Mapping Cumulative Risk in Delaware: Approach and Implications for Health Equity.

BACKGROUND: Addressing health equity requires attention to upstream determinants of health, including environmental and social factors that act in tandem to increase communities' exposure to and vulnerability to toxicants. Cumulative risk assessment, which evaluates combined risks from environmental and social factors, is a useful approach for estimating potential drivers of health disparities. We developed a cumulative risk score of multiple indices of environmental and social conditions and assessed block group-level differences in New Castle County, Delaware. METHODS: This cross-sectional study used choropleth maps to visualize the distribution of environmental, social, and cumulative risks and Moran's I statistics to assess spatial clustering of cumulative risk across the county and among individual block groups. RESULTS: Findings indicate that environmental risk rarely occurs without social risk and that environmental and social risks co-occur in distinct areas, resulting in large-scale clustering of cumulative risk. Areas of higher cumulative risk had more Black residents and people of lower socioeconomic status. CONCLUSIONS: Replicable measures of cumulative risk can show how environmental and social risks are inequitably distributed by race and socioeconomic status, as seen here in New Castle County. Such measures can support upstream approaches to reduce health disparities resulting from histories of environmental racism.

Factors Associated with Antihypertensive Therapy Prescription in Youth Delaware Medicaid Recipients with Primary Hypertension Diagnosis.

BACKGROUND: Higher neighborhood deprivation is associated with hypertension diagnosis in youth. In this study, we assess if there is an association between neighborhood deprivation and antihypertensive therapy prescription among insured youth with a primary hypertension diagnosis. METHODS: Using a retrospective cross-sectional design, we assessed the proportion of youth with a diagnosis of primary hypertension prescribed antihypertensive therapy. We evaluated the proportion of youth prescribed antihypertensive therapy and compared prescribing patterns by area deprivation index (ADI), age, sex, obesity diagnosis, race, ethnicity, and duration of Medicaid coverage. RESULTS: Of the 65,452 non-pregnant Delaware Medicaid recipients, 8-18 years of age, 1,145 (1.7%) had an International classification of diseases (ICD)-9/ICD-10 diagnosis of primary hypertension; 165 of the 1,145 (14%) were prescribed antihypertensive therapy. Factors associated with a greater odds of prescription by multivariable logistic regression were age, obesity diagnosis, and duration of Medicaid full benefit coverage. Odds of antihypertensive therapy prescription did not vary by race, ethnicity, or ADI. CONCLUSIONS: Antihypertensive therapy prescription rates are poor despite national guideline recommendations. Among youth receiving Delaware Medicaid between 2014 and 2019, prescription proportions were highest among youth of older age, with an obesity diagnosis, and among youth with longer duration of Medicaid benefit coverage. Although high area deprivation has been shown to be associated with the diagnosis of hypertension, high vs. low area deprivation was not associated with greater antihypertensive therapy prescription among youth with primary hypertension. Our finding of a mismatch between hypertension diagnosis and antihypertensive therapy prescription highlights a potential disparity in antihypertensive therapy prescription in youth.

Association of Area Deprivation With Primary Hypertension Diagnosis Among Youth Medicaid Recipients in Delaware.

Importance: The association between degree of neighborhood deprivation and primary hypertension diagnosis in youth remains understudied. Objective: To assess the association between neighborhood measures of deprivation and primary hypertension diagnosis in youth. Design, Setting, and Participants: This cross-sectional study included 65 452 Delaware Medicaid-insured youths aged 8 to 18 years between January 1, 2014, and December 31, 2019. Residence was geocoded by national area deprivation index (ADI). Exposures: Higher area deprivation. Main Outcomes and Measures: The main outcome was primary hypertension diagnosis based on International Classification of Diseases, Ninth Revision and Tenth Revision codes. Data were analyzed between September 1, 2021, and December 31, 2022. Results: A total of 65 452 youths were included in the analysis, including 64 307 (98.3%) without a hypertension diagnosis (30 491 [47%] female and 33 813 [53%] male; mean [SD] age, 12.5 (3.1) years; 12 500 [19%] Hispanic, 25 473 [40%] non-Hispanic Black, 24 565 [38%] non-Hispanic White, and 1769 [3%] other race or ethnicity; 13 029 [20%] with obesity; and 31 548 [49%] with an ADI ≥50) and 1145 (1.7%) with a diagnosis of primary hypertension (mean [SD] age, 13.3 [2.8] years; 464 [41%] female and 681 [59%] male; 271 [24%] Hispanic, 460 [40%] non-Hispanic Black, 396 [35%] non-Hispanic White, and 18 [2%] of other race or ethnicity; 705 [62%] with obesity; and 614 [54%] with an ADI ≥50). The mean (SD) duration of full Medicaid benefit coverage was 61 (16) months for those with a diagnosis of primary hypertension and 46.0 (24.3) months for those without. By multivariable logistic regression, residence within communities with ADI greater than or equal to 50 was associated with 60% greater odds of a hypertension diagnosis (odds ratio [OR], 1.61; 95% CI 1.04-2.51). Older age (OR per year, 1.16; 95%, CI, 1.14-1.18), an obesity diagnosis (OR, 5.16; 95% CI, 4.54-5.85), and longer duration of full Medicaid benefit coverage (OR, 1.03; 95% CI, 1.03-1.04) were associated with greater odds of primary hypertension diagnosis, whereas female sex was associated with lower odds (OR, 0.68; 95%, 0.61-0.77). Model fit including a Medicaid-by-ADI interaction term was significant for the interaction and revealed slightly greater odds of hypertension diagnosis for youths with ADI less than 50 (OR, 1.03; 95% CI, 1.03-1.04) vs ADI ≥50 (OR, 1.02; 95% CI, 1.02-1.03). Race and ethnicity were not associated with primary hypertension diagnosis. Conclusions and Relevance: In this cross-sectional study, higher childhood neighborhood ADI, obesity, age, sex, and duration of Medicaid benefit coverage were associated with a primary hypertension diagnosis in youth. Screening algorithms and national guidelines may consider the importance of ADI when assessing for the presence and prevalence of primary hypertension in youth.

Pandemic-Era WIC Participation in Wilmington, Delaware: Participants' Experiences and Challenges.

Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) participants faced unprecedented challenges during the coronavirus disease 2019 (COVID-19) pandemic including financial concerns, a national infant formula shortage, and rising food costs. To mitigate these challenges, the United States Department of Agriculture implemented WIC program waivers and flexibilities aiming to simplify program operations (e.g., remote appointments and food package substitutions). However, little is known about WIC participants' perceptions of these changes and their impact on in-store benefit redemption. As such, this study aimed to characterize how pandemic-related events impacted Delaware WIC participants' shopping experiences and program perceptions. The authors conducted semi-structured interviews with 51 WIC participants in Wilmington, Delaware. Survey measures included demographic questions, the Hunger Vital Sign, and open-ended questions regarding WIC program participation experiences during the pandemic. Data were analyzed using a hybrid inductive and deductive coding approach. The results demonstrate that WIC participants benefitted from the pandemic program's flexibilities. However, they continued to experience burdensome shopping trips as well as concerns about their ability to feed their families due to infant formula shortages and inflation. These findings indicate the importance of extending existing WIC flexibilities and providing continued support for both participants and WIC-authorized retailors.

A Population Health Assessment in a Community Cancer Center Catchment Area: Triple-Negative Breast Cancer, Alcohol Use, and Obesity in New Castle County, Delaware.

BACKGROUND: The NCI requires designated cancer centers to conduct catchment area assessments to guide cancer control and prevention efforts designed to reduce the local cancer burden. We extended and adapted this approach to a community cancer center catchment area with elevated rates of triple-negative breast cancer (TNBC). METHODS: Cancer registry data for 462 TNBC and 2,987 "Not-TNBC" cases diagnosed between 2012 and 2020 at the Helen F. Graham Cancer Center & Research Institute (HFGCCRI), located in New Castle County, Delaware, were geocoded to detect areas of elevated risk (hot spots) and decreased risk (cold spots). Next, electronic health record (EHR) data on obesity and alcohol use disorder (AUD) and catchment area measures of fast-food and alcohol retailers were used to assess for spatial relationships between TNBC hot spots and potentially modifiable risk factors. RESULTS: Two hot and two cold spots were identified for TNBC within the catchment area. The hot spots accounted for 11% of the catchment area but nearly a third of all TNBC cases. Higher rates of unhealthy alcohol use and obesity were observed within the hot spots. CONCLUSIONS: The use of spatial methods to analyze cancer registry and other secondary data sources can inform cancer control and prevention efforts within community cancer center catchment areas, where limited resources can preclude the collection of new primary data. IMPACT: Targeting community outreach and engagement activities to TNBC hot spots offers the potential to reduce the population-level burden of cancer efficiently and equitably.

Assessment of a Multifaceted Approach, Including Frequent PCR Testing, to Mitigation of COVID-19 Transmission at a Residential Historically Black University.

Importance: COVID-19 posed an unprecedented threat to residential colleges in the fall of 2020. While there were mathematical models of COVID-19 transmission, there were no established or tested protocols of COVID-19 testing or mitigation for school administrators to follow. Objective: To investigate the association of a multifaceted COVID-19 mitigation strategy using social, behavioral, and educational interventions and a program of frequent testing with prevalence of disease spread. Design, Setting, and Participants: This cohort study was conducted as a retrospective review of COVID-19 positivity from August 16, 2020, to April 30, 2021, at Delaware State University, a publicly funded historically Black university. Participants included all students, faculty, and staff members with a campus presence. Positivity rates after use of mitigation strategies and testing on campus were compared with those of the surrounding community. Data were analyzed from July through September 2021. Exposures: Mitigation strategies included education and outreach about social distancing, masking, and handwashing, and a COVID-19 testing plan consisted of twice-weekly polymerase chain reaction (PCR) screening using anterior nasal samples (fall and early spring semester) and then saliva-based samples (middle to late spring semester). Main Outcomes and Measures: Cumulative tests, infections, daily quarantine, and isolation residence hall occupancy were measured, and comparisons were made with statewide COVID-19 positivity rates. Results: The campus cohort included 2320 individuals (1575 resident students, 415 nonresident students, and 330 faculty or staff members). There were 1488 (64.1%) women and 832 (35.9%) men; mean (SD) age was 27.5 (12.9) years. During the fall semester, 36 500 COVID-19 PCR tests were performed. Weekly positivity rates ranged from 0 of 372 tests to 16 of 869 tests (1.8%) (mean [SD] positivity rate, 0.5% [0.5%]; 168 positive results and 36 312 negative results). During the same period, statewide positivity ranged from 589 of 25 120 tests (2.3%) to 5405 of 54 596 tests (9.9%) (mean [SD] positivity rate, 4.8% [2.6%]). In the spring semester, 39 045 PCR tests were performed. Weekly positivity rates ranged from 4 of 2028 tests (0.2%) to 36 of 900 tests (4.0%) (mean [SD] positivity rate, 0.8% [0.9%]; 267 positive results and 38 767 negative results). During the same period, statewide positivity ranged from 1336 of 37 254 tests (3.6%) to 3630 of 42 458 tests (8.5%) (mean [SD] positivity rate, 5.1% [1.3%]). Compared with statewide rates, campus positivity rates were mean (SD) 4.4 (2.6) percentage points lower during the fall semester (P < .001) and mean (SD) 5.6 (1.6) percentage points lower during the spring semester (P < .001). Total daily quarantine and isolation residence hall occupancy ranged from 0 to 43 students in the fall and 1 to 47 students during the spring. Conclusions and Relevance: This study found that the combination of campuswide mitigation policies and twice-weekly COVID-19 PCR screening was associated with a significant decrease in COVID-19 positivity at a residential historically Black university campus compared with the surrounding community. Given the socioeconomic demographics of many students at historically Black colleges and universities, keeping these resident campuses open is critical not only to ensure access to educational resources, but also to provide housing and food security.

Well-Being in the Nation: A Living Library of Measures to Drive Multi-Sector Population Health Improvement and Address Social Determinants.

Policy Points Well-being In the Nation (WIN) offers the first parsimonious set of vetted common measures to improve population health and social determinants across sectors at local, state, and national levels and is driven by what communities need to improve health, well-being, and equity. The WIN measures were codesigned with more than 100 communities, federal agencies, and national organizations across sectors, in alignment with the National Committee on Vital and Health Statistics, the Foundations for Evidence-Based Policymaking Act, and Healthy People 2030. WIN offers a process for a collaborative learning measurement system to drive a learning health and well-being system across sectors at the community, state, and national levels. The WIN development process identified critical gaps and opportunities in equitable community-level data infrastructure, interoperability, and protections that could be used to inform the Federal Data Strategy.

Lower Regional Pediatric In-hospital Mortality Albeit Racial/ethnic Disparities.

PURPOSE: Variability in pediatric morbidity and mortality tends to be influenced by several factors including though not limited to social determinants of health, namely health inequity as an exposure function of health disparities. We aimed to assess the cumulative incidence of pediatric mortality, racial/ethnic disparities, and the predisposing factors for the disparities. METHOD: The current study retrospectively examined the Nemours/Alfred I. duPont Hospital for Children medical records of 16,121 patients diagnosed with any pediatric condition during 2009 and 2010. RESULTS: In-hospital pediatric mortality cumulative incidence was relatively low (80 deaths, 0.49%) when compared with similar settings in the U.S. (national average range, 0.8e1.1%) during the same period. Compared with whites/Caucasians, mortality was higher among blacks/African Americans, prevalence odds ratio (POR), 1.06, 95% CI, 0.77e1.45, and higher for some other race, POR, 1.48, 95% CI, 1.06e2.10. After controlling for potential confounders (severity of illness, insurance status, and length of stay), racial differences in pediatric mortality did not persist between whites and some other race, adjusted POR, 1.08, 99% CI, 0.75e1.57. CONCLUSIONS: In-hospital pediatric mortality cumulative incidence was relatively low in our region, and racial disparities exist but did not persist after controlling for confounders. These findings are suggestive of the importance of social determinants of health namely quality care, adequate medical insurance, and early detection, diagnosis in pediatric morbidity and epigenomic alterations, as well as the need to go beyond the "close medical model" to improve pediatric morbidity and survival by addressing health inequity as a function of health disparities.

Using Medicaid Data to Characterize Persons With Intellectual and Developmental Disabilities in Five U.S. States.

This project sought to identify Medicaid members with intellectual and developmental disabilities (IDD) in five states (Delaware, Iowa, Massachusetts, New York, and South Carolina) to develop a cohort for subsequent analyses of medical conditions and service utilization. We estimated that over 300,000 Medicaid members in these states had IDD. All members with diagnostic codes for IDD were identified and the three most frequent diagnoses were unspecified intellectual disability, autism or pervasive developmental disorder, and cerebral palsy. The percentage of Medicaid members with IDD ranged from 2.3% in New York to 4.2% in South Carolina. Identifying and characterizing people with IDD is a first step that could guide public health promotion efforts for this population.

Reductions in High-End Imaging Utilization With Radiology Review and Consultation.

Following the uptake of value-based purchasing in concert with health care reform in the United States, providers, insurers, and patients are looking for ways to reduce excessive, dangerous, and/or inappropriate high-end imaging utilization (HEIU). Inappropriate HEIU is associated with patient safety risks due to unnecessary exposure to radiation, misappropriation of scarce equipment resources and staff, complications to clinical care, and needless, excessive costs for the patient, hospital, and payer. This paper presents a cost-effective radiology-initiated improvement program piloted in the Christiana Hospital Coordinated Care Network. The pilot demonstrated the effectiveness of regulating high-end imaging orders through radiologists' review of requests of the order as part of the consult process. Over the 2014-2015 fiscal year, 2,177 high-end imaging orders were reviewed by 26 radiologists for approval, rejection, or recommendation of an alternate examination. Of the orders, 86.7% (1887) were approved, 4.0% (87) were rejected, and 9.3% (203) received recommendation for an alternate examination. Based on improved patient safety, cost savings, and appropriate resource use, these findings suggest that radiologists' review can effectively reduce excessive HEIU. This method, with an appropriate algorithm to assist with handling a larger volume of orders, would be ideal to implement systemwide to manage HEIU cost efficiency, simultaneously providing radiologists with more control in their area of expertise and positively impacting quality, safety, and value-based purchasing goals.

Determining the magnitude of surveillance bias in the assessment of lower extremity deep venous thrombosis: A prospective observational study of two centers.

BACKGROUND: Venous thromboembolism (VTE) remains a significant cause of morbidity and mortality in trauma. Controversy exists regarding the use of lower extremity duplex ultrasound screening and surveillance (LEDUS). Advocates cite earlier diagnosis and treatment of deep venous thrombosis (DVT) to prevent clot propagation and pulmonary embolism (PE). Opponents argue that LEDUS identifies more DVT (surveillance bias) but does not reduce the incidence of PE. We sought to determine the magnitude of surveillance bias associated with LEDUS and test the hypothesis that LEDUS does not decrease the incidence of PE after injury. METHODS: We compared data from two Level 1 trauma centers: Scripps Mercy Hospital, which used serial LEDUS, and Christiana Care Health System, which used LEDUS only for symptomatic patients. Beginning in 2013, both centers prospectively collected data on demographics, injury severity, and VTE risk for patients admitted for more than 48 hours. Both centers used mechanical and pharmacologic prophylaxis based on VTE risk assessment. RESULTS: Scripps Mercy treated 772 patients and Christiana Care treated 454 patients with similar injury severity and VTE risk. The incidence of PE was 0.4% at both centers. The odds of a DVT diagnosis were 5.3 times higher (odds ratio, 5.3; 95% confidence interval, 2.5-12.9; p < 0.0001) for patients admitted to Scripps Mercy than for patients admitted to Christiana Care. Of the 80 patients who developed DVT, PE, or both, 99% received prophylaxis before the event. Among those who received pharmacologic prophylaxis, the VTE rates between the two centers were not statistically significantly different (Scripps Mercy, 11% vs. Christiana Care, 3%; p = 0.06). CONCLUSION: The odds of a diagnosis of DVT are increased significantly when a program of LEDUS is used in trauma patients. Neither pharmacologic prophylaxis nor mechanical prophylaxis is completely effective in preventing VTE in trauma patients. VTE should not be considered a "never event" in this cohort. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level III; therapeutic study, level III.

Increasing the efficiency of a targeted methicillin-resistant Staphylococcus aureus screening program.

An interdisciplinary team implemented a screening program targeting patients with a history of methicillin-resistant Staphylococcus aureus (MRSA), to reduce unnecessary contact isolation. After converting from a 2-step culture-based protocol to single polymerase chain reaction (PCR) testing, we increased the efficiency of the screening program from 77% to 100%. Despite the higher cost of PCR-based testing, this program remained cost-saving.

Pediatric Head Injury in the Delaware Trauma System: Toward Improved Calibration of Severity and Resource Utilization.

BACKGROUND: How the existence of trauma systems affects the care of less severely injured patients has received little attention. OBJECTIVE: The current study examines the longitudinal effect on the care of children with traumatic brain injuries (TBIs) of the incorporation of a pediatric trauma center into a regional trauma system. METHODS: The Delaware Trauma System provided registry data from 2000 to 2014. Inclusion criteria were age less than 18 years and ICD9 diagnostic coding for any head injury. Admissions were assessed as "substantial" or "non-substantial" based on study criteria. We hypothesized a step-wise increase in registrations of mild TBI and non-substantial admissions coinciding with the opening of Delaware's pediatric trauma center in late 2006. RESULTS: There were 5,272 registrations. Before the opening of the pediatric trauma center, 1,737 of 2,038 (85.2 percent) head injuries were mild; afterwards mild TBI accounted for 2,894 of 3,230 registrations (89.6 percent; odds ratio 1.49, 95 percent Cl 1.26 - 1.76; p < 0.0001). Before the opening, 850 of 2,038 (41.7 percent) encounters were categorized as non-substantial; afterwards 1,528 of 3,230 admissions (47.3 percent) were non-substantial (odds ratio 1.25; 95 percent C 1.12 - 1.40; p < 0.0001). Inter-hospital transports within the system exhibited similar trends. CONCLUSIONS: Registrations of mild TBI and non-substantial admissions trended upward steadily during the years of this study with a suggestive step-wise increase correlating with the opening of a pediatric trauma center. Guidelines are needed to facilitate management of patients with minor injuries at the lowest appropriate level of care.

Disparities in multiple risk factors for cardiovascular diseases - Delaware, 2011.

INTRODUCTION: The purpose of this study is to determine the prevalence of multiple risk factors for Cardiovascular Diseases (CVD) and to identify disparities in risk status among population subgroups in Delaware. As a secondary analysis the study will also analyze self-reported CVD prevalence overall and discuss differences in prevalence by age, sex, race/ethnicity, education, income, employment status, and county of residence. METHODS: Analysis was conducted using Delaware data for 4,777 respondents from the 2011 Behavioral Risk Factor Surveillance System (BRFSS). Survey participants having greater than or equal to two of the following risk factors: obesity, high blood pressure, high blood cholesterol, current smoking, and diabetes mellitus were considered as having multiple risk factors for CVD. RESULTS: In 2011, the prevalence of CVD in Delaware was 8.61 percent (95 percent Confidence Interval [CI, 7.55, 9.66]). Overall, 22.51 percent (95 percent CI, 20.62-24.40) of persons reported having no risk factors, 32.30 percent (95 percent CI, 30.31-34.28) reported one risk factor, and 45.20 percent (95 percent CI, 43.18-47.21) reported multiple risk factors. Prevalence of multiple risk factors was higher for the aged, less educated, and unemployed. Disparities by gender and race were not significant. Sussex County had a higher prevalence of CVD multiple risk factors, 53.18 percent (95 percent CI, 49.47-56.89) followed by Kent County, 49.75 percent (95 percent CI, 45.92-53.58). CONCLUSIONS: One of the priority goals of Healthy People 2020 is to improve cardiovascular health and quality of life through prevention, detection, and treatment of risk factors for heart attack and stroke and also prevention of repeat cardiovascular events. This study indicates that in 2011 a higher proportion of the Delaware population had multiple risk factors for heart disease and stroke, particularly certain population subgroups defined by socioeconomic status. Development of effective prevention programs targeting populations with greater risk factor prevalence should reduce CVD incidence, which will significantly contribute to the decline in both CVD prevalence and CVD mortality. Understanding the determinants for modifiable risk factors might facilitate their control for public health.

Placement and promotion strategies to increase sales of healthier products in supermarkets in low-income, ethnically diverse neighborhoods: a randomized controlled trial.

BACKGROUND: The greater presence of supermarkets in low-income, high-minority neighborhoods has the potential to positively affect diet quality among those at greatest risk of obesity. In-store marketing strategies that draw attention to healthier products may be effective, sustainable, and scalable for improving diet quality and health. Few controlled studies of in-store marketing strategies to promote sales of healthier items in low-income, high-minority neighborhoods have been conducted. OBJECTIVE: The objective of this study was to evaluate the effects of in-store marketing strategies to promote the purchase of specific healthier items in 5 product categories: milk, ready-to-eat cereal, frozen meals, in-aisle beverages, and checkout cooler beverages. DESIGN: The design was a cluster-randomized controlled trial conducted from 2011 to 2012. Eight urban supermarkets in low-income, high-minority neighborhoods were the unit of randomization, intervention, and analysis. Stores were matched on the percentage of sales from government food-assistance programs and store size and randomly assigned to an intervention or control group. The 4 intervention stores received a 6-mo, in-store marketing intervention that promoted the sales of healthier products through placement, signage, and product availability strategies. The 4 control stores received no intervention and were assessment-only controls. The main outcome measure was weekly sales of the targeted products, which was assessed on the basis of the stores' sales data. RESULTS: Intervention stores showed significantly greater sales of skim and 1% milk, water (in aisle and at checkout), and 2 of 3 types of frozen meals compared with control store sales during the same time period. No differences were found between the stores in sales of cereal, whole or 2% milk, beverages, or diet beverages. CONCLUSIONS: These data indicate that straightforward placement strategies can significantly enhance the sales of healthier items in several food and beverage categories. Such strategies show promise for significant public health effects in communities with the greatest risk of obesity.

The impact of a statewide training to increase child care providers' knowledge of nutrition and physical activity rules in Delaware.

BACKGROUND: Childhood obesity has been recognized as a national problem of epidemic proportions. Child care represents an ideal venue in which to address this problem, as many young children spend a significant amount of time and consume the majority of their meals in this setting. Recognizing this opportunity, Delaware recently enacted reforms to statewide licensing regulations designed to improve the quality of the nutrition-, physical activity-, and screen viewing-related environments in child care settings. METHODS: To facilitate the translation of these regulations into practices, a series of broad-scale trainings was held throughout the state. Attendance was required for all Child & Adult Care Food Program (CACFP)-participating facilities, although child care providers from non-CACFP facilities also attended. Pre- and posttraining surveys were used to assess changes in providers' knowledge of the regulations and satisfaction with the training. RESULTS: In total 1094 presurveys and 1076 postsurveys were received. Participants were highly satisfied with the training format and content, including the instructors, materials, and schedule. Data analysis demonstrates improved knowledge of all 26 regulation components from presurvey to postsurvey. Family child care providers, providers with more years of experience, CACFP-participating facilities, and facilities with food service personnel scored significantly higher than their center staff, less experienced and non-CACFP counterparts, as well as those without food service personnel. CONCLUSIONS: Broad-scale, in-person training can effectively increase child care providers' knowledge of the regulations and is well received by this audience. Other states and jurisdictions seeking to improve nutrition, physical activity, and screen-viewing practices in child care settings should consider this model of quality improvement.

Collaboration with the community cancer center: benefit for all.

Developing successful programs in a community cancer center involves collaborative efforts between employed and private practice physicians, hospital and cancer center administrations, support personnel, and significant resources, coupled with a vision that will lead to improved patient care and outcomes. Collaboration through a strong state cancer control program is another important component for a successful community cancer center. Delaware has one of the best state cancer control programs in the United States. In 2001, the Delaware Cancer Consortium was formed, which, in 2002, launched its first statewide program to screen all Delawareans older than 50 years with colonoscopy.

Sexual minority youth victimization and social support: the intersection of sexuality, gender, race, and victimization.

In comparison to heterosexual youth, sexual minority youth are more likely to experience victimization. Multiple studies have connected anti-gay prejudice and anti-gay victimization to negative outcomes. Research shows that social support may protect sexual minorities from the harmful effects of anti-gay victimization. However, rates of victimization and the negative outcomes linked to sexual identity within the sexual minority community have been relatively unexplored. Using data from three years of statewide data from heterosexual and sexual minority adolescents in grades 9-12, this study examines victimization, substance use, suicidality, and access to social support by sexuality. Results indicate that sexual minority youth are at increased risk for victimization, substance use, suicidality, and social isolation compared to their heterosexual counterparts. Results also indicate that there is very little bivariate difference within the sexual minority community. Multivariate results indicate differences among sexual minorities' experiences with victimization and substance use.