health and healthcare at csula and in the surrounding community by yaofenjin


									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
    Lead Authors

    Department of Public Health

    Cecilia Catalan
    Vicky Duarte
    Sarah Freeman
    Maritza Fernandez
    Aurora Lilly
    Elizabeth McMeans
    Kristina Punzalan

    Aurora Lilly

    Student Editor
    Sarah Freeman

    Project Advisor:
    Walter Zelman, Ph.D.
    Chair, Department of Public Health
       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
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


Chapter Four: Nutrition and Obesity                                                   page   26

           Nature and Prevalence of Obesity

           Campus Food Issues, Community Nutrition Issues


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
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-

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
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.

  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

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

                                                  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
              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.

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.
                    -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
                                                                                                     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

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
TWO at cSUla and in tHe
    neigHboring commUnity

               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.

                                                                                      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
                                                                    SCIENCE SURVEY
                                                                    SAID THAT
                                                                    CAMPUS DINING
                                                                    WAS THEIR MAIN
                                                                    SOURCE OF
                                                                    FOOD WHILE ON
        Figure 2

                      CSULA Students: Perceptions of Community Needs and Issues

           Figure 3

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

    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 	
U.S. average of 84.6%. Only 4.6% of East LA     These striking disparities Families	
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	

behaviors. For example, a presentation from     100,000 compared              Percentage	
the University of California, Los Angeles’      to 2.4 per 100,000            diagnosed	
Center for Health Policy Research found that    nationally. Additionally,
SPA 7 has at least 6 times as many fast food    the diabetes diagnosis        Diabetes	
restaurants and convenience stores as it does   and death rate also           adjusted	

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

           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
     THREE               acceSS to care
                  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.

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.

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
                                                              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.

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
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
     FOUR              nUtrition
                       and obeSity

                    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.

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
                                                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

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
     “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.

 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

      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
   leSSonS and commitmentS
         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
                                                               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.	<             20.	    Wagstaff,	Adam.	“Poverty	and	Health	Sector	
fault.aspx>.	                                                  Inequalities.”	2002.	<
                                                               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.	     Ibid.
                                                               22.	   United	States	Department	of	Labor,	Bureau	of	
6.	     Ibid.                                                  Labor	Statistics.	“Labor	Force	Statistics	from	the	Current	
                                                               Population	Survey.”	<http://www.>.
7.	      Overcoming	Obstacles	to	Health:	A	Report	to	the	
Commission	to	Build	a	Healthier	America.	Robert	Wood	 23.	       “East	Los	Angeles	CDP,	California	-	Population	
Johnson	Foundation,	2008.	                                and	Housing	Narrative	Profile:	2005-2009.”	Ameri-
                                                          can	FactFinder.	N.p.,	n.d.	Web.	2	Jan.	2012.	<http://
8.	      Wilensky,	Gail	R.,	and	David	Satcher.	“Don’t
Forget	About	the	Social	Determinants	of	Health.”	Health	 geo_id=16000US0620802&-qr_name=ACS_2009_5YR_
Affairs	28.2	(2009):	194-198.                             G00_NP01&-gc_url=&-ds_name=&-_lang=en&-
9.	      Zelman,	Walter.	“Health	Policy.”	Health	Policy.	 redoLog=false>.	
California	State	University,	Los	Angeles.	Winter	Quarter,	     24.	    Ibid.
2011.	Class	lecture.	
                                                               25.	    Overcoming	Obstacles	to	Health,	op.	cit.	
10.	    Overcoming	Obstacles	to	Health,	op.	cit.	
                                                               26.	    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.	

33.	   Key	Indicators	of	Health	by	Service	Planning	         Web.	<>.	
Area,	op.	cit.
                                                             50.	    “Obesity.”	Web.	<http://diction-
34.	    Ibid.                                      >.	

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!.	<	
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.           >.	

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.	
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-
41.	  Health	Science	446	research	paper,	March	10,	
2011.                                                        56.	     Calderon,	Dr.	Laura.	Interview	by	Walter	Zelman,	
                                                             op. cit.
42.	    “Young	Adult	Coverage.”	23	
Sept.	2010.	Web.	<	            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	Web.	<          Census	Bureau	Homepage.	13	Sept.	2011.	Web.	<http://
line/index.html#event43-pane>.	                    	/hhes/www/poverty/about/overview/index.
44.	    “Find	Out	if	I	Qualify.”	DHCS	Home	Page.	Web.	
<http://	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.	<
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
Legaspi,Rommel Erwin
Limon,Lauren Brittney
McCrory,Huldah Denise
Mejia,Celeste M
Mejia,Jusa Urbiztondo
Mendoza,Hilda Elena

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.

  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	        	           ____

  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		______


                                      Health and Healthcare at CSULA & Surrounding Community                        39

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