aftermath of the past two years we are also seeing a dramatic increase in public health admissions within universities across the nation and the rise of a younger generation of passionate visionaries committed to advancing health, justice, and equity within our communities and legislatures.

It gives me great hope, and confidence, to see these emerging leaders standing at the ready to help sustain and advance our movement. In the pages and issues to follow, we will introduce you to some of these future heroes as well as highlight and celebrate the work of current Public Health champions.

I would like to say a special thank you to Lisa Peters and Samantha Bertomen, our Emerging Leaders Committee, and contributors for making this happen.

I also want to say thanks to you, Colorado Public Health, for your tireless and courageous service to our state during these precarious, exciting, and historic times.

Jason Vitello, MSW President CPHA

President Vitello speaking at the 2021 Public Health in the Rockies Conference

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CPHA Members hike during Public Health in the Rockies 2021

Health Equity in Action: A Local LGBTQ+ Diabetes Prevention Pilot Tessa Cushman, RDN In my almost 2 years of being part of a local diabetes education program dedicated to reaching individuals at highest risk of diabetes and related complications, I have noticed that more often than not, those are the folks missing from the programs. I started questioning why.

Self-Management Education and Support.

Through the Cancer, Cardiovascular, and Chronic Pulmonary Disease grant from the Colorado Department of Public Health and Environment (CDPHE), we provide these services at no cost to participants with a mission to reach under- and uninsured community members.

To give some background, I am a registered dietitian nutritionist and diabetes coach that facilitates diabetes education classes with Tri-County Health Department (TCHD). Our Diabetes Education Program hosts the Center for Disease Control’s (CDC) National Diabetes Prevention Program – what we call Journey to Wellness – and Diabetes

This is where health equity comes in.

Programs could (and should) look at social determinants of health and higher priority needs, but the best place to start analyzing is internally. What makes our program difficult to access? What makes it feel unwelcoming, uninviting, or unsafe to some communities? These questions led me to

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start the research for our Health Equity Quality Improvement project, which helped us further identify our priority populations, or those who could benefit greatest from our no-cost services.

The most current studies and statistics reaffirmed notions I was already familiar with.

Diabetes Risk in the LGBTQ+ Population LGBTQ+ folks such as myself make up one of the many marginalized demographic groups that face higher risk of unmet social determinants of health, poor health outcomes, and chronic diseases like type 2 diabetes. Sexual orientation and gender identity alone do not affect our risk of these conditions. Rather, discriminatory systems and oppressive policies that have been around since colonization – whether overt or covert – are what puts “sexual or gender minorities” in harm’s way.

LGBTQ+ health remains underreported in research and wasn’t included in the US Department of Health and Human Services 10year national public health objectives until Healthy People 2010 (1,2). Despite this, the latest research confirms a clear trend of worse health outcomes and social determinants of health for LGBTQ+ folks. According to a 2021 study, transfeminine individuals are at a 40% greater risk of developing diabetes than their cisgender counterparts, unassociated with genderaffirming hormone therapy use (3). Bisexual and lesbian women have a higher prevalence of diabetes compared with heterosexual women (4). Gay and bisexual men and transgender women are disproportionately living with HIV, and more lesbians than heterosexual women are living with Polycystic Ovarian Syndrome (PCOS), both of which conditions are risk factors for developing type 2 diabetes (1,4). Lastly, research indicates up to 20% of people with diabetes engage in patterns of disordered eating (5), and a 2020 online survey showed that 28% of the LGBTQ+ respondents reported at least one behavior associated with eating disorders – while only 4.3% reported having sought treatment (6) – putting queer folks with diabetes at even higher risk of disordered eating and eating disorders.

These health inequities are clearly traced to discrimination and oppression.

In the Envision:You Colorado LGBTQ+ Behavioral Health State of the State Survey Report, 37% of the 588 LGBTQ+ survey respondents reported experiencing discriminating or non-affirming language, practices, or interactions in medical or primary healthcare, with trans folks significantly more likely to report this (7). A report by the Center for American Progress found that almost half of all transgender people and 68% of transgender people of color have experienced mistreatment by their healthcare providers (8). Difficulty obtaining medical care and health insurance may be influenced by family estrangement, legal discrimination in housing, employment, marriage, or retirement benefits (9,10). According to a 2016 report, queer folks experienced food insecurity at almost double the rate of straight, cisgender folks in 2015 (11). LGBTQ+ people experience mental illnesses such as depression at a rate up to four times higher than cis, straight counterparts, and are at higher risk of experiencing adverse childhood events, both of which are associated with an increased risk of developing diabetes (12,13).

The compounding prejudices stemming from white supremacy increase the allostatic load, or cumulative burden from chronic stress, experienced by further oppressed populations.

Queer Black, Indigenous, Latinx, and other people of color face the aggregate traumas of systemic racism and face a substantially higher risk of type 2 diabetes than queer white folks.

Immigrants and refugees experience additional barriers to receiving healthcare diagnoses.

Disabled queer folks must navigate the tribulations of ableism. Queer folks in larger bodies face weight discrimination – most namely in the healthcare setting – which increases risk of disease and death by up to 60% regardless of body mass index (BMI), according to a 2017 study on 10-year allostatic load of perceived weight discrimination (14). More research to fully understand the impacts of all kinds of discrimination on health should be prioritized in science and public health.

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In addition to experiencing increased risk of type 2 diabetes, LGBTQ+ people may feel that programs aimed at preventing diabetes are not safe, inclusive, or accessible. Such programs may have high fees or require health insurance coverage, and often follow strict standards that may include white-centered, weight-centric, and heteronormative curriculum. As stated in the March 2022 issue of ADCES in Practice, the publication of the Association of Diabetes Care & Education Specialists (ADCES), “non-LGBTQ specific groups may be perceived as potentially homophobic and/or transphobic, and therefore intrinsically non-safe spaces,” (8). To counter this, and as recommended by a Center for Medicare & Medicaid Services (CMS) resource inventory, adapting evidence-based interventions for the intended audience is a “promising way of meeting the needs of diverse populations,” (15). That is exactly what our program at TCHD set out to accomplish.

The First LGBTQ+ Diabetes Prevention Program Pilot OFM Journey to Wellness is a novel pilot intervention for LGBTQ+ diabetes prevention and health promotion. We have partnered with OUT FRONT Magazine (OFM), a local Colorado queer publication, to host the first (to our knowledge) LGBTQ+ focused diabetes prevention program. The program goals include expanding the equity and inclusiveness of all of our diabetes education programs, gathering program feedback from LGBTQ+ community members, and submitting our findings and curriculum to the CDC for consideration of national implementation through the National Diabetes Prevention Program.

As a Bloomberg Fellow with the Johns Hopkins Bloomberg School of Public Health, I plan to use knowledge gained from the graduate program, insight from collaborating agencies and other fellows, and university research arms to help achieve the goals of this program. Program evaluation will be strengthened, and curriculum will be refined and standardized before submission to the CDC. With the hopes of continuing this pilot intervention into the future, the program could be a candidate for future research conducted through the university.

The program’s novel diabetes prevention approach is in alignment with research and recommendations for LGBTQ+ health promotion. The aforementioned CMS Resource Inventory, Diabetes Prevention Programs: Equity Tailored Resources, recommends emphasizing overall health improvement rather than weight loss when tailoring services for the LGBTQ+ community. Such strategies include promoting increased physical activity, decreased consumption of sugar-sweetened beverages, and increased fruit and vegetable intake, rather than focusing on BMI and weight loss (15). A 2022 analysis of 55 women engaging in Health At Every Size®-based interventions found that, alongside the participants who lost weight, those who maintained weight or even gained weight also improved waist circumference, clustered metabolic and cardiovascular risk, and quality of life, “suggesting that weight-neutral, lifestyle modification interventions may improve healthand wellness-related markers even in the absence of weight loss,” (16). This approach is especially critical in a population with higher risks of disordered eating, eating disorders, and healthcare discrimination.

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OFM Journey to Wellness supports achieving individual health goals with this approach. We prioritize queer peer support, body-neutrality and acceptance, inclusive and joyful movement, anti- diet culture, and attention to mental health and trauma-informed care, all in an affirming environment. The program runs for a year, with one class per month held in-person and the other half held online. As our first hybrid program structure, we aim to break down barriers of both in-person (e.g. reliable transportation, additional time, childcare, immunocompromising conditions), and online formats (e.g. technology and stable internet access, visual or auditory impairment). Any participant with barriers to either format is offered flexibility and resources.

The adapted LGBTQ+ inclusive curriculum invites and honors open dialogue to promote “messy peer learning,” a term I have borrowed from a good friend and coworker. As the facilitator, I acknowledge the privileges that come with my identities of being white, cisgender, able-bodied, thin, and holding a degree in higher education; while simultaneously bringing my perspective as a bisexual woman with a family history of diabetes, nutrition insecurity, and low socioeconomic status. Each session encourages the sharing of topic ideas, resources, input, and realtime feedback or constructive criticism to uplift and value the unique perspectives that each participant brings.

Considering the privileges I hold, it is imperative for me to call out that white, thin women are the main demographic profiting and receiving credit as the leaders of the body-neutral, anti-

diet, Health At Every Size® movement. As Marquisele Mercedes – a writer, doctoral student, and Presidential Fellow at the Brown University School of Public Health – writes, the movement arose as a response from Black, Indigenous, disabled, and LGBTQ+ folks to the injustices against marginalized bodies (17). The Association for Size Diversity and Health states that the community movement was heavily influenced by the 1960s Fat Underground organization (18). Body image and fat acceptance advocate Stephanie Yeboah once said, “[Body positivity] stems from the fat acceptance movement, which is more political than anything, [and] was created as a safe space for fat women to celebrate themselves as no one was celebrating us or seeing us — and all our interior amazingness — for what we were. Now it’s used as a marketing term and has forgotten about the very bodies that created it…,” (17). The voices of leaders like Marquisele and Stephanie should be uplifted and followed by any program or agency that is adopting these approaches.

The Bottom Line OFM Journey to Wellness launched in January 2022 with a cohort full of inspiring, supportive, and kind-hearted folks. Participants are both aware of and eager to support the program’s mission by providing feedback on curriculum and approach. The rapport that has already been built is unmatched to any other group that I have facilitated, and I chalk that up to the environment we’ve created together. Below is a powerful quote from a participant that speaks to their experience thus far.

"This program has been nothing short of lifechanging for me.

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I know for me personally, I am healing because I am incredibly supported – and I've made some new friends too!

Public Health in the Rockies 2019

Over the years, I have tried several different programs to help improve my health and nutrition, from apps to point systems to inperson groups. Unfortunately, most of these programs were rooted in toxic diet culture – and I never felt like I learned anything sustainable.

This group busts through that toxicity, and creates a place to engage in collective wellness in a productive and inclusive way. Beyond that, the social support is something I have never experienced before as a trans, disabled and queer person of color. With community to support rather than judge, I have been hitting my goals, and finding myself motivated to reach for the next ones. I hope that this program is able to run again, so that more people will have the opportunity to try it. I know for me personally, I am healing because I am incredibly supported – and I've made some new friends too!"

Health equity has been an integral part of public health conversations for years, and has been substantially pushed to the forefront since the racial reckoning of 2020. It is the responsibility of agencies delivering health services to reduce harm and promote health of communities impacted most by oppressive systems. Any pilot that is the first of its kind has the potential to make the necessary waves of change and serve as a paradigm for other equitable programs to come to fruition.

Let’s put the health equity conversation into action, and allow vulnerability to birth new opportunities for meaningful change.

To connect more on this topic, please feel free to reach out to me at tcushman@tchd.org.

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RISE Public Health Crossword Sydney Chaves Answers on page 42

Across

Down

1 8 9 10

2 3

13 15 17 18 19 21 22 23

Social determinant of health (4 of 5) Summer mountain activity Colorado's Governor The improvement and accountability of programming Tallest peak in Colorado Math, related to biology Social determinant of health (3 of 5) The human process of change Equal opportunity to live the healthiest life possible Largest CoSPH campus Improvement of systems through new ideas Professors, peers, and colleagues

4 5 6 7 9 10 11 12 14 16 20

Northern most CoSPH campus Collaboration between inter-professional organizations Rulemaking at the population level Winter mountain activity Most populous county in CO Social determinant of health (1 of 5) What you gain from the top of a mountain Control of diseases and other factors leading to health Funding stream Social determinant of health (2 of 5) The absence of disease Social determinant of health (5 of 5) 12 Smallest CoSPH campus

Locating Autonomy Within Women’s Reproductive Health in Chiapas, Mexico Elizabeth Atwood

Beginning in the 1970s, Mexico adopted changes in public services, including a more privatized, Westernized healthcare system.

Mexico altered its health services to fit a global understanding of women’s reproductive care: to expand women’s reproductive health rights and reduce population levels. While perhaps wellintentioned, these policies are undergirded by a hegemonic history of Indigenous disregard and maltreatment by the Mexican government.

In rural regions such as Chiapas, Mexico’s southernmost state, there is a relatively high Indigenous population of 24% (1). Moreover, the maternal mortality rate is the second-highest in the country, at 68/100,000, and the infant mortality rate is the highest in the country, at 17.9/1000 (1). Chiapas is the most impoverished state, with 74.7% of the population considered impoverished in 2012 (2). Health discrepancies such as these have developed due to inconsistencies between local medical knowledge and Western biomedicine, obstacles in accessing care, and continued discrimination by the Mexican State.

City street in San Cristóbal de las Casas, Chiapas, Mexico, 2019.

Photo credit: Elizabeth Atwood.

In light of this context, I set out to examine if adopting Western concepts such as the medicalization of health necessarily lead to a better healthcare system. My undergraduate thesis, as part of the University of Denver Honors Program at the Josef Korbel School of International Studies, examines women patients’ (Indigenous and non-Indigenous)

perceptions of reproductive services offered by a private health clinic in San Cristóbal de Las Casas, Chiapas, Mexico called “Atención en Salud Sexual y Reproductiva para La Mujer” (AMASS) and seeks to understand if AMASS’ approach is working for and desired by patients.

To answer these research questions, my study employed a combination of survey data, a one-on-one patient interview, and participant observations from community health discussions. Twenty-two patients completed the voluntary, anonymous survey after receiving one of these services from the 13

AMASS clinic: family planning, prenatal, papsmear, or abortion. Twelve of the 22 patients indicated that they are Indigenous, 17 reported having been to AMASS before, and all patients indicated that they were either “very satisfied” or “satisfied” with quality of service, quality of care, and respect. The one-on-one patient interview elucidated similarly positive responses; the patient reported that the quality of care is different at AMASS than at other clinics; patients report feeling secure, trusted, and that their autonomy is supported.

Despite possible response bias, the overwhelmingly positive trends underscore the need for clinics like AMASS. Many patients seek their services because the clinic is welcoming, flexible, and accessible.

Regardless of Indigenous identity, patients were in support of AMASS’ services. This could be attributed to patient characteristics, such as being progressive and more accepting of medicalized care, or the positive results could be less about the services provided and more about the environment of care. AMASS engages in open conversations about women’s reproductive health, offers flexible prices, has female doctors who speak Indigenous languages, and respects Indigenous preferences such as keeping traditional clothing on during examinations.

The quality of the care provided, as suggested in the results of my survey, seems to be the paramount concern for women seeking reproductive services.

Additionally, my research aimed to identify why women come to AMASS rather than local clinics or hospitals. As cited in the literature, obstacles to public healthcare include: location, cost, misinformation, and cultural/linguistic barriers (3,4,5). Concerns with the healthcare system include: lack of respect from practitioners, disregard for cultural health practices, invasive practices, distrust of practitioners, and unequal power dynamics (3,4,5). How is AMASS addressing these obstacles and concerns?

AMASS is a private health clinic in the city of San Cristóbal, so indigenous women in rural communities may not have the means to access the clinic or may be unaware that it exists. The clinic combats cost concerns by offering low prices, working with women to pay

for services over time, or finding other funding.

While some staff speak Indigenous languages, there are several local Indigenous languages spoken in Chiapas and the physicians do not speak every language. AMASS aims to respect tradition and educate their patients. Family members are welcomed to attend consultation appointments to learn more about reproductive rights, for example, and AMASS only employs women because patients are more comfortable with female health professionals.

This case study presents evidence that both Indigenous and non-Indigenous women are seeking respectful reproductive care which serves to educate and empower them. Women’s reproductive health care must not be dismissive of local understandings, but actively incorporate this knowledge alongside advancements in technology offered by the Western world. As this study and many others emphasize, there is no one-size-fits-all approach to healthcare. To adopt a universal protocol is to align with global interests and to discount the complex interests of a multicultural nation.6 It is an act of blatant disregard of the histories and knowledge of different cultures within the region and around the globe.

Rather, frameworks for reproductive health must be created by local women. While autonomy should certainly be a universal goal, the means to this goal should be locally defined.

Women’s reproductive health care in Chiapas may have similar characteristics to other systems, but it should be unique in the ways local Indigenous knowledge is embedded. It should not be up to international organizations or nation-states—rather, this process should manifest authentically and with respect to local culture.

The conclusions of this research are not limited to Mexico and can also be applied in the United States: a one-size-fits-all approach to reproductive care is outdated, oppressive, and ineffective at meeting women’s diverse and personalized needs.

To read the full version of the thesis or to continue the discussion, please contact Elizabeth Atwood at liz.atwood0812@gmail.com or connect with her on LinkedIn. 14

Walk audit participants cross an intersection in Denver’s Montbello neighborhood, February 2022.

Community-Engaged Science for a Healthier Montbello Hannah Craig & Pam Jiner To get from Denver’s Montbello neighborhood to the nearest greenway is no easy feat.

Assuming one is able to make the journey by foot, the walk will take the better part of an hour.

To speed things up, a public bus stop or two dot the route but riders must stand, uncovered while they wait for a ride. Cars whizz past, and the noises from the road make it hard to hold a conversation. The journey proves inhospitable for most, the task not valued by the energetic systems that rule this part of the neighborhood.

Infrastructure and design changes, particularly ones that benefit the health of the Montbello community, like an enjoyable pedestrian journey to a nature trail, have lagged behind the social, political, and economic shifts that have occurred in the neighborhood since it was built in the 1960s. Today, the multicultural,

linguistically diverse community with veteran and older adult populations, has a relatively low median household income and experiences certain poorer health outcomes than other areas of Denver, such as rates of COVID-19 (1,2,3). A significant percentage of residents are located more than one mile from the nearest supermarket, and the neighborhood is considered a medically underserved area (4, 5).

Pam Jiner, a 45-year resident of Montbello and an award-winning community leader, is well acquainted with the physical realities of the neighborhood and the reciprocal relationships they have with community health outcomes.

Several years ago, she set out to make some changes.

Using the community-based participatory research methods (CBPR) and digital tool outlined in the evidence-based Our 15

Voice Initiative developed by the Stanford Prevention Research Center, Pam gathered community members, or “citizen scientists”, and began collecting data.

They used the Our Voice digital application, the Discovery Tool, which is downloaded by each citizen scientist and used to collect geotagged photos, narratives, ratings, and walking maps of the neighborhood. It coalesces a unique combination of data (qualitative perceptions of the built environment as well as quantitative geographical information) to tell a collective story of people and place.

Pam and Montbello citizen scientists then analyzed their aggregate findings from the Discovery Tool, prioritized needs, and used the data to generate recommendations for change.

Four years of collective action later, they ultimately secured miles of sidewalks, crosswalks, and other pedestrian infrastructure along a central neighborhood street, increasing access to public transportation, greenspace, health care, and a variety of businesses.

In October 2021, I began walking, learning, and working with Pam and community members, gaining experience with community-engaged research at the intersection of health and the built environment. As a first-year Master of Public Health student, the new neighborhood infrastructure and its potential to positively impact health outcomes is compelling, but I’m also intrigued by the process—the way the Discovery Tool and CBPR process create new information flows through social networks, building skillsets, connections, and capacities (data collection, stakeholder mapping, cost benefit analysis, etc.) along the way.

What are the ripple effects of this communityengaged process, and how will it impact people and the environment in the long-term? Could the generative aspects of this process be integrated with other methods for quantifying human-environment interactions to yield even more impactful change for healthier communities and sustainable environments?

As I approach these questions through our work in Montbello over the next several months, I look forward to uncovering and understanding the synergies of this work in Montbello and how they can be leveraged for continued human-environment progress in the neighborhood. For more context on this work, I interviewed Pam briefly on these topics in March 2022.

Tell me about community health in the neighborhood. From your point of view, what are the strengths, and what problems does the community experience?

“We are extremely diverse, and I think that’s where our strength lies—the fact that we can come together, build, connect, and unite our community—that, to me, is our biggest strength.

Some of the problems that we face health-wise are the financial strains on our community and neighborhood infrastructure. We are a lowincome community, and our infrastructure needs to be improved because it’s affecting our community’s health. Unsafe streets, incomplete sidewalks, the absence of stop signs—basic traffic and pedestrian access needs to be looked at.

Grocery stores are also a big thing. We have been advocating for a full-service grocery store that provides us with more healthy options.

Through that advocacy, we have a new store coming to our community. Through the planning process, we got together with developers, and we told them what we would like to have in our community, like a sit-down restaurant. That’s something that we don’t have. Everything is fast food. We would like for the new development to be designed so that residents can bike to it, walk to it, have access without putting their bodies in harm’s way.”

What connections do you observe between community health and the built environment?

“The ways that many neighborhoods have been built can be isolating for certain populations,

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We are extremely diverse, and I think that’s where our strength lies—the fact that we can come together, build, connect, and unite our community—that, to me, is our biggest strength.

including older adults, people in wheelchairs, children, people who speak different languages.

There’s a whole gamut of things that are isolating.

minds. It’s humiliating. It’s degrading. Every time we walk, with our handicapped, with our kids, we wonder why this isn’t a complete street.”

Montbello has been here for decades, and we are just now speaking out about things that we’ve all been tired of for 40 years. I think that’s why I garnered my community behind me. I knew my voice would not be heard. Why don’t we have sidewalk or safe routes to school? Why aren’t our schools safe? It’s like we have to prove ourselves worthy of amenities that most communities get automatically.”

What are your visions and goals for Montbello? What would a healthy community look and feel like for you?

What have you found to be the most effective strategies in your work? How have you observed decision-makers responding differently when you have data in hand?

“The biggest thing is getting community members involved. They talk about it with their families. Everybody calls their representatives, and City Council gets involved. We come together to let everybody know what we’re concerned about.

It took four years of advocating for sidewalks along sections of Peoria Street to get decisionmakers to come out for a community walk audit. We did a presentation of all the data we had gathered. City Council presented. We told the history. We said, “This is our normal, and we’re tired of it. It’s hard on our bodies and our

“If we get everything done that we’re working on—grocery stores with fresh produce, sit-down restaurants that are pedestrian-friendly, bicyclefriendly, and electric vehicle-friendly, playgrounds built into shopping centers with benches and coverings, lower traffic speeds— that is a great start.

In my vision, everybody would be outside. You wouldn’t be able to drive down a block without seeing people playing outside, walking, biking, hanging out. We’re going to get benches put all around the community so that if you are walking, you can sit and relax. We’re going to have plants and more traffic lights.

I see an active community. I see places where people can gather and connect. My vision is people are waving, talking, and laughing on street corners. I want everybody to feel included and connected.”

For more information, or to continue the conversation, please contact Hannah at Hannah.craig@cuanschutz.edu.

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CPHA President, Vitello, offering a few words at the Colorado School of Public Health Mixer 2022.

Photo Credit: Juan Roberto Madrid

Colorado’s Young People are Screaming for Help. It is Time to Stop Ignoring Them.

Elizabeth Boland Colorado’s pediatric mental health professionals are struggling to stay afloat amidst a tsunami of desperate need. On May 25th, 2021, Children’s Hospital of Colorado declared a state of emergency. Over two years, they experienced a 90% increase in demand for pediatric mental health services (1). Children’s Hospital Colorado and many other medical institutions across the state have been overwhelmed by children in desperate need of mental health care.

Emergency rooms are flooded with pediatric patients who have attempted suicide. In fact, suicide is now the leading cause of death for Colorado children aged 10 and older (2).

Youth mental health crises have deep reverberations across society.

Suicide contagion is a well-documented phenomenon - the suicide of one person can lead to others within that community, school, or peer group also taking their own lives (3). Suicide contagion causes despair to spread through a community in a manner like an infectious disease. For example, between 2013 and 2015, 29 children in El Paso County alone committed suicide (4). At one point, 5 students in a single Colorado Springs high school committed suicide in a semester long period (4). The COVID-19 pandemic has only exacerbated Colorado’s existing youth suicide crisis.

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The current mental health crisis is apparent to anyone working in Colorado’s classrooms.

Schools across the state are seeing higher rates of behavioral problems. Children are getting into more frequent physical altercations in the classroom, and teachers have reported elementary school students attempting to stab each other during class.(5) These behavioral problems are taking an enormous toll on teachers and students. In January of 2022, according to the National Education Association, 55% of teachers reported that they were preparing to leave education (6). The increase in behavioral problems in schools is certainly likely to be a contributing factor. If action is not taken to address the current crises, children, teachers, and the educational system will be at risk.

There are several immediate actions that we can and must take to improve our current situation. First, we must make a statewide effort to increase the pediatric mental health workforce. The government can provide schools with grants to hire mental and behavioral health professionals. This will be especially needed for schools in rural or otherwise medically under-served communities.

Additionally, government can work to increase the quality of broadband services in rural and medically under-served communities. Mental and behavioral health is often delivered very successfully through telehealth, so better broadband access translates to better healthcare access. At the same time, Colorado must prioritize the training and retention of the next generation of mental health professionals, including providers, counselors, and therapists.

In addition to increasing the accessibility of mental health services, action can be taken in schools. Topics like resiliency and mental health can be built into curriculum. Administrators can be better trained on how to support teachers in the classroom as they deal with behavioral issues. These changes can help improve the mental health of not just students, but also teachers and other school staff who are overwhelmed by the scale of the crisis they are being forced to shoulder.

However, the effort to improve youth mental health cannot and should not fall solely on the backs of educators. Policy makers and public health officials can begin to bring back structure and major life markers that students have lost throughout the COVID-19 pandemic. Pandemic policy must find the balance between preventing COVID spread and bringing normalcy back to kids’ lives.

Many pandemic policies have deprived students of access to friends, activities, athletics, and routines that act as valuable mental health supports during development.

Mental health professionals have cited the loss of structures and routines as contributing to the current crisis. Returning students to as much normalcy as possible is a broad, immediate mental health solution. Now that more is known about COVID prevention, transmission, and treatment, public health officials must use the data to take action to address both the COVID-19 pandemic and the pandemic of despair currently spreading across the state.

Lolina, Inc. is a healthcare and public health consultancy. They work with clients to strengthen essential components of the healthcare system to achieve improved population health.

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CPHA Members after a CPHA Outside Yoga event lead by Samantha Bertomen, 2022

PhD or DrPH? How Program Reformation Can Create Expert Research-to-Policy Translators Sarah Boland, MPH

In graduate school, I’ve been taught that good research translates to good policies and good health. If you can only just gather enough evidence, surely those in power will make the choice that is best for our community.

However, the COVID-19 pandemic has made clear the shortcomings of this belief. Despite the growing scientific evidence and death count, some policymakers remain resistant to mask and vaccine recommendations (1). A potential solution to this evidence and policy divide may lie in a less common but critical academic degree, the applied doctorate in public health (DrPH). However, DrPH programs across the U.S. prepare future public health professionals with applied skills, such as policy translation, to varying

degrees and are less common than traditional research doctorate (PhD) programs (2,3). The key to improving research-to-policy translation is multifold.

We must address curriculum inconsistencies to ensure that all DrPH graduates possess strong skills in policy, management, and communication, and we must simultaneously increase investment in and appreciation of DrPH programs.

To better equip this new generation of public health translators, I propose greater attention to DrPH curriculum and final project requirements so that each program is in alignment with accreditation requirements and practice-based skills.

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Last year, researchers from San Jose State University Department of Public Health and Recreation interviewed DrPH Program Directors across the U.S. and found that program requirements and training vary significantly from school to school (3). Some programs are administered by departments while others are offered school-wide (3). DrPH program websites also present stark variations in course requirements and final project (dissertation) requirements. My university, for instance, trains DrPH students more like research scientists than policy specialists or communication specialists. Whereas, at other universities, the curriculum differs more clearly from a research-focused degree (PhD), with substantial training in leadership development, applied public health, and policy analysis. Only by coordinating the structure and experience of DrPH programs can we train this important segment of public health professionals to translate good research into good health.

Regarding curriculum, Program Directors and their Dean of Students must prepare students to communicate with diverse audiences and to navigate political systems. This includes mandatory classes in communication and policy development alongside hands-on experience with advocacy organizations and policymakers. DrPH programs need more applied final project options that go beyond a traditional dissertation. Top schools like Tulane University (4), Boston University (5), and Columbia (6) allow students to choose from a variety of final project formats that deviate from traditional research dissertations (such as writing a case study, developing a legislative brief, or designing their own public health program). For example, students can develop case studies that look at how an organization, city, or state has implemented a policy or program. Case studies are commonly used in business and policy settings to decide how a successful strategy can be replicated. Given that the final project ideally prepares DrPH students to communicate with leaders of diverse backgrounds, it does not make sense to restrict students to academic journal writing.

To properly equip DrPH students with the communication skills they will require to be successful research-to-policy translators, we need more instructors and faculty with applied backgrounds. A second study from San Jose State University, which combined quantitative assessment of DrPH handbooks and qualitative assessment of DrPH program directors, highlights the limited faculty support available to DrPH students (7).

Interviewees mentioned mismatches between PhD faculty and DrPH students—the purpose of the DrPH degree is not clear to all faculty and lack an understanding of how to best prepare their students for non-academic careers (7). Part of the issue, according to Program Directors, is that university leadership does not prioritize hiring nontraditional faculty. Instead, professionals with applied backgrounds are brought on as adjunct or part-time faculty (7). In my own experience, faculty from governmental, nonprofit, and corporate sectors play a key role in public health training, as they bring outstanding skills and case examples to the classroom, drawing from their non-academic work experiences. Their presence is greatly needed in DrPH programs.

I call on accreditation institutions and leading programs to hold other universities accountable in providing an applied education as advertised on their webpages.

Schools of public health are accredited by one common organization, the Council on Education for Public Health, which establishes accreditation requirements, yet each school has its own interpretations of these requirements. For example,, my school advertises the DrPH program as preparing students for “leadership, management, and advocacy,” yet there are no required courses in communications or policy. Instead, there are plenty of required courses in research methods and a traditional dissertation requirement. This seems misaligned with the fact that over half the required competencies, or skills developed, in DrPH programs are focused on leadership, management, and policies.

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The public health community needs more professionals with an applied, versus solely research perspective, so I invite public health professionals to consider what a DrPH degree offers. The aforementioned study by San Jose State found that almost three-quarters of the DrPH program directors interviewed were eager to see the degree get the appreciation it deserves (3). Yet these critical translators are scarce with small programs scattered across the country. Though all the major schools of public health, such as Johns Hopkins and Harvard, have a DrPH program, these institutions represent less than a third of all public health institutions (7). The same is not true of more traditional research training programs like the PhD, where we see twice as many PhD programs as DrPH programs (2). With fewer programs and peers to look to, DrPH students and alumni have formed a national movement called the DrPH Coalition which amplifies DrPH voices and purpose (8).

This disconnect between the spirit of a DrPH and training realities is ultimately a disservice to our communities and their wellbeing. Research articles and presentations fall short in addressing health issues without the implementation and application pieces. We need to invest in training public health leaders with both research and policy knowledge. By increasing attention to DrPH programs and by creating more academic consistency in training, we increase the likelihood that data will reach the people and places that need it most; thus, increasing the chance that good research translates to good health.

Public Health in the Rockies 2019

CPHA Emerging Leaders Networking Event 2021

COVID-19: The Effects on Frontline Healthcare Workers Garvita Thareja, Autumn Ortega, and Andrew Salter The pandemic, as we all can attest, has made a significant impact in our lives and day to day operations. Since the beginning of the pandemic in 2020, we all have felt the devastating grasp that COVID-19 has had on everyone's normal life. As a human race, we have grieved terrible losses, experienced crippling sickness, and have been shoved into our homes for hiding to come out only as needed. The mental health impacts are devastating. A nationwide study found that during the first year of COVID, depression rates tripled (1). The same study also indicated that the symptoms of depression did not peak and fall, rather continued to rise (1). But what about the impacts on our frontline workers? Those working face-toface with the deadly virus… everyday! It’s clear that these populations, who directly interact with cases of COVID-19 and experience either

the symptoms of or death due to COVID, are possibly the most vulnerable population. In order to mitigate these mental health issues faced by healthcare workers, strategies for coping and public awareness of COVID prevention measures are crucial.

Picture this, you're an ICU nurse working your 12hour shift during a surge in COVID-19 cases. Your floor is full of COVID cases, patients are overflowing into the hallways, and you and your team are desperate to locate lifesaving respirators. Death is at every corner of the building, patients plead to see their loved ones, and all you can provide is a video call and your compassion. You’re understaffed, you're low on PPE, and the patient flow never stops. The result is burnout, turnover, depression, anxiety, PTSD, 23

and even COVID-19 itself (9). Further, during COVID-19, female nurses were twice as likely to commit suicide than their general female counterparts (7-9). It was even recorded that nurses working in stressful COVID conditions, such as witnessing tragic goodbyes, were experiencing moral distress like combat veterans (9).

Figure 1: Participants in a study indicating nurses are the largest healthcare workers on site. Data from study at the Suez Canal University hospitals6.

The data supports that these mental health impacts were real and measurable. In a short analysis of 37 studies, filtered for accuracy, the prevalence of mental health issues was clear among healthcare professionals who work directly with COVID-19 patients (8). A study in China indicated that 512 healthcare workers, who were in direct contact with COVID patients, had a prevalence of 12.5% in anxiety and generally were at risk for anxiety when compared with the workers who were not handling COVID-19 patients (8). Additionally, an examination of medical staff and administrative staff indicated that the medical staff experienced greater fear, anxiety, and depression levels than administrative staff, and that units for COVID-19 were experiencing higher levels of mental health issues than other medical units (8). The same study further showed that younger nurses who worked on the frontline in COVID-19 were at higher risk for depression and anxiety, with 13.5% experiencing mid to high levels of those symptoms. Another study in Canada (7) conducted among 455 ICU healthcare workers, made up of physicians, nurses, and other healthcare professionals,

utilized a self-reported questionnaire to analyze the levels of mental distress.

Approximately 60% of respondents felt that they were at great risk for COVID-19, while 76% showed concern for infecting family, 67% felt more stressed, and 37% considered leaving their job. This study indicated that approximately 25% had probable PTSD. Yet again, nurses were at the highest risk for psychological concern. Finally, a study (6) at the Suez Canal University hospitals examined the correlation between COVID-19 stress and work performance. They reported that COVID-19 significantly affected work performance and success in the job, when compared with other factors like confidence and knowledge of work. Additionally, about half of the workers had moderate psychological stress while few had severe stress. These studies show that the mental health impacts felt by frontline workers are felt across the globe.

Figure 2: Types of Psychological Stressors faced by healthcare workers. Data from study at the Suez Canal University hospitals6.

For healthcare workers, self-care to cope with stress is critical. Undoubtedly, witnessing traumatic events and repeatedly working long hours takes a physical and mental toll.

The first step is recognizing the symptoms of distress and mental health illness such as feeling out of control, lacking motivation, feeling burnt out, loss of mood, loss of pleasure in doing one’s job, having trouble sleeping, and lack of concentrating (3).

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Although there is very little that can be done as healthcare workers are overwhelmed with working extra hours and getting few breaks or time to disconnect from clinical work due to the ongoing pandemic, recognizing mental health issues early on can prevent adverse health effects from persistent stress. Positive coping skills include keeping a daily routine to maintain a sense of control. Coping looks like eating regularly, sleeping adequately, and maintaining regularity in one’s schedule (2,4).

With this, it is essential to take time away from work and disconnect for a healthy work-life balance. Time away from work must also include regulating one’s consumption of COVID-related news. Directly dealing with the pandemic and consuming media related to COVID is mentally exhausting and can lead to compassion fatigue

Ultimately, to help ourselves and our fellow healthcare workers, getting vaccinated, wearing a mask, and social distancing are imperative.

COVID-19 is primarily spread by inhaling respiratory drops from individuals carrying the virus when they talk, breathe, sneeze, or cough (2,4). The CDC recommends wearing a wellfitting mask to reduce the spread of “COVID-19”.

Mask wearing minimizes the number of droplets exhaled in the environment and can reduce the amount inhaled. Mask wearing can be encouraged by mask distribution, role modeling, and mask promotion. In a clusterrandomized study in Bangladesh, these three tactics tripled mask usage. Masks are proved effective in several studies (1-4, 9). One taking place on the “USS Theodore Roosevelt, an environment notable for congregate living quarters and close working environments, found that use of face coverings on-board was associated with a 70% reduced risk of infection” (2-4).

Additionally, the CDC recommends getting fully vaccinated against COVID-19. A report (2)

on the vaccine efficacy in preventing hospitalizations concluded that in adults aged 65-74, the Pfizer-BioNTech and Moderna vaccines were 96% effective in preventing hospitalization for fully vaccinated individuals.

For fully vaccinated adults, aged 75 and under, Pfizer-BioNTech was found to be 91% effective while Moderna was found to be 96% effective.

Figure 3. Role of masks in controlling the spread of COVID-19 virus. Data from Center of Disease Control and Prevention report2 .

The pandemic has had a significant effect on healthcare workers' mental health. More research is recommended on vaccine efficacy, and alternatives for those unable to get vaccinated should be provided. Vaccines are an excellent place to start; although many people have conflicting opinions about it, it is essential to appreciate the proven efficacy of the COVID-19 vaccines. Further, to save the lives of our loved ones as well as those in the community and public health and healthcare workforce, educational events and policy changes should be promoted to mitigate the spread of the virus. The public should be made aware that vaccines are a common and safe practice that we have been using for a long time. With PTSD, anxiety, and suicide rates the rise, we must do all we can to help eachother.

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OUTSTANDING CPHA EMERGING LEADER This acknowledgement recognizes an emerging leader who provided exemplary service to the Colorado Public Health Association. The nominee must have been involved in association activities, while demonstrating strong service initiative. This person was publicly nominated by CPHA members.

Jeni Mitchell Communications Delegate, Emerging Leaders Committee Student/ Social & Digital Media Assistant, Colorado School of Public Health

WHAT PEOPLE HAVE TO SAY ABOUT JENI Jeni has exemplified consistent and continued contributions with each ELC event where she creates graphic advertisements for each event and assists in disseminating the advertisements. With the number of events that ELC has executed, Jeni has always been ready to assist in every aspect of the event. As a ELC delegate, Jeni contributes more than what is asked of her role and does so positively!

Jeni is a leader wherever she goes. She consistently goes above and beyond what is expected of her. She has incredible ideas and the means to implement them. She is a leader because she shows up, and she encourages others. Jeni leads the emerging public health victory, and under her influence, all will become their best selves.

Jeni has created a tremendous force in the Colorado Public Health Association. She comes up with brilliant ideas, follows through, and creates valuable opportunities for the emerging leaders community. Jeni ensures that all emerging leaders in public health are included in the communications so that opportunities are more equitable. She exceeds all expectations of her, and she deserves to be recognized as the Outstanding CPHA Emerging Leader. Moreover, Jeni is not just involved in the Emerging Leaders Committee, but her impact extends to Communications, Membership and Public Health in the Rockies. She is passionate and determined to help CPHA continue in its success. All are lucky to have a peer, teammate, and friend like Jeni.

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Public Health Day at the Capitol 2020 Photo credit: Allison Howe

The State Government's Moral Obligation to Address the Mental Health Crisis Lindsey Wyatt In 1948, the Universal Declaration of Human Rights (UDHR) was adopted and became pivotal, as it outlined fundamental human rights that must be universally protected by both governments and their people for the first time. One of the most important components of the UDHR is the right to health outlined in Article 25 that states, “Everyone has the right to a standard of living adequate for the health and well-being for himself and his family- including food, clothing, housing, and medical care,” (1).

While the UDHR does not explicitly state mental health, modern research emphasizes that mental and physical health are deeply intertwined and must be treated

comprehensively (2). Comparatively, the International Covenant on Economic, Social and Cultural Rights (ICESC) explicitly states “the right to physical and mental health.” It documents that governmental parties have an obligation to prevent and control epidemic, endemic, infectious, occupational, and other diseases, as well as create the conditions that would assure access to medical services and medical attention in the event of sickness. The government has an obligation to set up the conditions in which individuals can exercise their right to the highest attainable standard of both physical and mental health by implementing these standards (3).

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Therefore, if the goal is to achieve the healthiest Colorado, mental health must be integrated, considered, and supported in all policies.

The Mental Health Crisis The State of Colorado is experiencing a mental health crisis due to an inadequate system of care. In their 2021 Health Access Survey Report, the Colorado Health Institute declared mental health a “Second Health Crisis.” The report also documented that about 24% of Coloradans have reported poor mental health-- a rate higher than ever before (4). This increase in mental health difficulties is not a new trend, as the Colorado Department of Public Health and Environment has documented an increase in suicides and overdoses both before and after the COVID-19 pandemic (5). Some more examples of the mental health crisis within the state are the widely documented opioid epidemic, rates of burnout, depression, and moral injury among healthcare workers, and increased suicidal ideation among school-aged children (6-8).

Despite the clear and unequivocal need for expanded mental and behavioral health services, Colorado was recently ranked one of

the worst for adult access to mental healthcare by Mental Health America’s 2021 Report (9). In many instances, individuals who do seek out help have been denied services or placed on lengthy waitlists by Community Mental Health Centers (CMHCs)-- leaving the most at-risk Coloradans without care (10).

The facts are sobering and can only indicate one conclusion: the state’s existing mental healthcare system is a blatant human rights violation. This violation shows where and how the government has failed to fulfill their historically recognized responsibility to set up the conditions in which an individual can exercise their right to health. While the violation has been noted as a national problem by President Biden, Colorado is bearing the brunt of this crisis (11-12). Our state’s system isn’t working. Therefore, if the goal is to achieve the healthiest Colorado, mental health must be integrated, considered, and supported in all policies.

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The Government’s Obligation The burning question is what exactly is the government’s obligation to meet these standards? Unfortunately, neither the UDHR nor ICESC have legal grounds for enforcement, but that does not mean they are not important.

They are morally enforceable - there is still the expectation that governments engage in the necessary steps to ensure that individuals can exercise these rights. It is important to clarify that the government does not have the responsibility to enforce that an individual exercises their rights-- that is the freedom of the individual to choose. However, these documents explicitly state that it is the government’s responsibility to create the conditions that provide capacity for an individual to exercise these rights if they choose to do so (1,3).

Since Colorado is ranked one of the worst in access to mental healthcare and entities are denying services to individuals with some of the highest need, it is clear that the government has failed to create conditions for individuals to exercise their right to mental health (9-10).

Legislators and government officials alike must recognize that at any given moment, each and every resident exists on a continuum of mental health. As they continue their roles within the state government, there is an expectation they will address mental health through their policies. This means legislators and government officials must actively demonstrate commitment to address this crisis through critical and intentional examination of the current system, acceptance of the system's strengths and weaknesses, proactive advocacy for change, and bipartisan collaboration that consistently puts citizens first.

Behavioral Health Transformational Task Force (BHTTF) to gain insight into what transformational change would look like within the mental healthcare system.

One of the most notable accomplishments of the BHTTF was the unanimous vote to form the new Behavioral Health Administration (BHA) that will be the government entity responsible for mental health and substance use funding and programs within Colorado (13). This recommendation was effectively put into law through Governor Polis’ signature on House Bill 2021-1097 Establish Behavioral Health Administration (14). In addition, the current legislative session contains House Bill 2022 – 1278 Behavioral Health Administration, which outlines the standards that the BHA must implement by July of 2024. According to this bill, the BHA must implement statewide grievance, performance monitoring, safety net, licensing, and authority systems to regulate the state’s mental healthcare system (15). Hopefully, the launch of the BHA and their implementation of these standards will finally create a cohesive, person-centered mental healthcare system that is accessible, high quality, and easy to navigate.

What the Colorado State Government Should Do to Address Mental Health

Colorado State Government’s Plans to Address Mental Health

While the BHA is an important start, it is not enough. The true effects of the BHA will not be noticeable for several years. This poses an important dilemma because of the magnitude of the current crisis. In order for residents of Colorado to truly be able to exercise their right to mental health and well-being, the Colorado State Legislature must enact and vote in favor of policies that have short-term and immediate impacts in addition to the long-term solutions to mitigate the current status of this crisis.

While the current situation seems bleak, not all hope is lost because the Colorado State Government has made efforts to address this crisis over the years. For example, in 2019 Governor Jared Polis directed the Colorado Department of Human Services to create the

Additionally, it is integral to consider, prioritize, and elevate the testimony of those with lived experience when enacting policy. It is one thing to enact a policy that one “thinks” is best. It is completely different to achieve transformational change based on the 29

experiences of those who have struggled to navigate and have been failed by the system. To do otherwise is reckless, dehumanizing, and ineffective. Oftentimes, individuals who end up utilizing mental health services within the existing system leave feeling invalidated and stigmatized, and those who have experienced a mental health crisis are released into unsafe conditions without support or access to followup care (16). This concern is frequently reflected among testimonies of support for bills such as House Bill 2022 1303 Increase Residential Behavioral Health Beds (17). Legislators have the duty to actively listen, critically analyze, and deeply reflect on the experiences of those who are in and have experienced a mental health crisis in which any level of intervention was needed. Once this occurs, effective and transformational change of the system will be achievable.

Finally, there needs to be more consistent data collection and reporting across entities and jurisdictions. The current mental healthcare system is extremely difficult to navigate due to the unclear role of different entities such as Community Mental Health Centers (CMHCs), Administrative Service Organizations (ASOs), Managed Service Organizations (MSOs), and Regional Accountable Entities (RAEs) (18), as well as the distinction between public and private services. While this is one of the goals outlined by the BHA, it is unclear how this is going to be enacted and enforced. There needs to be clearer, more tangible documentation on exactly how the BHA will accomplish their purpose. It is time for the government to lift some of the bureaucratic red tape that keeps residents in the dark and instead provide the opportunity for civic engagement that is consensual and informed.

Overall, the state is experiencing unprecedented rates of poor mental health due to a system that is a human rights violation (4). All individuals experience mental health across a continuum at any given moment, and the state government must create person-centered, holistic systems that acknowledge this spectrum. While strides have been taken, it is time to enact policies that address this problem immediately and provides the opportunity for individuals to exercise their fundamental human right to the highest attainable standard of mental health and well-being.

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OUTSTANDING COMMUNITY SERVICE This recognition is to highlight an emerging leader who has excelled in outstanding community service efforts.

The community service can be any non-school or non-work related contribution to the public health community.

They exhibit responsiveness to community needs, and contribute significantly to their community through their time, actions, talents and dedication. This person was publicly nominated by CPHA members.

Marisa Westbrook PhD Candidate, Health and Behavior Sciences University of Colorado Denver

WHAT PEOPLE HAVE TO SAY ABOUT MARISA Marisa is active in many facets of the Colorado public health community and very deserving of formal recognition for this work. Marisa has wholeheartedly committed herself to community service in support of public health. Most notably, she is a fierce advocate for organizations related to housing and homelessness and has worked tirelessly to promote the next generation of public health scholars, even as she herself is still a student.

Marisa’s most recent service to the public health community has centered on supporting the precariously housed, homeless, and food insecure. In this community service work, she has served as an unpaid expert witness in lawsuits related to homelessness, advocated to DDPHE and city officials about the need for housing support and to dispute reasons for sweeps of homeless encampments, supported the Denver Basic Income Project (a cash transfer programs for homeless individuals), served on the EarthLinks board (social enterprise non-profit for people experiencing homeless and economic poverty), and consulted (pro bono) for Denver Homeless Out Loud and Boulder Food Rescue. All this work has taken place in the last three years while she was a doctoral student.

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CPHA Committee Meeting, 2021

COVID-19 Pandemic: War on a Mother’s Mental Health?

Garvita Thareja and Medina Adem

COVID-19, also known as novel coronavirus disease, is an upper respiratory tract infection that has led to a pandemic since the year 2020. During these two challenging years, the world has been affected in all dimensions of health, especially both mentally and socially. Even though COVID-19 cases are declining at the moment, we are still seeing that mental illness and the demand for psychological services are increasing. According to the survey done at Ann and Robert H. Lurie Children’s Hospital of Chicago in 2022 (1,5), approximately 71% of parents reported that their children’s mental health was highly affected either due to social isolation or long-term impacts of COVID-19 exposure. As shown in a study by Olff et al. (6) in 2021, people that have been affected by COVID-19 are at risk for various types of mental health issues such as depression, anxiety disorders, stress, panic attacks, irrational anger, impulsivity,

somatization disorder, sleep disorders, emotional disturbance, posttraumatic stress symptoms, and suicidal behavior. A similar systematic review conducted by Xiong et al.

(7) indicated that the general population developed mental health symptoms; in particular, women and individuals younger than 40 years of age were at risk for developing some form of mental health illness due to the COVID-19 pandemic.

Though these mental health impacts are felt by everyone, they are more deeply felt by women, especially mothers. Mothers have disproportionately lost their employment and financial security during pandemic (11).

Those working full time report a feeling of failure as there has been increased pressure to take care of their family while working either in virtual or in-person spaces. They have experienced an unreasonably excessive burden of the responsibility of all household chores: taking care of their children and 32

spouse, as well as parents/in-laws, all in addition to working. This pressure has hit mothers mentally rather than physically, and mental health in this group has deteriorated during the pandemic (11). There is a broad range of symptoms and disorders they might experience, but the most commonly reported ones during the pandemic are depression, anxiety, and psychosis.

A survey conducted among mothers reported that they have developed mental health issues due to social isolation, lack of emotional and physical support due to social isolation, and fear of contracting COVID-19 for themselves and their children (3). This survey also indicated that the majority of mothers had reduced to no physical activity since the start of the pandemic as they were stressed about catching the virus.

As recommended by CDC, performing 150 minutes per week of physical activity has strong positive associations with improved mental health. Mothers who are unable to engage in physical activity are at risk for developing mental health issues such as depression, anxiety, and stress. Furthermore, another study from the year 2020, indicated that one in seven moms reported having depression and anxiety.

This research also identified an increase in preterm delivery and decreased mother and infant bonding, which further increases the chance of postpartum depression (3). Moms have also reported a feeling of guilt about not being able to take care of their kid’s physical and mental needs due to working from home, pay cuts due to the economic imbalance of the pandemic, lack of income, and social isolation (2,3). These studies also reported that mothers have been dealing with difficulties and time management issues regarding their kids’ schoolwork and academia (2,3). Kids have been struggling due to low focus and motivation as well, due to the limited accessibility of teachers and coaches.

Lastly, increases in domestic violence have also added to mental health issues among mothers (2,8). Based on the study led by Evans et al.), there has been “a pandemic within a pandemic” due to domestic violence against mothers (8).

This uptick of domestic abuse during

CPHA Members connecting at Public Health in the Rockies 2021

the pandemic has mostly targeted kids and mothers, which has taken an additional toll on their mental health. Especially during the beginning of the pandemic, when the lockdown was mandated, a conducive environment was created for domestic abusers.

Social isolation, economical dependency on their partners, and lack of ability to provide for themselves as well as for their kids silenced many moms who were unable to remove themselves from their environment (8).

According to Bright et al. (9), stress due to lack of income and quarantine has played a major role in the increase of relationship conflict, which further increases mental health issues for mothers.

In conclusion, women, especially mothers, have been affected in a multitude of ways by the pandemic and are still going through posttrauma effects and chronic illnesses. The pandemic is not over yet and its tragic socialemotional and financial impact will probably be here for the next few years as the world is trying to recover. While we are still trying to get back to normal, there are mutations and newer variants of the virus that can take us back to the era of lockdowns and social isolations. We need to find resources in public health, especially for mothers and other vulnerable populations such as children and elders so that their long-term health issues can be addressed in a timely manner. As a community, it’s very important to be compassionate, understanding, and helpful especially during these challenging times to create a welcoming and safe environment for all.

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The Shell Doesn't Fall Far Dannon G. Cox This photograph was taken during a camping trip on public lands in Colorado in 2021. While cooking breakfast, the children were busy with their tea set serving adults a nice beverage of bullet shells found around the campfire. Considering the normalization of firearms and the abundance of littering on public land, this photograph captures how youth naturally adapt and utilize their surroundings to be part of their everyday play.

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Connecting Classroom to the Field in the Healthcare Industry – Story of a Student from Peru Betty Granados and Garvita Thareja As a young girl in Peru, my family was fortunate to have access to affordable and equitable healthcare. It was only until I immigrated to the United States that I realized that this access to healthcare in my home country was atypical, and was only made possible to us through my father’s work in the United States. My father provided for our health insurance by sending money to our family in Peru. After arriving in the United States, the illusion that healthcare was equitable, accessible, or affordable for everyone quickly dissipated. I found myself lost due to navigating in-network versus out-of-network providers, being unable to see a physician when I was sick, and paying for expensive prescriptions and out-of-pocket expenses.

Although the healthcare system can be challenging for many, I realized through working as a case manager with the homeless that this population is especially susceptible to the disparities and inequities of the healthcare system. For example, patients in this population are often not aware of public health insurance plans like Medicaid, Medicare, and the Veterans Health Administration or how to apply for these programs. For example, when I would try to connect them with a physician, many of them didn’t have Medicaid or have money to pay out of pocket for healthcare services even though they would qualify for one of these programs.

All these events revealed to me that certain populations, such as the homeless population, have disadvantages in navigating the healthcare system in the U.S. I decided to pursue a Master of Health Administration (MHA) degree so I could be in a better position to help vulnerable

populations navigate the healthcare system and develop leadership principles to guide organizations and professionals with similar values.

The MHA program offered me the opportunity to develop these principles through a workstudy teaching assistant role. In this role, I had the opportunity to teach a population health class, which gave me insight into what is taught to students in academia about population health and the didactic methods used to educate the future leaders of our healthcare industries. Overall, this exposure helped me in refining my professional skills and learning technologies that I can utilize in my career.

These extracurricular activities made me a skilled person who now has options to work in the field of practice, academia, as well as research.

The personal values and career aspirations that inspired me to write this essay are in strong alignment with Metropolitan State University of Denver (MSU Denver) values. MSU Denver states under their vision and values “We are problem solvers”, which is one of the skills I have learned throughout my professional and academic journey. The MHA program at MSU Denver has enabled me to achieve strategic goals for myself and my organization, and taught me about the healthcare industry and how my contributions can make a difference. Coming to the U.S. from Peru gave me another perspective on health disparities that I was able to explore during my education and my work-study role. The roles I took part in polished my skills and allowed me to learn new skills to make my dreams come true in the healthcare administration field.

CPHA Outside snowshoeing event 2022

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Colorado School of Public Health Mixer 2022.

Photo Credit: Juan Roberto Madrid

Implementing a Health Behavior Theory – Opinion and Personal Experience Lyn Riebel and Garvita Thareja

As a student enrolled in the Health Behavior Theory course with Dr. Garvita Thareja, through the Public Health program at Metropolitan State University of Denver, we were offered an engaging assignment to expose us to real-world experience in the area of behavior change. As part of this assignment, students must utilize theories of health to change their own selected behavior. I chose to focus on increasing my cardio activity level from generally relying on long walks each day to adding more vigorous activities such as an at-home spin class and high-intensity interval training as the focus of my behavior change, and the Transtheoretical Model of Change (1) (TTM) as the theory to utilize for the practice of enacting this behavior change.

The Transtheoretical Model of Change, often referred to as “TTM'' or the “Stages of Change”, was introduced in 1983 by Prochaska & DiClemente to describe how most individuals progress through a process of identifiable stages (sometimes repeating the stage cycle) to move through or towards a behavior change (1). Through my research of TTM, I came across a book called Changing to Thrive (1) (2016) which was written by a founder of TTM (Prochaska) and his wife. This

book helped me dig deeper into the processes within the individual stages, which are: Precontemplation – where the individual is not ready or does not see a need for change Contemplation – where the individual is starting to see the benefits for change Preparation – where the individual is ready to work towards the change Action – where the individual is actively engaging in new behaviors of change Maintenance – where the individual is keeping up with the action of behavior change for at least six months Once I identified the behavior I wanted to change, increasing my physical activity, specifically cardio—which has been challenging over the last couple of years due to nerve damage—then I began to identify which stage I was currently in. To do this, I used TTM which was studied through coursework and the Changing to Thrive1 book. This helped me get a baseline for what stage I was currently in (Preparation) and where I wanted to be in the stages of change (Maintenance). I identified my initial stage as Preparation because I saw the benefits of

increasing my cardio activity, however I had not yet actively begun engaging in new habits that would lead to increased cardio. My goal throughout this activity was to progress to the Maintenance stage, where I would be enacting habits that would increase my cardio activity for many years to come.

An image by LaMorte (2019) depicts the stages of change cycle2.

Another aspect of this assignment was to keep a daily journal of my progression throughout this behavior change. This is where I was able to identify different barriers, strategies, motivators for achieving the change, and a plan for action.

This allowed me to set the stage to increase my internal belief, or self-efficacy, that I was capable of sustaining my desired change. Throughout this 4-week exercise, I was able to identify that scheduling and setting a plan for the entire week for what cardio activities I was going to do and at what times were the most helpful for progressing my behavior change. I also found that having a backup plan, one that allowed for an easy pivot, was also a key factor in keeping movement towards the progress of my change rather than falling back into an earlier stage in TTM. The other thing I found helpful was discussing my behavior change progress with others in situations where they were participating with me or encouraging me in other ways. For me, this primarily included my spouse, but for others this could be friends, family, or anyone who could provide similar encouragement.

Throughout this assignment, I also found other research articles that used TTM to increase the

level of physical activity in individuals (3,4,5).

Within both articles, it was identified that the TTM approach was effective in promoting selfefficacy, which then promoted an increase in level of physical activity. In seeing the effects of using TTM in my own behavior change, I agree with these authors that this model was effective in increasing my own self-efficacy, which in turn increased my engagement in enacting the change and ultimately increased my cardio activity in my life (2,3,5).

I thoroughly enjoyed this assignment particularly because I got so much more out of it than just a grade. It truly has been a rewarding way to implement not only a behavior change, but what feels like a lifestyle change. For me, that means getting more of my life back. I also found this assignment rewarding because I have been working as a health and wellness coach for over 5 years and utilize this behavior change model in my professional setting. While I was previously familiar with TTM, this was the first time that I focused on my own behavior change while using this model for this length of time. One of the main reasons I like this model is that it doesn’t feel demoralizing and allows an individual to progress at their own pace and choose how they want their path to look.

Putting this assignment into real-world action for my own personal behavior change now allows me to apply this model more effectively as an option when working with others. The TTM provides an individual with a good way to identify their various stages of change from the beginning to the end of a behavior change journey. In addition to learning more about TTM during this assignment, I found it an effective method for behavior change in my personal life as well. While TTM was originally used to understand how people change behaviors, particularly in smoking sensation and addiction settings, it is being used more and more in other areas of health and wellness and can ultimately be an effective way for an individual to enact any behavior change they are seeking (1,3,4,5).

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AUTHORS AND ARTISTS Medina Adem

Betty Granados, MHA

Biology Major Metropolitan State University

Metropolitan State University

Elizabeth Atwood School-Based Health Center Program Assistant Colorado Department of Public Health and Environment

Pam Jiner Executive Director of Montbello Walks

Elizabeth Boland, MPH

Jeni Mitchell

Colorado School of Public Health

Student, Social & Digital Media Assistant Colorado School of Public Health

Sarah Boland, MPH

Autumn Ortega

DrPH Student Colorado School of Public Health

Biology Major Metropolitan State University

Sydney Chaves

Lyn Riebel, NBC-HWC, B.A.

Learning and Evaluation Associate Caring for Denver

Public Health Candidate Metropolitan State University of Denver

Dannon G Cox

Andrew Salter

Assistant Professor Colorado School of Public Health

Public Health Major Metropolitan State University

Hannah Craig

Garvita Thareja, Ph.D., CHES

Master of Public Health Student Colorado School of Public Health

Assistant Professor Metropolitan State University of Denver

Tessa Cushman, RDN

Bloomberg Fellow Johns Hopkins Bloomberg School of Public Health Food Security Specialist Tri-County Health Department

Lindsey Wyatt, MPH Mental Health Colorado

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Community-Engaged Science for a Healthier Montbello 1. U.S. Census Bureau. American Community Survey: Languages spoken at home – 80238. Published 2020.

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Colorado's Young People are Screaming for Help. It is Time to Stop Ignoring Them.

1. Children's Colorado declares 'state of emergency' for youth mental health. Children's Hospital Colorado. (n.d.).

From https://www.childrenscolorado.org/about/news/2021/may-2021/youth-mental-health-state-of-emergency/ 2. Colorado kids and teens are dying at a rate higher than the U.S. average -- and suicide is to blame. The Colorado Sun. (2019, June 17). From https://coloradosun.com/2019/06/17/kids-count-report-colorado/ 3. (DCD), D. C. D. (2021, October 20). What does "suicide contagion" mean, and what can be done to prevent it?

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PhD or DrPH? How Program Reformation Can Create Expert Research-to-Policy Translators 1. Peeples L. What the science says about lifting mask mandates. Nature. 2021;593:495-498. doi:10.1038/D41586021-01394-0 2. Public Health Degrees. Explore Doctor of Public Health Programs (PhD & DPH). Published April 2020. Accessed March 30, 2022. https://www.publichealthdegrees.org/program/doctorate/drph/ 3. Park C, Migliaccio G, Edberg M, Frehywot S, Johnson G. Future directions of Doctor of Public Health education in the United States: a qualitative study. BMC Public Health. 2021;21(1). doi:10.1186/S12889-021-11086-Z 4. Tulane University. Social, Behavioral and Population Sciences, DrPH. Published 2021. Accessed March 30, 2022. https://catalog.tulane.edu/public-health-tropical-medicine/social--behavioral--and-population-sciences/globalcommunity-health-science-behavior-dph/#requirementstext 5. Boston University School of Public Health. Doctor of Public Health Program Handbook. Published online 2020.

6. Columbia Mailman School of Public Health. DrPH Leadership in Global Health and Humanitarian Systems.

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COVID-19: The Effects on Frontline Healthcare Workers 1. Depression rates tripled symptoms intensified during first year of COVID-19. Brown University. https://www.brown.edu/news/2021-10-05/pandemic-depression. Published October 5, 2021. Accessed March 11, 2022.

2. Effectiveness of COVID-19vaccines in preventing hospitalization among adults aged ≥65 years - Covid-Net, 13 states, February–April 2021. Centers for Disease Control and Prevention. https://www.cdc.gov/mmwr/volumes/70/wr/mm7032e3.htm. Published August 13, 2021. Accessed March 12, 2022.

3. Support for public health workers and health professionals. Centers for Disease Control and Prevention. https://www.cdc.gov/mentalhealth/stress-coping/healthcare-workers first-responders/index.html. Updated December 2, 2021. Accessed March 11, 2022.

4. Science brief: Community use of masks to control the spread of SARS-COV-2. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019- ncov/science/science-briefs/fully-vaccinated-people.html, Updated September 15, 2021. Accessed March 12, 2022.

5. Effectiveness of face mask or respirator use in indoor public settings for prevention of SARS-COV-2 infection California, February–December 2021. Centers for Disease Control and Prevention. https://www.cdc.gov/mmwr/volumes/71/wr/mm7106e1.htm. Published February 11, 2022. Accessed March 12, 2022.

6. Elbqry M, Elmansy FM, Elsayed AE, Mansour B, Tantawy A, Eldin MB, Sayed HH. Effect of covid-19 stressors on healthcare workers' performance and attitude at Suez Canal University Hospitals - Middle East. Middle East Current Psychiatry. 2021; 28(4).

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The State Government's Moral Obligation to Address the Mental Health Crisis 1. Universal Declaration of Human Rights. United Nations. https://www.un.org/en/about-us/universal-declarationof-human-rights. Accessed March 15, 2022.

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Published June 28, 2021. Accessed March 21, 2022.

3. UN, United Nations, UN treaties, treaties. United Nations. https://treaties.un.org/Pages/ViewDetails.aspx? src=IND&mtdsg_no=IV-3&chapter=4. Accessed March 20, 2022.

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16. Phu, K. Stigma and systemic barriers. Colorado Health Institute. 2021. Colorado Health Institute. https://www.coloradohealthinstitute.org/research/stigma-systemic-barriers-mental-health-care. Accessed March 29, 2022.

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18. Find behavioral health help. Colorado Department of Human Services. (n.d.). Retrieved March 29, 2022, from https://cdhs.colorado.gov/behavioral-health/find-behavioral-health-help 41

Covid-19 Pandemic: War for a Mother's Mental Health?

1. Children's mental health is in crisis. Monitor on Psychology. https://www.apa.org/monitor/2022/01/specialchildrens-mental-health. Accessed March 19, 2022.

2. Cannon C, Ferrieira, R, Buttell F et al. COVID-19, Intimate Partner Violence, and Communication Ecologies.

American Behavioral Scientist. 2021; 65(7), 992-1013, doi: https://doi.org/10.1177/0002764221992826. Accessed March 20, 2022.

3. Davenport MH, Meyer S, Meah VL, Strynadka MC, Khurana R. Moms are not ok: Covid-19 and Maternal Mental Health. Frontiers. Published January 1, 1AD. Accessed March 19, 2022. https://www.frontiersin.org/articles/10.3389/fgwh.2020.00001/full.

4. Hossain MM, Tasnim S, Sultana A, et al. Epidemiology of mental health problems in COVID-19: A Review.

F1000Research. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7549174/. Published June 23, 2020. Accessed March 19, 2022.

5. Omicron’s impact on youth’s physical, mental and behavioral health. luriechildrens.org. Published January 18, 2022. Accessed March 31, 2022. https://www.luriechildrens.org/en/news-stories/omicrons-impact-on-youthsphysical-mental--behavioral-health/ 6. Olff M, Primasari I, Qing Y et al. Mental health responses to COVID-19 around the world. European Journal of Psychotraumatol. 2021; 12(1): 1929754, doi: 10.1080/20008198.2021.1929754. Accessed March 31, 2021.

7. Xiong J, Lipsitz, O, Nasri, F et al. Impact of COVID-19 pandemic on mental health in the general population: A systematic review. Journal of Affective Disorder. 2020; 277: 55–64; doi: 10.1016/j.jad.2020.08.001.

8. Evans M, Lindauer M and Farrell M. A Pandemic within a Pandemic — Intimate Partner Violence during Covid19. The New England Journal of Medicine. 2020; 383, 2302-2304 doi: 10.1056/NEJMp2024046. Accessed March 31, 2022.

9. Bright C, Burton C and Kosky M. Considerations of the impacts of COVID-19 on domestic violence in the United States. Social Science and Humanities Open. 2020; 2(1), 100069, doi: https://doi.org/10.1016/j.ssaho.2020.100069.

10. Ranji U, Frederiksen B, Salganicoff A et al. Women, work and family during COVID-19: Findings from KFF women’s health survey. Published March 22, 2021. Accessed April 25, 2022.

11. Senior J. Mothers all over are losing it. The New York Times. Published Feb 24, 2021. Accessed April 29, 2022.

Implementing a Health Behavior Theory – Opinion and Personal Experience 1. Prochaska JO, Prochaska JM. Changing to Thrive: Using the stages of change to overcome the top threats to your health and happiness. Hazelden Publishing; 2016.

2. LaMorte W. The Transtheoretical Model (Stages of Change). Behavioral Change Models. Updated September 9, 2019. Accessed March 4, 2022. https://sphweb.bumc.bu.edu/otlt/mphmodules/sb/behavioralchangetheories/behavioralchangetheories6.html 3. Liu KT, Kueh YC, Arifin WN, Kim Y, Kuan G. Application of transtheoretical model on behavioral changes, and amount of physical activity among university’s students. Frontiers in Psychology. 2018;9. doi:10.3389/fpsyg.2018.02402 4. Pirzadeh A, Mostafavi F, Ghofranipour F, Feizi A. Applying transtheoretical model to promote physical activities among women. Iranian Journal of Psychiatry and Behavioral Sciences. 2015;9(4). doi:10.17795/ijpbs-1580.

5. Hayden J. Introduction to Health Behavior Theory. Jones and Bartlett Learning; 2019:111-124.

RISE Public Health Crossword answers Across 1 Economies 8 Hiking 9 Polis 10 Evaluation 13 Elbert 15 Biostatistics 17 Environment 18 Growth 19 Equity 21 Anschutz 22 Innovation 23 Network

Down 2 CSU 3 Coalitions 4 Policy 5 Skiing 6 El Paso 7 Housing 9 Perspective 10 Epidemiology 11 Grants 12 Education 14 Health 16 Healthcare 20 UNC

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