FOR STATE OF CALIFORNIA Esteban Cruz, MD Director, Community Initiatives Kaiser Permanente Southern...

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


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


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

2 3 410 8 9 1076


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.”


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


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.


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


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


COMMUNITY HEALTH

Community Health:

An Evidence-

Informed Approach


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


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


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


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


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?


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


COMMUNITY HEALTH

Which community PA interventions have insufficient evidence?


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


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


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


Which worksite interventions have good evidence?


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


COMMUNITY HEALTH

The Role of Health

Professionals in

Community Advocacy


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


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.


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


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


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


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


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


“Removing soda from school won’t help me lose weight. The only exercise I ever get is walking upstairs to this vending machine.”


COMMUNITY HEALTH


Use the internet

Contact individuals and organizations

Access public records and proceedings

Conduct polling and surveys

Review completed research



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/



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


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


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


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


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


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


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



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


Step 4 - Mobilizing and Communications


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


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 – [email protected] – 916-551-2874


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


COMMUNITY HEALTH


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


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)



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



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


COMMUNITY HEALTH



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


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


Step 4 - Mobilizing and Communications - Media


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


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


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


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


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 [email protected]


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


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


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

FOR STATE OF CALIFORNIA Esteban Cruz, MD Director, Community Initiatives Kaiser Permanente Southern...

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