Good afternoon, everyone. We're so appreciative that you've chosen to join us for the Advancing Health Equity through Civic Engagement, the Built Environment and Addressing Food Security session, in security, I should say, but we wish it were security. And this is really a session that is pulling together the foundational aspects of creating social and structural, you know, to advance health equity through the social and structural determinants of health, and then lifting up some specific policy arenas that we can be working together to influence. My name is Jean Ayres, and I am the Executive Director for Healthy People, Healthy Democracy Initiative, which is an alliance of 10 public health national organizations that are working to assure everyone has access to the ballot and strengthen civic participation. So I got to... There we go. So we have three sessions today, and Jessica Barba-Brown and I will be leading off in this first session on civic engagement, and then joined by our co-presenters on food and health and transportation or complete streets. Whoops, I have to get used to the clicker. So this first portion is not eligible for CME, and I think that's just a really good question that we'll ask ourselves at the end of the session as well. But Healthy People, Healthy Democracy, the mission and aim is to advance health equity and promote healthy communities by assuring access to the ballot is available to everyone. I'm going to be spending some time introducing three practices to build our power to advance health equity by influencing the conditions that are necessary for healthy, inclusive communities. But I really want to start by saying that civic engagement and participation is actually the foundation for us to have influence and representation in the policy arena. And when we realize that so much of our health is created in a broad set of policy sectors, that just highlights how important it is that we have a representation of all of us in that space. So to assure and build the influence, there are three practices that I'll be highlighting, and these are organizing narrative, organizing policy and processes, and organizing and strengthening community capacity. We'll also spend some time looking at what the dominant narratives are and what narratives we can be promoting and sharing, and name actions that preventive medicine practitioners can take to promote full civic participation. So the first thing I wanted to highlight is that assuring voting access aligns completely with our vision and priorities within ACPM and in our field of public health and prevention. And here are just some of the things that we've listed and named in our mission statements and vision statements and priorities. To achieve population health, we work to promote a comprehensive understanding of health and the drivers and determinants of health. So that's one of the things we're called to do. We work to empower patients and populations and providers to support approaches that strengthen civic participation. We work to embrace a health in all policies approach, where we really help people connect the dots between a policy and the health outcomes. And we work to advocate, many of us in our organizations have been working to advocate to address structural racism through concrete actions, and assuring voting access aligns with that aim. And when we think about how we connect the dots between clinical spaces and population health, again, assuring voting access is a great opportunity to be doing that. Many of you are in either training or are leadership roles within organizations and in your field, and we have been talking about being and serving as chief health equity or chief health strategists in our roles. And part of that role is really to use data, story, and policies to build and strengthen that public understanding of what creates health. I had the privilege of serving as chief health equity strategist for the state of Minnesota in the Minnesota Department of Health for eight years, and serve as a state health officer. And I think that we need all of us within this field to begin to really embrace the showing up in a broader policy arena, and helping to recognize how important the other determinants of health are beyond the medical care system. So the first thing that we talk about that actually promoting a comprehensive understanding, some of what we can be doing around voting is just declaring the voting and having an inclusive process where voting, where everyone is included in our opportunity to vote, is good for our health as individuals and as population. So voter participation is associated with better self-reported health, and there's studies across 44 countries that show that correlation. Those who did not report are shown to report poorer health outcomes. Countries and states and counties that have higher voter turnout report better health outcomes. And we can see this historically as well. When women got the right to vote in 1920, maternal and infant mortality dropped dramatically. When the Voting Rights Act of 1965 was passed, infant mortality rates dropped and the black-white disparities narrowed. So expanding civic participation and voter participation is key to advancing health equity. This is true even today, and it's important that we consider what is the impact when people who are experiencing the greatest health inequities are or are not represented in the policymaking arena. And this is just something very current that came out from 2020. The polls found that black youth were disproportionately affected by COVID-19. Over a third of young black voters knew someone who had died, and that was more than twice the proportion of white youth. 80% of young black women and 70% of young black men said they had been personally affected by COVID. And here I highlighted in red some of the things that are so critical right now to think about is that 84% of young black women and 71% of young black men strongly or somewhat strongly supported a national mask mandate. And when you consider how political the idea or the recommendation of wearing a mask was becoming in 2020, you can see how important it is to have people who are most directly impacted by an issue actually show up and participate in the decision-making process. 55% of young black women and 44% of young black men said COVID-19 was the single most important factor in determining their vote in the 2020 elections. This is just an example of how the relationship to policymaking and representation can make a difference. So I want to share a slide or a visual of an understanding of our ability to influence living conditions that changed my practice. If you look at these boxes, the first box with health is where we frequently collect our data and talk about health, and it is the health outcomes, the understanding of health. And over the years, we have become more clear about being able to say that our health is completely connected to our living conditions, and, you know, we kind of pat ourselves on the back for saying that, and we say, you know, it's got to do with housing security, and our health's got to do with a broader set of policies, including some of the things that we're talking about today. But I want to point out that our living conditions are completely connected to our capacity to act, to that third box, and that unless we, in our practice, embrace and appreciate our need to intentionally create and build our capacity to act, we are left in a position of describing the relationship between health and health conditions. So we basically have to build our skills to foster the capacity to act or build power, and I have to say I've been practicing for 20-some years, and I had never had a class in power. I had never really understood how to build power, and so what I did was I got very deeply engaged with people who build power intentionally, faith-based organizers, to better understand how we can incorporate this work into our practice. And so basically, the three practices, there are three practices that you can employ to change the pattern in a system and build power. They include organizing people, organizing narrative, and organizing resources, and how systems and places work. So those three practices, I'm just going to show a little bit about how we employed those practices in our work. We started out in 2020 as a coalition of public health organizations and called ourselves Vote Safe Public Health, but we worked to align our efforts across our various organizations to organize people. We intentionally worked to promote the understanding of the relationship between health to civic engagement, and we worked to influence policy. So here's the 10 organizations. This is organizing people. This is our organizing people and building the strength, our collective strength to influence conditions. And then we worked to organize narrative and knowledge and collectively promote the understanding of the relationship between civic participation and health. And ways that we did that is, first, if you haven't ever thought about how influential narrative is, it is really something that makes such a huge difference about what is understood and how it's framed and what policies do and don't pass. So dominant narratives kind of take over the public conversation and influence the public will and policymaking. And I'd have to say that over the course of the last 24 months, the public narratives around voting have seemed to be shifting from it's important that we all vote, which maybe not everyone embraced, but it wasn't as clearly in a more dominant narrative has emerged in the last 12 months, which is election integrity. No, it's not that everybody doesn't also want election integrity. It's just that as a dominant narrative, it is influencing what policies are and are not being considered. So the question to ask is, is our role as leaders? What are we reporting on? What are we saying? What set of issues are we addressing? And this applies not just to civic participation, but to the issues around food security and complete streets and housing. So to be reflecting on what data we collect and how we talk about it and how we show up in these spaces is important. How transparent are we about the values that are being amplified in the ways that we're talking and showing up? So this is really critical work. Just a few themes around a transformative narrative around health and voting include that civic participation is associated with better health outcomes, that people are deserving of dignity and respect and inclusion, and that's affirmed by access to voting. That everyone's vote is important. When we all vote, our government reflects who we are and what we want. It can help us care for our families and our communities. And through voting, we improve our individual and collective health, and we can shape our future together. These are not talking points. These are basically themes that talking points can be amplifying or not amplifying. And that's just a really fast introduction to... For some reason, this isn't going forward. There. So when we organize our narrative, we work to promote the understanding of the relationship between health and health equity, and in this case, civic participation, inclusion, and social cohesion, but it's true for food, it's true for housing, it's true for all the determinants. And we identified... So our group identified the dominant and transformative narratives and then used that to be sure that in our messaging, we weren't talking about, be careful and wash your hands when you go to vote and wear a mask. We were also saying voting is a good thing to do for our health, and we need to assure everyone has an opportunity. At this point, we are actually working to expand the opportunities and tools available to us as preventive medicine and public health leaders to continue to amplify this story. So we were expanding the public understanding in words and action, and that was the second practice that we incorporated into the initial work and that we're building from. And third, we work to organize resources, and that's not just money. It's how things and systems work. What policies and processes are in place that make the opportunity to be healthy available to everyone, and in this case, support safe voting for everyone. And I'm going to quickly turn this over to Jessica Barba-Brown, who is going to be sharing a little bit about the electoral process landscape, because that's... What do we need to be doing in terms of organizing resources? Thank you so much, Jean. Great to be with you all. My name is Jessica Barba-Brown. I am a senior advisor for the Healthy People, Healthy Democracy Initiative. I have worked at both civic engagement and healthcare access throughout my career, and I did not know how much these issues would collide in 2020, but in 2020, I helped run a coalition called We Can Vote that was focused on having a safe, secure, and successful election in the face of the COVID-19 pandemic, and worked extremely closely with Jean, and we are continuing this work to this day. So I just want to give people a little bit of context around where we've been and where we are right now in terms of elections and in terms of the laws that go into our elections. I'm not going to go all the way back. This is a very high level overview, but I do want to point out 2013 as being a really pivotal year. This is the year that the Shelby County versus Holder decision was decided by the Supreme Court. It struck down the preclearance formula of the Voting Rights Act, so states no longer had to go to the Department of Justice to get voting laws changed, and we saw after that Supreme Court decision a wave of changes in the states, and so we saw many states, mostly in the South, mostly those previous ones that were covered by preclearance, pass a lot of restrictions on voting and making it harder to vote, putting in new kinds of laws like voter ID, new types of requirements needed for absentee and early voting. We also saw thousands of polling place closures, and so this really affected people in terms of having access to the ballot and what were some of the ways that these laws were making it harder for people to vote. In 2020, we obviously had the pandemic, still have it, and this brought with it seismic changes in terms of voting. People knew that we couldn't vote in the way that we normally do because we couldn't pack everybody into polling places in the way that it used to be, and so many states moved very quickly and really election officials did some heroic efforts to make sure that people could have access to the ballot, and so you saw many states enacting changes like expanding access to absentee voting. They had online voter registration portals, Dropboxes, there were lots of creative things like drive-through voting, expanded early voting so that we could make sure that everybody could vote in the way that they wanted to and that we were not contributing to more infection rates. And so many of these changes were temporary, but they did work quickly to try to ensure that everybody could vote in this extraordinary year. Now we've seen the state legislation sessions are wrapping up in most states around the country this year, but there has been a backlash to a lot of that expansion of voting options, and we have seen states try to restrict those yet again. Some of the more notorious states, I'm sure you've heard about, in Georgia, for example. And so there is a lot of battle right now in terms of what does this look like on the state level? On the federal level, we have some major pieces of legislation trying to move forward, the For the People Act and the John Lewis Voting Rights Act. And so we're continuing to talk about and to have a lot of policy discussions about what is, how do we expand, how do we ensure access to the ballot for all Americans? Let me see if I can advance here, okay. Just to go over quickly, the voting rule changes that happened in 2020, we had over 30 states enacting changes to expanding absentee voting. Many of those were temporary, so many states said this only applies to the 2020 election because of the pandemic. We are also had that states that already had mail voting options, they did more to promote those and make those widely available. Many people voted by mail for the first time in 2020. And these are states that already had this option, but many people in their state didn't know about it. So they did a lot of PR, they sent applications, they had prepaid postage, things like that. We saw expanded early voting across the country. Many states had voting weeks before the election started. And again, this was a way to spread people out so that we wouldn't be infecting each other with COVID, but also introduce people to the idea that, oh, wait, I don't have to take off work on a Tuesday, I could go on a Saturday or at a time that's more convenient for me. So we saw a real expansion of early voting. Again, states creating online voter portals and lots of creative solutions. There were stadiums, there were drive-through voting, expanded curbside, things like that. And this was an example of really expanding public understanding in words and in action. So for the first time, people really had a different idea of this is what voting could be. Voting doesn't have to be, I go to my polling place on election day, it can be, it can look like all of these other things. And this was really new for folks, especially in 2020. So what were the results? We had unprecedented voter turnout, at least 161 million people voted, 66.8% turnout, the highest in over a century, and more than 100 million Americans voting early, that's either by mail or in person. This was really astounding in the face of election offices having to stand up new systems quickly, the public having to educate themselves quickly about how did they get their absentee ballot or what are their early voting options. And it was really a testament to the work that was put in by election offices, by advocates, by news outlets, educating the public about their options. And of course, by the work that we did with public health officials in terms of creating voter guides and sending them out to voters and things like that. And this really had an impact too, in terms of key populations that we think about. So significant increase in the youth voter turnout, up to 50%, which is pretty astounding. That was about a, it's estimated eight to about a 10 point jump, which is really impressive. Over 16, recruiting a new generation of election workers, which is really gonna be critical for election infrastructure going forward. So this is all good news and yet, there were still 80 million eligible non-voters. So there were 80 million Americans who were eligible to vote, who did not. And a lot of people have looked at different reasons for, why aren't these people voting? The top reason for not voting according to recent survey was not being registered. And so looking at registration is gonna be a key strategy to help reverse this trend. So what are some of the steps that we are going to undertake as a Healthy People, Healthy Democracy initiative? First of all, we're gonna be creating a Health and Democracy Report Card. This should be coming out next month. The Network for Public Health Law is doing the analysis there, it's going to be a health equity analysis of electoral system policies. And we'll give everybody a framework for how to connect voting and health. And this is a great example of organizing narrative as we've talked about. We also really wanna talk about automatic voter registration. As I mentioned, registration is still the number one people, reason why people are not voting. There is a push right now to really look at automatic voter registration and how we can streamline this for people and collect more registration so that they don't have that initial barrier to voting. We are approaching the Biden administration about automatic voter registration. What can they do within their agencies? And also around Healthy People 2030, civic engagement and statistics around registration and voting rates were leading health indicators in Healthy People 2020. And we would like for that to be included also in Healthy People 2030. And so we are in talks with CDC and the Biden administration around that. All of us about educating ourselves and engaging in state and national conversations about expanding access to the ballot. We are partnering with Vote ER. I know that Jean will talk about this later for Civic Health Month in August. And really what we're trying to do is plan and implement a set of collective actions over the next few years that are about prioritizing civic participation, really making it clear that this is a public health issue and that we have to work cross-sectorally to ensure that people's voices are heard at the ballot box, that this is foundational for every single health issue that we have and that we absolutely need to do it. So I will turn it back over to Jean and she'll close us out. Thank you, Jessica. I just wanted to highlight a few things that we as Preventive Medicine, am I, I'm not clicked into the clicker. Jessica, can you move the slide? So these are some of the actions that Preventive Medicine physicians can take to promote full civic participation. Again, we can all participate in promoting the understanding of the connections between participation and health, writing, speaking, actions. You can work to build and leverage your influence. You are currently leaders in your national and local organizations, in your professional arena. You are often seen as the Preventive Medicine, well, hopefully you are seen as the Preventive Medicine strategist and leader. And making sure that you are able to continue to speak up about the connections between health and participation is really important. We can work to promote policies that expand access to the ballot box and then fight policies that restrict access. And recognize that there is a theme and an aspect of reinforcing a pattern of change of structural racism in who is and is not participating in our policymaking structures. And so embracing the imperative to address structural racism by eliminating the barriers to full participation is so critical. Just a quick note that people, when power is being challenged, there will be all sorts of stories about why you shouldn't weigh in. It's partisan. Voting has suddenly become a partisan issue when in fact it is an inclusion in our society issue. And so not abdicating that and continuing to stand up to speak to it are really important. Can somebody, I think, okay, I'm connected. So here are some things in your very individual role you can take. You can encourage voter registration in your clinical services and or if you're supervising and leading programs like WIC or SNAP, you can be sure it gets incorporated into promotion of voter registration gets promoted into the processes. You can personally include questions on voter registration in the patient history and education. And you can encourage your colleagues and then your organizations to systematically incorporate voter registration in a patient history. Just asking, are you registered? Do you know how? Is an important action. And you can participate in conducting research and data analysis using the Healthy People 2030 data, the BRFSS and other spaces that you may have influence in. And then we are looking at how to sign on and you can sign on as a coalition partner in Civic Health Month and there's a link there. And that is the main things that I wanted to be sure to cover. I have included in the slide set, the opportunity, our contact information and just a reminder that every generation leaves behind a legacy and to recognize the pattern change to excluding people that has been occurring since 2013. And that this is a contentious area in that it is an area that we have to either show up as leaders and leave the legacy of inclusion and non-participation is not really an option if we're advancing health equity. Thank you. Hello, my name is Wilnice Jasmine. I am a medical director at the Chicago Department of Public Health. I'm your moderator today. So there are various ways to approach advancing health equity and many different aspects of our lives impact our health. Jean Eyre and Jessica Brown, they just highlighted the importance of maintaining civic engagement. So now we are going to transition to Bishoy Samuel who will tell us about how the built environment contributes to health equity. And I encourage you to enter your questions at the end. We'll address them all together. Okay, thank you very much, Wilnice. And thank you everyone for being here and attending the session. My name is Dr. Bishoy Samuel, one of the senior preventive medicine residents at University of Mississippi Medical Center. Prior to that, did internal medicine practice for a few years, switched to prevention as a career transition, more interested in some health policy things, medical leadership, and I'll be doing an addiction medicine fellowship starting this year in July. So today I wanted to talk to you about the local, how local policy sort of works through a hypothetical scenario where a local community wants to do a built environment intervention. And we'll start by talking about, kind of describing what the scenario is. This is a hypothetical. And then we're gonna go and say into what are complete streets, talk about both the philosophy of complete streets and more of a tangible definition of them. We'll talk about what kind of community things need to happen for this implementation to take place. And then local policy, we'll examine that through a discussion of multi-sectoral collaboration and then conclude from there. So if we can imagine a scenario where there was a call for community submission of proposals say from the state level is being made for local complete streets interventions, but there are limited funds and there will be allocated to the best submissions. So what does the submission look like? What kind of things do you need to consider? So let's start by kind of talking about what complete streets are first. So as a philosophy, complete streets really integrates people in place in the planning, the design, construction, operation and maintenance of transportation networks. It really ensures safety for all ages and abilities. So it's across all levels of society and balances the needs of different modes. Those being transportation, economic, educational, et cetera as well as both leverages and supports local uses, economies, culture and environment. Benefits can be public safety, both in the design and access and economic impact is ongoing as well. So complete streets and kind of a more tangible definition can really encompass a lot of things. So as far as interventions in a community that can sort of, they can sort of manifest in that economic benefit that we talked about. There are a couple of active sidewalks are a type of complete street interventions, community that has dedicated bike lanes, active roadways, crosswalks, spanning strips. There's kind of a approach called a road diet where you can for instance have concrete barriers and others to enhance traffic flow, minimize accidents, et cetera. And there's all kinds of other examples, special bus lanes, accessible public transportation stops, median islands are one type, signage and striping is another, et cetera. So now that we kind of have an idea of what complete streets are as an approach, both philosophically and tangibly, let's talk about what needs to happen on a community level to integrate this type of intervention. So it's good to keep in mind as we're talking about this, the built environment is one of the five social determinants of health as defined by the CDC where people live, work and play. So built environment has a direct impact on health across all socioeconomic groups. And really built environment includes the physical structures of human made environments like housing, schools, commercial centers, parks and public spaces, et cetera, and interventions in local level neighborhood all the way to communities at large. So because they contribute to accessibility to physical activity, they affect health on a whole. Any approach to doing any type of built environment intervention for population health improvement has to start with a needs assessment. And this is kind of a qualitative data gathering and quantitative as well about community perceptions and attitudes about values and what the built environment intervention will entail and contribute and needs. What are the more prominent needs? Is it more of a safety concern? More green spaces are needed. More, say a community is well off with those interventions and they wanna think a little bit more. So maybe bike lanes, et cetera. What are barriers and concerns to implementing these things? That'll be part of your assessment. From a built environment intervention perspective, you wanna do a walkability and bikeability assessment. And sometimes you can use also tools like GIS mapping. So graphical information systems, GIS, are kind of systems where you have overlay of different geographic data in a community and maybe their governorships as well. So you can get, say you wanna get a density of accessible bike lanes near schools or green spaces or parks near schools or neighborhoods. As you do that as part of your community assessment, you can kind of get an idea of where in your county or state are these interventions more necessary and kind of focus your efforts there. Okay, and so the overall plan and approach that includes assessment is that you wanna come up with sort of a design idea. You wanna also address land use and transportation planning as well as and what that looks like. We'll kind of go into that in a few seconds, how you're gonna implement it and then have a process of evaluating it where you're sort of doing like a quality improvement approach on a community-wide level. Implement the best approach, evaluate for outcomes and then re-implement again. So this has to be part of the process when you're undertaking this. Okay, so in order to talk about local policy, let's define really what a bill is. I know this is familiar to several folks. So a bill is really a written proposition that can be brought forth by a representative for interventions of any kind. Bill is defined by different sections where there are definitions and proposed intervention or changes. You always wanna talk about funding and budget allocations and then the relevant committees. There are gonna be looking at this bill where it's gonna pass through these committees and get approved or not or go back for revision or not and then any provisions or restrictions in the bill itself and what you're trying to implement. So where I'm living right now currently, Mississippi, the bill process, and this is probably similar in other states as well. It starts by introduction of the bill in the House of Origin. This can be the House of Representatives or the Senate. And it sags into, excuse me a second. And then it'll go to several committees where hearings will be taking place and reports to the committees. And then it'll be placed on a calendar. And then subsequently after that, it'll be debated. Again, this is still in the House of Origin and finally voted yes or no to pass. And then it'll go through the other house where the same process will take place. So if it started in House of Representatives it'll go to the Senate or vice versa. It'll be introduced, debated, gone through the parallel committees in the House with reports being written up and then placed on a calendar for voting and then voted. If both houses vote the same, then it's one step closer to getting to the governor to have a sign. So on the left-hand side there, if both vote yes, then it goes for passage. And if no, then usually if you can have yes votes, but with differences, because sometimes you don't only have to vote, both houses have to vote, but you also have to vote on the bill as it is. So if there are any changes, it might have to go back to the House of Origin in an invited conference and what's called, and usually this happens once. Did a health policy fellowship through my residency and one of the things I got to appreciate is how easily a bill can die, for instance, going through this process. In a sense, sometimes that's a good thing because you want to have all these measures in place to make sure that the bill passes, that it has consequences. So, but in another sense, it kind of makes you appreciate the difficulty and the complexity of the process. So usually this revision, if there's a difference in the bill in both houses, this revision will take place one time, any more than that, and it usually will die. If it gets revised and they can agree again, the conference committees can agree again, then it gets approved again. And now both houses have approved it in a conference report and it goes to the governor for signing and it becomes a bill. And that's also the step where the governor has a power to veto it. So local policy, in the scenario we kind of defined at the beginning, we talked about a hypothetically, kind of a call for submissions from the state, but local policy is kind of where you can actually make the most impact in your community because it really allows for engagement with policy work at community, county, municipal levels. We also have different inputs, so to speak. As part of public health, you'll have public health and local public health sectors, but also other industries, especially for something like built environment, you'll see you need to leverage engineering, education, transportation, et cetera. So local policies, I'm gonna end my portion of the discussion by discussing multi-sectoral collaborations. So this is a way that local policy can be implemented in the community. And there was a Canadian CLASP initiative study that kind of looked at this through two different levels that they had Healthy Canada by Design and Children's Mobility, Health and Happiness. Both those projects worked at local level to address change in physical activity through built environment implementation. And total 203 sites, multi-sectoral expertise was kind of called on. So this is public health, land use planning, transportation, et cetera, to inform the development of these local policy interventions in the areas of land use, transportation and school travel planning. So the identification of the pathways was kind of a two-step analysis. They had a review and qualitative analysis of 183 knowledge products identified by both these groups, the HCBD and CMHH. And then the pathways were grouped into three broad themes, people, tools, approaches and ways of working. And they basically outlined 14 successful pathways to policy across the five major themes, eight of which were multi-sectoral. So the five major themes are listed here, engagement with policy work, building and working with partners, proper evidence. There is a program development implementation level and then your marketing information sharing awareness. So what really needs a policy, and we're almost done here. So community scale, urban design and land use, same concept, but on a smaller level, street scale, urban design and land use, building a public facility, design, transportation, et cetera, as you can see here. And then interested groups will be all kinds of folks on the community, health community groups. We talked about obviously public health, professionals, transportation. You wanna get interest groups as well, fitness groups, bicyclists, AARP, for instance. So private groups, local businesses, education, et cetera. So I know we kind of went through this quickly because a lot more can be said about this, but to summarize, complete three-star philosophy, built environment interventions as part of the social determinant of health, integrates people and place, ensure safety for all. Your community approach has to include and needs assessment, setting committees, identifying stakeholders, engaging in data collection, coming up with a master plan that includes re-evaluation as well. We talked about a bill and what that is and how it goes through that bicameral local government and then local policy is a type of intervention allowing for several community interest groups across multiple industries to be engaged in local policymaking through which multi-sectoral collaboration is the best approach. So I just wanna thank the folks from Mississippi Health and from MSU Health Extension. And I thank you all for being here and listening. Thank you, Vishay. Now in the effort to save time, we'll transition directly to Widenar Mulligita to hear about how food insecurity can push the needle towards health equity. Thank you so much for having me today. I am a primary care physician and board certified in internal medicine, preventive medicine. I'm also a faculty at Harvard Medical School near Boston. And this is one of my research area interest looking at food insecurity. And also, let me just get the slides for you. Great. And so this, we will be talking about this important topic in terms of addressing food insecurity center through a unique partnership in the context of COVID-19. So these are the objectives. And we will be, this is outline for today. I hope we'll be discussing food insecurity, the definition, some screening tool we use, prevalence and health impact and implications of food insecurity. And I'll be sharing this case study, which we developed. And I hope this is something that you'll be able to take and implement at your practice as well. And of course, we'll talk about this in the context of COVID-19. So we'll define food insecurity. As you know, it is one with a social determinant of health and is defined by USDA as a condition with limited or uncertain access to adequate food. And clinically and practically, we use the hunger vital sign, which is a two item screening tool that we have. In our system, it's already integrated in our EMR. So that makes it easy to utilize and to use. And these two items, it would be positive if someone answered often through or sometimes through to either of these two questions. In terms of the prevalence before the pandemic, food insecurity affected about 11% of the total US household. And that's about 40 million people. But since the pandemic, unfortunately, it has doubled to 22%. And it can be as high at 33% among households with children. And we worry about food insecurity because it has been linked to significant negative health outcomes. And that will include diabetes, depression, obesity, oral health problems, poor adherence to blood sugar monitoring. And it has also been linked to forcing patients to choose between buying medicine or food. So at our health center, which is near Boston, we have largely immigrant underserved patient population. And that has also been significantly been impacted by the pandemic. We were one of those communities hit hardest by the pandemic. And before the pandemic, we actually did a survey to assess food insecurity in our patient population. And about 51% of our population was screened positive for food insecurity. So we developed this really collaborative approach to address that. And this is in collaboration with a local food bank as well as a local health plan and good measures, which is a nutritional coaching companies that works with our patient population. And this is really a farmer's market style, free produce market for our patients once a month, where they come to the clinic by the parking lot and they receive up to 30 pounds of fresh fruit and vegetable per household. And this is the data before the pandemic. And we were serving about 1200 patients and that's more than 320 household. And the setting as you can see is very different, is very close contact. And it's very much like a farmer's market style, free produce market where patients just come across and pick items of food, vegetable that they would like. And we also had our nutrition coaching staff that was doing food demos. And so they would be sharing some recipes to show healthy way of cooking and preparing the different fruits and vegetables that patients were picking. And of course, since the pandemic, we had to make some changes and we were actually seeing significant increase in the need. And so we were seeing three times more patients coming to our market than the year before. And so we had to make some changes to still continue the program throughout the pandemic. And one of the things that we have done is pre-bag the items for our patients instead of them going through the line before. So we would prepare and pre-bag the vegetable fruit. As you can see, volunteers are masked and physically distanced. And we were also able to add non-perishable items such as tuna and oatmeal for our patients. And this is just a time lapse I would like to share with you just to see what the market is like. And this is how the volunteers are preparing and pre-bagging the items. And this is since the pandemic. As you can see, everyone is physically distanced. You can see everyone is wearing mask. The items are produced are also six feet apart so to comply with the guidelines. You will also notice at the end, the items are placed six feet apart. So as the patients pick their bags, they are also keeping it with the physical distance guidelines. And as of March, 2021, we were able to provide more than 240,000 pounds of fresh fruits and vegetables. And these are just some of the items, the vegetable, the produce we were able to provide for our patients. And we have also been doing research along with this program to study the impact of the produce market. And we have been doing a mixed method study looking at both quantitative and qualitative data. The quantitative study is primarily based on the baseline and follow-up survey we have been conducting. And also we have a focus group to do the qualitative aspect. And as you can see from the table one, the baseline, we are the people who come to the market tend to be mostly females seem to be attending it. But there's very diverse patient population coming to our market by language and ethnic background. We are serving mostly low-income patient population, but working class families. So more than 57% of the participants say they do work. And the focus groups have been very insightful for us. We have contacted seven focus groups, three English, two Spanish and two Arabic language. And they run about one hour and we have done about 49 adult participants in the focus groups. And they have been really very insightful and in showing us the benefit that the patients have been gaining. And specifically with respect to diet, a lot of people report increase in fruit and vegetable intake. They also report reduction in junk food intake and overall improvement in health. And some also report that there's a benefit in terms of weight loss. Also financial benefit patients have mentioned include being able to save some money and ability to afford other essential goods and items and services because of the support. And finally, something that's really unexpected for us was the social benefit. People and patients really enjoyed interacting with the healthcare providers and also interacting and talking with each other, especially before the pandemic, where people were able to talk closely and just have friendship. And also as a provider, I would say it's been very rewarding and it's something that as physicians, we are used to seeing our patients in a small exam room. And so it's really nice to see them out and about and carrying 25, 30 pounds of fresh produce. So that's been something rewarding experience for us as providers. So I hope this is the main takeaway point. We talked about food insecurity. We talked about definition, some screening tools that we can use and also talk about prevalence and implication and the health impact. And I really hope that you might be able to take this to your practices, maybe something that you may consider implementing. I do believe that it is ideal setting. It could be ideal setting for addressing food insecurity because patients are familiar with their healthcare system, their health centers. And so it could really be ideal and possibly patients may feel less stigma coming to a healthcare center versus other options. And I hope we were able to discuss some of the changes we had to make in the context of COVID-19. And so there's so many people to thank for this. I can't really emphasize enough the collaboration that goes for such programs and collaboration within our institution, but also collaboration between institutions. And so I also would like to thank all the staff, the volunteers, the interns, the students, and many, many partners that made this possible. Thank you so much for your time. Thank you. It's always a challenge to fit so much information in one hour. I want to thank our speakers today and I hope those in the audience were inspired to connect, to see how their work connect to the initiatives that were discussed today. We don't have time for questions. So I hope you enjoy your break and rejoin us at 115 for conclusion. Thank you. And now we'll move on to our first session, number five. ♪♪♪

Advancing Health Equity

Civic Engagement

Built Environment

Addressing Food Security

Healthy People, Healthy Democracy Initiative

Civic Participation

Structural Racism

Complete Streets

Transportation Planning

Food Insecurity

Social Determinants of Health