InSight Fall 2018 by University of Iowa College of Public Health

THE UNIVERSITY OF IOWA COLLEGE OF PUBLIC HEALTH

INSIGHT The Path Ahead

Making strides in cancer care and research

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FROM THE DEAN

“Cancer” is one of those words we all dread hearing, yet it’s very likely that we all know someone affected by the disease or have battled it ourselves. In 2018, an estimated 1.7 million new cases of cancer will be diagnosed in the United States and more than 600,000 people will die from the disease, according to the National Cancer Institute. While we in public health don’t directly treat patients in a clinic, our work is integrated throughout the entire spectrum of cancer care—promoting preventive measures, encouraging screenings, researching causes of cancer, identifying disparities, evaluating the effectiveness of treatments and services, contributing to patient care programs, and measuring health outcomes. This issue of InSight takes a closer look at some of the many cancer-related projects that involve our faculty, staff, and students. The University of Iowa is home to Holden Comprehensive Cancer Center, which draws together teams of outstanding researchers from across campus, including many from the College of Public Health. Our college also houses the Iowa Cancer Registry, is a member of the Iowa Cancer Consortium, and conducts cancerrelated research funded by the National Cancer Institute, Centers for Disease Control and Prevention, Iowa Department of Public Health, and other agencies. While data and statistics are vitally important to research, public health is also concerned with the everyday realities of cancer patients. Some of the questions we ask are: What barriers to receiving cancer screenings or care do people face? How do they make decisions about their treatment? How do rural and urban residents differ when it comes to cancer? What special needs do adolescents and young adult cancer patients have? You’ll find answers to these and other questions as you read through this issue, along with research updates, news, class notes, and more. As we approach the holiday season and new year, I wish you joy and good health, and thank you for being part of our public health community.

Best regards,

Improving Rural Cancer Care Stronger collaborations, better information sharing, and innovative approaches are enhancing cancer care in rural areas.

InSight is published twice a year for alumni and friends of the University of Iowa College of Public Health. Director of Communications and External Relations Dan McMillan daniel-mcmillan@uiowa.edu Editor Debra Venzke Designer Leigh Bradford Marketing and Community Outreach Coordinator Mitch Overton Alumni and Constituent Relations Coordinator Tara McKee Webmaster Patrick Riepe Creative Media Specialist Katy Stites Correspondence, including requests to be added to or removed from the mailing list, should be directed to: Debra Venzke University of Iowa College of Public Health 145 N. Riverside Dr. 100 College of Public Health Bldg., Rm S173 Iowa City, Iowa 52242-2007 debra-venzke@uiowa.edu

Visit our website cph.uiowa.edu

Edith Parker

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Teaming Up to Fight Cancer

A Shot of Protection

Researchers from across the College of Public Health and UI campus are working together to prevent, detect, and treat cancer.

A network of cancer researchers are investigating ways to boost adolescent HPV vaccination rates.

Young, Complex, and Coping with Cancer

A new program strives to meet the life changes and special challenges of young cancer patients.

16 RISING STARS

The Healthy LifeStars program teaches kids important habits for lifelong health.

18 HAPPENINGS

News and research findings. 24 CLASS NOTES

Alumni news and notes. 25 GALLERY

Many of our students kicked off the school year by performing a day of service in the community. 26 SPARK

The College of Public Health offers plenty of cozy spots for studying.

The University of Iowa prohibits discrimination in employment, educational programs, and activities on the basis of race, creed, color, religion, national origin, age, sex, pregnancy, disability, genetic information, status as a U.S. veteran, service in the U.S. military, sexual orientation, gender identity, associational preferences, or any other classification that deprives the person of consideration as an individual. The university also affirms its commitment to providing equal opportunities and equal access to university facilities. For additional information on nondiscrimination policies, contact the Director, Office of Equal Opportunity and Diversity, the University of Iowa, 202 Jessup Hall, Iowa City, IA, 52242-1316, 319-335-0705 (voice), 319-335-0697 (TDD), diversity@uiowa.edu. W35992 /12-2018

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Improving Rural Cancer Care

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Stronger collaborations, better information sharing, and innovative approaches are enhancing cancer care in rural areas.

BY DEBRA VENZKE

hen it comes to progress against cancer, there’s good news to celebrate. Between 1990 and 2014, the overall cancer death rate in the United States fell by 25 percent. But not all parts of the country shared these improvements equally. Disparities in cancer outcomes continue to be an issue, including in rural areas where death rates are higher than urban areas. Cancer mortality also is decreasing more slowly in rural areas than urban areas. Mary Charlton, CPH assistant professor of epidemiology and an investigator with the Iowa Cancer Registry, studies rural–urban cancer disparities. In 2015, she and colleagues published a paper that outlined numerous challenges of rural cancer care in the U.S. The barriers to receiving care included limited availability of cancer treatments and cancer support providers (such as oncologists, social workers, mental health care providers, and palliative care specialists), long travel distances for care, transportation barriers, and financial barriers, including having no insurance or insufficient insurance coverage. Three years later, “a lot of the challenges are the same,” says Charlton, “but now there’s a bigger push, especially at the National Cancer Institute (NCI), to put funding and resources into projects to improve rural cancer care.”

Strengthening Rural Cancer Research Charlton, along with Anjali Deshpande, CPH clinical associate professor of epidemiology, are co-leading an initiative supported by NCI supplemental funding to the UI Holden Comprehensive Cancer Center (HCCC) aimed at strengthening cancer control research in Iowa’s rural underserved populations. George Weiner, HCCC director, serves as principal investigator.

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The goal of the project is to establish a statewide research infrastructure, based at HCCC, that will support rural hospitals and other rural health care providers in their search for new, sustainable cancer-control methods. “We’ll be working with six Critical Access Hospitals located in rural counties that will serve as the core of a rural cancer research advisory board,” says Charlton. “We want to hear what their biggest challenges and interests are.” Critical Access Hospital (CAH) is a designation given to eligible rural hospitals by the Centers for Medicare and Medicaid Services. The CAH designation is designed to reduce the financial vulnerability of rural hospitals and improve access to health care by keeping essential services in rural communities. These hospitals receive certain benefits, such as cost-based reimbursement for Medicare services. Every three years CAHs conduct a Community Health Needs Assessment and develop a strategic plan to address their findings. “We’ve looked closely at many hospitals’ needs assessments, and a lot don’t mention cancer as one of their priorities, or if they do mention it, they don’t have a lot of data in their plan to help guide them,” Charlton explains. “The Iowa Cancer Registry has great data and resources that we can help provide to these hospitals.” The Iowa Cancer Registry gathers statistics on cancer incidence and mortality at the county level. This information can be used to generate maps and reports that provide actionable, relevant evidence to guide community health assessments and cancer control decision-making in the six identified counties. The project will rely on established collaborations among HCCC, the Iowa Cancer Consortium, and the Iowa Cancer Registry, while building new relationships with the UI Rural Policy Research Institute’s Center for Rural Health Policy Analysis and the UI Cancer Prevention and Control Research Network. The supplemental funding will lay valuable groundwork for additional grants and projects going forward, Charlton adds.

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From Diagnosis to Treatment Decision Charlton’s research isn’t limited to specific cancers, but “the cancers that tend to be the bigger numbers in rural areas are breast and colorectal cancer because they can be treated by any hospital that has a general surgeon,” Charlton says. “So we see a lot of cancer patients in Iowa—about 40 percent—who go to hospitals that have no specific cancer accreditation.” Charlton and colleagues recently published a paper that examined rectal cancer patients’ decision-making process about where to receive surgery. Although colon cancer and rectal cancer tend to get grouped together, the two diseases are very different. “Rectal cancer is much rarer, and it’s a much more complicated surgery and course of treatment than colon cancer,” Charlton points out. Several studies have shown that rectal cancer patients treated by specialized surgeons who perform large volumes of rectal cancer resections have better outcomes and survival

Innovative Approaches

rates compared to patients treated at lower volume centers. Despite evidence of a volume-outcome relationship, less than half of rectal cancer resections are performed by highvolume surgeons in comprehensive facilities. Charlton’s research team interviewed 15 rectal cancer patients about their decisions regarding where to receive surgery. All lived in Iowa, averaged 63 years of age, and a little more than half resided in non-metropolitan areas. Overall, the researchers found that advice from primary care physicians, gastroenterologists, friends, and relatives was the most critical factor in choosing a surgical center. And while almost all of the respondents indicated that surgeon experience was important, most didn’t research their surgeon’s experience and none sought a second opinion. Because Iowa is a very rural state, distance was a factor in the decisions of some of the patients. However, in most cases where patients chose more local, lower volume centers, it wasn’t because they were unable to travel to a higher volume center. Rather, they chose the closer, low-volume centers because they were recommended to them by a local physician or because they were just more familiar with local providers. This highlights the importance of referrals received from physicians who diagnose rectal cancer. The researchers noted that primary care physicians and gastroenterologists aren’t typically involved with staging, treatment, or follow-up of rectal cancer; are often unfamiliar with the specifics of rectal cancer surgery; and may not be aware that there is a difference in care and outcomes at highvolume versus low-volume centers. As a result, they may base referrals on their professional relationships with surgeons rather than on expertise. The findings suggest that developing educational interventions to help guide more informed decision-making by patients and referring providers could be beneficial.

Technology offers additional tools for enhancing rural cancer care. Telehealth is the use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional healthrelated education, public health, and health administration, according to the Health Resources and Services Administration. Instead of remotely connecting rural cancer patients to specialists, it often makes more sense to link rural health providers to oncology specialists, says Marcia Ward, CPH professor of health management and policy and director of the Rural Telehealth Research Center. “Oncology specialists can serve as consultants and be a resource for primary care providers and other frontline health professionals in rural areas,” Ward explains. “Using telehealth, a family physician can ask questions or say, ‘I have this case, what would be the best referral?’” But, Ward notes, the telehealth consultant role “raises all sorts of issues about reimbursement” in the current fee-for-service health care system. “There are still challenges to putting this approach into place,” she says. Other solutions for rural cancer care include outreach clinics, where specialists travel to certain rural sites several times a week or month, thereby reducing cancer patients’ travel time; and incentives and programs to increase recruitment and retention of the oncology workforce. Although rural cancer disparities can be addressed in a number of ways, Charlton summarizes the goal behind these efforts into one overarching question: “What is the best way to get everyone the best care without making them go farther than they need to go?”

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Teaming Up to Fight Cancer Researchers from across the College of Public Health and UI campus are working together to prevent, detect, and treat cancer. BY DEBRA VENZKE

hen Kim Merchant learned she had breast cancer in January 2018, she “was a little shell-shocked.” As an active person with a healthy diet and no family history of the disease, she was stunned to be diagnosed with stage II invasive ductal carcinoma at the age of 61. “It just wasn’t on my horizon,” she says. An annual mammogram detected the first of two spots on her left breast, setting off a chain of additional tests, biopsies, diagnosis, two surgeries, and six weeks of daily radiation treatment and its side effects. Cancer consumed six months of Merchant’s life, during which she continued to work as much as possible. Although Merchant is extremely grateful for the support and care shown by her friends, family, and coworkers, she’s honest about the difficulties of coping with cancer: “It’s really a frightening and lonely time.” Merchant says the experience was made easier thanks to the excellent care she received at the University of Iowa Hospitals & Clinics. “Knowing you’re in good hands takes away a lot of stress,” she says.

A Multidisciplinary Approach Merchant is one of an estimated 17,800 Iowans diagnosed with a new cancer in 2018 and among thousands of cancer patients who receive treatment at the UI Hospitals & Clinics. The University of Iowa is home to the Holden Comprehensive Cancer Center, one of the nation’s top cancer research and treatment centers and Iowa’s only National Cancer Institute (NCI)-designated comprehensive cancer center. The center coordinates all cancer-related research, education, and patient care by faculty from 41 departments and six colleges, as well as UI Hospitals & Clinics and UI Stead Family Children’s Hospital. The center is committed to making breakthrough scientific discoveries and turning them into improved approaches to

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cancer prevention, early detection, and treatment that directly benefit cancer patients. Research at Holden is organized into four programs: cancer genes and pathways, experimental therapeutics, free radical metabolism and imaging, and cancer epidemiology and population science. The latter category—cancer epidemiology and population science (CEPS)—is where public health really shows its strengths.

and in evaluating health services and outcomes, says Lynch. CEPS members are highly productive researchers. To give a snapshot, between January and August 2018, CEPS investigators produced 74 publications and secured 35 grants totaling $4.4 million. Current research projects involving CEPS members include studies on breast and ovarian cancer, environmental exposures such as PCBs and nanomaterials, and smokeless tobacco use in rural veterans.

Population-Based Research CEPS is a multidisciplinary team of more than 50 faculty members and researchers from the Colleges of Public Health, Nursing, Medicine, Pharmacy, and Liberal Arts and Sciences. Their research focuses on cancer etiology, including studies that explore genetic and/or environmental risk factors for cancer at the population level; cancer prevention and control; and cancer health services and outcomes. “The goal of the CEPS program is to conduct population-based research that improves our understanding of what causes cancer, how cancer can be prevented and, if not prevented, how it can be detected early in its course, and to increase quantity and quality of life for cancer survivors,” says Charles Lynch, CPH professor of epidemiology and the CEPS program co-leader along with Richard Hoffman, professor of internal medicine. Given that “population science” is in the research program’s title, it’s not surprising that public health researchers make up almost half of the CEPS team. Public health plays an important role in addressing cancer by reducing risk factor exposure and enhancing protective factors, getting more people screened for the early detection and treatment of cancer,

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Big Data and Cancer Research A key component of cancer research is large data sets such as those provided through the Surveillance, Epidemiology, and End Results (SEER) Program funded by NCI. SEER collects and publishes cancer incidence and survival data from population-based cancer registries, including the Iowa Cancer Registry based in the College of Public Health. Wrangling big data requires the expertise of biostatisticians. Brian Smith and Gideon Zamba, CPH professors of biostatistics, frequently collaborate with investigators in Holden Comprehensive Cancer Center on the design, analysis, and reporting of cancer research projects. Smith directs the Biostatistics Core within the center. The core’s services include consultation on study design, selection of outcome variables, and formulation of hypotheses; sample size estimation; protocol development; data analysis; and education and training. One initiative designed to harness the power of big data to make it faster, easier, and less costly to conduct clinical research is the National PatientCentered Clinical Research Network (PCORnet). PCORnet is a national “network of networks” that collects data routinely gathered in a variety

of health care settings. These data are used to answer practical questions that help patients, clinicians, and other stakeholders make informed health care decisions.

Linking Data Elizabeth Chrischilles, CPH professor and head of epidemiology, co-leads PCORnet’s Cancer Collaborative Research Group. The collaborative places special emphasis on developing standardized electronic heath record data across multiple sites so they can be linked together to support cancer research. “In real-world practice, doctors and patients often have questions about which drug is best for a certain situation,” says Chrischilles, who also serves as associate director for population sciences in the Holden Comprehensive Cancer Center. “A lot of these questions never get answered in a clinical trial. Organizing data into a standard structure makes conducting comparative effectiveness research into these questions much more efficient.” Data that are coded consistently across sites enable researchers to study how new treatments compare in effectiveness and safety to other therapies, understand how patients differ in response to specific treatments, and identify optimum drug dosages and regimes, along with many other questions. Chrischilles is co-principal investigator of a PCORnet-funded project that is examining the patterns of use of molecular biomarkers and associated targeted cancer therapies for patients with invasive solid tumors. The project involves nine participating sites and is designed to test and expand the capacity of PCORnet to describe the details of cancer pathology, test results, and cancer treatment outcomes.

Living with Cancer Almost a year after her diagnosis, Kim Merchant is actively engaged with work and life, although life is different than it was before cancer. She’ll be taking medication for years and will continue to have follow-ups with her care team. “I’m still a cancer patient,” she says. “Every time I get ready to have my annual checkup, I’m going to think about concerns I never had before.” Merchant found it helpful to reflect on her experience by journaling. Following a radiation treatment, she wrote: It is a strange sisterhood. As I walk into the pavilion, a female patient I’ve seen in the clinic patient waiting area is walking out. We smile and nod. Some women talk while waiting…Some don’t talk. Some have hair; some don’t or have a fuzzy buzz. Even out of the hospital, women who are survivors want to help, reach out, encourage—from my cousin’s friend to my banker. She also met with a psychologist who specializes in working with cancer patients. “I thought, What can I learn from this?” says Merchant. “How can I help others, and help myself?” Part of that process has been openly sharing her experience. “I hope that honesty helps others,” she says. “I don’t want there to be a stigma about having cancer.”

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A Shot of Protection

A network of cancer researchers are investigating ways to boost adolescent HPV vaccination rates. BY JENNIFER NEW f a form of cancer could be prevented through a vaccination, why wouldn’t that vaccination be as widely given as those for diphtheria or the mumps? The primary cause of cervical cancer is the Human Papillomavirus (HPV), and the HPV vaccine is 90 percent effective at preventing it. Yet less than half of the adolescents in the United States who are eligible to receive the HPV vaccination do so. Why? This question underlies the work of Natoshia Askelson and her Cancer Prevention and Control Research Network (CPCRN) team at the University of Iowa. “Currently,” says Askelson, CPH assistant professor of community and behavioral health, “we know that only 49 percent of U.S. teens and 54 percent of Iowa teens are receiving the complete HPV series. How can we increase those numbers?”

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Vaccination Rate Disparities

To be most effective, the immunization is administered at 11 and 12 years of age, a time when a young person’s immune response is highest.

The Centers for Disease Control and Prevention (CDC) recommends three vaccines for adolescents: meningococcal (meningitis); tetanus, diphtheria, and pertussis (Tdap); and human papillomavirus (HPV). The HPV vaccine is one of the biggest breakthroughs in cancer prevention in the last decade, providing nearly complete protection from HPV-related cancers—including cancers of the mouth and genitals, as well as the more prevalent cervical cancer. Yet recent studies have shown that while national adolescent vaccination rates are fairly high for Tdap and meningococcal, the rates are substantially lower for HPV. Figuring out the disparity in these numbers and how to shift them is at the heart of the work of the CPCRN. Initiated in 2002 with funding from the CDC and the National Cancer Institute, the network includes eight funded research institutions. Together, these institutions seek to translate research into practice to prevent and control cancer. The University of Iowa joined the CPCRN in 2014. Being part of the network allows the UI to access community-based cancer research across geographic boundaries. “The advantage of being in the network is that we get to use the expertise of people across the country,” Askelson explains. “If we are looking at rural data, for example, we can pool our resources and talents and compare or combine experiences from different states.” Iowa is not alone in finding that HPV vaccinations are lower in rural and less affluent communities. One issue is that health care providers do not relay the same level of surety regarding the vaccines as they do others. As Askelson notes, a health care provider will say, “‘You’ll get the Tdap and the meningitis; then there’s this other vaccine that you can get if you want.’ That really leaves the door open.”

Reaching Families To be most effective, the immunization is administered at 11 and 12 years of age, a time when a young person’s immune response is highest. It also needs to be given in a series of two to three vaccinations spread over several months.Unlike infants who don’t have a routine filled with soccer practice and music lessons, adolescents and their working parents are much harder to schedule.

Culture and gender also play a role. Parents may not realize that HPV can infect both males and females, and forego vaccinating their son. Another member of the UI’s CPCRN team, Jason Daniel-Ulloa, clinical assistant professor of community and behavioral health, has focused on rural Latino communities, including developing collaborations between clinics, public health, and community organizations. Daniel-Ulloa has worked hard to build relationships within the community and to better understand hindrances to the vaccination and find creative ways to overcome them. Noting that Latinos in general, but especially boys, receive the HPV vaccine at a much lower rate than their non-Latino peers, he started a men’s group to develop conversations about health and masculinity. He also helped to bring the UI’s Mobile Clinic to West Liberty, Iowa, a Latino-majority community, to make vaccinations more accessible for busy families.

Amplifying the Message In addition to collaborating with the other CPCRN institutions, Askelson says that the Iowa Department of Public Health Immunization Bureau, the American Cancer Society, and Iowa’s Medicaid managed care organizations have been excellent partners in helping pilot projects that amplify information about the HPV vaccine to health care providers. Another recent theme of the CPCRN has been increasing the rate of colorectal screenings, especially among people with limited health care insurance. As with the HPV vaccine, Askelson and her colleagues have found that it is effective when providers increase reminders, such as phone messages and texts, as well as establishing flags in people’s charts who are overdue for a colonoscopy, the gold standard for detecting colon cancer. Askelson hopes that both projects will lead to better information and better health for all Iowans. “Getting kids vaccinated now against HPV,” she says, “could eliminate HPV-related cancers from ever happening in an entire generation of people.”

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Young, Complex, and

Coping with Cancer

A new program strives to meet the life changes and special challenges of young cancer patients. BY JENNIFER NEW

ia is in her last year of college carrying a full load of classes. When her thoughts aren’t consumed by applying for law school, she’s worrying about her dad who’s been laid off of his longtime job. She tries to keep her energy up by catching a Zumba class with a friend, but she’s been exhausted for most of the fall. She’s lost weight and chalks it up to stress, but she has to admit that something doesn’t seem right. The doctor at student health furrows her brow and sends Mia to the ER for more tests. The results are quick and life altering: Mia has leukemia. She is admitted to the hospital and before her parents can arrive from Chicago, bone marrow tests are underway to figure out what kind of leukemia she has and next steps. In the midst of all this, a nurse talks to her about something called fertility preservation— freezing her eggs definitely had not been on her mind just a few days earlier. 13 INSIGHT FALL 2018

Now Mia wonders if she’ll have to drop all of her classes and sublease her apartment. As the weeks go by, she finds herself in her childhood bedroom. Friends at college return her texts with emojis or silence. Except for grandparents, most of them have never known anyone with cancer and their discomfort is palpable. Mia feels deeply alone—the only 20-year-old in the world who isn’t going to parties and thinking about school. Since most of her care takes place in an adult wing of the hospital surrounded by patients three times her age, she doesn’t realize that this is far from the truth. Every eight minutes, an adolescent or young adult in the United States is diagnosed with cancer.

Different Ages, Different Needs Although Mia is fictional, her story represents what many young cancer patients go through. Hospitals are coming to understand that Mia and her cohort, identified as adolescents and young adults (AYA) who range from 15 to 39 years old, have different experiences and needs. They also have different survival rates. While the survival rates for infants, children, and adults with cancer continue to improve, the rates for AYA cancer patients have remained stagnant. Starting with movements in the United Kingdom and Australia, hospitals are increasingly trying to provide whole-patient care that is focused on the particular needs of this group with the hope of giving them better odds. In order to inform a new AYA cancer program that was initiated jointly by the University of Iowa Stead Family Children’s Hospital and the Holden Comprehensive Cancer Center, a series of focus groups was held with AYA patients. The result was a recently published article co-authored by Erin Mobley, a CPH doctoral student in health management and policy; Kristin Foster, a pediatric oncology nurse; and William W. Terry, a pediatric oncologist. The paper, “Identifying and Understanding the Gaps in Care Experienced by Adolescent and Young Adult Cancer Patients at the University of Iowa Hospitals and Clinics,” was made possible by funding from the Iowa Cancer Consortium and the Iowa Department of Public Health.

An Understudied Age Group The new AYA program started in 2015, the same year that Mobley arrived at the University of Iowa. As a pediatric cancer survivor, she has had a lifelong goal of working on the frontline of cancer care. “First I wanted to be an administrator,” recalls the Florida native, “but after doing research following graduation around bone marrow transplant, I knew that I wanted to be able to do my own research.”

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Terry, who directs the AYA program, invited Mobley to be part of the team that conducted the focus groups. The published paper is planned to be one chapter in Mobley’s dissertation, which focuses on young people and cancer. “This is an age group that’s really understudied in terms of their needs,” Mobley says. “There are a lot of changes that occur during this time of life that get overlooked. We want to create a program at Iowa that is aligned with what patients want and need.” Two dozen AYA patients participated in the conversations, responding to questions that ranged in focus from finances and insurance, to relationships with family and friends, to spirituality and suicide. The results give a much more robust picture about what this group has not been receiving in terms of care and information, what it needs, and what it wants.

Finding the Gaps Mobley knew that gaps in care would surface, but she was surprised by some of the results. For example, many participants noted that they would have liked more frequent information about risky behavior, such as drug and alcohol use, domestic violence, and emotional distress. They shared that they hadn’t used the Internet to research their illness very much and would appreciate a list of reputable sources. And although cancer affected their body image, this topic wasn’t touched on by care providers. One area of the AYA experience that Mobley says might be related to the lower improvement rate for survival is less access to clinical trials. “Nationally, we know that about 80 percent of adolescents and young adults are treated in community cancer centers,” Mobley says, noting that such centers do not have access to trials. As patients at the UI Hospitals & Clinics, this is not the case; nonetheless, many of the young people interviewed did not seem to sufficiently understand the studies, whether they were part of one, and if they’d been offered the opportunity.

“How do we better educate them?” wonders Mobley. “How do we present information in a way that matters to them and that conveys what is most important?”

Thinking Ahead to the Future Building a strong, patient-driven program is the goal of the UI’s burgeoning AYA cancer program. This means taking into consideration both the quantitative and qualitative realities of this age group. It’s a fact that many AYA patients are underinsured as they move from their parents’ health coverage to their own while entering the workforce. It’s more subjectively understood that this is a group in flux in terms of personal identity, often trying on different friend groups and belief systems, all of which can make them less tethered to the community than older patients. Mobley and her co-authors point out that AYA patients must be viewed as eventual older cancer survivors. How can the treatment today of a 20-year-old like Mia provide the best overall outcomes for all parts of his or her life? One new approach of the AYA cancer program that tries to be more mindful of the future is the nurse coordinator who, among other things, presents fertility information to all patients. This task used to be left to individual doctors, and the information was too often skimmed over or presented inconsistently. A diagram in the paper shows four overlapping circles of relationships: Self, Cancer, Others, Future. The flower-like symbol that the circles create portrays the multiple facets that the AYA program is striving to address. By treating the whole patient at a complex time of life, the Iowa team hopes for better outcomes in each sector.

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Rising Stars The Healthy LifeStars program teaches kids important habits for lifelong health. BY DEBRA VENZKE PHOTOS BY KATY STITES

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n a sunny fall afternoon, a group of second- and thirdgraders sits in a circle on the playground to talk about goals. “Who can tell me what that word means?” asks Hailey Boudreau, a College of Public Health graduate student who is guiding the discussion at an after-school program. The kids’ hands shoot up as fast as their answers: “Winning!” “Medals!” “A trophy!” “You study and practice to pass a test,” Boudreau continues. “Does it make you happy when you pass?” The kids nod. “How about exercise? What’s your goal for exercise?” “Sixty minutes a day!” several kids shout. “So we need goals to help us move forward, right?” Boudreau asks. The kids soon put their exercise goal into action as Boudreau leads them in lively games of sharks and minnows, freeze tag, and duck, duck, goose. Boudreau is serving as a coach for Healthy LifeStars, an innovative program aimed at reducing childhood obesity. Developed for elementary-age kids, the program motivates and teaches children to set personal health goals, be active every day, and eat the right foods in the right amounts.

Teaching Healthy Habits The program is being implemented through a partnership between Healthy LifeStars and the Iowa Institute of Public Health Research and Policy (IIPHRP) based in the UI College of Public Health. Healthy LifeStars is a national non-profit organization dedicated to ending childhood obesity through education, awareness, and changed habits to influence future generations of healthy children. Healthy LifeStars was founded in 2003 and has reached over 35,000 schoolchildren in Arizona and Colorado. In 2018, it launched programs in Iowa and Ohio and has the goal of growing nationwide. “Nationally, one in three children is overweight or obese,” says Edith Parker, dean of the College of Public Health. “We’re excited to introduce this program in Iowa and expand it statewide to help teach kids healthy, lifelong habits.” The program is offered in Iowa at no charge, thanks to a gift from the Stead Family Foundation and Jerre and Mary Joy Stead, two former Iowans who are among the most generous donors to the University of Iowa.

Partnership Power Healthy LifeStars started in Iowa this fall with several sites in the Iowa City area. The program is delivered in before- and after-school programs and is led in part by UI student coaches.

“We’re building a network of student volunteers who are an integral part of getting this program off the ground in our state,” says Vickie Miene, interim director of IIPHRP and director of the Iowa Healthy LifeStars program. Students from a variety of majors volunteer as coaches and contribute ideas to the program through a UI student advisory council. In addition, students contribute to social media articles and healthy lifestyle campaigns associated with the program. IIPHRP will partner with additional schools, youth-serving organizations, and health initiatives to continue to grow the program across the state. The goal is to enroll 5,400 Iowa children in the first three years in both urban and rural locations. To help motivate kids to reach their goals, each Healthy LifeStars participant receives a lanyard and chain to display reward tokens. Kids earn a colorful plastic star every time they achieve one of the goals they set for themselves.

Connecting the Dots Boudreau, who is earning a Master of Public Health degree in community and behavioral health, visits Grant Wood Elementary in Iowa City twice a week to work with groups of K-6 students. “It’s amazing, the connections the kids are able to make between all of the subjects,” she says. “For example, when we talked about nutrition, the kids were able to make the connection between skipping meals or eating poor options for lunch and how they would feel during class and recess.” Boudreau also enjoys playing active games with the students. “During our exercise lesson recently, we talked about feelings while exercising. They spoke about feeling sweaty, tired, and sore, but also about how they laugh and smile,” she says. “We all laugh and smile when we start our activity portion of the class. It’s contagious!” For more information about the program, visit cph.uiowa.edu/ healthy-lifestars/. 17 INSIGHT FALL 2018

HAPPENINGS

Causes and Effects of Rural Pharmacy Closings A recent research brief from the RUPRI Center for Rural Health Policy Analysis outlines the trends and issues surrounding the high rate of closures among independently owned rural pharmacies. Researchers found that since 2002, more than 1,200 independently owned rural pharmacies in the United States have closed, with the most drastic decline occurring between 2007 and 2009. The report states that 630 rural communities that had at least one retail (independent, chain, or franchise) pharmacy in March 2003 had no retail pharmacy in March 2018. This decline has continued through 2018, although at a slower rate. Keith Mueller, CPH professor and head of health management and policy and director of the RUPRI Center for Rural Health Policy Analysis, is the lead author on the report. According to Mueller, the spike in rural pharmacy closures can be attributed to the financial challenges posed to these pharmacies by the implementation of Medicare Part D. “The biggest challenge for these pharmacies is the delayed maximum allowable cost adjustment and remuneration fees that drive up the cost of providing medications when the payments from Medicare Part D and others do not keep pace,” he says. The report also states that the closing of so many rural pharmacies can pose significant obstacles to residents living in these communities. “Local pharmacists are part of the health care system who provide essential services such as counseling residents as prescriptions are filled, attending to residents with mild illnesses that can be treated with over-the-counter medications, providing immunizations, and supporting other local providers,” Mueller says. “Their departure creates a big gap in these communities.”

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Drug Slows Brain Shrinkage in People with MS A recent study published in the New England Journal of Medicine found that the drug ibudilast slows down brain shrinkage in people with multiple sclerosis (MS). Clinical trial results showed that ibudilast slowed the rate of brain atrophy by 48 percent among 255 participants with progressive MS when compared with an inactive placebo. The Clinical Trials and Statistical Data Management Center (CTSDMC) based in the UI College of Public Health served as the data coordinating center for this study. The center is part of the NeuroNEXT group, a nationwide network founded in 2011 to conduct efficient and rigorous phase II and biomarker studies across all areas of the neurosciences. Christopher Coffey, CPH professor of biostatistics, director of the CTSDMC, and co-author of the study, says that this study is the first phase II intervention study completed by NeuroNEXT. “These findings are in alignment with the overall objective of the network for conducting rigorous phase II studies with clear go/no-go criteria for determining whether further study in larger, confirmatory studies is warranted,” says Coffey. “This is a major milestone for NeuroNEXT, since it is a high bar to get a phase II clinical trial published in a journal as prestigious as the NEJM.” Coffey says that while the results of the study are encouraging and exciting, larger studies are needed to determine whether similar benefits are observed with respect to clinical endpoints of interest. The study was supported by the National Institute of Neurological Disorders and Stroke, part of the National Institutes of Health.

ADHD Diagnoses on the Rise The number of children in the United States diagnosed with Attention Deficit/Hyperactivity Disorder (ADHD) increased from 6.1 percent to 10.2 percent from 1997 to 2016, according to an analysis from the University of Iowa published in JAMA Network Open. This upward trend cut across all demographic subgroups, says Wei Bao, CPH assistant professor of epidemiology and study co-author. The study analyzed the health information of more than 186,000 children and adolescents gathered by the U.S. National Health Interview Survey. The data were collected annually from 1997 to 2016. The analysis also found this upward trend across gender, racial, family, and geographic lines. However, it found that not all increases were uniform, and that there were distinct differences within groups. For instance, in the gender subgroup, the research showed 14 percent of boys were diagnosed with ADHD in 2016, up from 9 percent in 1997. However, only 6.3 percent of girls were diagnosed with ADHD in 2016, up from 3.1 percent in the 1997 survey. While the number of Hispanic children diagnosed with ADHD jumped from 3.6 percent to 6.1 percent, they are still far less likely to receive a diagnosis than children from other racial groups. White children in the survey were diagnosed with ADHD at a 12 percent rate in 2016, up from 7.2 percent in 1997; 12.8 percent of African American children were diagnosed with ADHD in 2016, up from 4.7 percent in 1997.

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HAPPENINGS

UI Joins National Institute to Research Antimicrobial Resistance The University of Iowa is partnering with Iowa State University in a new national institute that will address the global public health concern of antimicrobial resistance. Iowa State will be home to the new Institute for Antimicrobial Resistance Research and Education, aimed at improving health for people, animals, and the environment. The University of Iowa Center for Emerging Infectious Diseases (CEID)—housed in the College of Public Health—is a part of the initiative. Christine Petersen, associate professor of epidemiology and CEID director, will serve as a co-director of the new institute and will coordinate involvement of participants from the College of Public Health and Carver College of Medicine. Other institutions involved in the initiative include the University of Nebraska-Lincoln and the Mayo Clinic. “This new institute will provide a platform for a coalition of scientists from across our agricultural region to consider antimicrobial resistance and stewardship across all partners in health,” says Petersen. “With this new center we will be able to openly discuss the root causes of antimicrobial resistance and the best ways to protect ourselves, our pets, and our livestock from disease while also ensuring effective antibiotics for our future.”

Thorne Honored with Regents Award for Faculty Excellence Peter Thorne, CPH professor and head of occupational and environmental health, received a 2018 Board of Regents Award for Faculty Excellence. The award honors faculty members for work representing a significant contribution to excellence in public education.

Lynch Receives Brody Award for Faculty Excellence Charles Lynch, CPH professor of epidemiology, was honored with the 2018 Michael J. Brody Award for Faculty Excellence in Service to the University and the State of Iowa. The Brody Award is named in honor of the late Michael J. Brody, former president of the UI Faculty Senate. It recognizes outstanding faculty who have made exceptional contributions to the UI and the community.

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Study Looks at Machinery Vibration, Back Pain among Farmers Farmers often work 10 to 14 hours a day, but long hours sitting on agricultural equipment can take a physical toll on the body and lead to back pain. A recent study by College of Public Health researchers examined whole-body vibration exposures during the operation of several types of agricultural machinery. Whole-body vibration is defined as mechanical vibrations that are transmitted to the human body through a contact surface, such as a seat. “Exposure to whole-body vibration is a key occupational risk factor for back pain, which is common among agricultural workers,” says the study’s lead investigator, Nathan Fethke, CPH associate professor of occupational and environmental health. Reducing exposures to whole-body vibration can help improve health and may reduce long-term health care costs. Fethke’s team measured whole-body vibration by attaching sensors to the seats and floors of more than 100 machines, including tractors, combines, forklifts, skid loaders, and allterrain vehicles as more than 50 Midwestern farmers went

about their daily routines. A paper describing the results appears in Annals of Work Exposure and Health. Combines exhibited the lowest levels of whole-body vibration exposures, while tractors and heavy utility vehicles did not fare as well. Farmers should check seat suspension systems to make sure they are greased and working properly. They should also make sure the seat suspension is properly adjusted for the operator’s body weight.

Janssen Leads Team Focusing on Overdose Prevention in Iowa Brandi Janssen, CPH clinical assistant professor of occupational and environmental health, has been selected by the Iowa Institute of Public Health Research and Policy to establish a new collaboratory that will gather data to help prevent drug overdoses in Iowa. Janssen’s project, “Iowa Substance Use Data Set: Preventing Overdoes Through Actionable Data,” is intended to be a first step toward developing a multi-stream, multi-sourced, comprehensive data warehouse for partners, and will include information directly from substance users. “This data base will be different from existing substance use information sources in that its focus is on timeliness, local relevance, and integration of multiple data sets,” Janssen explains. “The team hopes to design a data warehouse infrastructure to manage storing, updating, and sharing pertinent data. In addition, we will identify the data needs of providers and stakeholders regarding substance misuse and abuse and will design the data structure and applications to accommodate those needs.” In addition to Janssen, the collaboratory includes researchers from the Colleges of Public Health, Liberal Arts and Sciences, Education, Carver College of Medicine, and the VA Health Care System.

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‘LGBTQ Health in Iowa’ Report Finds Strengths and Problem Areas A new report from a team of Iowa researchers summarizes the findings of a survey conducted last year about the health of lesbian, gay, bisexual, transgender, and queer (LGTBQ) individuals in Iowa. The project was a collaborative of faculty and staff from the UI College of Public Health, One Iowa (an advocacy organization), the Iowa Cancer Consortium, and Des Moines University. The survey identified several strengths as well as some problem areas concerning the health of Iowa’s LGBTQ population, according to Paul Gilbert, lead researcher on the project and CPH assistant professor of community and behavioral health. “On the positive side, we found that this population had high levels of health insurance coverage, general satisfaction with recent health care, low current smoking rates, and general feelings of safety and acceptance in the communities where respondents lived,” he says. The survey also identified problem areas, such as unmet mental health needs, high levels of binge drinking, low perceived knowledge of LGBTQ health issues among health care providers, and ongoing experiences of discrimination. “Some sub-groups, such as transgender people, had an excessive amount of health deficits,” Gilbert says. “They constitute a minority within a minority and should be a priority group for supportive services.” While this study serves as an important starting point for researchers, the team has already begun the next phase of the project and is currently conducting focus group discussions to develop a deeper understanding of the health profiles and needs of LGBTQ Iowans.

Grant Expands Birth Defect Research The Centers for Disease Control and Prevention has renewed a $4.3 million grant to the UI College of Public Health for a project to identify factors in early pregnancy that may increase the risk of major structural birth defects. The award is to continue the work of the Iowa Center of Excellence for Birth Defects Research and Prevention, including participation in the Birth Defects Study to Evaluate Pregnancy Exposures. Among the goals are conducting comprehensive ascertainment of common, severe major structural birth defects, identifying associations with environmental exposures and genetic factors, and expanding a training program to develop the future generation of birth defect researchers. Paul Romitti, CPH professor of epidemiology, is the principal investigator on the award, and Kristin Conway, CPH associate research scientist, is the co-principal investigator. Romitti also directs the Iowa Center and Iowa Registry for Congenital and Inherited Disorders.

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HAPPENINGS

Food Allergy Linked to Autism Spectrum Disorder in Children

Study Seeks to Reduce Falls among Elderly Iowans According to the Iowa Department of Public Health, Iowa’s death rate from falls among people older than 65 is 9.4 per 1,000, higher than the U.S. average of 7.8 per 100,000. Medical costs of treating older Iowans who injure themselves in a fall is $135 million per year. The UI College of Public Health and the Mercy Accountable Care Organization (ACO), a Des Moines–based subsidiary of Mercy Health Network, are part of the nationwide STRIDE study, a five-year research project that seeks to reduce fallrelated injuries among older adults. “Every year, about 30 percent of adults over age 65 suffer an injury from a fall, and about 30 percent of those result in injuries severe enough to lead to declines in health and loss of confidence,” says Robert Wallace, CPH professor of epidemiology, who is leading the study. “This patient-centered group research study is to determine how we can best prevent falls by reaching out to seniors directly in a primary care setting.” The UI/Mercy ACO partnership is one of 10 research sites to receive a portion of the $30 million STRIDE grant, awarded by the National Institutes on Aging. The study involves more than 5,400 adults nationally who are at risk of falling, about 360 of whom are Iowans who see their doctors in Mercy Clinics. Some of the patients are assigned to a nurse falls care manager, who screens them individually and identifies their risks for falling. The falls care manager then prepares a report on risk factors for falling, which is sent to the patient’s primary care provider. Together, they develop an overall falls prevention and management plan. Once the study ends in 2019, the researchers will analyze the data to determine which strategies and combination of strategies were most effective.

A University of Iowa study finds that children with autism spectrum disorder (ASD) are more than twice as likely to suffer from a food allergy than children who do not have ASD. Wei Bao, CPH assistant professor of epidemiology and the study’s corresponding author, says the finding adds to a growing body of research that suggests immunological dysfunction as a possible risk factor for the development of ASD. “It is possible that the immunologic disruptions may have processes beginning early in life, which then influence brain development and social functioning, leading to the development of ASD,” says Bao. The study analyzed the health information of nearly 200,000 children gathered by the U.S. National Health Interview Survey. The children were between the ages of 3 and 17 and the data were gathered between 1997 and 2016. The study found that 11.25 percent of children reportedly diagnosed with ASD have a food allergy, significantly higher than the 4.25 percent of children who are not diagnosed with ASD and have a food allergy. Bao says his study could not determine the causality of this relationship given its observational nature. But previous studies have suggested possible links—increased production of antibodies, immune system overreactions causing impaired brain function, neurodevelopmental abnormalities, and alterations in the gut biome. He says those connections warrant further investigation. The study was published in JAMA Network Open.

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CLASS NOTES

TALA AL-ROUSAN (15MPH) has been named an Atlantic Fellow for Equity in Brain Health by the Atlantic Institute at the University of California in San Francisco, Calif. JIM ATTY (09MHA) received the 2018 Iowa Hospital Association Young Executive Award that recognizes health care executives, age 40 or younger, who have made a significant contribution to health care in the state of Iowa. Atty is CEO of Waverly Health Center in Waverly, Iowa. ZEINAB MOHAMAD BABA (06MS) is an assistant professor in the Department of Health at West Chester University in West Chester, Pa. HIND BAYDOUN (09PhD) is a statistician with the Defense Health Agency at Fort Belvoir Community Hospital in Fort Belvoir, Va. TYLER BENNETT (17MHA) is manager of system orthopedics at Sentara Healthcare based in Norfolk, Va. JANET BENTON (08MHA) is vice president of clinic services at Twin Cities Orthopedics in Minneapolis, Minn. HEIDI BOWMAN (11MHA) is director of clinical operations at Colorado Retina Associates PC in Denver, Colo. KELLY L. BREFFLE-STARBIRD (96MA) is administrative director of the Des Moines Area Medical Education Consortium in Des Moines, Iowa. RICHARD C. BREON (80MA) recently retired after serving 18 years as president and CEO of Spectrum Health in Grand Rapids, Mich. Breon was named the 2018 Business Person of the Year by the Economic Club of Grand Rapids. TINA FREESE DECKER (02MHA) became president and CEO of Spectrum Health in Grand Rapids, Mich., in September 2018. 24 INSIGHT FALL 2018

REBECCA DOVE (12MPH) is an oncology RN at The Johns Hopkins Hospital in Baltimore, Md. DESIREE EINSWEILER (07MHA) is president of Lemfco, Inc. in Galena, Ill. LAUREN ERICKSON (12MPH) is business change manager senior at Anthem, Inc. in Washington, D.C. JOSHUA FINE (18MPH) is principal, senior scientific advisor at Tunnell Government Services in Laurel, Md. MARTIN FRANKLIN GORANSSON (06MPH) is a business area manager at Namndemansgarden AB in Hassleholm, Sweden. KAYLA HESLIN (18MPH) is a biostatistician at Aurora Health Care in Milwaukee, Wis. PAIGE JAEGER (14MHA) is executive director of radiology and respiratory therapy at UnityPoint Health-Des Moines in Des Moines, Iowa. HANNAH KINRADE (14MHA) is practice administrator at Scope Anesthesia in Charlotte, N.C. MEREDITH MCKEAN (12MPH) is an investigator with the Melanoma Research Program at Sarah Cannon Research Institute at Tennessee Oncology in Nashville, Tenn. MAREK MIKULSKI (11PhD, 02MPH) has been appointed to the U.S. Department of Labor Advisory Board on Toxic Substances and Worker Health for the Energy Employees Occupational Illness Compensation Program Act. ERIN MOEN (14MHA) is director of strategy and business development at Oregon Health and Science University in Portland, Ore.

MICHELLE NIERMANN (94MA) is currently executive vice president and chief operating officer of UnityPoint Health-Cedar Rapids, Iowa, and will become president and CEO of UnityPoint Health-Cedar Rapids in January 2019. CHIBUIKE OBIOHA (17MPH) is medical director at Fort Hamilton Hospital Center for Wound Healing in Hamilton, Ohio. LOUIS PALEN (15MPH) is lead infection control coordinator at Froedtert Hospital in Whitefish Bay, Wis. LAWRENCE PRYBIL (64MA, 70PhD) has been appointed to the Foundation for a Healthy Kentucky board of directors in Louisville, Ky. LINDSEY REED (16MHA) is a skilled nursing facility lead WI at Advocate Aurora Health in Milwaukee, Wis. CHARLES SICHER (76PhD) has come out of retirement to join Don M. Michaels (76PhD) at the Apollo Consulting Group in Westborough, Mass., where they provide strategic planning services to multiple academic medical centers. JERALYN G. WESTERCAMP (16MHA) has been appointed chair of the State of Iowa Juvenile Justice Advisory Council. SHARE YOUR NEWS Have you started a new job, received an honor or award, or achieved a noteworthy milestone or accomplishment? Share your professional news and updates with fellow College of Public Health alumni! Submit your news to tara-mckee@uiowa.edu with Class Notes in the subject line. Be sure to include your year of graduation, department or program, and contact information so we can follow up with any questions.

GALLERY

Giving Back to the Community

PHOTO BY JUSTIN TORNER

any of our students kicked off the school year by performing a day of service in the community. Some harvested vegetables at a local farm dedicated to combating food insecurity. Others volunteered with a local agency that rescues surplus food from area restaurants and grocery stores and delivers it to homeless shelters, soup kitchens, and food pantries. Others cleaned kitchens and kids’ play rooms at community centers serving some of Iowa City’s most diverse neighborhoods. Wherever they served, all of our students made a huge difference in our community. At the same time, they learned valuable lessons about what binds us all together and how strong community connections are essential to enacting changes that improve health and wellbeing. That’s public health in action.

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145 N. Riverside Dr. 100 College of Public Health Bldg., Room S173 Iowa City, IowaÂ 52242-2007

SPARK

(From left) CPH students Kevin Gettz, Virgil Jackson, Alyson Gray, and Lexi Pratt share a light moment while studying in the College of Public Health Building. PHOTO BY JOHN CHOATE