Bringing order to chaos: ICH's data services

Karen Finnegan, MPH 

Research and Evaluation Scientist 

As an epidemiologist trained in health systems research, I spend much of my time with quantitative data—numbers, statistics, writing code in SAS or R. However, my favorite projects are those which are a jumble of data and require making sense of a heap of numbers before we can even begin the analysis. My background is in global health, specifically in using service numbers collected by governments to document the number of diagnoses made at community health centers and hospitals throughout the country. In those databases, it is common to have missing data for a few months—maybe even a year—at a time.

Drawing on this background, my favorite ICH projects are those which are rich in data, but only when we do some digging to understand what we have. The challenges have been varied. We’ve worked with:

• Data from a 14-year period with each year stored in a different database;
• Data collected by different people over time and documented in different ways;
• Changing variable names and definitions;
• Surveys with low response rates;
• Organizational data with changing metrics and variability across departments;
• Data stored in Access, Excel, SQL, online databases, and on paper;
• Changing electronic medical records databases.

Each data challenge has its own unique solution and determining how to use the data is part of the fun. My work at ICH has involved large and small databases, each of which has its own compelling story to tell.

Last year, we assisted the Mental Health First Aid program at Cambridge Public Health Department in managing their registration data. Mental Health First Aid educates community members about how to support people who are experiencing a mental health or substance-use related crisis. The program had registration data for hundreds of trainees, but data were stored in numerous files, there was no way to automatically know when people were due for a refresher course, and reporting on numbers trained was an onerous challenge. Our support included:

• Developing an online registration form to streamline data collection
• Building a registration database with fields which automatically flag participants who did not complete the initial training or who are eligible for refresher training
• Creating reports to make monthly, quarterly, and annual reporting a streamlined process.

By creating a user-friendly database that meets the needs of the program, we were able to support the data collection process and pave the way for future evaluation work.

The challenge of pursuing higher education for low-income, minority students in Cambridge, MA

Sharon Touw, MPH

Martina Todaro, MA

As the school year comes to an end, many high school seniors are getting excited about finding out what college they are headed to, and some are probably making plans for the big move. Boston is home to some of the most well-known universities in the country, and, with over 46%[1] of the adults holding a college degree, is one of the most educated cities in the United States (national average: 30.3%[2]).

There are many factors influencing one’s decision to pursue higher education. One of the most debated is the financial burden that may result from such a choice. Guidance related to college selection and financial planning is especially critical for low-income students, many of whom are young men and women of color. Their college and post-college experience may depend entirely on the cost of the institution, and the amount and type of financial aid received.

The Institute for Community Health (ICH) is the evaluation partner of Cambridge’s College Success Initiative (CSI), aimed at supporting low-income and first-generation students at Cambridge Rindge and Latin (CRLS), the local Cambridge high school, as well as students working with other local organizations. Their goal is for these students to access and complete post-secondary programs within 6 years at a rate equal to their non-low-income peers.

Data show the need for CSI’s work. In Cambridge, 82% of white residents aged 25 or older hold a bachelor’s degree or higher title. In the same city, less than 50% of residents of color have a college degree[3].This disparity is both a matter of high school retention, as well as college completion. According to the Department of Elementary and Secondary Education (DESE), in 2017, on average, the dropout rate among white CRLS students[4] was 2% (state average[5]: 3%), compared to 5% for their non-white counterpart (state average: 8%). Among 2009 graduates from CRLS, 50% of white students completed a credential within 6 years, compared with 42% of Hispanic students and 31% of Black or African American students. There was also a disparity by income; low-income students were less likely to complete college within 6 years than their higher-income peers (31% vs. 51%)[6].

CSI brings together stakeholders from CRLS, community-based organizations, and local higher-education institutions to work together to remove barriers for students’ achievements. Specifically, around college planning and persistence, CSI has created a partnership between CRLS and Bunker Hill Community College (BHCC) that allows CRLS students to take college-level classes within the high school setting. This positions them to succeed in college, by giving them the opportunity to experience a college course and to earn college credits if they choose to matriculate into BHCC.

While at BHCC or UMass Boston, students can decide to work together with a Success Coach, who guides them through the matriculation and financial aid processes, and helps them to understand how to register for classes and learn about available resources. Coaches also provide emotional support and encouragement.

Recently, ICH conducted qualitative interviews with 11 students who are working with a coach, and we’d like to share a couple of comments to give you a glimpse of their experiences.

“I am very thankful for this program. I look back… I probably wouldn’t be in college now. [My coach] helps me with everything. She has done a lot. I feel so thankful for the program.”

“When I was having problems balancing school and work, [my coach] used to say: ‘Stick with it. You can do it!’ It makes you confident (…) That makes me work even harder to not disappoint her.”

On a final note, we would like to stress that we acknowledge that a student’s socio-economic status is a characteristic that does not exist in a vacuum, but more often than not intersects with race, country of origin, family’s education level, and many other dimensions of one’s life. Exploring how all these characteristics co-exist and function is out of this blog post’s scope, but stay tuned and who knows…ICH may tell you more in the future!

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[1] 2012-2016 ACS estimates, found at:  https://www.census.gov/quickfacts/fact/table/bostoncitymassachusetts/EDU685216#viewtop

[2] 2012-2016 ACS estimates, found at:  https://www.census.gov/quickfacts/fact/table/US/PST045217

[3] 2012-2016 ACS estimates, found at: https://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=ACS_16_5YR_S1501&prodType=table. Excludes ‘some other races’, ‘two or more races’,

[4] http://profiles.doe.mass.edu/grad/grad_report.aspx?&orgtypecode=5&orgcode=00490000&fycode=2017

[5] chrome-extension://gbkeegbaiigmenfmjfclcdgdpimamgkj/views/app.html

[6] MA Department of Education, District Analysis Review Tool (DART)

A Tuberculosis (TB) free US?

Blessing Dube, MPH 

Manager of Epidemiology and Data Services

“Wanted: Leaders for a TB –free world” is this year’s theme for World TB Day! Early last year, I participated in a strategy and visioning workshop here at the Institute for Community Health (ICH). My group envisioned successfully co-leading an initiative aimed at eradicating TB in the US and making the headlines as award recipients who collaborated with the Centers for Disease Control and Prevention (CDC). It was a fun activity, and as I pondered over this exercise, I realized the US might actually be at the brink of eliminating TB!

In the US, the trend for new TB cases has been decreasing from 52.6 cases per 100,000 persons in 1953 to 2.9 cases per 100,000 persons in 2016, as shown in the chart above. We have made a steady progress largely due to the promotion of best practices in managing patients with TB, directly observing patients to improve adherence, as well as reducing TB drug resistance.

I believe my group’s vision was not too far from reality. In fact, ICH is currently evaluating a Massachusetts Department of Public Health three-year demonstration project that aims at scaling up latent TB infection (LTBI) testing and treatment among high-risk populations. The implementing partner is Lynn Community Health Center, in Lynn MA. As evaluators, we are utilizing mixed methods to gather data to monitor progress towards the goal, understand  challenges, and record lessons learned, so that the key findings from this initiative can be disseminated and spearhead a bundle of best practices for increasing testing and treatment for LTBI in the US. The ultimate goal of this project is to promote the sustainability of these efforts, so that they can replicated in similar health care settings. The hope is to accelerate the progress towards TB elimination in this country.

Here is a video on 5 Things to know about TB

Video shared by CDC

As we commemorate World TB day, and in the spirit of ‘Wakanda’, I challenge you today to leave a comment and your thoughts about what we can do to eliminate TB. How can we engage the public and private sectors in eliminating TB? Trivia question: which year do you think the US will eliminate TB?  

International Women’s Day: Where it came from and where it is going

Abigail Tapper, MPH Research Associate

International Women’s Day is a celebration of women across the globe.  The roots of the day are found in the oppression of women and the fight for the right to vote in the United States, and have evolved into a force for socio-political change around the world.

History

International Women’s Day first came out of the United States’ women’s movement starting in 1908.  Following the momentum of 15,000 women marching through the streets of New York City, National Women’s Day began to be celebrated in the US in 1909.  At the International Conference of Working Women in 1910, attendees voted unanimously to create an International Women’s Day. It was celebrated for the first time in 1911.  According to the website for the day, “More than one million women and men attended IWD rallies campaigning for women's rights to work, vote, be trained, to hold public office and end discrimination”.

In 1975, the United Nation’s celebrated International Women’s Day for the first time and the holiday was reinvigorated with the invention of the internet and international data sharing.  Today it is celebrated around the world with parades and marches to increase women’s visibility across numerous sectors and continue the fight for women’s rights.¹

The Institute for Community Health (ICH)

ICH is a nonprofit consulting firm that provides participatory evaluation, applied research, and planning for hospitals, health centers, health departments, and community-based organizations.   ICH strongly believes in the power of collaborative work for collective change, and strives to work to create gender equity through health.

Program Spotlight: Bridges to Moms

ICH is currently working with Health Care Without Walls to evaluate their Bridges to Moms program.  Bridges to Moms provides a variety of social services to homeless women who are pregnant or new mothers. The program supports women throughout their pregnancies and after.  Activities include case management, health education, housing assistance, and securing transportation, food, and baby supplies. Bridges to Moms works to ensure that women and babies have primary care providers after birth, have transportation to appointments, and are supported during the first year of the baby’s life. ICH is evaluating the Bridges to Moms program by conducting interviews with participants and facilitating staff focus groups, as well as using medical records to compare birth outcomes between Bridges to Moms participants and others who have delivered at Brigham and Women’s Hospital. ICH is helping Bridges to Moms understand the impact that they have on the women they work with, as well as understanding how the program can be strengthened to meet participant needs.  

Bridges to Moms was started by Roseanna Means, MD, a warrior for social justice and one of CNN’s 2011 Heroes.² Dr. Means, the dedicated staff of Bridges to Moms, the program beneficiaries, and the ICH evaluators together demonstrate the power of women-led programming and collaborative evaluation in advancing gender equity.

Sources
1.   All information about International Women’s Day came from https://www.internationalwomensday.com/
2.  http://www.cnn.com/2011/LIVING/01/20/cnnheroes.means.homeless.clinics/index.html

Growing Environmental Public Health Challenges

Megan Hatch, MPH 
Research Associate 

Environmental public health covers a vast area, from the air humans breathe to the way industrialization effects the communities we live in and the food we eat. There are two branches that are particularly of growing concern to Massachusetts however: rising temperatures and water levels.  As an organization committed to public and community health, the Institute for Community Health (ICH) is concerned about the damages occurring because of climate change.  Some of these issues are described below.

Rising Temperatures:

Massachusetts has seen some warm temperatures during the recent winter. While some might enjoy these warmer temperatures, the warmth can support disease transmission, particularly of Lyme disease. When winter temperatures are warm, fewer ticks die, resulting in more ticks alive to carry Lyme disease and transmit it to humans¹. Massachusetts is already a hotbed for ticks, with 4518 confirmed and probable cases of Lyme reported in MA in 2016². Lyme disease can cause significant morbidity in life, including fatigue, swollen joints, and even cognitive decline³. Lyme has been a public health issue for decades, and an increase in temperatures should cause states to re-evaluate the type of educational programs and screening mechanisms that are currently in use. 

*from http://www.wbur.org/commonhealth/2017/07/18/massachusetts-map-lyme-disease

Along with expanded timeframes for vectors to spread disease, rising temperatures can also give way to heat waves, which increase the incidence of heat stroke. Heat stroke is a condition characterized by the body’s inability to regulate its own temperature⁴. Cities have seen rises in death rates during heat waves in the past few years⁴. Cities are in a unique position during heatwaves, as they are hotter than surrounding rural areas, due to the Urban Heat Island Effect⁵. The danger of heat in cities has caused some, such as Chicago, to implement targeted outreach to vulnerable neighborhoods, as a preventative measure before heatwaves⁶.

 Water Levels:

Water is another facet of environmental public health that is of concern. Access to water due to droughts is a growing problem across the world⁷, and so is flooding due to sea level rise. Massachusetts is in a bit of a precarious position when it comes to flooding, a 2016 study predicted⁸. Due to a combination of gravitational pull on the ocean, South Pole ice melt, and sinking of the Northeast, East Coast cities could have a 25% higher increase in sea level than other areas of the planet⁸. Flooding due to seawater rise, but also heavy downpours, can be vehicles for waterborne illnesses, such as cryptosporidiosis and campylobacteriosis, among many others⁹.

The danger is not over once floodwaters recede or heavy rainfalls stop, however. The water-soaked items left in floodwater’s wake are perfect for growing mold and harboring other bacteria that can make humans sick. A study done after in New Orleans after Hurricane Katrina looked at asthma rates in children. While mold is commonly a trigger for asthma and a concern after water damage, the study also considered stress after a traumatizing event as a trigger for asthmatic children¹⁰. This crossover from strictly environmental factors such as bacteria, viruses, and mold, to behavioral risk factors (stress), caused by environmental factors like flooding, highlights that public health does not exist in a vacuum and all parts of human health can be influenced by environmental public health. Large swaths of the greater Boston area (including Malden, Cambridge, Revere, Chelsea, and Winthrop) are all in the predicted flood zone of the below model¹¹. The position of these communities means public health agencies should look into needs assessments, and public health prevention efforts, to be prepared should a flood ever occur. Boston and Revere have already seen a taste of coastal flooding in January, due to Winter Storm Grayson¹². 

*2050 sea level rise + Major storm. Boston could experience 7 feet of flooding (2 feet of sea level rise + 5 feet of storm surge = 7 feet of flooding). Data from http://seachange.sasaki.com

As mentioned before, the various sections of public health do not occur in a vacuum. In 2015, Researchers published their findings that refugees (due to civil war or other conflicts) experience health disparities at a greater rate than other populations¹³. On the horizon is a new type of refugee: climate refugees, people who have been forced out of their homes by environmental factors. Like other refugees, they will face barriers to health equity, and the field of public health will need to add resources to addressing these challenges.

For all public health issues mentioned above, it is important to note that children, communities of color, and low-income communities are usually more heavily affected than other demographics.

Need for evaluation, research and assessment:

            As public health departments, cities, towns, and hospitals encounter these new challenges caused by environmental factors, they will need to undertake needs assessments to inform the type of programs that would benefit their populations. Additionally, once programs are in place, they will need to be evaluated to ensure they are meeting the population’s needs, and to seek out areas of improvement. ICH has worked with local public health departments, the Massachusetts Department of Public Health, and hospitals in the past, working with a variety of data, from medical records claims, to the YBRS for social behavioral risk factors for health. As such, ICH’s previous work puts us in an excellent position to help other public health agencies plan, evaluate, and improve programs to reach their climate-change preparedness goals. 

Sources:

1: https://www.cdc.gov/climateandhealth/pubs/vector-borne-disease-final_508.pdf

2: http://www.wbur.org/commonhealth/2017/07/18/massachusetts-map-lyme-disease

3: https://www.healthline.com/health/lyme-disease-symptoms#cognitive-decline

4: https://www.cdc.gov/climateandhealth/pubs/extreme-heat-final_508.pdf

5: https://qz.com/737167/why-its-so-much-hotter-in-the-city-than-the-countryside/

6: https://www.epa.gov/arc-x/chicago-il-adapts-improve-extreme-heat-preparedness

7: http://www.businessinsider.com/americas-about-to-hit-a-water-crisis-2015-4

8: https://www.bostonglobe.com/metro/2018/01/05/threat-rising-sea-levels-hits-home/kRSnmY2avJ2kLbvcYEYRbP/story.html

9: https://www.cdc.gov/climateandhealth/pubs/warmer-water-final_508.pdf

10: https://ehp.niehs.nih.gov/trp100212/

11: http://seachange.sasaki.com

12: http://www.businessinsider.com/noreaster-bomb-cyclone-boston-floods-2018-1

13: https://www.ncbi.nlm.nih.gov/pubmed/26157042

What is being done about the opioid epidemic at a national, state, and local level

Elaine Zhang, BS

Research Associate 

The rise in pain killer prescriptions from doctors combined with aggressive marketing campaigns from large pharmaceutical companies in the 1990’s awakened a tsunami of addiction that has swept through the US resulting in significant increase in opioid drug overdose death rates. From 2000 to 2015 more than half a million people died from a drug overdose.¹  Since 2011, the rate of drug overdose deaths due to opioid prescriptions started to level out while death rate due to heroin overdose experienced a sharp increase, see graph below. In 2016, roughly 64,000 people died due to drug overdoses making it the leading cause of death for Americans under 50 years old.²

Source: https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates

Massachusetts is experiencing the opioid epidemic at a much higher rate than the rest of US. In 2014, Massachusetts’s age adjusted overdose death rate was 23.3 per 100,000 which is more than doubled the national rate of 9.6 per 100,000³. In 2017, there were 932 confirmed opioid related deaths in Massachusetts; 76% of deaths were male and 24% were female.⁴ The opioid epidemic also affects the white non-Hispanic population at a much higher rate than any other race. Of the 932 confirmed opioid-related deaths in 2017, 81% or 753 of those deaths were of people of white non-Hispanic race/ethnicity. This group has historically had higher death rates than any other race/ethnic group in the past three years⁴, see graph below. 

Source: https://www.mass.gov/files/documents/2017/11/13/sec4-od%20deaths%20demo%20Nov-17.pdf

At a county level, certain counties are experiencing higher opioid overdose death rates than other ones. Barnstable, Berkshire, Bristol, Duke, Essex, Norfolk, Plymouth, and Worcester counties currently have the highest opioid overdose death rate,⁵ see map below. 

Source: https://www.mass.gov/files/documents/2017/11/13/sec2-od%20deaths%20by%20county%20Nov-17.pdf

In October 2017, the president declared the opioid epidemic a national public health emergency. The Department of Health and Human Services has outlined a five-point strategy to combat the opioid epidemic:

1.       Improving access to treatment and recovery services

2.       Promoting use of overdose reversing drugs

3.       Strengthening our understanding of the epidemic through better public health surveillance

4.       Providing support for cutting edge research on pain and addiction

5.       Advancing better practices for pain management.

The Center for Disease Control and Prevention (CDC) awarded $28.6 million in funds to 44 states and the District of Columbia to help strengthen prevention efforts and better understand the epidemic through public health data⁶, which aligns with part of the HHS five point strategy.

In 2015, Massachusetts Governor Charlie Baker signed Chapter 55 into law in response to the opioid epidemic. The new law allowed different government data sets to be analyzed to help guide policy decisions and better understand the opioid epidemic.⁷ The Baker administration also allocated $34.5 million to combat the opioid epidemic through raising awareness, increasing prevention, and providing education. Recent data shows that in the first 9 months of 2017 there were 167 fewer opioid related overdose deaths when compared to the first 9 months of 2016, a 10% drop in deaths.⁸ Along with the decrease in deaths, there has also been a 30% decrease in the number of patients who were prescribed an opioid in the third quarter of 2017 when compared to the first quarter of 2015.⁸

At ICH, we work on several projects that focus on the opioid substance use disorders. SUSTAIN Communities Evaluation is an initiative funded by the GE Foundation with support from Partners HealthCare. SUSTAIN Communities provide grants and technical assistance to community health centers to build capacity for Medication Assisted Treatment (MAT) for patients with opioid use disorder.  ICH Assistant Director of Research, Leah Zallman, MD, MPH, works on a project funded by a small foundation (McManus) that uses electronic health record data to understand the relationship between opioid prescriptions and the development of opioid abuse disorder. ICH is looking into Cambridge Health Alliance data among patients who have ever been prescribed opioids and tracking how many developed opioid use disorders, how long it took, and what are the clinical predictors. Promoting Older Women’s Engagement in Recovery (POWER) is a collaborative project aimed at the prevention of opioid misuse in older women ages 55 or older in Cambridge and Somerville. The Institute for Health and Recovery received the grant and works alongside with Cambridge Health Alliance, Somerville Cambridge Elder Services, and the Cambridge Council on Aging to address the risk factors of opioid misuse among older women through technical assistance for partnership sites and direct support groups for women 55+. ICH is the evaluator on the project.

If you or someone you know is struggling with addition, there are some resources available to help. The Massachusetts SubstanceAbuse Information and Education Helpline provides free and confidential information and referrals for alcohol and other drug abuse problems. The Institute for Health and Recovery helps families and youth with substance abuse issues access publicly funded services. The Suboxone Hotline Office Based Opioid Treatment Program at Boston Medical Center provides referrals and information on opiate and heroin treatments available at doctor’s offices statewide. Cambridge Health Alliance offers an outpatient addiction service which helps adults to and maintain sobriety. The Fresh Start Alcohol and Drug Recovery Group is an anonymous peer support group that meets on Thursday evenings at CHA Revere Care Center. Smart Recovery is a scientifically tested program for adults who want to manage their addiction and is held every Tuesday evening at CHA Everett Care Center.

Below are the numbers for each helpline:

The Massachusetts Substance Abuse Information and Education Helpline:

Phone Toll Free: 1-800-327-5050

TTY: 1-888-448-8321

The Institute for Health and Recovery:

Phone: 1-866-705-2807
TTY: 1-617-661-9051

Suboxone Hotline Office Based Opioid Treatment Program at BMC:

Phone: 1-866-414-6926 or 1-617-414-6926

Sources:

1: https://www.cdc.gov/drugoverdose/epidemic/index.html

2: https://www.nytimes.com/2017/10/26/us/opioid-crisis-public-health-emergency.html

3: http://www.mass.gov/chapter55/

4: https://www.mass.gov/files/documents/2017/11/13/sec4-od%20deaths%20demo%20Nov-17.pdf

5: https://www.mass.gov/files/documents/2017/11/13/sec2-od%20deaths%20by%20county%20Nov-17.pdf

6: https://www.cdc.gov/media/releases/2017/p0905-opioid-funding.html

7: http://www.mass.gov/chapter55/

8: http://www.wbur.org/commonhealth/2017/11/13/opioid-state-snapshot-third-quarter 

The Heart of ICH

Luisa Raleza 

Executive Assistant 

During this holiday season of giving and blessings, I am reflecting on how blessed I am.  I am fortunate to have good health, great family, friends, and colleagues.  The biggest blessing of all is that I am working for the Institute for Community Health (ICH).  ICH is a nonprofit consulting organization that provides participatory evaluation, applied research, and assessment and planning to help the helpers and, ultimately, assist local communities to create sustainable health.  Since the inception of ICH, it has contributed to communities, creating engagement and a chain of giving, which leads to a gratefulness for both the giver and the recipient alike.  The work ICH does leads to improved health, happier living, and better communities.

According to one of our founding fathers, Dr. David Bor, “ICH was created in response to the growing AIDS epidemic in the 1980's: David Bor, Marshall Forstein and Paul Epstein started the Cambridge AIDS Task Force. The task force considered health care to be the fourth priority after housing, work place anti-discrimination policies, and education about contagion -- a surprise to many health practitioners. That model of community engagement formed the basis for the ‘Cambridge-Harvard Health of the City Program (HoC)’, with funding from the Rockefeller Foundation and Pew Charitable Trusts. The co-directors of HoC included David Bor, representing the public hospital (CHA), Ron Arky, representing the private hospital (Mt. Auburn), and Frank Duehay, representing the city of Cambridge. The organization spawned the Men of Color Task Force, Healthy Children's Task force, and a "health information unit" whose purpose was to collect data to inform the public about local health and health needs. When funding ran out, the Cambridge Health Alliance, Mt. Auburn, and Mass General Hospital agreed to co-sponsor a new organization, The Institute for Community Health, based upon the same principles.”

The cosponsoring of ICH started this chain of partnership, involvement, caring, and giving to the communities.  My colleagues take this caring and giving to their partner organizations, who in turn pass it on to the communities they serve.  ICH assists our partners, for example, to help educate new parents on how to care for their children, and to improve the lives and health of folks that have health problems such as HIV, mental health, and/or substance use disorder.  ICH also assists our partners to prevent violence such as gang violence, domestic violence, and other relationship violence. And these are just a few of the areas in which we assist.  Overall, ICH creates better communities, especially for the underserved.  Best of all, ICH helps these foundations and programs work with the resources they do have and use them to the fullest. 

With great care, passion, and devotion, my colleagues assist ICH’s partners with creating safe and healthy environments.  Safe healthy environments then lead to greater prosperity and health equity, and in turn it gets passed on and given to others, who are able to make better lives for themselves.  I have always wished to work in an organization like this one and have been blessed.

Happy New Year to all!