Brown School › 2020 › Page 5

The National Institute of Child Health and Development has awarded $3.4 million to three Brown School faculty to test the long-term impact of an intervention that has shown early success in improving adherence to medication through economic support for families with HIV-positive youth.

Fred Ssewamala, William E. Gordon Distinguished Professor at the Brown School, and Research Assistant Professors Proscovia Nabunya and Ozge Sensoy Bahar will lead the extended Suubi+Adherence study, which extends their original 2012-18 research in southwest Uganda. Suubi means ‘hope’ in Luganda, one of the main languages in southwest Uganda.

In the original study, participants received incentivized financial savings, financial literacy training and income-generation workshops. Early results were promising, with data showing that participants who received the intervention consistently reported improved adherence to antiretroviral medications. 

Moreover, the suppression of HIV among youth receiving the intervention increased significantly compared to the control group, and the cost per participant was not prohibitive. The results were published in several peer-reviewed journals, including PLOS One and AIDS and Behavior.

“We found that the first five years of the Suubi+Adherence study produced several desired outcomes,” said Ssewamala. “But the question remains as to how long the reported outcomes will be sustained through young adulthood. There is a need for a longer-term follow-up to establish the impact across the years as participants go through social transitions – a very vulnerable stage for adherence – and the associated costs and cost-effectiveness.” He said the continued funding will extend one of the largest and longest-running studies of young people living with HIV in sub-Saharan Africa.

In addition to tracking the original cohort of study participants for five more years, the new funding will allow the team to dig deeper into the potential mechanisms of change, including long-term effects on economic stability, sexual risk-taking behavior, adherence self-efficacy, cognitive functioning, mental health, and social support. 

“We believe that providing a financial support system for these youth has the potential to lead to long-term systemic, positive life choices,”  said Nabunya. “To my knowledge, the long-term effects on this population have never been measured, which is why this continued funding is so essential.”

In-depth interviews with participants and the continued measurement of cost-effectiveness will enable the team to assess the long-term value of the intervention compared to other options.

“Lessons learned from interviews and cost measurement will give us richer tools and data to share with policymakers and stakeholders to ensure sustainability of this important intervention,” added Sensoy Bahar.

COVID-19 caught public health systems in the U.S. unprepared to detect, track and contain the virus. The pandemic has exposed a multitude of deficiencies that require a wholesale reinvention of the field of public health, said four leading experts in a recently published essay.

“Our insufficient capabilities have been complicated by long-standing and worsening health inequalities and the rapid spread of misinformation that needs to be countered,” said Ross Brownson, the Steven H. and Susan U. Lipstein Distinguished Professor and director of the Prevention Research Center at Washington University in St. Louis.

Brownson is lead author of the essay “Reimagining Public Health in the Aftermath of a Pandemic,” published Aug. 20 in the American Journal of Public Health. Co-authors are: Graham A. Colditz, MD, DrPH, the Niess-Gain professor of surgery and director of the Division of Public Health Sciences at Washington University School of Medicine in St. Louis; Thomas Burke of Johns Hopkins University Bloomberg School of Public Health; and Jonathan Samet of the Colorado School of Public Health.

“Resources put into public health and prevention can have an amazing return on investment,” Colditz said. “This new vision for the public health system can help us harness that potential and move toward becoming a better prepared, more equitable and healthier nation. But it will take some effort.”

The essay suggests the reinvention will take place over the next five years, beginning with three phases of action to deal with the immediate crisis:

The COVID-19 pandemic will change the world permanently in ways that are not yet predictable, Brownson said. “The events of the past several months have revealed immediate health and social needs and pointed directly to the urgent need to redouble our commitment to prevention and public health investment. Without explicit attention to social determinants of health, the aftermath of the immediate societal outcomes of COVID-19 will be still greater health inequities.”

The authors list four ingredients that are needed to change public health:

“The lessons of COVID-19 present an opportunity and an urgency to reimagine public health,” the authors wrote. “We must recognize that public health is a public good that deserves greater investment — that message has never been more important. We must reach across the silos of the health system, reduce the burden and costs of poor health, and advance the science to identify and respond more quickly to emerging threats in our changing world.”

On Election Day in 2008, Gena Gunn McClendon, project director with the Center for Social Development (CSD), volunteered with CSD colleagues at a polling place in Jennings, Mo., a predominantly Black community just north of St. Louis. They were stunned by late openings at polling places and the long lines. People waited for hours to vote. 

“Voters did not stand in line for hours where I lived,” McClendon recalls. “I saw the lines and thought, ‘This is unacceptable.’”

As a result, in 2017, the Center for Social Development started a new initiative, Voter Access and Engagement (VAE). “We had several questions,” McClendon says of starting VAE. “Are voters engaged? If not, why not? Do people in lower-income communities have fewer opportunities to vote? Are voting conditions equitable?”

On Election Day in 2018, McClendon dispatched 38 graduate students to observe 20 polling places across St. Louis City and St. Louis County. The sites were in low- and high-income neighborhoods, and with majority-white or majority-Black populations. VAE researchers found that living in low-income, predominantly Black communities was associated with long voting lines, late polling place openings, broken machines, poor polling-site accessibility for people with disabilities, and insufficient signage outside polls.

“When that happens, is it intentional?” McClendon asks. “Probably not.” For instance, Missouri law demands that every polling place have an election judge from each political party. If one party isn’t represented, the polling place must shut down until a judge from that party arrives. McClendon points out that residents in St. Louis City and northern portions of St. Louis County tend to be Democrats, and election authorities have trouble recruiting enough Republican judges.

These circumstances can affect voting outcomes. “In 2008, Barack Obama lost Missouri by fewer than 4,000 votes. If you factor in late openings of polls, broken voting machines, and long lines that discourage voting, you have to wonder whether Obama could have won Missouri.”

To raise awareness about the problem, VAE published its findings in “Will I Be Able to Cast My Ballot? Race, Income, and Voting Access on Election Day.” McClendon has spoken to students in local high schools, organized a film festival, and held multiple screenings of Rigged: The Voter Suppression Playbook, which documents voter-suppression tactics used in several states, including Missouri.

McClendon noted some progress. Missouri’s voter ID law disproportionately affects low-income, elderly and Black voters, who are less likely to have state-issued identification. In a small but hopeful step, a recent court decision threw out the requirement that voters sign a sworn affidavit if using non-photo identification to vote.

Despite this positive step, barriers remain, she says. Missouri does not offer early voting, same-day voter registration, or no-excuse absentee balloting — all of which could improve voter access and engagement, especially in the time of a global pandemic.

This year, thanks to voter advocates and lawmakers, Missouri expanded the absentee and mail-in voting options for the 2020 Election season due to risks related to COVID-19. But there are still shortcomings with casting an absentee or mail-in ballot. “For instance, if voters fail to sign the back of the envelope, or do not check a small box on the preprinted return envelope confirming their current address, then their ballot can get rejected,” McClendon says.  And the new law requires a notarized affidavit for all mail-in ballots and all absentee ballots unless the excuse for voting absentee is medical. For some voters, identifying a notary is difficult.

The process of applying for, receiving, and returning the ballot to the Board of Elections with the postal service can take 30 days or more, and in many instances, the voter never receives the ballot. All of these challenges make it difficult to cast an absentee ballot successfully.

“People shouldn’t have to go through so many barriers to vote,” McClendon says. But she adds, “while the system isn’t perfect, it works well for most voters and poses less risk of exposure to COVID-19 than in-person voting.”

McClendon works with the County Board of Elections as part of her project with the VAE. This month, she joined the League of Women Voters volunteers to assist the  Board of Elections with the August 4 primaries. In this role, deputized volunteers called voters whose cast ballots had been rejected, and told them how to correct it.

St. Louis County election officials relaxed the notary requirements for absentee ballots received from voters 65 years and older. “While the decision to relax the notary requirement for the elderly was a positive for many absentee voters, unfortunately many of the ballots were [still] rejected for multiple reasons,” she says.

Despite everything, McClendon says she is cautiously optimistic. “I have to believe we can have fair elections, or I could not continue to do this work,” McClendon says. She reflects on the loss of U.S. Rep. John Lewis. Many of the stands he took during the civil rights movement, and throughout his congressional career, were to ensure that the right to vote was protected for all Americans.

“If John Lewis could endure being beaten and arrested dozens of times in order for us to vote, then the least I can do is vote, and try to clear a pathway so others can vote,” McClendon says.

She hopes to continue studying and raising awareness about voter suppression in Missouri. VAE is working on two new studies: one on voting conditions and voter turnout, and another on how race, income and turnout are related.

“I don’t want to leave the world in this situation,” McClendon says, “where there’s a threat to democracy for our young people. It’s not fair. People fought for me, and I need to fight to make sure everyone can vote.”

Thirteen years after they began, researchers in a landmark study of asset building in Oklahoma are poised to receive new information gathered despite obstacles posed by COVID-19, which struck just as the new phase of research was getting underway.

The experiment, SEED for Oklahoma Kids (SEED OK), began in 2007 with interviews of over 2,700 mothers of Oklahoma newborns. Next, half of the newborns automatically received $1,000 in a state-owned Oklahoma 529 plan account as part of this long-term study of the benefits of Child Development Accounts. Early analyses show promising results, some especially for financially vulnerable families, and also provide lessons from the Great Recession for the current COVID crisis.

In early 2020, a third round of surveys—Wave 3—began in order to assess the impact of the accounts as the children in the study turned age 12.

“As far as we know, SEED OK is the longest running social experiment in the country,” said Michael Sherraden, Director of the Center for Social Development (CSD) at Washington University in St. Louis, which is leading the study. “Research methods are robust, and results are informing policy innovations.” Deposits to the state 529 plan were funded by the Ford Foundation and SEED OK is administered by the Oklahoma State Treasurer’s office. As the study progresses, survey data from families and account and savings data from the Oklahoma 529 plan provide key information on outcomes, such as the growth of the accounts; the social development of children; and the mental health, parenting practices and educational expectations of mothers.

But the advent of COVID-19 made traditional information-gathering methods, such as call-center interviewing and in-person contacting, impossible, so major adjustments were required. An on-line data collection system was created, and the research timeframe was extended, with a continued focus on high-quality data and a high response rate.

“The very good news is that we are now on track to receive the SEED OK Wave 3 data set by mid-August,” said Margaret Clancy, CSD’s Policy Director who has been leading the study.

“The response rate will be over 66% of the initial sample, which is very respectable after 13 years. CSD has reviewed preliminary data files and we are well prepared to begin analyzing the data.”

A benefit of the delay is that CSD researchers will be able to test the impact of the virus, with survey data both before and after its arrival. CSD researchers also added some new survey questions about COVID-19 for study participants responding after its onset.

The success was achieved through intensive planning with RTI, the firm CSD contracted with to collect the data, and by adopting the following changes:

“We know from long experience that achieving high-quality data positions us to inform policy innovations going forward,” Clancy said. “We believe the SEED OK Wave 3 data will help us achieve this goal.”

There have been more than 3.5 million requests for assistance to 2-1-1 help lines around the United States since the coronavirus pandemic hit this spring. The impact was immediate and dramatic, said a Brown School researcher who tracks calls to 2-1-1 help lines across the U.S.

During COVID-19, the volume of requests to 2-1-1s has increased exponentially, said Matthew Kreuter, the Kahn Family Professor of Public Health at Washington University in St. Louis.

“Questions about COVID-19 symptoms and testing account for part of this increase, but mostly people need help dealing with the economic consequences of the pandemic,” said Kreuter, senior scientist at the university’s Health Communication Research Laboratory. The lab developed 2-1-1 Counts, the first tool to provide real-time, searchable and visual presentations of data from 2-1-1 call centers across the country.

2-1-1 is a free and confidential service that helps people across North America find the local resources they need 24 hours a day, seven days a week, in most communities. Each year, 2-1-1s receive 16 million requests, not only seeking emergency services, but also basic needs such as food, shelter and clothing.

The World Health Organization declared COVID-19 a pandemic on March 11. “In the first two full weeks afterward (March 16–29), food-related requests to 2-1-1s skyrocketed, increasing 486%,” Kreuter said in a recent Health Affairs blog post.

“Requests for rent assistance were up 137%, and, across all need categories, daily requests more than doubled compared to pre-COVID-19 rates in 2020,” he said. “The overall rate of increase is even more striking given that requests to 2-1-1 for help with some other social needs declined sharply as a direct result of COVID-19.

“The potential applications of 2-1-1’s social and economic needs data are many,” Kreuter and his co-authors wrote in the blog post. “For a social service safety-net system that is stretched thin in the best of times, COVID-19 presents a daunting challenge and a renewed sense of urgency for investment and improvement. When requests to 2-1-1 double, that means referrals to community-based agencies double as well. Understanding which needs are rising and falling in which neighborhoods should inform community priorities and resource allocation to better and more efficiently meet demand.”

Data tracked by 2-1-1 Counts can be searched and displayed by date, county, congressional district and more.

Kreuter’s team has established a web page, FOCUS-19, to report new findings daily.

As China’s government seeks solutions to social problems related to an evolving society, professional social work is increasingly entering new areas, including migrant and aging services, and is poised to take on a larger role in assisting lesbian, gay, bisexual, transgender and queer (LGBTQ) people, said two experts from the Brown School at Washington University in St. Louis.

“There is a growing awareness about LGBTQ people and their experiences in China. However, most LGBTQ issues are largely framed as public health matters only, and ignore the complex social and psychological dynamics that create vulnerability with respect to heterosexual and cisgender norms in China,” said Yuekang Li, a doctoral student.

Li and Vanessa Fabbre, assistant professor, are co-authors of the recent paper “The Health and Well-being of LGBTQ People in Mainland China: The Role of Social Work,” published in the journal International Social Work.

“Since we are writing from the premise that health is more than the absence of disease, we want to use this brief to draw attention to the social determinants of health and well-being in the contemporary Chinese context,” Li said.

Li and Fabbre highlighted the social, economic and political forces in mainland China that are rapidly changing with the country’s increasing embrace of state capitalism and the influence of globalization. One such change, Fabbre and Li argued, is a growing awareness about lesbian, gay, bisexual, transgender and queer people and their experiences.

“Social work is an emerging profession in mainland China,” they wrote. “Though in this current stage of development, social workers largely play an assistant role to traditional social service providers, the profession is increasingly entering areas such as migrant worker services, aging services and employment promotion, which is beginning to elevate its status in the social welfare system.”

Though much of the current social activism and services for LGBTQ people in mainland China are conducted outside of the profession of social work, “we believe social work is well-positioned in its early stage of development to support LGBTQ people,” they argued.

“This may mean leveraging the strength of social work in dealing with the multitude of social factors that inhibit the health and well-being of LGBTQ people in China, and providing services in ways that empower LGBTQ people,” Li and Fabbre wrote.