The Survey of the Health of Wisconsin Makes House Calls

 If you live in Wisconsin, you soon may notice in your town a large, specially outfitted truck emblazoned with the red letters SHOW. It's not a touring rock band or a Great Circus Parade vehicle gone astray.

SHOW-the Survey of the Health of Wisconsin-is an expansive health checkup of the Badger State launched in June 2008 by the University of Wisconsin School of Medicine and Public Health (SMPH). Researchers, public health officials and doctors believe that this permanent infrastructure for annual health surveys will be critically important to identifying and addressing Wisconsin's future health needs.

Two state-of-the-art mobile survey centers staffed by 10 health surveyors are the most visible feature of SHOW. Traveling from Park Falls to Janesville and Eau Claire to Milwaukee, the specially trained health surveyors are taking composite measurements of health and related factors in hundreds of adults and their communities. The teams knock on doors of randomly selected households in 120 different neighborhoods, working to enroll participants who will represent the state's 5.6 million residents. With two permanent survey centers also established in Milwaukee and Middleton, outside Madison, researchers expect to recruit approximately 1,200 Wisconsinites each year.

According to F. Javier Nieto, MD, PhD, MPH, the project's director and principal investigator, SHOW's goal is to build a growing health data and bio-sample bank, which will give public health champions and healthcare providers accurate and timely information about the prevalence of health issues Wisconsinites face.

This will mean better insight into the condition of health and wellness in the state. For example, SHOW will give estimates of how many residents get enough physical activity and have healthy dietary habits, how many have access to adequate healthcare resources, and how many may be at risk for diabetes or suffer from undiagnosed mental health problems or other conditions.

Nieto, also chair of the SMPH Department of Population Health Sciences, explains the drive behind the project.

"Health officials, policy makers, organizations and other stakeholders rely on research and statistics to guide community public health planning," he says.

But statewide statistics are limited, consisting primarily of mortality data and self-reported information collected by mail or telephone surveys.

"To expand and complement the current information, SHOW recruits at Wisconsin residents' homes, which will help us reach a truly representative sample," he says. "SHOW then administers a broad array of in-person health interviews and collects physical measurements and bio-samples. All of this will provide a comprehensive picture of health in our state that is unprecedented."

In preparation for SHOW, project leaders have built community partnerships all over the state.

"We know that community involvement is a key component for a successful project," says Nieto, "so it's a strong focus for our team."

Every SHOW community is unique, adds SHOW research manager Kathleen Massoth, MPH, so awareness campaigns are tailored to each of them. Officials at local and regional public health departments, leaders on other UW campuses, contacts from various community organizations-all have contributed to making SHOW effective in their towns, she says.

"They help us to spread the word, and identify opportunities to encourage awareness and participation," says Massoth, adding that SHOW works with local press, from big TV stations to neighborhood newsletters.

The mobile survey centers have parked at local libraries, baseball diamonds, health centers, village halls and supermarkets. Hosts have also included the Germantown public library, UW-Manitowoc campus, Joe's Family Market in Bloomer, Witter baseball field in Wisconsin Rapids, Aurora Health Care in Lake Geneva, Gateway Technical College in Kenosha and Chippewa Valley Technical College.

"Community members are excited and interested when we roll into town. We get a warm welcome," says Emilio Delboy, one of SHOW's team members. "Many community members want to learn more about our work. Wisconsinites are concerned about the health of their families, neighborhoods and communities, and they're excited about the possibilities of improving it. I think that's why SHOW speaks to them."

Adds Liz Snowden, of the Milwaukee-based field team, "The University of Wisconsin link is strong throughout the state. Many people feel a personal connection to the university, so they stop by to say hi and to see what we are up to."

SHOW's routine in a selected community looks like this: Previously identified households receive a letter notifying them that they are invited to participate in the study. Recruitment teams come to town and visit each selected household in-person, introducing the project and signing people up. The first part of the survey-an in-home interview and questionnaire session-typically occurs during this initial week.

Appointments are then made for additional survey components to take place a couple of weeks later at a SHOW survey center located nearby. Participants visit one of the two fixed survey sites or one of the program's two mobile survey centers. The 38-foot-long, extra-wide research vehicles, custom designed by Lifeline Mobile, feature private and comfortable examination and interview areas, as well as a laboratory for secure specimen processing.

Inside the temperature-controlled vehicles, field team members conduct additional interviews, take physical measurements-including blood pressure, heart rate, respiratory function, height, weight and body composition-and collect blood, urine and saliva specimens for basic testing and long-term storage for future studies.

By the time the researchers finish with each SHOW participant, they have assembled a detailed picture consisting of the following:

• A snapshot of the household-tracking and enumerating household residents, their age, gender, relationships to each other and contact information
• Demographics-each individual's education, marital status, race and ethnic ancestry
• Housing characteristics
• Occupation and military experience
• Medical health history, including most major diseases, conditions and health events
• Weight history
• Women's reproductive history and health
• Prescription and over-the-counter medications inventory
• Vision, hearing and dental history
• Screening tests and vaccinations
• Health insurance and healthcare utilization, access and satisfaction
• Health literacy (the participant's ability to understand detailed medical information and instructions)
• Quality of life and current health status
• Depression, post-traumatic stress disorder status and general mental health
• Stress and anxiety levels
• Cognitive status
• Life events inventory
• Discrimination experiences
• Food security
• Caregiving
• Sleep habits and disorders
• Smoking habits (current and past)
• Alcohol intake (current and past)
• Dietary habits and food and beverage intake frequencies
• Physical activity and fitness
• Sexual behavior and contraceptive use
• Prevention and safety habits
• Assessment of the "fitness friendliness" and other characteristics of subjects' communities

All information collected for SHOW is kept strictly confidential. The data will be updated yearly, when researchers contact participants by telephone to learn of new health developments, such as a hospitalization or a new diagnosis of cardiovascular disease or cancer.

The first and only such health check-up of any state in the country, SHOW has been modeled after the Centers for Disease Control and Prevention's National Health and Nutrition Examination Survey (NHANES), which has provided key information about the nation's health for more than 40 years. Using NHANES as a guide, SHOW has been specifically designed for the state by including regionally important health measures, such as assessments of the local environment and Great Lakes fish consumption.

"SHOW will immediately provide us current health as well as prospective, long-term clinical information never before available in Wisconsin," says Henry Anderson, MD, chief medical officer for the state Bureau of Environmental and Occupational Health in the Division of Public Health. "This survey will make us much better equipped to develop initiatives to help make Wisconsin healthier than ever."

The data and samples collected through SHOW will become a valuable resource for researchers down the road, providing them the means to investigate the causes of disease in Wisconsin, the factors that determine access to healthcare and the health effects of the characteristics of Badger State communities.

Stored biological samples will offer future health researchers opportunities to explore cutting-edge questions, such as how genes shape or determine how people respond to environmental health challenges.

SHOW will also offer expansive partnership opportunities for researchers, communities and institutions developing research projects that aim to improve the health of Wisconsin communities.

"Many communities and institutions around the state are excited by the possibility of utilizing the project's infrastructure to carry out research not previously possible due to the expenses involved in this caliber of data collection," says Nieto. Researchers are also encouraged to propose ancillary studies that build on the SHOW core survey components and samples. Currently, a special SHOW committee is forming to review proposals for expanding the survey's work within Wisconsin communities.

So be on the lookout for SHOW in a community near you. If you aren't invited to participate, it's likely someone you know will be. Each SHOW participant represents about 5,000 other Wisconsinites and plays a special role in building healthy communities.

What SHOW Will Tell Us

SHOW sits at the forefront of population health research efforts in that it gathers a breadth of measures not typically included in other surveys. The survey collects physical measurements and biological samples-including DNA.

SHOW records data about participants' communities, and geo-codes households, making it possible for researchers to link health information with environmental factors that might influence health. Among many other measures, the survey collects information about participants' sleep, nutrition and exercise habits, quality of life, mental health status and access to health insurance and healthcare.

School leaders hope that, in time, SHOW will answers many important questions about the health of Wisconsin residents.

Below are just a few examples of how the project will shed light on Wisconsin's pressing health issues:

• Based on physical and laboratory examinations, SHOW will offer an accurate evaluation of Wisconsin residents' blood pressure, and cholesterol and glucose levels. The data will indicate what proportion of people have healthy readings or a medical condition, and how many are getting treated for such conditions and have the problems adequately controlled.
• With measurements of height, weight and waist circumference, as well as participant interviews about diet and physical activity and direct observations of the local community environment, SHOW's data will offer insight into factors that are associated with higher risks of obesity.
• With its confidential, computer-assisted and paper-based surveys, SHOW will gather a more comprehensive picture of sensitive health topics that people may feel uncomfortable sharing with others, such as alcohol use and sexual behavior.
• SHOW studies community environments and geo-codes households by pinpointing and recording their geographic coordinates. With this level of detail, it will be possible for researchers to link health outcomes with environmental factors that might influence health.
• SHOW will provide an accurate measure of how many Wisconsinites suffer from depression and other chronic mental and physical conditions.

Putting the SHOW on the Road

SHOW is funded by the Wisconsin Partnership for a Healthy Future, which represents a far-reaching commitment by the School of Medicine and Public Health (SMPH) to help improve the health of people in Wisconsin for years to come. The UW Institute for Clinical and Translational Research also supports SHOW.

"In essence, SHOW is a gift to the state of Wisconsin," says Paul DeLuca, PhD, vice dean of the SMPH. "It's a mechanism for the school to broadly apply the skill set of our entire faculty, students and staff to a spectrum of public health issues that otherwise probably would not get the attention they need."

The deep commitment to SHOW reflects the school's current emphasis on public health and translational research, which moves rapidly from basic laboratory discovery to the clinic bedside and then on to the community curbside.

"SHOW is a wonderful example of combining the complete discovery process from fundamental discovery all the way to ultimate analysis, interpretation and application," says DeLuca. "No one can anticipate the magnitude of the long-term benefits that this kind of initiative can have."

For current updates about the SHOW program, please visit www.show.wisc.edu.

by Phoebe Frenette
This article appears in the fall 2008 issue of Quarterly.