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FOR STATE OF CALIFORNIA
Esteban Cruz, MDDirector, Community InitiativesKaiser Permanente Southern California
August 12, 2006Los Angeles, CA
Community Health The Role of Health Professionals
THE ROLE OF HEALTH PROFESSIONALS
COMMUNITY HEALTH
Today we will talk about...
Kaiser Permanente’s Approach to Overweight and Obesity
Community Health - An Evidence-Informed Approach
The Role of Health Professionals in Community Advocacy
THE ROLE OF HEALTH PROFESSIONALS
COMMUNITY HEALTH
By the end of this lecture participants will be able to…
Describe 2 evidence-based community strategies to improve physical activity
Develop a community talk to support advocacy efforts
Choose a next step to become a community advocate
THE ROLE OF HEALTH PROFESSIONALS
COMMUNITY HEALTH
What are the major health issues facing children in my community?
Which health issue should I work on?
How ready am I to commit time to work on this issue as a community advocate?
Health Professional Community Advocacy
5
ReadyNot Ready
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THE ROLE OF HEALTH PROFESSIONALS
COMMUNITY HEALTH
“I think we’re looking at a first
generation of children who may
live less long than their parents
as a result of the consequences
of overweight and type 2
diabetes.”
The Epidemic of Overweight and Obesity
www.discoveryhealthCME.com, N Engl J Med Vol. 352(11) March 2005, pp. 1138-1145
“By 2040 all Americans will be
overweight or obese.”
THE ROLE OF HEALTH PROFESSIONALS
COMMUNITY HEALTH
JAMA, April 5, 2006, Vol 295, No. 13, 1549-1555
What is the trajectory of the obesity epidemic?
13.8 14.416
33.4 33.3 33.2
14
16.418.2
27.5 27.8
31.1
10
15
20
25
30
35
1999-2000 2001-2002 2003-2004
% O
ve
rwe
igh
t o
r O
be
se
Females 2-19YrFemales >=20YrMales 2-19 Yr
Males >=20 Yr
THE ROLE OF HEALTH PROFESSIONALS
COMMUNITY HEALTH
About Kaiser Permanente (KP)
One of the nation’s oldest not-for-profit health care delivery systems and a leader in quality.
8.2 million members nationwide; 6.2 million in California.
KP has made a deep and longstanding commitment to healthy eating and active living in our communities with intensive interventions since 2001.
THE ROLE OF HEALTH PROFESSIONALS
COMMUNITY HEALTH
Kaiser Permanente’s Approach to Overweight and Obesity
Medical Office Visit Interventions
Weight Management Interventions
Environmental Changes
MEDICAL OFFICE VISITINTERVENTIONS
BMI Screening Physician Counseling Patient Education Materials Referral and Follow-Up
WEIGHT MANAGEMENTINTERVENTIONS
Individual Counseling Group Programs Intensive Programs Internet Resources
ENVIRONMENTALCHANGES
School Programs Work Site Programs Community Programs Legislation & Partnerships
THE ROLE OF HEALTH PROFESSIONALS
COMMUNITY HEALTH
A Longitudinal Approach to Preventing Overweight
FetusFetus
Preventing:
• SGA
• LGA
InfantsInfants
Promoting:
• Breastfeeding ToddlersToddlers
Diagnosing:
• Early AdiposityRebound
ChildrenChildren
Increasing:
• Physical Activity
Decreasing:
• TV Viewing
• SweetenedBeverageConsumption
AdultsAdults
Increasing:
• Physical Activity
Decreasing:
• Portion Size
Encouraging:
• WeightMaintenanceThe Permanente Journal/ Summer 2003/ Volume 7 No. 3 pp. 6-7
THE ROLE OF HEALTH PROFESSIONALS
COMMUNITY HEALTH
Community Health:
An Evidence-
Informed Approach
THE ROLE OF HEALTH PROFESSIONALS
COMMUNITY HEALTH
Are overweight children a personal or community issue?
No Opinion1%
Community Issue53%Personal Issue
30%
Both16%
1,068 random sample CA residents, telephone survey 10-11/2003 http://calendow.org/caobesityattitudes/index.htm
THE ROLE OF HEALTH PROFESSIONALS
COMMUNITY HEALTH
Motor Vehicle Safety Safer Workplaces Control of Infectious Disease Safer and Healthier Foods Fluoridation of Drinking Water Vaccination* Family Planning* Healthier Mothers and Babies* Decline in Deaths from Cardiovascular Disease* Recognition of Tobacco Use as a Health Hazard*
CDC - 1999
Ten Great Public Health Achievements 1900-99
THE ROLE OF HEALTH PROFESSIONALS
COMMUNITY HEALTH
Fiscal Control - tobacco taxes, agriculture price supports
Regulatory Controls - clean indoor air, regulation and labeling of tobacco products, advertising and promotion, restrictions on sales to minors
Litigation - federal suit against tobacco companies
Smoking Cessation Programs - quit lines
Research, Leadership & International Trade
U.S. Tobacco Control Strategies
N Engl J Med Vol. 350(3) 1/2004 pp. 293-301
THE ROLE OF HEALTH PROFESSIONALS
COMMUNITY HEALTH
Collaborate with our communities to establish a specific, short-term health related goal (community data, needs assessment)
Identify evidence-based best practice(s) for achieving shared goal (Medline, Community Guide)
Collaborate with our communities to adapt this best practice to the community’s unique assets and constraints
Evaluate the project by using appropriate expertise
Community Health - An Evidence-Informed Approach
Pediatrics April 2005;115:1142-1147
THE ROLE OF HEALTH PROFESSIONALS
COMMUNITY HEALTH
Community-wide campaigns
Point-of-decision prompts
School-based physical education
Social support in community settings
Individually-adapted health behavior change
Creation and/or enhanced access to places for physical activity combined with informational outreach activities
Community-scale urban design/land-use policies & practices
Street-scale urban design/land-use policies and practices
http://www.thecommunityguide.org
Which community PA interventions have good evidence?
THE ROLE OF HEALTH PROFESSIONALS
COMMUNITY HEALTH
Which community HEAL interventions have good evidence?
Am J Health Promotion 2005;19(3):167-193
Prompts to increase stair use
Access to places and opportunities for PA
School based PE with better trained PE teachers and increased length of time students are physically active
Comprehensive work-site approaches including education, employee and peer support for PA, incentives, and access to exercise facilities.
Availability of nutritious foods, point of purchase strategies, train health care providers to provide nutritional counseling
THE ROLE OF HEALTH PROFESSIONALS
COMMUNITY HEALTH
Which community PA interventions have insufficient evidence?
http://www.thecommunityguide.org
Classroom-based health education focused on information provision
Mass media campaigns
Health education w/ TV/video game turnoff component
College-age physical education/health education
Family-based social support
THE ROLE OF HEALTH PROFESSIONALS
COMMUNITY HEALTH
School Food Practices and Overweight
Cross-sectional study of 3,088 eighth-grade students in 16 middle schools in Minneapolis
Food practices studied: Allowed to have food or beverages in the classroom Allowed to have snacks or beverages in the hallways Food or food coupons used as a reward for students Fundraising that included food sales
BMI of students increased 10% for every additional food practice permitted (P<.03)
Arch Pediatr Adolesc Med. December 2005;159:1111-1114
THE ROLE OF HEALTH PROFESSIONALS
COMMUNITY HEALTH
Multi-component interventions
Interventions that combine nutrition and physical activity
Published worksite interventions include: Didactic nutrition education Prescriptions for physical activity or nutrition Training in behavioral techniques Self-help materials Group exercise sessions
http://www.thecommunityguide.org
Which worksite interventions have good evidence?
THE ROLE OF HEALTH PROFESSIONALS
COMMUNITY HEALTH
Education and Counseling - probably least effective (1)
Environmental Changes and Policy (e.g., safe crosswalks)
Enforcement of Legislation (e.g., seat belt laws)
The first US child safety seat law was passed in 1977 as the result of the hard work and persistence of Robert S. Sanders, MD, a pediatrician. (2)
(1) Cochrane Database Syst Rev 2001(2) Crit Care Med Vol.30 No. 11 2002 pp. 385-392
Injury Prevention Strategies
THE ROLE OF HEALTH PROFESSIONALS
COMMUNITY HEALTH
The Role of Health
Professionals in
Community Advocacy
THE ROLE OF HEALTH PROFESSIONALS
COMMUNITY HEALTH
Governor’s Summit on Health, Nutrition and Obesity – September 15, 2005
Pleasanton 2002 Pleasanton 2006
Policy, Legislation and Environmental Change
SB 19 – nutritional standards in schools 10/01
SB 677 – Soda Ban 9/03
SB 65 – School Food Contracts 9/03
SB 965 – ban of unhealthy beverages in high schools.
SB 12 – rigorous nutritional standards for foods in schools K-12. 9/05
THE ROLE OF HEALTH PROFESSIONALS
COMMUNITY HEALTH
The Role of Health Professionals in Community Advocacy
Provide quality care to individual patients in regular practice.
Improve the system of care delivered by group/organization.
JAMA January 7, 2004 - Vol. 291, No. 1 pp. 94-98
Environmental change in local schools and communities to address tobacco, injury prevention, and obesity.
Public policy to address same issues.
Provide quality care to uninsured patients.
Improve insurance coverage, after-hours care and geographic distribution of services.
THE ROLE OF HEALTH PROFESSIONALS
COMMUNITY HEALTH
The Role of Health Professionals in Community Interventions
Leadership and Advocacy Subject matter expertise and credibility Participation in community collaborative activities Consultation on policy recommendations and
interventions
Education and Social Marketing Presentations to government, school boards, teachers,
parents and students Training community health professionals Media interventions
Pediatrics Vol. 112 No. 4 October 2003, pp. e328-346Pediatrics Vol. 115 No. 4 April 2005, pp. 1142-1147
THE ROLE OF HEALTH PROFESSIONALS
COMMUNITY HEALTH
Advocacy Overview
Advocacy Defined Identifying an issue Drawing attention to the issue Working towards a solution
Advocacy Process1. Organizing and coalition building
2. Finding information/research
3. Policy and strategy development
4. Mobilizing and communications
Policy Link - www.policylink.org Physicians for Healthy Communities Section #3 pp. 4-6
THE ROLE OF HEALTH PROFESSIONALS
COMMUNITY HEALTH
Community organizing Commitment Structure, roles & decision making Conflict resolution Resources Communication Duration Keeping people engaged & motivated
Immediately connect people to action Celebrate victories and analyze efforts
Policy Link - www.policylink.org
Step 1 - Organization and Coalition Building
THE ROLE OF HEALTH PROFESSIONALS
COMMUNITY HEALTH
Professional Partnerships California Medical Association American Medical Association American Academy of Pediatrics
Community Coalitions and Initiatives CNN: statewide projects KP HEAL-CHI: Richmond, Modesto, Santa Rosa TCE-HEAC: Oakland, Shasta, Baldwin Park, Santa Ana, San
Diego, South LA DHHS-Steps: Santa Clara, Monterey Other: Concord, East Palo Alto, Vallejo, Sacramento, Fresno
Step 1 - Organization and Coalition Building
THE ROLE OF HEALTH PROFESSIONALS
COMMUNITY HEALTH
Step 2 - Finding Information and Research
Why To help understand the
issues To help identify priorities To help make your
argument
What Accessible, credible, clear Data and stories
Policy Link - www.policylink.org
“Removing soda from school won’t help me lose weight. The only exercise I ever get is walking upstairs to this vending machine.”
THE ROLE OF HEALTH PROFESSIONALS
COMMUNITY HEALTH
Step 2 - Finding Information and Research
Use the internet
Contact individuals and organizations
Access public records and proceedings
Conduct polling and surveys
Review completed research
Policy Link - www.policylink.org
THE ROLE OF HEALTH PROFESSIONALS
COMMUNITY HEALTH
U.C. Berkeley Center for Weight and Health http://www.cnr.berkeley.edu/cwh
Centers for Disease Control and Prevention http://www.cdc.gov/
Institute of Medicine http://www.iom.edu
Guide to Community Preventive Services http://www.thecommunityguide.org
California Project LEAN http://www.californiaprojectlean.org/
E. N. A. C. T. http://www.preventioninstitute.org/
Shaping America’s Youth http://www.shapingamericasyouth.com/
Step 2 - Finding Information and Research
THE ROLE OF HEALTH PROFESSIONALS
COMMUNITY HEALTH
California Health Interview Survey (CHIS) Overweight & Chronic Conditions Health Behaviors Adults and Children http://www.chis.ucla.edu
Center for Public Health Advocacy Overweight & Fitness Children in 5th, 7th & 9th Grades http://www.publichealthadvocacy.org
Step 2 - Finding Information and Research – Data Sources
THE ROLE OF HEALTH PROFESSIONALS
COMMUNITY HEALTH
The Problem What issue will be your focus? Is it big enough? Is it small
enough?
The Solution How much can you ask for?
The Process The Players
Allies and opponents Power mapping - strength of
opposition or support
Policy Link - www.policylink.org
Identifying targets, opposition and tactics Primary targets: the people
who have the power to give you what you want
Secondary targets: the people who can influence the primary targets (media)
Who has the power to organize an effective opposition?
Pick an action you believe has some chance of success
Know your priorities and the bottom line
Step 3 - Policy and Strategy Development
THE ROLE OF HEALTH PROFESSIONALS
COMMUNITY HEALTH
Step 3 - Policy and Strategy Development
National Policy Food advertising to children Farm subsidies Medicare reimbursement
State or Local Policy School nutrition and physical activity Built environment and organizational practices
Local Policy and Organizational Practices Implementation and enforcement of existing regulations Pilot testing of potential new state legislation
THE ROLE OF HEALTH PROFESSIONALS
COMMUNITY HEALTH
Step 3 - Policy and Strategy Development - The Players
Howard Taras, MD, FAAP, UCSD, Division of Community Pediatrics & School Health
State level
School district level
School level PrincipalPrincipal
School boardSchool board
SuperintendentSuperintendent
School Improvement Council
Central office staffCentral office staff
Chief state school officerChief state school officer
State education agency staffState education agency staff
Local government
State board of educationState board of educationLegislatureLegislatureGovernorGovernor
School staffSchool staff
THE ROLE OF HEALTH PROFESSIONALS
COMMUNITY HEALTH
School Boards: responsible for: vision, budget choices, policies within state/federal laws, (curricula)
Superintendents: hired by school board; provide leadership; translate board policy to actual operations
Principals: supervise school programs in their school and enforce regulations. Some have discretion over: schedules, curriculum, food services. Key gatekeepers; support is crucial.
Food Service Directors: day-to-day decisions on: school lunch, breakfast, cafeteria staffing, food safety, food environment. Responsible for being within budget and complying with regulations. Varying influence on vending contracts and school advertisements.
Step 3 - Policy and Strategy Development - The Players
Howard Taras, MD, FAAP, UCSD, Division of Community Pediatrics & School Health
THE ROLE OF HEALTH PROFESSIONALS
COMMUNITY HEALTH
Step 4 - Mobilizing and Communications
Outreach Directly to Policymakers Letters, phone calls, e-mails to decision-makers Meet with decision-makers and/or their staff Testify before a committee
Reach People Who Can Influence Policymakers Outreach to other organizations for support Educate the public through strategic events and
media coverage Produce fact sheets or reports Protests and grassroots activities
Policy Link - www.policylink.org
THE ROLE OF HEALTH PROFESSIONALS
COMMUNITY HEALTH
Framing the issue in such a way that others see themselves affected by it
Develop 3 key strategic messages Identify the target audience Identify spokespeople Build and nurture relationships with the media Become familiar with media tools: press conferences,
letters to the editor Develop communication products: media packets, fact
sheets, success stories news clippings Clear timeline: short and long term goals
Policy Link - www.policylink.org
Step 4 - Mobilizing and Communications
THE ROLE OF HEALTH PROFESSIONALS
COMMUNITY HEALTH
Subject Matter Expertise
Prevention and Health Promotion
Population Management
Public Health Strategies
Skills
Leadership and Influence
Advocacy Strategies
Public Speaking and Media Events
Step 4 - Mobilizing and Communications – Knowledge & Skills
THE ROLE OF HEALTH PROFESSIONALS
COMMUNITY HEALTH
Physicians for Healthy Communities Toolkit
School Presentation Toolkit
Speaker’s Bureau Manual
Key Messages
School and Community Power Point Presentations
Colleague Recruitment Power Point Presentation
Research Articles
Other Resources Available to Physicians
Physicians for Healthy Communities CD Rom
Christine Maulhardt – CMA Foundation – cmaulhardt@cmanet.org – 916-551-2874
THE ROLE OF HEALTH PROFESSIONALS
COMMUNITY HEALTH
Step 4 - Mobilizing and Communications - Effective Speaking
Adapt your presentation to meet the needs of your audience
Practice, practice practice Use the simplest (low-literacy) words possible, avoid
jargon Ask for audience participation “What are your ideas on
how to get kids to eat healthier or be more active?” Relax and use a conversational tone Use examples from your practice Use powerful stories to convey your message Use humor carefully, it is safest to joke about yourself
CMA Foundation - Physicians for Healthy Communities Initiative - sect #2 pp. 9-14
THE ROLE OF HEALTH PROFESSIONALS
COMMUNITY HEALTH
Step 4 - Mobilizing and Communications - Effective Speaking
Opening - Point of View
Key Point #1 - The Problem
Key Point #2 - The Solution
Key Point #3 - The Benefits
Closing - Reinforce Point of View
CMA Foundation - Physicians for Healthy Communities Initiative
Organizing Your Talk
THE ROLE OF HEALTH PROFESSIONALS
COMMUNITY HEALTH
Step 4 - Mobilizing and Communications - Organizing Your Talk
Opening Use storytelling to convey your point State what you are advocating for (sect. #3 pp. 4-5)
Key Point #1 - The Problem Define the problem (sect. #3 pp. 2-3, 7, 11, 12; sect. #4 pp. 3-
17; sect. #5 pp. 1-20; sect. #6 pp. 4, 6-8) Tailor the message to match the audience using
community or race/ethnicity data (sect. #3 pp. 3)
Key Point #2 - The Solution Ask audience for their ideas for solutions Give proposed solutions tailored to the
audience/community (sect. #3 pp. 8, 10, 12; sect. #4 pp. 19, 20; Sect. #5 pp. 19, 20; sect. #6 pp. 12-18)
CMA Foundation - Physicians for Healthy Communities Initiative
THE ROLE OF HEALTH PROFESSIONALS
COMMUNITY HEALTH
Step 4 - Mobilizing and Communications - Organizing Your Talk
Key Point #3 - The Benefits What’s in it for me? Give proposed benefits tailored to
the audience/community (sect. #3 pp. 8, 9, 12; sect. #4 pp. 18)
Closing Re-state what you are advocating
for (sect. #3 pp. 4-5)
Use storytelling to reinforce your recommendation and improve self-efficacy
CMA Foundation - Physicians for Healthy Communities Initiative
THE ROLE OF HEALTH PROFESSIONALS
COMMUNITY HEALTH
Over 20% of children and 60% of adults in California are overweight. (CDC,
www.chis.ucla.edu, www.publichealthadvocacy.org)
I think we’re looking at a first generation of children who may live less long than their parents as a result of the consequences of overweight and type 2 diabetes. (N Engl J Med Vol. 352(11) March 2005, p1138-1145)
A Latina born in the year 2000 has a 1 in 2 lifetime risk of developing diabetes - (JAMA 2003 October 8;290(14):1884-1890)
Once rare in children, Type 2 Diabetes is now 32% of new cases, a 10 fold increase from 1982-1994. (Pediatrics May 2005 Vol. 115 No. 5: pp. e553-e560)
Health care for obese individuals costs an average of 37% more than for people of normal weight, adding an average of $732 to the annual medical bills of every American. (Health Affairs May 14, 2003; W3:219-226)
Step 4 - Mobilizing and Communications – Key Messages
THE ROLE OF HEALTH PROFESSIONALS
COMMUNITY HEALTH
Step 4 - Mobilizing and Communications - Effective Speaking
CMA Foundation - Physicians for Healthy Communities Initiative
Case Study…You are asked by a community coalition to give a talk to community members to gain support for improving pedestrian and bicycle safety in the community.
What specifically do you want to advocate for? (sect. #3 pp. 4-5)
Who are the key policy makers (primary targets)? Develop an opening story to illustrate your point of
view
THE ROLE OF HEALTH PROFESSIONALS
COMMUNITY HEALTH
Media: Must Do... Your homework - know your key points and media format Practice delivering your introduction, message and presentation Dress professionally and maintain eye contact with the host Stay on message, insert your key points or story within the
context of their questions
Media: Must Do Not… Assume the reporter knows the subject Ever tell a lie, provide incorrect data or stretch the truth Try to cover too many subjects, ramble or use jargon Become defensive or argumentative with a reporter
Policy Link - www.policylink.org
Step 4 - Mobilizing and Communications - Media
THE ROLE OF HEALTH PROFESSIONALS
COMMUNITY HEALTH
Where can I start working on community advocacy?
What changes would you like to see happen in your schools or community?
What community efforts could you join?
Who is in your circle of influence? Your Clinic or Hospital
Your Child’s School
Your Place of Worship
Your Clubs or Organizations
THE ROLE OF HEALTH PROFESSIONALS
COMMUNITY HEALTH
Using a Proactive Focus to Improve Effectiveness
Proactive people focus their efforts in the circle of influence, working on things they can do something about.
The results of these activities are usually positive which leads to an expansion of the circle of influence into the circle of concern
Circle of
Concern
Circle of
Influence
The 7 Habits of Highly Effective People S.Covey
THE ROLE OF HEALTH PROFESSIONALS
COMMUNITY HEALTH
Possible Strategies for Health Care
Train physicians to routinely measure BMI and provide counseling
Provide weight management services for patients who are overweight
Provide lactation services for breastfeeding mothers Track BMI, diabetes and other complications and implement
quality improvement and population based strategies Train physicians to be community advocates Physical activity programs and food policy at healthcare
facilities
THE ROLE OF HEALTH PROFESSIONALS
COMMUNITY HEALTH
Policy & Environmental Change at Healthcare Facilities Food policy - cafeteria, vending machines, patient meals, gift
stores, food at professional meetings Pumping rooms for breast feeding mothers Infant formula - eliminate free samples and marketing Baby Friendly hospitals
Organizational Practices Access to health care BMI as a vital sign Access to weight management and breastfeeding programs Breast feeding, communication & advocacy training
Possible Health Care Policy and Organizational Practices
THE ROLE OF HEALTH PROFESSIONALS
COMMUNITY HEALTH
CATCH - Community Access to Child HealthOne Pediatrician Can Make a Difference!
Mission - to support pediatricians who work with communities to assure that children have medical homes and access to other needed health care services. The medical home. Local people can solve local problems using local resources. Pediatricians can make a difference in their communities. Experiences and successes can be shared.
The CATCH Program Provides: Training Technical Assistance and Resources Funding Opportunities
CATCH Program - 847-434-7085 catch@aap.org
THE ROLE OF HEALTH PROFESSIONALS
COMMUNITY HEALTH
10 Tips for Health Professional Advocates
1. Choose Your Issue2. Identify Solutions3. Identify Supporters4. Develop a Strategy5. Frame Your Message6. Educate7. Mobilize Supporters8. Testify9. Don’t Give Up10. Vote!
AAP Division of State Government Affairs – stgov@ aap.org
THE ROLE OF HEALTH PROFESSIONALS
COMMUNITY HEALTH
“The normal physician treats the problem;
the good physician treats the person;
the best physician treats the community.”
Chinese proverb
A Latina Born in the Year 2000 Has a 1 in 2 Lifetime Risk of Developing Diabetes - JAMA 290(14):1884
The Power of Storytelling
THE ROLE OF HEALTH PROFESSIONALS
COMMUNITY HEALTH
How ready am I to commit time to work on this issue as a community advocate?
Who is in my circle of influence?
What is one thing I can do in the next month?
Health Professional Community Advocacy
5
ReadyNot Ready
2 3 410 8 9 1076
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