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Lisa de Saxe Zerden, MSW, PhD Kelsey A. White, MSW/MPH Candidate Leadership in Public Health Social Work Education Summer 2015 Health & Social Justice: Understanding Social Determinants of Health to Achieve Health Equity

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Lisa de Saxe Zerden, MSW, PhDKelsey A. White, MSW/MPH CandidateLeadership in Public Health Social Work EducationSummer 2015

Health & Social Justice: Understanding Social Determinants of Health to Achieve Health Equity

AGENDA

I. Objectives

II. A Suggested Framework

III. Health Disparities

IV. Health Equity

V. Social Determinants of Health

VI. Implications for Policy and Practice

VII. Additional Resources

Activities:

Mapping Inequity

Equality versus Equity

Why Race and Place Matter

Disparities in Context

Eliminating Health Disparities

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MODULE OBJECTIVES

By the end of this module, participants will be able to:

• Define key terms and their meanings related to health disparities, health equity and social determinants of health.

• Understand why public health social work practitioners need to address health disparities in their work.

• Apply key concepts to their own practice contexts based on skills introduced in reflection activities.

• Utilize key resources and readings to enhance their knowledge on this content.

LPHSWE at UNCLeadership in Public Health Social Work Education

A SUGGESTED FRAMEWORK

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HEALTH AS A HUMAN RIGHT

• Ground our thinking in the human right to health (a value judgment) and treat each and every health disparity as unfair and unjust until we can prove otherwise.

• According to the National Economic and Social Rights Initiative, “The human right to health means that everyone has the right to the highest attainable standard of physical and mental health, which includes access to all medical services, sanitation, adequate food, decent housing, healthy working conditions, and a clean environment.”

• The United Nations and the World Health Organization define the human right to health (and health care) as having four elements:

AvailabilityAccessibility Acceptability

Quality

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based on race, class, gender, and other social classifications underlies

the inequitable distribution of social,

economic, and political resources and opportunities.

SOCIAL JUSTICE AND HEALTH• Social justice refers to the equitable distribution of social, economic and

political resources, opportunities, and responsibilities and their consequences.

A Social Justice Framework for Health

of resources and opportunities manifests

through inequitable access and exposure to social determinants of

health.

result through direct and indirect mechanisms.

Marginalization Unequal Distribution Health Inequities

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HEALTH DISPARITIES

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DEFINING HEALTH DISPARITIES

• Health disparities are “differences in length and quality of life and rates and severity of disease and disability because of social position, race, ethnicity, gender, sexual orientation, education, or other factors.” (Health Services and Resources Administration)

• “Healthy disparities adversely affect groups of people who have systematically experienced greater social or economic obstacles to health based on their racial or ethnic group, religion, socioeconomic status, gender, age, or mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion.” (Healthy People 2020)

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Source: http://info.umkc.edu/research/faith-in-research

LPHSWE at UNCLeadership in Public Health Social Work Education

DISPARITIES BY RACE AND ETHNICITY

• Non-Hispanic Black women are more than twice as likely as non-Hispanic White women to lose an infant within the first year of life: 12.40 deaths per 1,000 live births compared to 5.33 deaths per 1,000 live births (Mathews & MacDorman, 2013).

• The age-adjusted rate of obesity among Hispanics is 42.5%, compared to a rate of 32.6% among non-Hispanic Whites and just 10.8% among non-Hispanic Asians (Ogden, Carroll, Kit, & Flegal, 2014).

• American Indian and Alaska Native adults are 2.3 times more likely to have diagnosed diabetes compared with non-Hispanic Whites (CDC, 2011), while American Indian and Alaska Native youth are 9 times more likely to have diagnosed type 2 diabetes compared with non-Hispanic Whites (SEARCH, 2006).

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DISPARITIES BY SEX

• In the United States, women report worse health status and experience more hospitalization episodes, yet live about five years longer than men (Case & Paxson, 2005; Gorman & Read, 2006).

• One in 12 women, compared to 1 in 20 men, will develop some kind of autoimmune disease (Crowson et al., 2011).

• Among both African Americans and Whites, men are twice as likely as women to die from accidents, suicide, cirrhosis of the liver, and homicide (Williams, 2003).

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DISPARITIES IN MATERNAL AND CHILD HEALTH• During 2006-2010, the rate of pregnancy-related mortality among African

American women was 38.9 deaths per 100,000 live births, as compared to 12.0 deaths per 100,000 for White women and 11.7 deaths per 100,000 for Hispanic women (Creanga et al., 2015).

• African American women are nearly twice as likely as White women to have low birthweight babies: 13.08% vs 6.98% according to 2013 data (Martin et al., 2015).

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DISPARITIES AFFECTING LGBT POPULATIONS• Lesbian, gay, bisexual, and transgender youth are 2 to 3 times more likely

to attempt suicide than are heterosexual youth (Garofalo, 1999).

• Women in same-sex relationships are less likely to receive preventive services for cancer, such as Pap smears and mammograms, than women in different-sex relationships (Buchmueller & Carpenter, 2010).

• LGBT populations use tobacco at significantly higher rates than the general population (Lee et al., 2007).

• Transgender individuals have a high prevalence of HIV/STDs and mental health issues than heterosexual individuals or lesbian, gay, and bisexual individuals (Herbst et al., 2008; Diaz et al., 2001).

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DISPARITIES BY GEOGRAPHYA National Rural Health Snapshot Rural Urban

Percentage of USA Population** nearly 25% 75% +

Percentage of USA Physicians** 10% 90%

Num. of Specialists per 100,000 population** 40.1 134.1

Population aged 65 and older 18% 15%

Population below the poverty level 14% 11%

Average per capita income $19K $26K

Population who are non-Hispanic Whites 83% 69%

Adults who describe health status as fair/poor 28% 21%

Adolescents (Aged 12-17) who smoke 19% 11%

Male death rate per 100,000 (Ages 1-24) 80 60

Female death rate per 100,000 (Ages 1-24) 40 30

Population covered by private insurance 64% 69%

Population who are Medicare beneficiaries 23% 20%

Medicare beneficiaries without drug coverage 45% 31%

Medicare spends per capita compared to USA average 85% 106%

Medicare hospital payment-to-cost ratio 90% 100%

Percentage of poor covered by Medicaid 45% 49%

Statistics used with permission from "Eye on Health" by the Rural Wisconsin Health Cooperative, from an article entitled "Rural Health Can Lead the Way," by former NRHA President, Tim Size; Executive Director of the Rural Wisconsin Health Cooperative

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Source: http://www.ruralhealthweb.org/go/left/about-rural-health/what-s-different-about-rural-health-care

ACTIVITY – Mapping Inequity

• Across America, babies born just a few miles apart have dramatic differences in life expectancy.

• Please use the following maps provided by the Robert Wood Johnson Foundation to identify and discuss risk and protective factors that contribute to these differences in life expectancy.

– What are unique contextual factors about each location?

– What, if any, similarities exist between these locations?

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WHY STUDY HEALTH DISPARITIES?

• Social justice mandate by professional codes of ethics– National Association of Social Workers

– Public Health Leadership Society

• Healthy People 2010, 2020

• Consensus that U.S. healthcare system is a mess

• Socioeconomic status (SES) = #1 determinant of health

• Health disparities, illness, and ideology

• Discrimination can be covert and/or overt:– According to Jones (2000), three levels of racism include

institutionalized racism, personally mediated or interpersonalracism, and internalized racism.

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CENTRALITY OF SOCIAL JUSTICE

“[At the heart of the concept of health disparities is…social justice]—that is,

justice with respect to the treatment of more advantaged vs. less advantaged

socioeconomic groups when it comes to health and health care”

(Braveman, 2014)

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HEALTHY PEOPLE

• Healthy People is a national health promotion and disease prevention initiative started in 1979.

• During the past two decades, one of Healthy People’s overarching goals has been to address disparities:– In Healthy People 2000, it was to reduce health disparities

among Americans.

– In Healthy People 2010, it was to eliminate, not just reduce, health disparities.

– In Healthy People 2020, that goal was expanded even further: to achieve health equity, eliminate disparities, and improve the health of all groups.

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Target Year 1990 2000 2010 2020

OverarchingGoals

Decrease mortality: infants-adults

Increase independence among older adults

Increase span of healthy life

Reduce health disparities

Achieve access to preventive services for all

Increase quality and years of healthy life

Eliminate health disparities

Attain high quality, longer lives free of preventable disease…

Achieve health equity, eliminate disparities…

Create social and physical environments that promote good health…

Promote quality of life, healthy development, healthy behaviors across life stages…

Topic Areas 15 22 28 42*

# Objectives 226 312 467 > 580

EVOLUTION OF HEALTHY PEOPLE

*39 Topic areas with objectives Source: Tebo, 2011

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LPHSWE at UNCLeadership in Public Health Social Work Education

Source: Tebo, 2011

HEALTH—IS IT JUST FOR THE 1%?

• The wider the income gap, the higher a country’s mortality and morbidity rates (Wilkinson, 2006).

• The U.S. is the wealthiest nation in the world and spends more per capita on health care than any other country, yet it has poorer health outcomes than 16 other developed countries (Woolf & Aron, 2013).

• Wealth begets wealth, and this can lead to health begets health: – Link and Phelan’s (1995) Fundamental Causes of Health Inequalities

theory highlights how SES embodies an array of resources, (i.e., money, knowledge, prestige, power, social capital) that protect health no matter what mechanisms are relevant at any given time.

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HEALTH EQUITY

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Health inequity refers to the presence of such differences, disparities in health (or health care) that are systemic and avoidable and, therefore, considered unfair or unjust.

HEALTH EQUITY—WHAT IS IT?

Health equity refers to the absence of systematic disparities in health (or in the major social determinants of health) between groups with different social advantage/disadvantage (i.e., wealth, power, prestige).

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GOALS OF HEALTH EQUITY

Healthy People 2020 identifies two major goals of health equity, and ties in the theme of social justice:

1. To achieve the highest level of health for all people.

2. To address avoidable inequalities by equalizing the conditions for health for all groups, especially for those who have experienced socioeconomic disadvantage or historical injustices.

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Source: https://uofa.ualberta.ca/nursing/research/areas-of-excellence/health-equity

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LPHSWE at UNCLeadership in Public Health Social Work Education

Source: Beatty & Foster, 2015

ACTIVITY—Equality versus Equity

Is equality the same as equity?

Consider this image. Why and how these are two different issues?

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LPHSWE at UNCLeadership in Public Health Social Work Education

Source: http://www.maine.gov/dhhs/mecdc/health-equity/

SOCIAL DETERMINANTS OF HEALTH

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SOCIAL DETERMINANTS OF HEALTH

According to Raphael (2009), social determinants of health

• Are the economic and social conditions that shape the health of individuals, communities, and jurisdictions as a whole.

• Are the primary determinants of whether individuals stay healthy or become ill (a narrow definition of health).

• Determine the extent to which a person possesses the physical, social, and personal resources to identify and achieve personal aspirations, satisfy needs, and cope with the environment (a broader definition of health).

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ACROSS AMERICA, DIFFERENCES IN HOW LONG AND HOW WELL WE LIVE

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Source: https://www.apha.org/topics-and-issues/healthiest-nation/disparities-in-the-us

DISPARITIES IN LIFE EXPECTANCYThis chart shows the difference between the highest and lowest life expectancies (based on county-level data*) found in each state.

*No data included for Alaska or the District of Columbia

(Murray, et al., 2006)

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SOCIAL DETERMINANTS OF HEALTH• Social determinants of health include, but are not limited to:

• Social epidemiology “is distinguished by its insistence on explicitly investigating social determinants of […] health, disease, and wellbeing, rather than treating such determinants as mere background to biomedical phenomena” (Krieger, 2001).

Socioeconomic status Discrimination Housing Physical environment Food security Child development

Culture Social support Healthcare services/access Transportation Working conditions Civic participation

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NEIGHBORHOOD AND HEALTH

Where you live affects your health and the choices/constraints that impact your ability to make changes and improve your neighborhood and health conditions.

Neighborhood Conditions

Individual Socioeconomic

Resources

Health

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ACTIVITY – Why Race and Place Matter

Economic Social

Physical Service

Consider your neighborhood or community and the qualities that characterize it. For each domain listed below,

• What are strengths or protective factors associated with your neighborhood or community?

• What are risk factors associated with your neighborhood or community?

• How might these factors impact residents’ health outcomes or ability to achieve health equity?

• How do the levels of racism delineated by Jones (2000) relate to these domains?

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IMPLICATIONS FOR POLICY AND PRACTICE

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ACTIVITY – Disparities in Context

What does it mean to recognize and address health disparities in the context of public health social work practice?

• Read the linked Equity Stories from the American Public Health Association and choose one as your focus.

• In small groups or on your own, answer the following:

1. How would you summarize the health disparity in this story? What specific factors contributed to this issue?

2. What was done to improve outcomes for the population affected? In particular, how did public health social work leaders partner with the population affected?

3. What lessons could you take away to use in your own context or with your population of interest?

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THE IMPACT OF ENVIRONMENT

Economic Environment

Wealth, employment and economic mobility are

important to foster good health, now and in the future.

Social Environment

Communities that have strong social networks and foster

social inclusion are healthier and able to build social and

human capital

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EXAMPLES OF POLICIES THAT IMPACT NEIGHBORHOOD CHARACTERISTICS

Access to markets

and other retail

options

Zoning laws

Housing policy

Social welfare policy

Others?

All policy is health policy

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Transportation policy

Community development

Education policy

ELIMINATING HEALTH DISPARITIES

The Commonwealth Fund recommends the following steps in developing policies to eliminate racial and ethnic disparities:

1. Consistent racial and ethnic data collection by health care providers

2. Effective evaluation of disparities-reduction programs

3. Minimum standards for culturally and linguistically competent health services

4. Greater minority representation within the health care workforce

5. Establishment or enhancement of government offices of minority health

6. Expanded access to services for all ethnic and racial groups

7. Involvement of all health system representatives in minority health improvement efforts

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ACTIVITY – Eliminating Health Disparities

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1.

2.

3.

Discuss specific steps you would need to take in order to address at least three of the Commonwealth Fund recommendations on the previous slide.

REFERENCES AND ADDITIONAL RESOURCES

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REFERENCES

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Beatty, A., & Foster, D. (2015). The determinants of equity: Identifying indicators to establish a baseline of equity in KingCounty. [PDF document]. King County Office of Performance, Strategy and Budget. Retrieved from http://www.kingcounty.gov/~/media/elected/executive/equity-social justice/2015/The_Determinants_of_Equity_Report.ashx?la=en

Buchmueller, T., & Carpenter, C. S. (2010). Disparities in health insurance coverage, access, and outcomes for individuals in same-sex versus different-sex relationships, 2000–2007. American Journal of Public Health, 100(3), 489-495.

Case, A., & Paxson, C. H. (2005). Sex differences in morbidity and mortality. Demography, 42(2), 189-214.Centers for Disease Control and Prevention. (2011). National diabetes fact sheet: National estimates and general information on diabetes and prediabetes in the United States, 2011. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention.

Creanga, A., Berg, C., Syverson, C., Seed, K., Bruce, F., & Callaghan, W. (2015). Pregnancy-related mortality in the United States, 2006-2010. Obstetrics and Gynecology, 125(1), 5-12.

Crowson, C. S., Matteson, E. L., Myasoedova, E., Michet, C. J., Ernste, F. C., Warrington, K. J., … Gabriel, S. E. (2011). The lifetime risk of adult-onset rheumatoid arthritis and other inflammatory autoimmune rheumatic diseases. Arthritis & Rheumatism, 63(3), 633-639.

Diaz, R. M., Ayala, G., Bein, E., et al. (2001). The impact of homophobia, poverty, and racism on the mental health of gay and bisexual Latino men: Findings from three US cities. American Journal of Public Health 91(6), 141-146.

Garofalo, R., Wolf, R. C., Wissow, L. S., Woods, E. R., & Goodman, E. (1999). Sexual orientation and risk of suicide attempts among a representative sample of youth. Archives of Pediatrics & Adolescent Medicine, 153(5), 487-493.

REFERENCES, cont’d.

LPHSWE at UNCLeadership in Public Health Social Work Education

Gorman, B. K., & Read, J. N. G. (2006). Gender disparities in adult health: An examination of three measures of morbidity. Journal of Health and Social Behavior, 47(2), 95-110.

Herbst, J. H., Jacobs, E. D., Finlayson, T. J., McKleroy, V. S., Neumann, M. S., Crepaz, N., & HIV/AIDS Prevention Research Synthesis Team. (2008). Estimating HIV prevalence and risk behaviors of transgender persons in the United States: A systematic review. AIDS and Behavior, 12(1), 1-17.

Jones, C. P. (2000). Levels of racism: A theoretic framework and a gardener’s tale. American Journal of Public Health, 90(8), 1212-1215.

Krieger, N. (2001). A glossary for social epidemiology. Journal of Epidemiology and Community Health, 55(10), 693-700.

Lee, G. L., Griffin, G. K., & Melvin, C. L. (2009). Tobacco use among sexual minorities in the USA: 1987 to May 2007: A systematic review. Tobacco Control, 18, 275-282.

Link, B. G., & Phelan, J. (2006). Fundamental sources of health inequalities. In D. Mechanic, L. Rogut, D. Colby, & J. Knickman(Eds.), Policy challenges in modern health care (pp. 71-84). New Brunswick, NJ: Rutgers University Press.

Martin, J. A., Hamilton, B. E., Osterman, M. J. K., Curtin, S. C., & Mathews, T. J. (2015). Births: Final data for 2013. National Vital Statistics Reports, 64(1). Hyattsville, MD: National Center for Health Statistics.

Mathews, T. J., & MacDorman, M. F. (2013). Infant mortality statistics from the 2009 period: Linked birth/infant death data set. National Vital Statistics Reports, 61(8). Hyattsville, MD: National Center for Health Statistics.

Murray, C. J., Kulkami, S. C., Michaud, C., et al. (2006.) Eight Americas: Investigating mortality disparities across race, counties, and race-counties in the United States.” Public Library of Science, 3(9): e260.

REFERENCES, cont’d.

LPHSWE at UNCLeadership in Public Health Social Work Education

National Research Council (US), Institute of Medicine (US), Woolf S. H., & Aron, L. (Eds.). U.S. health in international perspective: Shorter lives, poorer health. Washington, DC: National Academies Press (US); 2013. Retrieved from http://www.ncbi.nlm.nih.gov.libproxy.lib.unc.edu/books/NBK115854

National Rural Health Association. (2007). What’s different about rural health? Retrieved from http://www.ruralhealthweb.org/go/left/about-rural-health/what-s-different-about-rural-health-care

Ogden, C. L., Carroll, M. D., Kit, B. K., & Flegal, K. M. (2014). Prevalence of childhood and adult obesity in the United States, 2011-2012. Journal of the American Medical Association, 311(8), 806-814.

Phelan, J. C., Link, B. G., & Tehranifar, P. (2010). Social conditions as fundamental causes of health inequalities theory, evidence, and policy implications. Journal of Health and Social Behavior, 51(1 suppl), S28-S40.

Raphael, D. (2009). Social determinants of health: An overview of key issues and themes. In D. Raphael (Ed.), Social determinants of health: Canadian perspectives (2nd ed.). Toronto: Canadian Scholars’ Press.

SEARCH for Diabetes in Youth Study Group. (2006). The burden of diabetes mellitus among US youth: Prevalence estimates from the SEARCH for Diabetes in Youth Study. Pediatrics, 118(4), 1510-1518.

Tebo, G. (2011). Healthy People 2020: Preparing for a new decade. [PowerPoint slides]. Office of Disease Prevention and Health Promotion, Health and Human Services.

Wilkinson, R. G., & Pickett, K. E. (2006). Income inequality and population health: A review and explanation of the evidence. Social Science and Medicine 62(7), 1768-1784.

Williams, D. R. (2003). The health of men: Structured inequalities and opportunities. American Journal of Public Health, 93(5), 724-731.

ADDITIONAL RESOURCES

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Readings

Beachamp, D. E. (1976). Public health as social justice. Inquiry, 13(1), 3-14.

Braveman, P. (2014). What are health disparities and health equity? We need to be clear. Public Health Reports, 129(Suppl 2), 5-8.

Halfon, N. (2009). Life course health development: A new approach for addressing upstream determinants of health and spending. [Policy brief]. Retrieved from http://www.nihcm.org/pdf/ExpertVoices_Halfon_FINAL.pdf

Moniz, C. (2010). Social work and the social determinants of health perspective: A good fit. Health & Social Work, 35(4), 310-313.

Robert Wood Johnson Foundation. (2011, October 6). Health policy brief: Achieving equity in health. Health Affairs. Retrieved from http://healthaffairs.org/healthpolicybriefs/brief_pdfs/healthpolicybrief_53.pdf

Woolf, S. H., & Braveman, P. (2011). Where health disparities begin: The role of social and economic determinants—and why current policies may make matters worse. Health Affairs 30(10), 1852-1859.

Williams, D. R. (2006). Patterns and causes of disparities. In D. Mechanic, L. B. Rogurt, D. C. Colby, & J. R. Knickman (Eds.), Policy changes in modern health care (115-134). New Brunswick, NJ: Rutgers University Press.

Yin, S. (2007). Gender disparities in health and mortality. Population Reference Bureau. Retrieved fromhttp://www.prb.org/Publications/Articles/2007/genderdisparities.aspx

ADDITIONAL RESOURCES, cont’d.Websites

Kaiser Family Foundation

Medicare

Centers for Medicare & Medicaid Services (CMS)

National Association of County and City Health Officials

The Commonwealth Fund

National Association of State Medicaid Directors

Center on Budget and Policy Priorities

Robert Wood Johnson Foundation

Multimedia

Unnatural Causes

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THANK YOU

Lisa de Saxe Zerden, MSW, PhD

Associate Dean for Academic Affairs

University of North Carolina at Chapel Hill

School of Social Work

[email protected]

Kelsey A. White

MSW/MPH Candidate (2016)

University of North Carolina at Chapel Hill

School of Social Work

[email protected]

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