The impact of the baby friendly hospital initiative on healthcare utilization among newborns insured by Medicaid in Delaware.

BACKGROUND: The Baby Friendly Hospital Initiative was created to enhance breastfeeding, although its impact on infant healthcare utilization is unclear. Breast feeding infants are vulnerable to readmission soon after birth secondary to dehydration and hyperbilirubinemia. Breastfeeding can also protect infants from unnecessary health care utilization later in life by preventing infection. The objective of this study was to examine the impact of the Baby Friendly Hospital Initiative on readmissions and emergency department utilization among Medicaid births in Delaware. METHODS: The study was a quasi-experimental design. Medicaid claims files were used to study births at five hospitals in Delaware born between January 1, 2014, and December 31, 2018, and covered under Medicaid at time of birth. Three hospitals were designated Baby Friendly, two were not and served as controls. Outcomes included Emergency Department (ED) utilization and readmissions within 30 days and one-year of birth hospitalization. Exposure to the Baby Friendly Hospital Initiative was determined by year and hospital of birth. Logistic regression and interrupted time series segmented regression analysis with controls were used to assess the effect of Baby Friendly Hospital Initiative on healthcare utilization. RESULTS: In total, 19,695 infants were born at five hospitals with 80% (15,939) born at hospitals that were designated Baby Friendly. ED utilization and readmissions over the 1st year of life for breastfeeding related diagnosis at the Baby Friendly hospitals occurred in 240 (1.5%) and 226 (1.4%) of infants, respectively. Exposure to the Baby Friendly Hospital Initiative was associated with increased odds of all cause 30-day readmission (AOR: 1.15; 95% CI: 1.03-1.28) but not readmissions over the 1st year of life. While 30-day ED visits did not change after BFHI, one-year ED visits were reduced (0.91, 95% CI 0.86-0.97). A significant negative trend was seen over time for ED utilization post BFHI compared to controls (B: -5.90, p < 0.01). CONCLUSION: There was a small observed increase in the odds of all cause 30-day readmissions with no change in one-year readmissions after BFHI in Delaware. Although there were no observed changes in 30-day ED utilization, there was a reduction in one-year ED utilization following the implementation of the Baby Friendly Hospital Initiative in Delaware birth hospitals. Our data help to inform policy and decision making for statewide systems of care that may be used to support breast feeding.

Factors Affecting BMI Changes in Mothers during the First Year Postpartum.

We tested the hypotheses that mothers of infants who exclusively breastfed would differ in the trajectories of postpartum BMI changes than mothers of infants who exclusively formula fed, but such benefits would differ based on the maternal BMI status prepregnancy (primary hypothesis) and that psychological eating behavior traits would have independent effects on postpartum BMI changes (secondary hypothesis). To these aims, linear mixed-effects models analyzed measured anthropometric data collected monthly from 0.5 month (baseline) to 1 year postpartum from two groups of mothers distinct in infant feeding modality (Lactating vs. Non-lactating). While infant feeding modality group and prepregnancy BMI status had independent effects on postpartum BMI changes, the benefits of lactation on BMI changes differed based on prepregnancy BMI. When compared to lactating women, initial rates of BMI loss were significantly slower in the non-lactating women who were with Prepregnancy Healthy Weight (ß = 0.63 percent BMI change, 95% CI: 0.19, 1.06) and with Prepregnancy Overweight (ß = 2.10 percent BMI change, 95% CI: 1.16, 3.03); the difference was only a trend for those in the Prepregnancy Obesity group (ß = 0.60 percent BMI change, 95% CI: -0.03, 1.23). For those with Prepregnancy Overweight, a greater percentage of non-lactating mothers (47%) gained ≥ 3 BMI units by 1 year postpartum than did lactating mothers (9%; p < 0.04). Psychological eating behavior traits of higher dietary restraint, higher disinhibition, and lower susceptibility to hunger were associated with greater BMI loss. In conclusion, while there are myriad advantages to lactation, including greater initial rates of postpartum weight loss regardless of prepregnancy BMI, mothers who were with overweight prior to the pregnancy experienced substantially greater loss if they breastfed their infants. Individual differences in psychological eating behavior traits hold promise as modifiable targets for postpartum weight management.

Relationship Between Human Milk Feeding Patterns and Growth in the First Year of Life in Infants with Congenital Heart Defects.

The purpose of this study was to determine the relationship between patterning of human milk feeding and growth of infants with congenital heart defects in the first year of life. Inclusion criteria for this prospective cohort study included infants 0-21 days, who had undergone or had planned neonatal corrective or palliative surgery prior to hospital discharge, and whose mothers planned to feed human milk. Data on anthropometric measures (weight, length, head circumference) and infant milk type (human milk, formula, other) were collected at nine time points (0.5, 1, 2, 3, 4, 6, 8, 10, 12 months). Anthropometric data were converted to weight-for-age, length-for-age, head circumference-for-age, and weight-for-length Z-scores using World Health Organization growth reference data. Cluster analysis identified three milk type feeding patterns in the first year: Infants fed human milk only with no formula supplementation, infants fed human milk who then transitioned to a mix of human milk and formula, and infants who fed human milk and transitioned to formula only. General linear models assessed the effect of milk type feeding patterns on growth parameters over time. No effect of milk type pattern × time was found on longitudinal changes in weight-for-age (p for interaction = 0.228), length-for-age (p for interaction = 0.173), weight-for-length (p for interaction = 0.507), or head circumference-for-age (p for interaction = 0.311) Z-scores. In this cohort study, human milk alone or combined with infant formula supported age-appropriate growth in infants with congenital heart defects in the first year.

Use of Voice-Assisted Technology to Enhance the Home Health Care Patient Experience.

One of the greatest challenges for older, homebound patients receiving health care is accessibility, particularly following a hospitalization. The current study evaluates the effects of using voice-activated technology in the homes of recently discharged patients and its effects on health care outcomes. Voice-based software was embedded in a smart device, which allowed patients to ask questions and receive answers about their own specific care plan. A pre-post study design was used. Forty-eight patients completed the pre and post survey. There was a 63% reduction in emergency department visits and a 26% reduction in physician calls. There was no change in the number of patients requiring hospitalization. More than one half of patients used the smart device daily for their health care needs. More than 70% of patients believed the device was helpful for their general health care needs and assisted in the achievement of care goals. This is the first study of its kind to evaluate patient engagement and outcomes after the use of a smart device with embedded health care directions. [Journal of Gerontological Nursing, 48(12), 17-24.].

Feasibility of a Novel COVID-19 Telehealth Care Management Program Among Individuals Receiving Treatment for Opioid Use Disorder: Analysis of a Pilot Program.

BACKGROUND: The emergence of COVID-19 exacerbated the existing epidemic of opioid use disorder (OUD) across the United States due to the disruption of in-person treatment and support services. Increased use of technology including telehealth and the development of new partnerships may facilitate coordinated treatment interventions that comprehensively address the health and well-being of individuals with OUD. OBJECTIVE: The analysis of this pilot program aimed to determine the feasibility of delivering a COVID-19 telehealth care management program using SMS text messages for patients receiving OUD treatment. METHODS: Eligible individuals were identified from a statewide opioid treatment program (OTP) network. Those who screened positive for COVID-19 symptoms were invited to connect to care management through a secure SMS text message that was compliant with Health Insurance Portability and Accountability Act standards. Care management monitoring for COVID-19 was provided for a period of up to 14 days. Monitoring services consisted of daily SMS text messages from the care manager inquiring about the participant's physical health in relation to COVID-19 symptoms by confirming their temperature, if the participant was feeling worse since the prior day, and if the participant was experiencing symptoms such as coughing or shortness of breath. If COVID-19 symptoms worsened during this observation period, the care manager was instructed to refer participants to the hospital for acute care services. The feasibility of the telehealth care management intervention was assessed by the rates of adoption in terms of program enrollment, engagement as measured by the number of SMS text message responses per participant, and retention in terms of the number of days participants remained in the program. RESULTS: Between January and April 2021, OTP staff members referred 21 patients with COVID-19 symptoms, and 18 (82%) agreed to be contacted by a care manager. Participants ranged in age from 27 to 65 years and primarily identified as female (n=12, 67%) and White (n=15, 83%). The majority of participants were Medicaid recipients (n=14, 78%). There were no statistically significant differences in the demographic characteristics between those enrolled and not enrolled in the program. A total of 12 (67%) patients were enrolled in the program, with 2 (11%) opting out of SMS text message communication and choosing instead to speak with a care manager verbally by telephone. The remaining 10 participants answered a median of 7 (IQR 4-10) SMS text messages and were enrolled in the program for a median of 9 (IQR 7.5-12) days. No participants were referred for acute care services or hospitalized during program enrollment. CONCLUSIONS: These results demonstrate the feasibility of a novel telehealth intervention to monitor COVID-19 symptoms among OTP patients in treatment for OUD. Further research is needed to determine the applicability of this intervention to monitor patients with comorbid chronic conditions in addition to the acceptability among patients and providers using the SMS text messaging modality.

Diabetes and acculturation in African immigrants to the United States: analysis of the 2010-2017 National Health Interview Survey (NHIS).

Objective: This study sought to assess the association between unidimensional acculturation and diabetes, and analyze mediating pathways of the association in African immigrants to the United States (U.S.).Hypothesis: Acculturation would be positively associated with diabetes and that BMI (Body mass index), physical activity, and psychological distress would mediate this association.Methods: An analysis of cross-sectional data from the 2010-2017 National Health Interview Surveys was performed. Adults aged ≥ 18 years who were born in Africa (African immigrants) and residing in the U.S. were considered. The outcome was self-reported diabetes, and acculturation was defined by percent of life spent in the U.S. and citizenship. Multivariable logistic regression analysis was used to assess the association between acculturation and diabetes, and mediation analysis was used to examine the mediating effects of BMI, physical activity, and psychological distress on this association.Results: The analytic sample included 1648 African immigrants with mean (SD) age of 41.3 ± 0.45 years; 56.4% male. Additionally, 46% had ≥ college education, and 21.4% lived below the poverty threshold. About two-thirds were overweight/obese. Less than 50% exercised at adequate levels of physical activity levels. A small percentage (1.8%) reported psychological distress. The prevalence of self-reported diabetes was 6.1%, and 76.5% reported being acculturated. In the multivariate logistic regression analysis, higher levels of acculturation were associated with higher odds of diabetes diagnosis (Odds Ratio (OR) = 2.2; 95% CI = 1.1-4.4). Although BMI mediated the association between acculturation and diabetes (ZMediation = 2.11, p = 0.036), only 18.9% of the total effect of acculturation on diabetes was explained by BMI.Conclusions: Acculturation increased the odds of diabetes diagnosis, and BMI mediated the association. Thus, tailoring culturally-appropriate interventions to control BMI may contribute to preventing diabetes within African immigrant communities to the U.S.

Hospital length of stay among COVID-19-positive patients.

BACKGROUND AND AIM: This study aims to determine COVID-19 patient demographics and comorbidities associated with their hospital length of stay (LOS). METHODS: Design: Single-site, retrospective study. Setting: A suburban 700-bed community hospital in Newark, Delaware, USA. Patients: Patients admitted to the hospital from March 11, 2020, to August 11, 2020, with a positive COVID-19 status. We followed a time-to-event analysis approach and used Kaplan-Meir curves and log-rank tests for bivariate analyses, and an accelerated failure time model for a multivariable model of hospital LOS. RESULTS: Six hundred and eighty-seven patients discharged alive (mean [SD] age, 60.94 [18.10] years; 339 men [49.34%]; 307 Black/African-American [44.69%]; and 267 White [38.86%]) were included in the investigation. Bivariate analysis using Kaplan-Meir curves showed that patients' age, sex, ethnicity, insurance type, comorbidity of fluid and electrolyte disorder, hypertension, renal failure, diabetes, coagulopathy, congestive heart failure, peripheral vascular disease, neurological disorder, coronary artery disease, and cardiac arrhythmias to be significantly associated with LOS (P<0.05). In the multivariable analysis, patients' age, sex, ethnicity, number of Elixhauser comorbidities, and number of weeks since onset of the pandemic was significantly associated with LOS (P<0.05). Fluid and electrolyte disorder is the only comorbidity independently associated with LOS after adjusting for patients' age, sex, race, ethnicity, number of Elixhauser comorbidities, and weeks since onset of pandemic. CONCLUSION: COVID-19 patients LOS vary based on multiple factors. Understanding these factors are crucial to improving the prediction accuracy of COVID-19 patient census in hospitals for resource planning and care delivery. RELEVANCE FOR PATIENTS: Understanding of the factors associated with LOS of the COVID-19 patients may help the care providers and the patients to better anticipate the LOS, optimize the resources and processes, and prevent protracted stays.

Prediction model for COVID-19 patient visits in the ambulatory setting.

Objective: Healthcare systems globally were shocked by coronavirus disease 2019 (COVID-19). Policies put in place to curb the tide of the pandemic resulted in a decrease of patient volumes throughout the ambulatory system. The future implications of COVID-19 in healthcare are still unknown, specifically the continued impact on the ambulatory landscape. The primary objective of this study is to accurately forecast the number of COVID-19 and non-COVID-19 weekly visits in primary care practices. Materials and Methods: This retrospective study was conducted in a single health system in Delaware. All patients' records were abstracted from our electronic health records system (EHR) from January 1, 2019 to July 25, 2020. Patient demographics and comorbidities were compared using t-tests, Chi square, and Mann Whitney U analyses as appropriate. ARIMA time series models were developed to provide an 8-week future forecast for two ambulatory practices (AmbP) and compare it to a naïve moving average approach. Results: Among the 271,530 patients considered during this study period, 4,195 patients (1.5%) were identified as COVID-19 patients. The best fitting ARIMA models for the two AmbP are as follows: AmbP1 COVID-19+ ARIMAX(4,0,1), AmbP1 nonCOVID-19 ARIMA(2,0,1), AmbP2 COVID-19+ ARIMAX(1,1,1), and AmbP2 nonCOVID-19 ARIMA(1,0,0). Discussion and Conclusion: Accurately predicting future patient volumes in the ambulatory setting is essential for resource planning and developing safety guidelines. Our findings show that a time series model that accounts for the number of positive COVID-19 patients delivers better performance than a moving average approach for predicting weekly ambulatory patient volumes in a short-term period.

Validation of a 2-Item Food Insecurity Screen Among Adult General Medicine Outpatients.

Food insecurity is defined as limited access to food and is associated with adverse physical, social, and emotional health outcomes. As social needs are addressed in heath care, efficient methods to identify patients living in food insecure households are necessary. A 2-item screen (HFSS-2) derived from the US Department of Agriculture Household Food Security Scale (HFSS-18) has been validated among parents of pediatric patients with a sensitivity of 97% and specificity of 83%. The objective was to validate the HFSS-2 in adult general medicine outpatients. HFSS-18 was administered to a sample of adult general medicine outpatients in Delaware from 2018 to 2019. The authors evaluated the sensitivity and specificity of the HFSS-2. Multivariable logistic regression was used to calculate convergent validity between the HFSS-18 and the HFSS-2. Three hundred ninety patients were approached with 295 (75%) enrolling in this study; 17.6% (52/295) were food insecure. A confirmatory response to either of the 2 items from the HFSS-2 had a sensitivity of 98% (95% CI: 94%, 100%) and specificity of 91% (95% CI: 87%, 94%). Food insecurity was associated with increased odds of coronary heart disease (adjusted odds ratio [AOR] 4.63; 95% CI: 1.55, 13.79; AOR 4.19; 95% CI: 1.51, 11.59) and diabetes (AOR 4.19; 95% CI: 1.94, 9.08; AOR 3.73; 95% CI: 1.83, 7.92) using both the HFSS-18 and the HFSS-2. HFSS-2 was found to be highly sensitive and specific. This is the first study to validate this tool in this population that the authors are aware of.

Impact of early rapid weight gain on odds for overweight at one year differs between breastfed and formula-fed infants.

BACKGROUND: Early rapid weight gain (RWG) increases, whereas longer durations of breastfeeding decreases, odds for later obesity. OBJECTIVES: To determine the independent and interactive effects of early weight gain and diet on infant weight status trajectories and odds for overweight at 1 year. METHODS: We conducted secondary analysis on data from two longitudinal trials with repeated anthropometric measures. One trial consisted of predominantly or exclusively breastfed (BF, n = 97) infants, whereas the other consisted of exclusively formula-fed (FF, n = 113) infants. Weight-for-length z-score (WLZ) change from 0.5 to 4.5 months was used to categorize early weight gain as slow (<-0.67; SWG), normal (-0.67 to 0.67; NWG) or rapid (>0.67; RWG). Linear-mixed effects models were fit to examine the independent effects and interaction of early diet (BF, FF) and weight gain (SWG, NWG, RWG) groups on WLZ trajectories; logistic regression was used to assess odds for overweight at 1 year. RESULTS: While similar percentages (41%) of BF and FF infants experienced RWG, we found a significant diet × early weight gain group interaction (P < .001) on weight status. At 1 year, the WLZ of FF infants with RWG (1.57 ± 0.99) was twice that of BF infants with RWG (0.83 ± 0.92). Using BF infants with NWG as the reference group, FF infants with RWG had increased odds [OR: 25.3 (95% CI: 3.21, 199.7)] for overweight at 1 year, whereas BF infants with RWG did not. CONCLUSIONS: Early diet interacts with early weight gain and influences weight status trajectories and overweight risk at 1 year.

Overcoming a Pandemic:: How Engineering and Modeling Techniques Are Used to Inform a Health System From Preparation to Recovery from the COVID-19 Pandemic.

COVID-19, a novel disease that spreads across the globe, has posed multiple challenges to the healthcare systems around the world. Due to the lack of understanding of the spread and management of this disease, one major challenge is for healthcare systems to anticipate the volumes and needs of patients infected with the disease. In order to provide insights into optimal allocation of resources from preparing ChristianaCare for the pandemic to the recovery of the healthcare system, industrial engineering and predictive modeling approaches are used. This paper discusses five interrelated studies that utilize various techniques to inform multiple aspects of the healthcare system in order to be better prepared for the pandemic.

Does Preparedness Matter? The Influence of Household Preparedness on Disaster Outcomes During Superstorm Sandy.

OBJECTIVES: This study empirically examines preparedness with a kit, medication, and a disaster plan on disaster outcomes including perceived recovery, property damage, and use of medical or mental health services. METHODS: Using a cross-sectional, retrospective study design, 1114 households in New York City were interviewed 21-34 months following Super Storm Sandy. Bivariate associations were examined and logistic regression models fit to predict the odds of disaster outcomes given the level of preparedness. RESULTS: Respondents with an evacuation plan were more likely to report not being recovered (odds ratio [OR] = 2.4; 95% confidence interval [CI]: 1.5-3.8), property damage (OR = 1.4; 95% CI: 1.1-1.9), and use of medical services (OR = 2.3; 95% CI: 1.1-4.5). Respondents reporting a supply of prescription medication were more likely to report using mental health (OR = 3.5; 95% CI: 1.2-9.8) and medical services (OR = 2.3; 95% CI: 1.1-4.8). CONCLUSIONS: Having a kit, plan, and medication did not reduce risk of adverse outcomes in Superstorm Sandy in this sample. Disaster managers should consider the lack of evidence for preparedness when making public education and resource allocation decisions. Additional research is needed to identify preparedness measures that lead to better outcomes for more efficient and effective response and recovery.

Visual outcomes after traumatic retrobulbar hemorrhage are not related to time or intraocular pressure.

BACKGROUND: The paucity of literature regarding the role of time and intraocular pressure (IOP) when treating ocular compartment syndrome (OCS) has resulted in limited guidance for emergency physicians (EP). OBJECTIVES: Our goals were to investigate the ideal time frame for lateral canthotomy, to understand the relationship between IOP and visual outcome, and to determine the impact of EP performance on visual acuity (VA). METHODS: The study population included patients presenting over an 18-year period with traumatic retrobulbar hemorrhage (RBH) treated with lateral canthotomy. Efficacy was evaluated using visual outcome and IOP. Patients were grouped by time from injury and arrival to canthotomy. Procedures completed in the emergency department (ED) and by EPs were evaluated regarding visual outcome. RESULTS: Sixty cases of RBH treated with lateral canthotomy were identified. Over two-thirds (43/60, 71.7%) were discharged with baseline vision. Lateral canthotomy lowered IOP from a median of 50.0 mmHg (IQR: 40.5, 61) preprocedure to 23.0 mmHg (IQR: 18, 27) post-procedure (p-value = 0.000001). No correlation was found between time, IOP, location, specialty of clinician, and visual outcome. CONCLUSION: Lateral canthotomy is an effective at lowering IOP. Our data suggest that using time and IOP to predict procedural outcome is flawed. If OCS is suspected, lateral canthotomy should be considered and can be effectively performed by EPs. Neither the time of injury to ED presentation nor degree of IOP elevation should be factored into the decision of when to perform the procedure.

A Comparison of Efficacy of Treatment and Time to Administration of Naloxone by BLS and ALS Providers.

INTRODUCTION: The administration of naloxone therapy is restricted by scope of practice to Advanced Life Support (ALS) in many Emergency Medical Services (EMS) systems throughout the United States. In Delaware's two-tiered EMS system, Basic Life Support (BLS) often arrives on-scene prior to ALS, but BLS providers were not previously authorized to administer naloxone. Through a BLS naloxone pilot study, the researchers sought to evaluate BLS naloxone administration and timing compared to ALS. HYPOTHESIS: After undergoing specialized training, BLS providers would be able to appropriately administer naloxone to opioid overdose patients in a more timely manner than ALS providers. METHODS: This was a retrospective, observational study using data collected from February 2014 through May 2015 throughout a state BLS naloxone pilot program. A total of 14 out of 72 state BLS agencies participated in the study. Pilot BLS agencies attended a training session on the indications and administration of naloxone, and then were authorized to carry and administer naloxone. Researchers then compared vital signs and the time of BLS arrival to administration of naloxone by BLS and ALS. Data were analyzed using paired and independent sample t-tests, as well as chi-square, as appropriate. RESULTS: A total of 131 incidents of naloxone administration were reviewed. Of those, 62 patients received naloxone by BLS (pilot group) and 69 patients received naloxone by ALS (control group). After naloxone administration, BLS patients showed improvements in heart rate (HR; P < .01), respiratory rate (RR; P < .01), and pulse oximetry (spO2; P < .01); ALS patients also showed improvement in RR (P < .01), and in spO2 (P = .005). There was no significant improvement in HR for ALS providers (P = .189).There was a significant difference in arrival time of BLS to the time of naloxone administration between the two groups, with shorter times in the BLS group compared to the ALS group (1.9 minutes versus 9.8 minutes; P < .01); BLS administration was 7.8 minutes faster when compared to ALS administration (95% CI, 6.2-9.3 minutes). CONCLUSIONS: Patients improved similarly and received naloxone therapy sooner when treated by BLS agencies carrying naloxone than those who awaited ALS arrival. All EMS systems should consider allowing BLS to carry and administer naloxone for an effective and potentially faster naloxone administration when treating respiratory compromise related to opiate overdose.

An Evaluation of the Incidence of Nephrotoxicity After a Loading Dose of Vancomycin in Patients With Severe Renal Impairment.

BACKGROUND: Loading doses of vancomycin assist in the rapid achievement of target trough concentrations. Patients with renal dysfunction have been excluded from studies evaluating loading doses. OBJECTIVE: The purpose of this study was to investigate nephrotoxicity related to initial vancomycin dose in patients with severe renal dysfunction. METHODS: A retrospective cohort study was approved by the Institutional Review Board of a large, academic health system. Adults were included if they received intravenous vancomycin in the emergency department and presented with creatinine clearance < 30 mL/min. Chronic dialysis patients were excluded. The primary outcome was incidence of nephrotoxicity after an initial high (>20 mg/kg) vs. low (≤20 mg/kg) dose of vancomycin. Secondary outcomes included dialysis, vancomycin concentrations, length of stay, in-hospital mortality, and a composite outcome of nephrotoxicity or dialysis. RESULTS: Of the 927 patients included in the analysis, nephrotoxicity occurred in 7.2% and 13.8% of patients in the high- and low-dose groups, respectively (p < 0.01). Patients in the high-dose group had a reduced risk of nephrotoxicity (relative risk 0.53; 95% confidence interval 0.35-0.78). The reduction in risk remained after fitting a generalized linear model adjusting for weight, age, sex, initial serum creatinine, diabetes, and chronic kidney disease (relative risk 0.61; 95% confidence interval 0.39-0.93). Limitations of this study include its retrospective design and single-center population. CONCLUSION: These data suggest that vancomycin loading doses do not increase nephrotoxicity compared with lower doses in patients with severe renal dysfunction. These patients should be included in future studies relating to vancomycin loading doses.

Mapping the Burden of Chronic Diseases in Delaware for Public Health Decision Making.

Public health decision-makers need to consider geographic differences in rates of chronic disease risk factors and outcomes in order to focus intervention efforts on populations exhibiting the greatest burden of disease. Increasingly, public health agencies are using geographic information systems (GIS) to analyze area-based variations and identify geographic priority areas for health promoting interventions. The articles in this issue are descriptive studies presenting the geographic distribution of select chronic disease risk factors and outcomes among Delaware communities. These studies emerged from a collaboration between the Christiana Care Value Institute and the Jefferson College of Population Health. These studies show that the burden of chronic diseases is not distributed evenly among communities in Delaware. The results of these studies add to the evidence base about public health in Delaware, and should inform public health practitioners working to improve the health of Delaware communities.

Acculturation, diet, and psychological health among Asian students.

Objective: The study examined the association between acculturation level, dietary nutrient intake, and psychological health of Asian students at the University of Delaware. Participants: A total of 172 students completed the study. Methods: Data were collected, using questionnaires, through Qualtrics®. Linear regression models were used to examine the association between normally distributed diet and acculturation and demographic data. Results: As length of residence in the United States increased, acculturation level and maintenance of original culture both increased. There was no significant association between acculturation and nutrient intake. Chinese students were more likely than other Asian students to have nonspecific psychological distress. Conclusion: There was no significant association between diet and acculturation level. A larger sample population with longer US residence is needed to further investigate this association. In an effort to improve psychological health of Asian students, challenges specific to this population, such as the language barrier, should be addressed.