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HealtH and HealtHcare at cSUla and in tHe SUrroUnding commUnity An Assessment by students in the Department of Public Health, California State University, Los Angeles Credits: Lead Authors CALIFORNIA STATE UNIVERSITY, LOS ANGELES Department of Public Health Cecilia Catalan Vicky Duarte Sarah Freeman Maritza Fernandez Aurora Lilly Elizabeth McMeans Kristina Punzalan Design Aurora Lilly Student Editor Sarah Freeman Project Advisor: Walter Zelman, Ph.D. Chair, Department of Public Health 2 D edicated to past, present and future students of California State University, Los Angeles Department of Public Health, who will become leaders in promoting health and healthcare in their communities. Health and Healthcare at CSULA & Surrounding Community 3 4 Executive Summary page 8 Chapter One: The Focus and Tools of Public Health page 10 What is public health? Public health is about prevention and populations Community Health Frameworks, Constructs, and Tools Chapter Two: Health and Healthcare at CSULA and in The Surrounding Community page 14 Student Health Assessment: CSULA Health Assessment: the Larger CSULA Community Chapter Conclusion Chapter Three: Access to Care page 20 Student Health Center Student Health Insurance Health Care Reform Health Access in the Community Recommendations Chapter Four: Nutrition and Obesity page 26 Nature and Prevalence of Obesity Campus Food Issues, Community Nutrition Issues Recommendations Conclusion: Lessons and Commitments page 33 Endnotes page 34 Appendix A: Health Policy Class List page 36 Appendix B: Student Survey page 37 Health and Healthcare at CSULA & Surrounding Community 5 6 W e, the authors of this report, hope it will be of value to all members of the CSULA community. We also hope it raises concerns about some health and healthcare challenges in the neighboring community. We recognize that while most of the challenges we have identified may require the action of univer- sity officials or state or national policymaking bodies, we our- selves must play the critical part in the search for solutions and in producing the changes that may be required to improve the health and healthcare of our fellow students and larger com- munity. W e wish to thank those who have provided important as- sistance or leadership in this project. Above all, we want to thank the students of Public Health 446 who provided the great bulk of research and analysis that went into this report. We also wish to thank those faculty members and other uni- versity officials who gave us their time and insight. This project would not have been possible without their invaluable assis- tance. We also wish to thank Shani Miller, a CSULA Commu- nications student for editing our paper. We also wish to thank the Robert Wood Johnson Foundation for providing hard cop- ies of several of its reports on matters critical to our inquiry. Health and Healthcare at CSULA & Surrounding Community 7 Executive Summary During the winter and spring quarters of 2011 students in the Department of Public Health (then Health Science) undertook a health assessment of the health and healthcare of students at CSULA and of the surrounding East Los Angeles community. I n the winter quarter, students enrolled The entire class studied a variety of issues, In the spring quarter of 2011, a group in a course in health policy collected programs, or problems in health policy of seven Public Health students, (four of most of the information required for the that seemed particularly relevant to this whom were students in the health policy assessment of health and healthcare of assessment project, including: Medicaid, course) undertook the task of consolidating CSULA students. They conducted a survey of the uninsured, public health policy, and the work of the policy class, undertaking over 300 CSULA students, asking questions the safety net. They wrote papers on topics additional research, including interviews, about views and activities, the answers related to the assessment itself and to policy to fill in gaps, and drafting a report on to which would produce a picture of the options that might address the challenges findings and recommendations. They health status of the CSULA student body revealed in the assessment. undertook this project as part of their Public population. (Students were not asked if they Health internship requirement. Both the were undergraduate or graduate students). At the conclusion of the health policy health policy class and the internship were Teams of students also interviewed the course, and based on all the research offered by Dr. Walter Zelman, Chair of the Dean of Health and Human Services, as done throughout the quarter, the students Department of Public Health. well as faculty members in Health Science, identified two health care challenges as the Nutrition, Kinesiology, and Criminal Justice. most pressing: nutrition and the related The director and the health educator at the obesity epidemic; and access to healthcare Student Health Center and the administrator and insurance. They determined that these in charge of food services on campus were challenges stood out both for the CSULA also interviewed. student body and for the surrounding community. 8 1: Chapter One defines and explains some of the principal tools and concepts members had no health insurance. Many reported postponing or foregoing medical care they felt they needed. Also, many East Los Angeles community. This chapter also offers a series of recommendations relating to the Student Health Center, employed by public health administrators, reported poor eating habits, acknowledging education on the new health reform advocates and researchers. These include the that they ate junk food on a fairly regular law, and other matters. As in the case of concept of disparities, social determinants basis. They saw these personal challenges as recommendations in the previous chapter a of health, the Healthy People 2020 report, problems in their communities as well. number of recommendations here place the health policy and the concept of community responsibility on students to take leadership Chapter Two also reviews the demographics in addressing some key challenges. empowerment. The primary theme of the East Los Angeles community. This data emphasized here is that health status at both reveals a clearly low-income community with the individual and community level is greatly influenced by socio-economic factors such as income, employment, social status, and a variety of pressing healthcare needs. Low rates of insurance, high rates of delaying needed care, high rates of obesity, and 4: Chapter Four delves into the area of nutrition and the related challenge education. limited access to healthy food choices are of obesity. It defines the issues, outlines the This theme seems particularly relevant in all part of that East Los Angeles healthcare extent of various nutrition/obesity related studying health and healthcare in minority landscape. issues, and attempts to explain some of the and low-income communities, such as those causes of these healthcare challenges, both being studied in this report. The analysis for the student body and the surrounding raises the critical question of how effectively community. With regard to the student body, a society can improve health and healthcare in a lower-income community if it does not address the underlying socio-economic 3: Chapter Three addresses issues of student and community access to healthcare the focus is largely on the university food court and how the healthy food options there might be increased. With regard to challenges in that community. and insurance. The chapter explores the the surrounding community, the focus is services – strengths and gaps—of the on the lack of healthy food options, the dominance of fast food, and the challenges 2: Student Health Center and the student health insurance plan. It highlights the faced by low-income families with limited Chapter Two reviews the findings high percentages of uninsured students and time for food preparation and limited access of the student survey and other data community members. It looks at the pivotal to large grocery stores, fresh produce, and gathering activities. It indicates that CSULA role of the safety net and the financial other nutritional options more associated students did not reveal significant health shortages that parts of the safety net tend to with healthy nutrition. Recommendations concerns on a number of measures. In fact, experience at times when those services are to address the defined problems are overall, they reported themselves to be in most needed. offered, both for the campus and for the good health. Few students reported smoking surrounding community. Several of these or engaging in risky behaviors such as binge It reviews elements of the nation’s new recommendations call for student leadership drinking or risky sexual behavior. However, health reform law and emphasizes the value in addressing the problems. large numbers of students reported that they of that reform (however controversial it may had no health insurance and that family be) for CSULA students and the surrounding Health and Healthcare at CSULA & Surrounding Community 9 CHAPTER tHe FocUS and toolS ONE oF PUblic HealtH L ittle is more important than maintaining our health. Without health it is difficult to pursue even the most basic life functions, such as attaining an education, maintaining employment, or pursing life goals. Public health activities aim to address all factors related to health including, but not limited to, nutrition, access to preventive care, air and water quality, safe environments, and hygiene. W Hat is publiC HealtH ? p ubliC HealtH is about prevention and populations What distinguishes public health from other practices is the emphasis on disease prevention and population health; this differs from the focus of traditional medicine on the treatment and curing of disease on an individual basis. It emphasizes identifying the common factors that makeup a community, using them to understand health issues, and implementing effective interventions. public health is a collaborative effort between government health departments, hospitals, health agencies, community organizations, and businesses. To achieve its goals, public health incorporates a variety of disciplines such as Epidemiology, Biostatistics, Community Health, Environmental Health, Occupational Health, and Mental Health. This practice requires these interdisciplinary professions to work as a cohesive unit to fully understand the underlying causes of disease, disability, and premature death in order to formulate and implement preventive measures. C ommunity H ealtH One facet of public health is community health, which attempts combine prevention and health promotion at an interpersonal level, by studying theories and applying them to programs and policies in order to improve health outcomes. An important component of health promotion is that it relies on applying interventions and actions that will identify risks and reduce the possibility of health threats. This includes “any planned combination of educational, political and environmental mechanisms, that support actions and conditions [contributing to] the health of individuals, groups, and communities”.1 Such an approach assumes that individuals and their health are influenced by economic, social, cultural, and environmental factors. Community assessments are essential in order to apply appropriate theories and planning models. Any community health intervention must be based on actual and perceived population needs. When assessed and implemented correctly, an intervention should lead to a sustainable change in that community, thus improving the overall quality of life. 10 Public Health employs many frameworks, constructs, and tools to understand, explain, and assess health F rameWorks , C onstruCts , and t ools challenges. Five concepts that are particularly relevant Healthy People 2020 One the four overarching goals of Healthy People is to “achieve health equity, eliminate disparities, and improve the health of to this report include: all groups”.2 Healthy People 2020 (HP2020) is a federal report produced by health objectives outlined the United States Department of Health and Human Services that is intended in Healthy People 2020, to organize national health goals. It was created to serve as a tool to improve health disparities, social population health by providing science-based national objectives, guided by determinants and socio- public input, and is often used as a basis for community health planning. economic status, public policy, HP2020 creates a complete, strategic framework that brings together health and empowerment. promotion and disease prevention issues under a single umbrella. This allows national research, program planning, and policy efforts to promote health and prevent disease effectively. Additionally, it provides a specific list of leading health indicators “ that are used to monitor progress towards its stated objectives.3 By releasing an updated version every 10 years, the Healthy People reports serve as an instrument for monitoring improvements, and can be used to compare results from community interventions to those on a national level. “A particular type of health difference that is closely linked with social, economic, and/or environmental Health Disparities Disparities are defined as differences or inequalities. When trying to understand the causes of disparities and how they might be disadvantage. Health disparities reduced, public health practitioners analyze factors such as race, ethnicity, adversely affect groups of people gender, and socio-economic status that can lead to inequalities or differences who have systematically experienced between populations in health status or outcomes. Learning tools, such as greater obstacles to health based on health disparities research, indicate where problems might lie, and open their racial or ethnic group; religion; up pathways to find the reasons such factors undermine health. socio-economic status; gender; age; Much of the vocabulary used among public health professionals is as ambiguous as mental health; cognitive, sensory, or the definition of public health itself. Since there is no single specific definition for the physical disability; sexual orientation term “health disparity”, the term can have slight differences in use and practice. Our or gender identity; geographic report uses the term “health disparities” in the same context as HP2020, as outlined ” location; or other characteristics in the box to the left. The most important thing to remember about a disparity is that historically linked to discrimination or it is an indicator that something may be wrong and may need to be addressed. exclusion.” -Healthy People 2020 Health and Healthcare at CSULA & Surrounding Community 11 F rameWorks , C onstruCts , and t ools : C ontinued such as health insurance; conversely, those who are unemployed Social Determinants and matters of Socio- have higher risk factors for poor health status due to high stress economic status When seeking to assess and explain the levels. 5 Secondly, occupations differ in qualifications and prestige; health status of a community, the social determinants of health those working in lower status jobs are more likely to experience are of primary interest. They place importance on examining the occupational injuries when compared to workers in positions of underlying issues leading to poor health status and outcomes higher prestige. within communities and can provide guidance for further research. A commission created by the Robert Wood Johnson Foundation The social determinants of health include economic and social addressed the social determinants of health in their report on circumstances with which individuals and communities are “Overcoming Obstacles to Health.” The report emphasized the confronted that can influence health impact on health of such factors as the outcomes. These circumstances availability of safe walking paths, air often produce health disparities quality, and convenient healthy food among populations. Our choices.6 Because these determinants examination of social determinants “Quality of life is defined as an individuals’ perception of their are part of the physical environment involves questioning correlation and exist outside individual health and causal relationships such as: position in life in the context of the culture and value system in which behaviors, the problems on which they How does wealth or they live, and in relation to their focus cannot be effectively addressed poverty impact health goals, expectations, standards through such interventions as status? lectures on eating habits and exercise and concerns. It is a broad How do environmental ranging concept, incorporating regiments. The effort to address these conditions, such as in a complex way a person’s challenges, their causes, and the neighborhoods, affect physical health, psychological health? disparities they may produce may state, level of independence, require public policy or community Do education and work social relationships, personal action. In their article, “Don’t Forget status impact health? beliefs, and relationship to salient about the Social Determinants of features of the environment” Health,” national public health leaders Socio-economic status (SES) -World Health Organization, Gail Wilensky and David Satcher traditionally involves factors such as Geneva, 1996 Quality of Life argue that proactively focusing on education, income and occupation. Assessment SES determinants will prove to be Adler and Newman, authors of less expensive than waiting for the “Socio-economic Disparities In population to become sick before Health: Pathways And Policies”, seeking medical care. 7 describe these factors in detail starting with education, recognizing education’s impact on earning They assert that even as the nation focuses on access to health potential.4 Second, income is listed as an important SES factor insurance, focusing on social determinants, such as income and as it impacts many aspects of life that may be related to health. education, are important as they influence the ability to access Although a positive correlation between income and health status medical care. 8 Their reminder is that addressing poverty and other has been established, the relationship extends beyond the ability socio-economic issues is vital to creating an overall healthier society. to secure housing, subsistence, and basic needs. Additionally, they emphasize that prevention strategies (in line with public health ideology) are the most cost-effective method of Occupation status is the last mentioned variable in SES. For two reasons, it may be the most complex of the factors. First, those improving the community’s health. who are employed are more likely to have entitlement benefits 12 Involvement in Policy Policy is the bridge that begins at the problem and creates a path towards the achievement of selected goals. These community-based collaborations are most successful when community members are engaged in identifying key stakeholders with leverage to garner their support for policy change, and have a vested interest in the community health issue. Our research revealed the extensive scope of health policy options available to address public health challenges, the occasional controversies arising from such policies and their impact – both positive and negative – on individuals and communities. Such policy interventions can and do occur at all levels of government –federal, state, and local. They involve multiple political and community actors including elected officials, lobbyists, community activists, government administrative officials and policy analysts. Because of the ties between community public health needs and fundamental economic and social circumstances relating to social determinants of health and SES factors, public policy around public health issues can become highly controversial, requiring policymakers to address core matters of economic and social opportunity. 9 Community Empowerment and Assessment A key construct of public and community health posits that community empowerment, through capacity building, helps communities to solve their problems with their own resources.10 Community participation fosters opportunities for ownership and empowerment, leading to a sense of community responsibility and accountability. When truly empowered, the responsibility of maintaining healthy behaviors must remain largely with the community. This report serves as a baseline assessment of the health concerns within the student body at California State University, Los Angeles (CSULA), and within the surrounding community of East Los Angeles. Using the aforementioned frameworks, constructs, and tools, this report analyzes health issues warranting change. By understanding what has to change, recommendations can be made to the CSULA community for policy changes that will improve health outcomes and provide a sense of empowerment within the campus and community. Health and Healthcare at CSULA & Surrounding Community 13 HealtH and HealtHcare CHAPTER TWO at cSUla and in tHe neigHboring commUnity T his chapter discusses the health assessment of the students of California State University, Los Angeles (CSULA), as well as the surrounding community of East Los Angeles. The initial set of data for this project was collected in a student survey conducted by students enrolled in the Department of Public Health’s Health Policy course in the winter quarter of 2011.11 Additional survey information was obtained from a thesis study from the School of Kinesiology and Nutritional Science. Information on the demographics of the student body was collected from the Office of Institutional Research at CSULA, as well as from the California State University’s Division of Analytic Studies. All data collected on the community of East Los Angeles or SPA 7 was obtained from official Los Angeles County sources or the U.S. Census Bureau. 14 The net price includes tuition and fees, books and supplies, and the average cost of room s H tudent ealtH ssessment a : Csula and board minus any financial aid. Although the percentage of students receiving grants is comparable to students at other universities, Although each campus within the California An even more significant difference CSULA students receive an average of $1000 State University (CSU) system is required between CSULA students and those more per year.17 Perhaps this difference can to provide their students with a quality attending other CSU campuses is financial be attributed to scholarships, less expensive education in accordance with the same status. Over 28% of textbooks and supplies, or set of standards put forth by the Board of CSULA’s incoming students opting to live at Trustees, every school is not made equally. freshmen are from Only 55% of CSULA’s home and commuting to Student demographics vary by school and families with an annual incoming freshmen school. CSULA is one of the more diverse. The parental income equal were native English- CSULA student body is comprised mostly of to or less than $20,000. speakers. When Between their minority minority groups, mainly Latinos at 62%.12 This percentage is looking at all 4-year status and poverty level Statewide the majority population is self- twice that of freshmen public institutions, family incomes, our identified as white.13 attending other CSUs.16 94% of students research suggests that However, when looking CSULA students face This is particularly important when looking at the median net price were native English- unique challenges in many at language; in 2007, only 55% of CSULA’s of attendance, students speakers aspects of life, including incoming freshmen were native English- at CSULA are paying health and healthcare. The speakers. When looking at all 4-year public less than half ($3,263) Student Survey responses, institutions in the United States 94% of of those attending the schools within the however, indicate this may not always be students were native English-speakers.14 comparison group, ($6,871) per academic the case and that the overall picture may Additionally, as of Fall 2009, 8% of CSULA year. be more complex and less predictable. For students are non-resident aliens, compared example, over three-quarters of students to 3% in the comparison group.15 surveyed describe their health status as good or excellent. Additionally, the majority of CSULA Students: Personal Behavior students report avoiding unhealthy behaviors such as smoking, binge drinking, and having unprotected sex outside of a committed relationship. (See Figure 1) The Student Survey also found that 58% of students think that CSULA does a good or excellent job encouraging exercise and other healthy behaviors. About three-quarters of students said that they feel safe on campus, and that the school does a good or excellent job at providing student health services. (See Figure 2, p. 16) But students did acknowledge significant concerns about, or potential risks to their health and healthcare in two critical areas: nutrition and obesity, and access to healthcare and insurance. Figure 1 Health and Healthcare at CSULA & Surrounding Community 15 Student Views of Health Efforts at CSULA, by Percent 33% OF STUDENTS WHO TOOK THE SCHOOL OF KINESIOLOGY AND NUTRITIONAL SCIENCE SURVEY SAID THAT CAMPUS DINING WAS THEIR MAIN SOURCE OF FOOD WHILE ON CAMPUS. Figure 2 CSULA Students: Perceptions of Community Needs and Issues Figure 3 16 Nutrition was the only area in which students In addition to nutrition and obesity, access Health and Healthcare in the acknowledged engaging in unhealthy to health care and insurance is the other behaviors. According to a survey taken as significant concern of the students. According Surrounding Community: part of a thesis for the School of Kinesiology to the U.S. Government Accountability Office, Student Views The students’ views also and Nutritional Science, 50% of students 80% of 18-23 year old college students had reflected considerable concern regarding describe themselves as overweight.18 health insurance in 2006.19 However, only nutrition and obesity, as well as health and Additionally, 83% of students in our Student 59% of the CSULA students surveyed said health care within their own community, Survey reported that they sometimes or that they have health insurance coverage, and the community surrounding CSULA. frequently eat foods that they perceive to be and 39% said that someone in their As shown in Figure 3 on page16, poor air unhealthy. immediate family does not have insurance. quality, low income levels, exposure to drugs and/or alcohol, personal safety, and not When asked about the CSULA campus, about Approximately 40% of students report having enough safe places to exercise were two-thirds of students reported that they feel that they have forgone medical treatment of concern. Additionally, many students food choices on campus were poor or fair. (including doctors visits, prescriptions, etc.) had concerns about adequate access to This number jumps to 99% in the survey due to inability to pay, with 10% saying that health care services and access to healthy taken by the Nutrition Department, when they do so frequently. Perhaps this is the foods within the community. The public students were asked if they would like to reason that nearly every student surveyed health perspective outlined in Chapter One see healthier food choices on campus. This reported that they believe all Americans suggests that any assessment of health and is particularly important because 33% of should have access to quality healthcare, healthcare status focused on a community students who took the Nutrition Department’s regardless of there ability to pay, and 56% such as East Los Angeles must begin with one survey said that campus dining was their believed that their health and healthcare fundamental reality: many of the individuals main source of food while on campus. should be a significant concern to the and families living within the area face university. Do CSULA Students Engaging in Riskier Behaviors than They Suggest? During an interview, CSULA health Although this number does seem high, educator Joanna Gaspar mentioned that even in the event that each test was given from her experience it seemed as though to a different person, this figure would students under-reported partaking in only represent approximately 10% of the these types of behaviors. total enrollment at CSULA for that year. Interestingly, a similar percentage (9%) of She referred to a report from the CSULA students reported having had sex outside Student Health Center, showing that of a committed relationship sometimes or 2,060 tests for sexually transmitted frequently. infections were ordered in the 2009- 2010 academic year. Health and Healthcare at CSULA & Surrounding Community 17 H ealtH a ssessment : t He l arger Csula C ommunity of worse health outcomes. Figure 4 (left) indicates what studies have concluded – lower income is directly correlated with worse health outcomes.25 Community Assessment: Access to Care The Los Angeles Public Health Department (LAPHD) has divided Los Angeles County into 8 geographic regions known as Service Planning Areas (SPA). CSULA falls in SPA 7, which includes the East LA, Bellflower, San Antonio, and Whittier districts. According to the California Health Information Survey(CHIS), 22.8% Figure 4 of residents in SPA 7 did not have health insurance coverage versus the California state average of 16.2%. Additionally, 17.2% considerable socio-economic challenges. As almost six times as great. of the community stated they do not have a the analysis of social determinants suggests, usual source of care, compared to the state “the connection between poverty and ill Although the unemployment rate for East LA is not available, the unemployment rate for average of only14.2%. health is a double-edged sword in the sense that poverty breeds ill-health and ill-health the city of Los Angeles (likely to have a rate The survey also found that one quarter of the maintains poverty”20 When considering the well below that of East LA) stands at 13.4%,21 residents relied on community clinics and/ circumstances of the community surrounding significantly higher than the national or government hospitals for any medical CSULA, we must recognize that a population average of 9.0%.22 treatment they needed. These disparities with very low socio-economic status (SES) is For those who are fortunate enough to be affect not only those living in the area, but likely a very underserved population. employed, per capita income in East LA the future of the area as well. For example, was $12,690 in 2009, while the average 9.7% of pregnant women in SPA 7 received SES assessment According to the in California was $29,020. The national late or no prenatal care. This is much higher U.S. Census Bureau (2009), the population average was $27,041. The median household than the state average. Additionally, when of East Los Angeles (East LA) consisted of income in East LA was $35,645, with the these women were asked about their health 122,000 people with the median age of average family size being four. This means status, their responses tended to be more 28.4 years. The majority of residents are that more than half of all homeowners and skewed to the lower end of the spectrum than members of minority groups, with 98% of renters had to spend a minimum of 30% of in other SPAs.26 the population being Hispanic, more than their household income on housing costs.23 half of which (56%) was foreign born. LA County Health Assessment Ninety percent speak a language other than There are also noticeably high disparities In terms of environment, the socio-economic English. Education rates within this area with individuals and families living below status of a person’s locality may limit, or are alarmingly lower than the national the national poverty level. Figure 5 (below) even determine, their access to healthful average. For example, only 42.9% of the shows that, relative to the national average, residents in East LA graduated high school, more than twice as many families of East approximately half of the percentage of the LA live below poverty.24 East L.A. U.S. U.S. average of 84.6%. Only 4.6% of East LA These striking disparities Families below poverty level 23.1% 9.9% residents have obtained a Bachelor’s degree, in the community are, Figure 5 while the average for the nation (27.5%) is no doubt, at the heart Individuals below poverty level 24.2% 13.5% 18 SPA 7 L.A. County behaviors. For example, a presentation from 100,000 compared Percentage of adults ever the University of California, Los Angeles’ to 2.4 per 100,000 diagnosed with diabetes 11.0% 8.7% Center for Health Policy Research found that nationally. Additionally, SPA 7 has at least 6 times as many fast food the diabetes diagnosis Diabetes death rate (age-‐ restaurants and convenience stores as it does and death rate also adjusted per 100,000 32.8% 24.7% grocery stores and fresh produce vendors.27 stand out as high for population) both women and men. obese (27%) is remarkably Figure 6 (right) compares the percentage The statistics in Figure 7 (above) depict the Figure 7 higher than the percentage of adults and children who eat fast food at disparity in death rates for this preventable of L.A. County adults who are least once a week, as well the percentage disease. overweight (36%) or obese (22%).33 of adults and children who drink at least one soda or other sweetened drink per Finally, The number of children and adults day in SPA 7 versus LA County as a whole. who are overweight or obese is the greatest More people consume soda in SPA 7 than health concern for this population. The in LA County as a whole.28 Even for those prevalece of obesity is higher among who would like to consume fresh foods, the children who live SPA 7 (27%) than County Key Indicator Report showed that children who live in L.A. County (23%). The only 30.6% of adults rated the quality of proportions are similar when the weight of fresh fruits and vegetables where they shop adults is examined. The percentage of adults as high. 29 living in SPA 7 who are overweight (40%) or Other behavioral factors are associated with poorer health outcomes within this community as well. For example, the 79.5% percent of children ages 6-23 months watch (any) television daily compared to only 67.6% in LA County.30 As for adults, alcohol consumption was also significantly different; data showed 18.4% of adults reported binge drinking on at least one occasion in the last 30 days compared to only 15.4% at a national level.31 These behavioral factors lead to health problems in the community. Children in SPA 7 whose mental health development rated normal stands at only 84%, compared to 90.9% for the entire state.32 For women in SPA 7, the cervical cancer death rate is at 5.1 per Figure 6 C Hapter 2: C onClusion A s discussed previously, findings like those in East Los Angeles and SPA 7 suggest that low socio-economic status and social determinants lead to greater health disparities. Although studies have also shown that lifestyle behavior is the greatest contributor to poor health, it is understood that many unhealthy behaviors may be directly attributed to socio-economic and environmental factors. 34 Overall, our assessment indicates that students at CSULA were rightfully most concerned about nutrition related issues and choices, and about matters of health care access. The remainder of this report will focus on these two issues and suggest solutions that may be the first steps in changing the trajectory of the health status of students of CSULA, as well as the surrounding community. Health and Healthcare at CSULA & Surrounding Community 19 CHAPTER THREE acceSS to care T he extent to which a population gains access to affordable care depends on financial, organizational and social or cultural barriers that limit the utilization of such services, and on efforts of individuals and communities to understand and address those barriers.35 Facilitating the proper health care for those in need has been a significant concern for many low-income communities and those who advocate for them. Hence, access is measured by affordability and physical accessibility. Services available must be appropriate, affordable, and effective if the population in question is to achieve adequate health outcomes. Furthermore, those who are less likely to have access to care are more likely to have health challenges. As noted in Chapter One, social determinants of health can produce significant challenges to efforts to improve care and health status in low socio-economic status communities. In this chapter, we will first explore the services and utilization as well as the strengths and weaknesses of the healthcare services offered by CSULA. Next, we will provide a brief overview of the nation’s new health reform law, focusing on those provisions likely to have the greatest impact on the current student body as well as the safety net that is used by the students of CSULA and the surrounding community. Finally, we will draw on our analysis to offer recommendations that we believe will help to address the problems we have identified. 20 s tudent H ealtH C enter The California State University, Los Angeles’ Student Health Center Student Health Insurance (SHC) and the off-campus Student Health Insurance Plan are affordable and accessible healthcare resources available to CSULA For those who seek health insurance at an affordable cost, CSULA students . The SHC aims to provide high-quality, affordable health offers a health and dental insurance plan that is designed to care and health education for the students of California State meet the needs of students in the event of an emergency. The University, Los Angeles to preserve and enhance their potential for Student Injury and Sickness Insurance Plan is effective for one academic success and personal development.36 The SHC provides year starting in September. The insurance plan is purchased students with primary health care services. It focuses on providing through United Healthcare and is available to all matriculated basic physical examinations and primary care physician services, students meeting unit requirements - 9 units for undergraduate especially preventative care. Figuere 8 lists all services provided. students and 3 units for graduate students, their spouse, and The 2009-2010 CSULA student health service benchmarking study any dependent children under 19 years old. The plan covers reported that 8,919 CSULA students (45% of the enrolled student approved annual medical expenses up to $100,000 after a body) took advantage of these services. 37 According to the Student preferred-provider deductible of $150 per insured person/per Survey, a total of 72% of students believed that the SHC provided policy year or an out-of-network deductible of $250 per insured/ either good or excellent health services.38 per policy year.40 The student insurance plan contains several gaps, excluding some services generally considered essential to Furthermore, every quarter the SHC initiates free clinical services adequate primary health care. Important services not covered such as rapid HIV testing in order to address health concerns of include routine preventative care and exams, dental treatment, students. For the most part, many of these services are provided at reproductive services, many prescription drugs, and treatment for no cost to the student. However,although the SHC provides numerous pre-existing conditions. services, it still faces serious challenges - the most serious of which is financing. The SHC at CSULA is solely supported by a $55 fee included in each student’s quarterly registration costs. This fee is significantly lower than those imposed by the health centers of other CSUs, which may also receive other state or school funding. Services Provided by the Financial challenges limit personnel in the SHC. The SHC has just one Student Health Center full-time physician, two part- time physicians, and a few mid-level providers (nurses, nurse practitioners). According to the SHC’s health educator, Joanna Gaspar, the SHC needs to provide more access in several areas. She emphasized that the SHC is in crucial need of more health professionals, especially those providing psychological services. As of the 2011 Spring quarter, there is a 3-4 week waiting period to see a psychologist, unless it is considered a crisis.39 Figure 8 Health and Healthcare at CSULA & Surrounding Community 21 children were considered full-time students.42 nationwide (Figure 10). Incomes were not H ealtH C are r eForm The ACA extended coverage periods allowing reported in the survey, but as noted in children to remain on their parents’ policy Chapter Two, 28% of families of incoming In March 2010 the Affordable Care Act until the age of 26. This expansion applies freshmen make less than $20,000 annually. (ACA) was signed into law, enacting the to children of covered parents whether or This suggests that, under the health care largest health care reform in the United not they are married, considered financial reform law, many CSULA students and their States since the passage of Medicare and dependents, or living with their parents. For families who are now uninsured will be Medicaid in 1965. The ACA focuses on several many students who are under the age of 26, eligible for Medi-Cal in 2014. issues that affect an individual’s access to this is a major benefit in terms of access to care, including the cost of healthcare, how insurance and healthcare, enabling them to Lastly, another provision of the recent reform healthcare is organized and delivered, and remain insured until they can find a place in that will impact students substantially is the expansions of coverage to the uninsured. the workforce with health benefits. mandate requiring all individuals to have health insurance by 2014. This mandate In the student survey, CSULA students As indicated in Figure 9, approximately will be accompanied by subsidies to small expressed strong support for the 80% of students surveyed would be eligible businesses in order to aid their employees fundamental goals of new law. As previously to remain on their parents’ health care to purchase essential health coverage. As a stated, ninety-four percent of students plan. If parents do not have an insurance result, students who work at small businesses either strongly or somewhat agreed that all plan that covers their children or cannot may find it more likely that their employer Americans should have the right to quality obtain insurance for themselves, low-income will offer them coverage. If an employer does healthcare regardless of ability to pay. At students under the age of twenty-six will be not offer insurance, then an individual will CSULA, the student body should be greatly able to access subsidized coverage through have the right to participate in an insurance impacted by the ACA. As one student paper the new health exchanges to be created exchange. For those who are cannot afford concluded, “This [The ACA] is going to allow under ACA. that insurance the government will provide college students more options on how they substantial subsidies. Individuals making obtain [insurance] coverage and at an Expansion of the nation’s Medicaid program up to $43,000 and families of four making affordable rate.” 41 is another element of reform that stands to up to $88,000 will be eligible for those offer significant benefit to many students. subsidies.44 Before passage of the new law, children As of January 2014, individuals who earn were only covered by their parents’ policies less than $14,000 annually or a family of Although the recent health care reform act up until age 19, or a little longer if those four that earns less than $29,000 annually is a significant step in expanding access, (133% of the poverty level)43 will become some challenges remain. Barriers to access eligible for Medicaid (known in California as may include how the public looks at the Medi-Cal), an expansion that should benefit Affordable Care Act as a whole. Some many low-income individuals and families. Americans, mostly liberal Democrats, feel Under current Medi-Cal rules, only low- the recent health reform has not gone far income children, their in-home parents, some enough and continue to call for a single pregnant women, and those with significant payer plan or a public option. On the other disabilities are eligible. Low-income, single side of the spectrum there are individuals, adults are generally not eligible for Medi-Cal mostly Republicans, who feel that the new under its current guidelines. health reform is a violation of individual rights or feel that the cost of reform is too According to the Student Survey, this much for the United States’ current economy. expansion is likely to be of great benefit In an age where political will cannot be to CSULA students and their families. As taken lightly, there are legal and political discussed in Chapter Two, forty-one percent challenges ahead that will determine of surveyed students stated that they were whether or not some or all provisions of ≤ uninsured at the time of the survey as the new law remain in force in the years to Figure 9 compared to just 20% of college students come. 22 H ealtH a CCess in tHe C ommunity : t He s aFety n et In the Student Survey, 41% answered “yes, Another local program is the Ability Insured and Uninsured Students often” or “yes, but rarely” to the question: to Pay Plan. Residents of the “In the last year, have you ever not sought county can utilize this plan when medical care (including filling a prescription) not eligible for Medi-Cal, but when you think you should have because you their health costs for clinic care couldn’t afford it?” In response to a similar or hospitalization are based question, 27.2% of SPA 7 residents “reported on a sliding scale, contingent difficulty accessing medical on their income. care.” When an individual Before passage 45 The safety net is is uninsured or underinsured of the new law, funded by a variety it is typically the local safety children were only of sources. Health net to which they turn for covered by their centers that serve health care. The safety parents’ polices a disproportionate net is comprised of local up until age 19, share of low-income, hospitals, clinics or federally or a little longer uninsured and qualified health centers that if those children Medicaid patients provide health services at a were considered receive federal minimal cost to the patient. full time students and state funds. The Medi-Cal program is a Grants can be used key element of the safety to provide services, Figure 10 net because it provides coverage to many as well as general federal funds low-income individuals. In providing that such as the American Recovery coverage, it is also a major source of funding and Reinvestment Act, which have been for safety net providers and organizations. distributed to hospitals in need in the past.46 The national Children’s Health Insurance Program (CHIP), known as Healthy Families may be most challenged to provide services. in California, is another key safety net Safety Net Concerns The safety Although the safety net does generally prove program. It provides insurance to low-income net is an essential resource for residents of to be providing quality care, there may be children who live in families that earn too Los Angeles County, including students who inevitable gaps in the quantity and of the much to qualify for Medi-Cal but not more may not have the money to pay for health quality of that care. Long wait times are a than 250% of poverty. When an individual care. However, there are some concerns major complaint, and the closure of King- does not fully qualify for statewide health about its services or adequacy. Overall, the Harbor hospital due to a federal investigation plans, Los Angeles County does provide safety net can be strained due to limited that found several health violations 47 did health plans that are based on residency resources and a high demand for services. not help with credibility in the community. status and income. The Outpatient Reduced- When the unemployment rate rises and Thus, the limited resources of the safety net Cost Simplified Plan (ORSA) is open to more individuals become uninsured, or pose a problem along with the high cost of residents who cannot get full coverage for when the economy slows, already scarce healthcare in an emergency room and the Medi-Cal and do not have private health resources become more strained. Thus, at limited operating hours of free clinics. insurance. the time of greatest need, the safety net Health and Healthcare at CSULA & Surrounding Community 23 r eCommendations Student Health Center and Student Insurance Plan The gaps outlined with regard to the SHC and the Student Insurance Plan suggest that some changes are necessary. An emerging concern for the SHC is the lack of resources available to better serve the CSULA community. The Student Insurance Plan includes several exclusions that limit student access to proper primary health care. To address these issues we offer the following recommendations: 1 The CSULA administration, in coordination with the Associated Students Inc. (ASI) should appoint a student leadership committee to study and offer recommendations to address the coverage gaps of the SHC and Student Insurance Plan. If the university fails to appoint such a committee, then students in the most relevant majors including Public Health, Nursing, and Nutrition should create their own working group to address these challenges. 2 In order to maximize its capacity to serve students, the SHC should work with ASI and other university organizations to improve (1) the marketing of its services, (2) its outreach to the student populations, and (3) its capacity to generate greater financial support. 3 As a means of compensating for its limited resources, the SHC should also expand its utilization of student health interns to form a public health coalition that could work for improved health outcomes for today and the future. 24 Health Reform The Affordable Care Act provides many benefits to CSULA students and graduates. But taking advantage of the new legislation may be challenging. To secure the potential advantages of reform we recommend the following: Safety Net The safety net provides numerous health services to the students as well as residents within the community. Health reform may change the 4 The university administration, the Student Health Center, and/or the Department of Public Health should consider creating a coalition of faculty, staff and way the safety net is funded and may have unknown, unanticipated consequences on the safety net. We students who are interested in creating an ongoing series acknowledge that this issue is beyond some of the of seminars or briefings that help educate students about resources of the university. However, given what we health reform. ASI may wish to set up an office where have discussed, we recommend the following: students can learn about health reform, how it affects them and how to utilize the ACA to their advantage. 7 The university can provide research on the issues that affect the safety net and its impact on the student body. It can work with community coalitions and 5 Given that students will face a mandate to purchase health insurance, often from the new exchanges established under reform, the CSU system can aid in foundations such as the California Endowment to address the new role of the safety net after the implementation creating a bridge between the students and future of health care reform. insurance exchanges. We suggest student advocates urge the new insurance exchange to create special student- focused programs to ensure maximum student enrollment in exchanges. 8 The university may also wish to create a special topics course or diversity course in order to address vulnerable populations within the community as well as the nation. The Department of Public Health, which already offers an upper division vulnerable populations 6 Students must learn about the benefits of health care reform and learn what they can do to protect those benefits that may come under attack. Whether course, should create a lower division, GE course on this topic.48 students choose to communicate directly with their local representatives or vote for representatives who will protect their interests, it is their individual and collective responsibility to be educated and informed members of the citizenry. Health and Healthcare at CSULA & Surrounding Community 25 CHAPTER FOUR nUtrition and obeSity N utrition involves the consumption of food and use of food by the body for energy, growth, and other purposes. 49 As described in Chapter One, the Department of Public Health health policy class of the winter quarter, 2011 conducted a student survey and a series of interviews with faculty and university administrators. From review of the survey and those interviews it is clear that matters relating to nutrition and obesity stood out as a serious challenges both to the CSULA student community and the surrounding community. These challenges are not new, but efforts to address them have been only modest. This section of the report will focus on nutrition- related issues on the CSULA campus, as well as in the surrounding community of East Los Angeles and Service Planning Area (SPA) 7. We will provide data about each community, review the challenges, and consider options for change. We will conclude with some recommendations that we believe may address the challenges. 26 n ature and p revalenCe oF o besity In this section, we will provide an overview of due to many factors research data that helps one to understand including genetics, over O besity R ates : sPa 7 vs . L.a. C Ounty the breadth of the problem of nutrition/ consumption of food, obesity. The data indicate that these lack of exercise, and problems are significant not just on the poor food choices, such CSULA campus, but in the surrounding as junk food. American community and in communities across culture is fast paced, the nation. Today there is widespread and work and other agreement, at least in the research world, demands often leave that these problems have become true little or no time to national challenges requiring interventions prepare healthy foods or at all levels of community and government. exercise regularly. The Obesity is defined as being very fat or combination of too much overweight; corpulent (large or bulky of food, unhealthy food, body, fat).50 It is seen as an increasingly and too little exercise prevalent problem that afflicts children as can lead to obesity. well as adults.51 According to a 2009 CDC report, 62% of females As of today, 25% of American children and 67% of males are are overweight and that percentage will considered overweight, Figure 11 continue to rise unless their diet and exercise suggesting that being patterns change.52 According to the Centers overweight has no is that students are still relatively young, for Disease Control and Prevention (CDC), sexual preference. As noted above, 25% of healthy and active; their poor eating habits the prevalence of obese adults age twenty children are already overweight, and at high may not produce ill effects until later. CSULA and over in the United States reached 34% risk of remaining so. Still other children will students’ barriers to improved nutrition seem in 2007-2008, about a third of U.S. adult come to be at greater risk as they age and to include stress, cultural norms, lifestyle population. For adolescents age 12-19 years become less active. choices, peer pressure, limited finances, and the obesity rate was 18% in 2007-2008, lack of access to healthier foods. Students, and for children 6-11 years, 20%. For Obesity on the College Campus especially those with family or work children age 2-5 years the rate was 10%. Obesity also is hitting some college campuses responsibilities, are often in a rush and have The same report estimated that there are hard. According to research from the little time to seek out or prepare healthy approximately 400,000 deaths per year due University of New Hampshire in 2007, a meals. Another reason can be that students to obesity, accounting for 16% of all deaths.53 majority of 18- to 24-year-olds are obese. lack an understanding of what constitutes Furthermore, it is estimated that 10% of U.S. Our CSULA student survey indicated that a healthy food and lack the skills on how medical spending goes to obesity-related 84% of students sometimes or frequently to make healthy meals or how to go about diseases.54 eat unhealthy food. Sixty-three percent buying them.56 As a result, like many other responded that CSULA offers them fair or Americans, they turn to fast foods because of Effects and Causes of Obesity It poor food choices. Clearly, students know their convenience and low price. From then has been found that obesity is a key factor they are at least sometimes making poor onwards, students may develop bad habits in many of the leading health problems in food choices. However, they also noted that that are hard to break. If the bad eating America. For example, heart disease, often poor choices were often all that was readily habit continues, and lifestyle becomes more associated with obesity, has now become available to them. Interestingly, many of sedentary, the chance of becoming obese the number one killer in America.55 Cancer, those same students who acknowledged increases significantly. stroke, hypertension, and diabetes are poor eating habits also felt that they were among other obesity-related diseases that in good health. Perhaps the reason for this are becoming more prevalent. Obesity is Health and Healthcare at CSULA & Surrounding Community 27 Faculty Views of the Nutrition, Lastly, Dr. Walter Zelman, professor and Chair of the Department of Public Health, Obesity Challenge Several faculty emphasized that while obesity and diabetes Student Views of members shared their concerns about CSULA might be significant issues for CSULA Health Efforts at students and matters of nutrition. Dean students in the future, the surrounding CSULA Beatrice Yorker, from the College of Health and East Los Angeles community was already snapshot of figure 2 Human Services, noted that her main concerns experiencing major problems in this area. about student health are obesity, diabetes and hypertension. She also added that unhealthy food is usually cheaper, and people are C ampus Food issues addicted to sugar and high sodium products. The University Auxiliary Services (UAS) Dr. Mandy Graves-Hillstrom, a faculty monitors food choices on campus through the member who teaches Nutritional Science, Food Services Department. Most food services believes that there is a lack of healthy foods on-campus are also funded by UAS. Daniel on campus. She also stated that when people Keenan, Executive Chef and Food Services The University Café located in Salazar Hall. eat certain foods filled with sugars, salts, Director, is in charge of the department. Both restaurants allow students to enjoy and fats, a brain mechanism is triggered Mr. Keenan explained in an interview for freshly prepared meals that are made to that generates a continued craving for those this report that all on-campus vendors have order, an alternative to pre-packaged and specific foods. She went on to suggest that contracts containing stipulations that need processed meals. The University Club even food labeling in the food court will likely to be followed concerning health codes. Each offers a 10% discount to students who dine make students choose their food more wisely. vendor offers different types of food, which there. But even with the discount, a full meal allows the food court to offer several fast at The University Club costs students about food choices. While offering choice, this type the same as it does at the neighboring Carl’s of arrangement can also reduce competition Jr. between franchises, a fact that may make Although students the vendors more willing to pay the higher Vending machines are another source of have complained about fees associated with securing a space in food on campus. A company called First-Class the lack of healthy the food court. Vendors give funds to the Vending supplies the university’s vending options foods sold in university, and as Professor Laura Calderon machines as well as those located in student vending machines, of the School of Kinesiology and Nutritional housing. First-Class Vending tracks the most little has been done Science stated in an interview, given recent popular items and stocks the machines to address that their budget cuts, vendors who can pay more accordingly. 57 Although students have concerns. CSULA (because they sell more) are attractive to complained about the lack of healthy food encourages vendors university administrators. options sold in vending machines, little has to offer what students want. Unfortunately, been done to address their concerns. CSULA In this way, university administrators have students don’t seem to encourages vendors to offer what students to be sensitive to the need for revenues, be favoring the healthier want. Unfortunately, students don’t seem to and may find the economic pressures to add options. be favoring the healthier options. revenue competing with the need and desire to offer healthier food options. Aside from the franchises, CSULA also houses The University Club and a small eatery called 28 C ommunity Eat Fast Food At Least Once Per Week n utrition i ssues In this section, we discuss the food and health issues in the SPA 7 community. Community nutrition challenges there are extremely serious, much more so than those facing students at CSULA. But, clearly, the challenges of school and community are linked. Healty eating habits start at home, and for many CSULA students home is in communities like SPA 7. The students, staffs and SPA 7 residents’ eating habits are brought from home to campus and Figure 13 work places. Additionally, when it comes to improving nutrition status and options for exercise, the community surrounding CSULA the issue of socio-economic determinants report that they are in “fair” or “poor” faces a number of major barriers. These outlined earlier. According to the U.S. Census health, compared to 16.5% for Los Angeles challenges include a largely low-income Bureau, in 2009 the poverty level in L.A. County as a whole.59 Nor should it be a population, lower overall health status, County was 16.1%, a 0.9% increase over surprise that 27% of SPA 7 residents are limited access to major grocery stores (thus the previous year. Nationwide, the official reported to be obese, as compared to 22% restricting access to fresh fruits, vegetables poverty rate in 2009 was 14.3%, which is for Los Angeles County.60 County reports also and lean meats) and high numbers of up from 13.2% in 2008.58 As discussed in indicate that fresh fruits and vegetables are fast-food establishments. Other barriers Chapter Two, unemployment rates, per capita less available in SPA 7 than in the county include higher costs of nutritious foods, a incomes, and high school graduation rates as a whole (ratings of 30% as compared to lack of safe places to exercise, and relatively are much lower in communities surrounding 36%).61 These findings reflect the reality high crime rates. An examination of the CSULA than in the nation as a whole. Given that varied food choices, often provided nutrition challenges of the community these socio-economic realities, it is not by larger grocery stores, are significantly surrounding CSULA starts with a return to surprising that in SPA 7, 19.1% of adults limited in lower-income communities, which usually have higher percentages of small independent grocery stores and fast food vendors. These findings were supported by the opinions expressed in the Student Survey. Drink At Least One Soda/Sweetened Drink Per Day Many students recognized the problem of access to nutritious foods in the surrounding community. Sixty-four percent expressed the view that having too much junk food, and too little healthy food is a serious problem in the surrounding community. As one student paper concluded, because SPA 7 is lacking in access to fresh fruits and vegetables, whole grains, low-fat meals, and other foods associated with healthy diets, it can be labeled a “food desert”.62 As a result of these deficiencies such communities are likely to experience higher rates of obesity. Figure 12 Health and Healthcare at CSULA & Surrounding Community 29 r eCommendations There are many actions that might be taken to improve nutrition-related conditions on the CSULA campus and in the surrounding community; outlined below are a few that seem most applicable. We will present recommendations in the following categories: CSULA food court, CSULA vending machines, and health education and promotion for the CSULA community and for the surrounding community of East Los Angeles. Health Education and Promotion CSULA Food Court 1 Vendors should be required or at least incentivized to prominently display calorie counts, provide 7 Department of Public Health students, in conjunction with the Kinesiology students, should take responsibility for developing a proposal to create a lower calorie options to patrons, and provide smaller walking/jogging path around the campus. The path portion/lower calorie choices at lower prices. New should include markers such as “Walking for 10 minutes laws may already require some such disclosure, but at a fast pace will burn x calories” to encourage users to CSULA administrators can consider imposing additional come often and to feel gratification when they hit a goal requirements. marker. 2 When current contracts expire, the university should seek to contract with franchises that provide healthier food choices, such as Subway. 8 The School of Kinesiology and Nutritional Sciences should explore means of offering free exercise classes during the afternoon period in which there are no 3 The food court should offer a salad bar, at least on a classes. trial basis. Such a venue might offer other high value food options. 9 The disciplines of Public Health and Nutrition should review General Education curriculum options that would expand student knowledge of health and health 4 Food service providers on campus should consider offering incentives for students to make healthier choices by making healthier items less expensive. This improvement. E.g., how to read a food label and determine correct portion size. might be achieved if the healthier items are, in fact, less expensive for students or are sold in slightly small sizes. 10 ASI, working with the Department of Public Health and other relevant departments, should create a health- based student consortium in order to make future CSULA Vending Machines recommendations for improving health and healthcare on campus. Public Health and other departments should 5 The university should require vending machines on campus to provide calorie counts for each option offered, including fat calories, not just information on consider creating internship programs that could “staff” the consortium and ensure it becomes an ongoing process. “healthy options.” 6 An all healthy choice vending machine should be considered. A test could be run to determine if these will prove to be more successful than the vending machines in which junk food is mostly available. 30 Recommendations: Surrounding Community Community advocates, students, legislators and others should consider the following as means of improving nutrition in the surrounding community. 11 Student and university lobbying organizations should oppose budget cuts that would reduce school meal funding or force reductions in health education in public would be useful both for children and adults is the Instant Recess program, developed by UCLA Public Health Professor Toni Yancey. It promotes ten-minute exercise breaks instead schools. of having snack breaks or smoke breaks. 12 Student organizations and advocates should support legislation that will increase information about nutritional value in foods. 16 Concerned students and community leaders should support policies and incentives that would encourage the conversion of corner stores into neighborhood groceries as a strategy to improve food choices and nutrition in low- 13 Student advocacy organizations should encourage grocery store placements in low-income areas. Students and community representatives should meet income communities. Some possible means of addressing this problem include: tax incentives for larger grocery chains; new zoning rules; incentives for smaller storeowners with local state legislators to press for action that might in underserved areas that begin to provide healthier food encourage larger grocery chains to build facilities in low- items, such as fresh fruits and vegetables.63 Such initiatives income neighborhoods, or to provide more healthy food will require a coordinated effort with local government, choices. especially public health departments. Support from private funders and foundations might also be required. 14 ASI and relevant academic departments should create 17 a CSULA student/faculty collaborative, to work with Finally, it is strongly recommended that health care the East Los Angeles and SPA 7 communities to develop researchers, practitioners and advocates review the multi-lingual, educational materials on improving nutrition- impact of the terms “obese” and “obesity” on society’s related conditions and options, and to consider community- attitudes and views of individuals with this condition. They focused research projects that would address nutrition issues should consider whether terms other than “obese” and in the community. “obesity” may be less stigmatizing and more likely to generate support for the public policy initiatives necessary 15 Nutrition advocates should urge campus and community adoption of programs such as First Lady Michelle Obama’s Let’s Move program that encourages to address the society’s current nutritional challenges. children to adopt active lifestyles. Another program that Health and Healthcare at CSULA & Surrounding Community 31 32 leSSonS and commitmentS T he recommendations in the previous and obesity, public health must be a core housing, and other socio-economic-status chapters bring us full circle, back to part of any solution. We need a focus on factors—in influencing health status and the concepts and tools of public health prevention and wellness, and we need to outcomes for individuals and communities. we outlined in Chapter One. Whether the focus on populations and communities, not Public health policy, wisely created and challenge is ensuring access to healthcare just individuals. implemented, can provide the bridge from or addressing the nation’s obesity epidemic, where we are to where we need to be. That the tools and constructs of public health In the end, we believe in a simple, but policy will need to consider both specific are central to proposing, analyzing, and powerful truth: At some point in time, healthcare needs and the broader – perhaps implementing solutions. Ensuring access probably, most of us are going to need access more controversial – needs of reducing to health care and insurance will be no to the best (and maybe the most expensive) disparities and addressing the social substitute for the need of the nation and of medical technologies. But as nation, or determinants that sometimes form barriers its citizens to take better care of its self and as a student body, the key to a healthier, to improved community health. themselves. longer life lies in learning how to keep our communities and ourselves healthy. Finally, the concepts of empowerment and Without better use of health education of assuming responsibility for our own and prevention strategies, the nation’s The tools and concepts of public health health and, to some extent, for that of healthcare costs will continue to soar and outlined in this report can guide us in the communities around us, will require well-intentioned reforms will be at risk. The seeking those goals. Healthy People 2020 something from every one of us. As students same realities leap out when considering can establish goals to seek and means by of and advocates for public health, we will the nation’s obesity epidemic. If we take a which to measure our progress. The concept need to lead, to educate, to innovate, and to one by one, medical intervention approach of disparities and research that defines and empower others and ourselves. We hope that to addressing this challenge our efforts will explains those disparities can direct attention this publication will be the first of many such fall far short of any reasonable goals, and to where it is most needed. The realities efforts to come. will certainly break the healthcare bank. and lessons of social determinants will So whether the issue is access to care or remind us of the importance of non-medical growing concerns over nutrition practices circumstances –education, income, jobs, Health and Healthcare at CSULA & Surrounding Community 33 END NOTES 17. National Center for Education Statistics, op. cit. 18. Calderon, Dr. Laura. Interview by Walter Zelman. Personal interview. Spring Quarter 2011. 1. “Report of the 2000 Joint Committee on Health Education and Promotion Terminology.” Journal of 19. United States Government Accountability Office. School Health 72.1 (2002). “Most College Students Are Covered through Employer- Sponsored Plans, and States Are Taking Steps to Increase 2. “About Healthy People - Healthy People 2020.” Coverage.” Highlight, 2008. Healthy People 2020 - Improving the Health of Ameri- cans. <http://www.healthypeople.gov/2020/about/de- 20. Wagstaff, Adam. “Poverty and Health Sector fault.aspx>. Inequalities.” 2002. <http://www.who.int/docstore/bul- letin/pdf/2002/bul-2-E-2002/80(2)97 -105.pdf>. Cited 3. Ibid. from student paper. 4. Adler, Nancy E., and Katherine Newman. “Socio- 21. Policy Map, TRF. “United States Unemployment economic Disparities In Health: Pathways And Policies.” Rates and Statistics.” <http://www.policymap. com/ Health Affairs 21.2 (2002): 60-76. LandingPages/unemployment.html?gclid=CMinrKX_ lqgCFeoZQgodw36WCQ >. 5. 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Key Indicators of Health by Service Planning 11. Ibid. Area. Los Angeles: Los Angeles County Department of 12. Offices of Public Affairs and Institutional Re- Public Health, 2009. search. “Cal State L.A. Facts.” Fact Sheet 42, California 27. Brown, Richard. Agency for Healthcare Qual- State University, Los Angeles, Los Angeles, 2008. ity and Research, “Population Health Surveys: Data to 13. The California State University. “Student Profile.” Improve Public Health in Era of Health Care Reform.” Statistical Abstract, Analytic Studies, 2010. 28. Key Indicators of Health by Service Planning 14. Offices of Public Affairs and Institutional Re- Area, op. cit. search, op. cit. 29. Ibid. 15. National Center for Education Statistics. “IPEDS 30. Ibid. Data Feedback Report 2010.” Institution Data, California State University, Los Angeles, 2010. 31. Ibid. 16. Offices of Public Affairs and Institutional Re- 32. 2009 California Health Interview Survey, UCLA search, op. cit. Center for Health Policy Research. “CHIS 2009 Adult Public Use.” 2009. 34 33. Key Indicators of Health by Service Planning Web. <http://www.nutritionwerks.net/glossary.asp>. Area, op. cit. 50. “Obesity.” Dictionary.com. Web. <http://diction- 34. Ibid. ary.reference.com/browse/obesity>. 35. Guiford M, Figueroa-Munoz J, Morgan M, 51. “America’s Move to Raise A Healthier Genera- Hughes D. “What Does Health Care Mean?”. Journal of tion of Kids.” Let’s Move!. <http://www.letsmove.gov/ Health Research &Policy. 7.3 (2002). about>. 36. California State University, Los Angeles Student 52. “Obesity and Overweight for Professionals.” Cen- Health Center. “CSULA Student Health Center 009-2010 ters for Disease Control and Prevention. <http:// www. Utilization of Services”. Print handout. cdc.gov/obesity/childhood/data.html>. 37. Ibid. 53. Ibid. 38. Student Health Assessment Survey, Department 54. Steenhuysen, Julie. “Better than a BMI? New of Public Health, Health Policy Winter, 2011. Obesity Scale Proposed.” Reuters. 11 Mar. 2006. Web. <http://www.reuters.com/article/2011/03/07/us-obesi- 39. Gaspar, Joanna. Interviewed by Walter Zelman. ty-scale-idUSTRE7260N420110307>. Personal Interview. 2011. 55. “CDC Features - February is American Heart 40. Student Insurance Plan, 2010-2011, provided by Month.” Centers for Disease Control and Prevention.31 Student Health Center. Jan. 2011. Web. <http://www.cdc. gov/features/Heart- Month/>. 41. Health Science 446 research paper, March 10, 2011. 56. Calderon, Dr. Laura. Interview by Walter Zelman, op. cit. 42. “Young Adult Coverage.” HealthCare.gov. 23 Sept. 2010. Web. <http://www.healthcare.gov/law/ 57. Rios, Cristina. March 10, 2011. Health Science provisions/youngadult/index.htm 446 research paper. 43. “Timeline of the Affordable Care Act.” Health- 58. “About Poverty - Highlights.” United States Care.gov. Web. <http://www.healthcare.gov/law/time- Census Bureau Homepage. 13 Sept. 2011. Web. <http:// line/index.html#event43-pane>. census.gov /hhes/www/poverty/about/overview/index. html>. 44. “Find Out if I Qualify.” DHCS Home Page. Web. <http:// www.dhcs.ca. gov/services/medi-cal/Pages/ 59. Key Indicators of Health by Service Planning Medi-CalEligibility.aspx>. Area, op. cit. 45. Key Indicators of Health by Service Planning 60. Ibid. Area, op. cit. 61. Ibid. 46. Felland, Laurie E., Peter J. Cunningham, Genna R. Cohen, Elizabeth A. November, and Brian C. Quinn. 62. Rovetti, Cassandra. March 10, 2011. Health Sci- “The Economic Recession: Early Impacts on Health Care ence 446 research paper. Safety Net Providers.” Health System Change 15 (2010). 63. Bolen, Ed, and Kenneth Hecht. “Neighborhood 47. Leonard, Jack. “King-Harbor Inspection Re- Groceries: New Access to Healthy Food in Low-Income port Released.” Los Angeles Times. 14 Aug. 2007. Communities.” California Food Policy Advocates (2003). Web. <http://www.latimes.com/news/local/la-me- king14aug14,0,5074949. story>. 48. Such a new course might be taught from a multi- disciplinary perspective. 49. Borchardt, Nan. “Glossary.” NutritionsWerks, Inc. Health and Healthcare at CSULA & Surrounding Community 35 Appendix A: Health Policy Class List Abacan, Joan Angeles Moran,Kenny Esmeralda Acuna,Claudia J Nganga,Alex Muhanda Barba,Joshua Ngo,Shelly K Beltran,Karen Guadalupe Noelle,Sophie Marie Bernabe,Nino Ortiz,Jeanette Catalan,Cecilia Palicpic,Maricris Dimaano Chavez,David Pobre,Jasmine Sales Danila,Louie David Punzalan,Kristina Biangco Duarte,Vicky Rios,Cristina Escalante,Flor Yohena Romero,Karina Marisol Fernandez,Maritza Rovetti,Cassandra Kristina Fu,Minhjohnny Gia Sugay,Sarah Danielle Garcia,Summer Snow Tagle,Cathryn Ashley-Eden Garcia,Xochitl Thai,Ngan Tuyet Hughes,Aneesa Lashae Tran,Christina San Isabel,Ronald Amstrong Ulloa,Sandra Johnson,Derica Leanne Velarde,Eugenia Keshoyan,Ani Mary Villafana,Yanine Kinfemichael,Lozan Zhao,Shelly Lam,Kimberly Vance Landicho,Rochelle Liz Lara,Gisselle Legaspi,Rommel Erwin Limon,Lauren Brittney Martin,Stephanie McCrory,Huldah Denise Mejia,Celeste M Mejia,Jusa Urbiztondo Mendoza,Hilda Elena 36 Appendix B: Student Survey A Health Science class is conducting an assessment of the health and health care needs of CSULA students and their community. Please respond to the following questions. The results of this survey will be used only for on-campus purposes. THIS SURVEY IS ANONYMOUS AND CONFIDENTIAL; DO NOT PUT YOUR NAME ON THE SURVEY FORM 1. Do you have health insurance now? (Private, or public like Medi-Cal) Yes ___ No ___ 2. Have you been uninsured for any part of last year? (No private or public insurance) Yes _____ No _____ 3. Other than yourself is any member of your immediate family uninsured? (Immediate family includes parents, siblings, spouse, children. Uninsured means no private or public insurance. Yes ____ No ____ Don’t know ____ 4. How would you describe your health status? Poor ____ Fair ____ Good ____ Excellent ____ 5. Over the past year, has anyone in your family, including yourself, not sought medical care (including prescriptions) they thought they needed because they could not afford it? Yes, often ____ Yes, but rarely ____ No ___ 6. In the last year, have you had the flu shot? Yes ___ No ___ 7. How often do you engage in the following: Never rarely sometimes frequently Smoking ____ _____ ____ _____ Binge or other excessive drinking ____ _____ ____ _____ Unprotected sex, outside of a partner relationship ____ ____ _____ ______ Eating what you think are unhealthy foods ____ _____ _____ ______ Health and Healthcare at CSULA & Surrounding Community 37 8. Thinking about where you live, to what extent does each of the following represent a problem in terms of the overall health of your community? No Small Significant Very Serious Problem Problem Problem Problem Crime, gangs ____ ____ ____ ____ Low income levels, poverty ____ ____ ____ ____ Inadequate access to health services ____ ____ ____ ____ Too much junk food, too little healthy food ___ ____ ____ ____ Not enough safe places to exercise ___ ____ ____ ____ Poor air quality ____ ____ ____ ____ Too much exposure to drugs and/or alcohol___ ____ ____ ____ 9. Thinking only about the CSULA campus and the promotion of good health, how would you rate CSULA in terms of each of the following: Poor Fair Good Excellent No opinion Making you feel safe ____ ___ ____ ____ ____ Providing you with appropriate food choices ___ ___ ___ ____ ____ Providing student health services ___ ___ ___ ___ ___ Encouraging exercise and other healthy behaviors __ ___ ____ ___ ____ 10. To what extent do you agree with the following statement? My health and health care are my and my family’s responsibility. They should not be a significant concern of the university. Agree strongly ____ Agree somewhat ____ Disagree ____ Disagree strongly ____ 11. To what extent do you agree with the following statement? All Americans regardless of ability to pay, should have the right to quality health care at an affordable cost Agree Strongly ____ Agree ____ Disagree ____ Disagree Strongly ____ 38 12. To what extent do you agree with the following statement? The government should make sure that even those who may be here illegally have access to quality care at an affordable cost Agree strongly ____ Agree ____ Disagree ____ Disagree strongly ____ 13. Are you Under 20 years old ____ 21-25 years old ____ Over 25 years old ___ 14. Are you Male ____ Female ______ THANK YOU FOR PARTICIPATING IN THIS SURVEY Health and Healthcare at CSULA & Surrounding Community 39
"health and healthcare at csula and in the surrounding community"