Decmeber 2007: Healing Across the Divides meeting with PMRS

Meeting Objectives

• Evaluation of community assessment/ readiness – 1 hr minutes

• Measurement of improvement in women’s health and measurement of empowerment as it pertains to health- 1 hr

Clinical versus public health perspectives on diabetes (any public health issue)

Characteristics Clinical Perspective Public Health Perspective

Problem definition Individual, lifestyle Community, public policy, environment

Target Self-referred or recruited samples

Populations and/or high-risk groups

Setting Medical/specialized clinics Community environments (work, schools, primary care, home)

Provider Trained professionals Professionals, lay, automated (internet, 1-800 service)

Intervention Brief counseling or intensive, multi-session

Brief, low-cost, self-change focus

Outcome measure: HgbA1C Measures: I feel that diabetes does not interfere with my life: I have access to affordable food; I have a supportive community for exercising

Population of eligible individuals screened

Small percentage Large percentage

Cost-effectiveness Lower Higher

Rabbi Adin Steinsaltz

• "If there is any hope for change in this world, people must turn to the only thing that can indeed make a difference: themselves"

Stages of change

1. Precontemplation: not thinking about change

2. Contemplation: unsure or ambivalent about change

3. Preparation: ready to initiate change in next four weeks

4. Action: taking steps toward the behavioral goal

5. Maintenance: trying to maintain change over the long term-at least 6 months

Social determinants of health1. Social gradient: the poorest and most disadvantaged are especially

affected. The poorest have the lowest diabetes control. Copays on medications leads to poorer diabetes control.

2. Stress: social and psychological environment impact diabetes control 3. Early life: importance of a good start in life4. Unemployment: job security and satisfaction. Poor job security

impacts diabetes control5. Work environment: impacts on health and risk of disease. Lack of job

control impacts diabetes control6. Social support: positive role of friendship and social cohesion7. Social exclusion: impact of social isolation and relative deprivation.

Rapid community change can impact decrease social relations thus decreasing diabetes control.

8. Addictions: effects of tobacco, alcohol and other drugs9. Food: access to reasonably priced nutritious food is a community

issue and its lack leads to poorer diabetes control. 10. Transport: better public transport, reducing driving and encouraging

healthier means (walking, cycling). Lack of culturally encouraged exercising leads to poorer diabetes control.

Ten great achievements in Public Health: Adding 25 years

to life expectancy in the 20th Century

Vaccination

• Eradication of small pox; elimination of poliomyelitis; control of measles, rubella, tetanus, diphtheria, Haemophilus influenzae type b

Motor-Vehicle Safety

• Engineering efforts making vehicles and highways safer; personal behavior change (e.g., using seat belts, child safety seats, motorcycle helmets, decreased drinking and driving

Safer workplaces

• Control of environments: e.g., reducing coal workers’ pneumoconiosis (black lung) and silicosis; reduction in severe injuries and death related to mining, construction, manufacturing and transportation industries

Control of infectious diseases

• Resulting from clean water and improved sanitation. Typhoid and cholera transmitted by contaminated water reduced dramatically; discovery of antimicrobial therapy to control tuberculosis and sexually transmitted diseases

Prevention of Heart Disease and Stroke

• Risk factor modification such as smoking cessation and blood pressure control combined with improved access to early detection and better treatment

Safer and healthier foods

• Decreases in microbial contamination and increases in nutritional content; establishing food-fortification programs to eliminate diseases such as rickets, goiter and, pellagra

Healthier mothers and babies

• Resulting from better hygiene and nutrition, availability of antibiotics, greater access to health care, and technologic advances in maternal and neonatal medicine

Family planning

• Access to family planning and contraceptive services has altered social and economic roles of women; smaller family size and longer interval between birth of children; fewer infant, child and maternal deaths; using contraceptives to prevent pregnancy and transmission of HIV and other STDs

Fluoridation of drinking water

• Safely and inexpensively benefits children and adults by effectively preventing tooth decay, regardless of socioeconomic status or access to care

Tobacco prevention

• Recognition of tobacco as a health hazard and subsequent public health anti-smoking campaigns changed social norms to prevent initiation of tobacco use, promote cessation and reduce exposure to environmental tobacco smoke. Since the 1964 Surgeon General’s Repot on the health risks of smoking, smoking among adults has decreased substantially and millions of smoking related deaths have been prevented.

Empowerment: Definition

• increasing the capacity of individuals and groups to make choices and to transform these choices into desired actions and outcomes

Self-Management Goals• Identify self-management tools, including the

following:– an action plan that includes goals and describes

behavior (e.g., increasing activity by walking 15 minutes 3 times per week)

– A review of the patient’s personal barriers (e.g., too busy to exercise)

– Steps to overcome barriers– The patient’s confidence level (e.g., on a scale of 1 to

10, how confident are you that you can meet your goals?)

– follow-up plan

Historical analysis of the development of health care facilities in Kerala State, India

• Though poor by standards of per capita income, industrialization or agricultural production, the Indian state of Kerala has shown that these constraints need not hinder the development of social sectors. The state has achieved near universal literacy for both males and females and the health care indices are comparable to countries with more advanced economies

Illustration

If a team were trying to assess the degree of political empowerment of women as it pertains to health, information would first need to be gathered on the existence of women’s access to health services. Then the question would be asked, do women choose to access these services and why/why not? Finally, the team would assess the health outcome of these choices; that is, does the health of women actually improve?

Empowerment is dependent on interplay of two inter-related factors: agency and opportunity

structure.

• Agency is defined as an actor’s ability to make meaningful choices; that is, the actor is able to envisage and purposively choose options.

• Opportunity structure is defined as those aspects of the context within which actors operate that affect their ability to transform agency into effective action.

cont

• Making poverty a public, moral, and political issue often helps the poor gain leverage. Rights-based approaches are similarly dependent on politicization. One problem with bringing empowerment issues into the political sphere is that political capacity is gained at the cost of conceding power to a political system and its own autonomous logic, which may be less than hospitable to poor people.

Holland and Brook suggest threetypes of empowerment indicators:

• data generated through household and other surveys;

• intermediate and direct indicators derived from existing survey instruments;

• and indicators not yet captured by existing instruments.

Human rights are a priori about power relations.

cont

• despite the ideals of participation, “people become empowered not in themselves, but through relationships with outsiders; and not through the validation of their existing knowledge and actions, but by seeking out and acknowledging the superiority of modern technology and lifestyles, and by aligning themselves with dominant cultural forms”

Direct Indicators of Empowerment

• Direct indicators of empowerment relate to the four forms of empowerment identified by the ME study: passive access, active participation, influence, and control. These indicators measure empowerment in the following three areas:

• 1) Opportunity to use influence/exercise choice;• 2) Using influence/exercising choice; and• 3) Effectiveness of using influence/exercising

choice in terms of the desired outcome.

Three types of quality problems or ‘defects’ in health care:

1. Underuse: failing to identify conditions or offer treatments of know effectiveness (e.g., failure in primary care to diagnose and treat depression in almost half of cases: Wells et al., 1989)

2. Overuse: subjecting patients to tests, procedures or medications that are unnecessary or of questionable value on scientific grounds (cf., RAND corporation study, estimated that 30% of acute care is unnecessary: Chassin et al,. 1987)

3. Misuse: errors (e.g., medication errors) and poorly executed tests and procedures (cf., Harvard Medical Practice Study of hospitalizations found adverse medical events in over 3% of patients: Brennan et al,. 1991)

Six aims for improvement• Safe: avoiding injuries to patients form the care that is

intended to help them• Effective: providing services based on scientific knowledge to

all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and overuse, respectively)

• Patient-centered: proving care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions

• Timely: reducing waits and sometimes harmful delays for both those who receive and those who give care

• Efficient: avoiding waste of equipment, supplies, ideas and energy

• Equitable: providing care that does not vary in quality because of personal characteristics, such as gender, ethnicity, geographical location and socioeconomic status.

Social determinants of health

1. Social gradient: the poorest and most disadvantaged are especially affected

2. Stress: social and psychological environment3. Early life: importance of a good start in life4. Unemployment: job security and satisfaction5. Work environment: impacts on health and risk of disease6. Social support: positive role of friendship and social

cohesion7. Social exclusion: impact of social isolation and relative

deprivation8. Addictions: effects of tobacco, alcohol and other drugs9. Food: access to nutritious food is a political issue10. Transport: better public transport, reducing driving and

encouraging healthier means (walking, cycling)

Clinical versus public health perspectives on smoking cessation

Characteristics Clinical Perspective Public Health Perspective

Problem definition Individual, lifestyle Community, public policy, environment

Target Self-referred or recruited samples

Populations and/or high-risk groups

Setting Medical/specialized clinics Community environments (work, schools, primary care, home)

Provider Trained professionals Professionals, lay, automated (internet, 1-800 service)

Intervention Brief counseling or intensive, multi-session

Brief, low-cost, self-change focus

Outcome Higher quit rates (20-30% over 1 year)

Lower quit rates(5-15% over 1 year)

Population of smokers reached

Small percentage Large percentage

Cost-effectiveness Lower Higher

Stages of change

1. Precontemplation: not thinking about change

2. Contemplation: unsure or ambivalent about change

3. Preparation: ready to initiate change in next four weeks

4. Action: taking steps toward the behavioral goal

5. Maintenance: trying to maintain change over the long term-at least 6 months

Miller and Rollnick (1991) describe five basic principles for enhancing motivation:

1. Express empathy: listen rather than tell2. Develop a discrepancy: distinguish between

where a patient is now (i.e. risk behavior) and where he/she wants to be (goal).

3. Avoid argumentation: the force of argument alone rarely convinces patients

4. Roll with resistance: avoid meeting patient resistance head-on

5. Support self-efficacy: instill hope and support patients’ belief that they can change.

The use of these principles requires health practitioners to take a very different stance (e.g., nonconfrontational) with respect to the patient. The basic goal is to develop a ‘shared’ understanding of the health issue and to stimulate the patient’s commitment to change.

Improving the organization

It’s easy to get the players. Getting’ ‘em to play together that’s the hardest part.

-Casey Tengel

Approximately 85% of opportunities for improvement lie with system changes such as role assignment, whereas 15% lie with people - Deming

Cohen (1983) found that a simple change in the clinic routine had a profound effect on physicians’ behavior regarding preventative care of diabetic patients. Whether or not the physician performed a foot examination was largely determined by whether the nurse instructed the patient to remove his/her shoes and socks before being seen by the physician. Physicians were almost five times as likely to examine the feet when patients presented barefoot (70%) than when wearing shoes (15%).

The Group Health Cooperative of Puget Sound (GHC), located in Seattle, Washington, is a consumer-governed Health Maintenance Organization (HMO) with almost 500,000 members residing in the greater Puget Sound area and approximately 675,000 members overall in Washington and Idaho. The GHC employs approximately 1000 physicians (40% in primary care). The population served by the GHC is similar to that in the surrounding area in terms of age, race, gender distribution and income. What sets GHC apart from other HMO’s in the region (and in the country) is its approach to primary and secondary prevention. Indeed, this focus has been evident since the GHC’s inception in 1947; the original bylaws decree:

The Cooperative shall endeavor to develop some of the most outstanding hospitals and medical centers to be found anywhere, with special attention to preventive medicine.

Bicycle safety

This program uses research on barriers to, and effectiveness of, bicycle helmet use and relies on broad-based community participation to achieve its positive outcomes. GHC was one of 18 community groups participating in this campaign, which included extensive media coverage and discount coupons for helmets. Participation by primary care physicians in distributing the discount coupons was a significant component. Between 1987 and 1992, a 67% decrease was found in the rate of GHC emergency department attendee head injuries due to bicycling in the target population of children aged 5 to 14 years.

The essentials of GHC’s success

Lesson1. Clear vision and direction are essential to a preventive care provision system.

GHC began in 1947 with a mission statement that emphasized prevention-quite unique at this time. Guided by its mission, GHC determined exactly what it needed to constitute an ideal or ‘gold standard’ system for preventive care. Clearly articulating the details of a prevention system ensures organizational cohesiveness, sets the directions of efforts, plans the route and establishes the criteria by which an organization tests its interventions.

Lesson 2. Leadership and on organizational focus are key

Because a wide variety of GHC departments and individuals are involved in preventative care, effective leadership and good communication is critical to ensure that prevention remains a priority and that preventive efforts are effectively coordinated.

The work of a Preventive Care Task Force in 1973 led to the establishment of the Department of Preventive Care. The Department undertook the following initiatives:

•Committee on Prevention: a broad-based committee that develops and facilitates implementation of guidelines and provides implementation oversight.•Center for Health Studies: conducts epidemiological and health services research, established by Dr. Edward Wagner and now lead by Dr. Susan Curry•Center for Health Promotion: the principal planning and implementation partner.

Elements of an ideal Preventive Care System

• A population-based, multilevel planning approach is used.• Direct your efforts at major causes of morbidity and mortality

as determined by epidemiological research. Consider both the epidemiology of “needs” (disease and risks) and the epidemiology of “wants” (desires of patients and practitioners)

• Evidence for intervention effectiveness is available, or will be generated by well designed program evaluations.

• Functions linked at multiple levels of care: one-to-one, infrastructural, organizational, community.

• Use prospective and automated programs to the maximum extent feasible.

• Health is the result of shared decision-making between practitioners and patients. Informed consent encourages shared planning and input from patients.

Criteria used to evaluate prevention issues

1. The condition (disease/risk factor) is important to the individual and society. What is the burden of suffering due to the condition (individual, community, population perspectives)?

2. The risk factor or disease has a recognizable pre-symptomatic stage. The natural history of the disease is known.

3. Reliable methods for detecting the risk factor or disease exist. Consider screening test validity: sensitivity, specificity, and predictive values.

4. Intervention effectiveness is considered. Modification of the risk factor or intervention a the pre-symptomatic stage reduces morbidity and mortality more than intervention after symptoms appear.

5. Facilities or capacity to address the identified risk factor or condition exist.6. The cots/harms and potential benefits of implementing a state of the art

approach have been considered.

The intention to perform a behavior is determined by:

• Attitudes and beliefs about a specific action and the value attached to the outcome.

• The person's belief about likely social reactions (approval or disapproval) from certain individuals or groups regarding the behavior, and the person’s motivation to comply or not with what others think.

Miller and Rollnick (1991) describe five basic principles for enhancing motivation:

1. Express empathy: through listening rather than telling

2. Develop discrepancy: between where the patient is now (i.e., risk behavior) and where he or she wants to be

3. Avoid argumentation: do not try to convince patients by the force of your argument

4. Roll with resistance: rather than meet patient resistance head-on

5. Support self-efficacy: instill hope and support patients; belief that they can do it (change)

Miller and Rollnick (1991) divide motivational counseling into two major phases. The first phase, Building Motivation for change, is directed at patients who are fairly early in their readiness for change (precontemplation). They may be reluctant about change or even show marked resistance at the outset. Using eight related strategies the aim is to work with the patient in ways that will tip the motivational balance in favor of change; that is, increase perceived concerns of change.

Four elements that are common to successful initiatives include

(Berwick & Nolan, 1998)

1. Aim: organizational improvement is not seen as an accident but as the result of a clearly intended aim

2. Measurement: data collection and feedback show that a system change has actually resulted in an improvement

3. Good Ideas for Change: multiple sources are drawn upon to identify opportunities and alternatives for change.

4. Testing: ideas for change are promptly tested on a small scale, adjustments are made based on test results and redesigns are tested in an iterative fashion.

Three organizational prototypes

• Reactive organizations lack direction, have poor morale and are caught up in the present ‘fighting fires’.

• Proactive organizations are more supportive, have a clearer sense of purpose, and have systems aligned to achieve results

• High performing organizations have excellent morale, a long range vision and emphasis on continuous improvement throughout the organization.