Fengqiong Zhou

Department of Health Management

Canadian Conference on Global Health 2010(formerly Canadian Conference on International Health)

GLOBAL HEALTH: A HUMANITARIAN CRISIS?Sunday, October 31st to Wednesday November 3rd, 2010,Oattwa

Cross-Culture Research for Developing

Chinese version of the WHO Self-Assessment

Tool for Health Promotion in Hospital

OUTLINE

1. Object

2. Context

3. Methodology

4. Result

5. Result explanation and discuss

6. Conclusion

Objective -1Develop a Chinese version of WHO Self-Assessment Tool for Health Promotion in Hospital (WHOSATHPH) through cross-culture research method.

Objective -2 Discuss the strategies of developing health

promotion in hospital(HPH) inundeveloped regions;

Explore the role of value and culture ofHPH on performance effect of health caresystem.

Context Why develop HPH?

Hospitals play a central role in the health care system;

Hospital expenditures

are the main part of total health

investment in most countries;

Hospital cost $

>= 60% of total health

expenditure

Hospitals produce a great

deal of waste materials;

Hospitals can become

Potentially hazardous

workplaces.

Hospitals are high “people volume” institutions

and are the distribution centers of health and

disease knowledge.

Why develop WHOSATHPH ?

WHOHPH theory and principles offset the defects of the current hospital service evaluation standard system.

Traditional Hospital Service Evaluation System

International Organization for Standardization (ISO),

Total Quality Management (TQM),

Principles of European Foundation for Quality Management (EFQM) .

The Joint Commission on Accreditation of Health Care Organizations (JCAHO),

Joint Commission International (JCI)

Traditional Values and Strategies for Hospital Management

Health Expert

In hospital

Quality Control

Medical Science

Technology

Pharmacy

Disease Treatment

The defects of Traditional Hospital Service Model

Health Expert

American people assess their health care system

Source: Debating Health: Election 2008, Harvard School of Public

Health/Harris Interactive. March 5-8, 2008

http://www.hsph.harvard.edu/news/press-releases/2008-releases/republicans-

democrats-disagree-us-health-care-system.html.

U.S. is...

Better Worse Same DK/Ref

Canada 40% 30% 4% 26%

France 31% 14% 3% 53%

Great Britain 37% 17% 6% 40%

WHO HPH Conception and Principle

Theory and Principles of HPH

Source from: Groene Oliver, 2006

Patient & People’s

HEALTH

In and outside Hospital

Nutrition, water, air, exercise

Social Science

Foster Health Values and

Culture

Lifestyle intervention

Health Education

Medias and propaganda

Medical science and technology

Pharmacy

New functions and roles for HPH

Main values and principles of WHO HPH development

HEALTH

Health Investment and Health Promotion

6714

342

The United States China

Total expenditure on health per capita (Intl $, 2006)

The United

States

China

80

7575

72

Female Male

Life Expectancy at Birth

26

94

145

1410 9

Physicians

density

Nursing and

midwifery

personnel

density

Other health

service

providers

density

The United States(2000)

China(2005)

per 10000 population ( data resource : WHO)

In Unite States, the cost of medical service

is 5.9% of total family expenditure

In China, the cost of medical service is

12.5% of total family expenditure

The resources for HPH development between

China and USA

The effectiveness and strategies for HPH

development;

The management and performance of HPH in

health care system;

The Relationship between Health Promotion and

economic development, burden or motivation?

The challenges and questions for HPH

development

The changes for Chinese health professionals to develop HPH are

very big.

Serve 1.3billion population who live in the polluted environment.

China’s health service resources are scarce. Even so, the limited

Health resource distribution is extremely unbalance and unfair.

•

The Challenges for China HPH Development

Because of the serious defect of health policy and political policy

and institution, serious insufficient financial investment on health

care system, China health professionals have to gain money from

patients’ pocket directly.

Patient can not get equal access health service.

China’s health service resources are scarce.

Even so, the limited Health resource distribution is

extremely unbalance and unfair. Patient can not get

equal access health service.

China Hospital VIP Ward

Sanitarium for

Senior Officers

General hospital

for Public

Nursing Hospitals and wards for

Officers

China General Hospital and ward

China Doctors’ Work Environment

Health workers generally have to face various huge work

stress and work in unsafe work environment.

China Doctor Moral Models: China government requirements

to health workers,

only contribute their life and talent without asking for any remuneration

= be a happy slavery

One Chinese Hospital’s doctors and Nurse have to

take on Helmet when they work.

Developing a Chinese version WHOASHPH

and test its reliability for further international

comparison research and help China hospital

leaders practice and follow complete HPH

principle;

Give a primary description of China HPH

developing level;

Found the further research for HPH theory

developing and practices.

A falling leaf can indicate that

autumn’s coming……

Methodology

Cross-culture research process

Translated the source

instrument from English into

Chinese

Pilot

test

Spot field

investigation

(Non-probability

sampling )

Back translated

it into English

Reliability Test

Cross-culture research process:

Translated the source instrument from English into

Chinese;

Pilot test: Investigated 8 Chinese health specialists in

Montréal;

Back translated it into English;

Two health specialists and the author of WHO self-

assessment tool for HPH (Prof. Oliver Groëne)

commented the language equivalence of the back

translation version.

WHOSATHPH (Groene Oliver, 2006)

WHOSATHPH (Groene Oliver,2006)

Standard1 Management policy

Semantic Equivalence Research

Chinese version and English version

准确 corre

ct

不清楚no

clear

错误wrong

能 yes

不能no

符合逻辑 logical

不符合illogi

cal

准确 corre

ct

不清楚no clear

错误wrong不理解的词

can`t

understand

不合适的词 not proper

建议用词suggested word

有价值valuab

le

没有no

不清楚don`t

know

1.1

1.2

1.3

1.4

2.1

2.2

2.3

3.1

3.2

对条目作用意义的评

价comment the value to this item每个词语的理解 understanding to words

一

1

2

3

标准 stand

ard

针对问题 to item 针对词语 to word and phrase

维度domain

条目

i tem

code

你认为这个问题问的是什么what do you think about

this question

用自己的

话复述 repeat by own`s

words

对选择答案的解释

explanation

对某个特定术语和词组的认识 understanding to a term and

phrase

22 Hospitals were sampled from three different

“GRADS” Chinese Hospitals from 5 June to 30

August 2008;

40 hospital leaders, 3 health management

researchers, and 1 government officer were

interviewed or investigated;

The Sampling cities chosen were from the different

economic development levels in China developed

East region (Shanghai), middle developed region

(Hefei), and undeveloped West-South region

(Kunming);

Spot field investigation

(Non-probability sampling )

The Geography of the Sample Hospitals

The name of Shanghai Sample Hospitals GradeSick-

beds

The First Affiliated Hospital of Kunming Medical University3

1500

The Second Affiliated Hospital of Kunming Medical University 1200

Wu Hua People Hospital 2 160

Wu Hua Fengning Community Hospital1

22

Wu Hua Community Health Service Center 0

Kunming Sample Hospitals Grade Sick-beds

The First Affiliated Hospital of Anhui Medical University

3

1890

Hefei Second Civic People Hospital 550

Hefei First Civic People Hospital 1600

Anhui Provincial Hospital 1400

Hefei Second Civic People Hospital 2 321

Shushan Administration Division San Li An Community Health Service Center

1

48

Shushan District community Health Service Center 50

Shushan Jingang Town Community Health Service Center 50

Anhui Sample Hospitals Grade Sick-beds

China Best Teaching Hospitals

Shanghai Community Hospital

9 hospitals, 15 hospital leaders were from Shanghai;

8 hospitals, 10 hospital leaders were from Hefei;

4 hospitals, 15 hospital leaders were from Kunming.

All the respondents voluntarily completed the

questionnaire survey independently; Repeated

questionnaire survey was also completed voluntarily after

3-7 days .

The HPH activities Record in Kunming First Affiliated Hospital

Results

48

Language equivalence test

Backward translation English version compared with the original

English version;

1.2 The hospital arranges the resources for the

implementation of health promotion• 1.2.1• The hospital makes a special budget

and materials to ensure the implementation of health promotion services.(evidence: check the budget and personnel resources)

• 1.2.2• All clinical departments can provide the

operational guidelines or pathways with regard to health promotion.(evidence: check guidelines)

• 1.2.3• The easy recognized structures and

facilities (including resources, spaces, equipments) for health promotion have been built up by the hospital.

• (evidence: special elevator for patients.)

WHO Self assessment tool for HPHcompletely the same

9

Objective:

1. to describe the framework of health promotion, to integrate health promotion as a part into the quality management system in hospital.

WHO Self assessment tool for HPH

Objective• To describe the framework for the

organization’s activities concerning health promotion as an integral part of the organization’s quality management system.

1. completely the same thing 2.almost the same3. Some 4. almost not5. completely different

6

The Reliability of Chinese version WHOSATHPH

Only one word was marked as having a different meaning between

the back translation version and the original version by all of 40

items ( the word in Chinese version --- back-translation -- the originalversion is : 满足 – Satisfy -- Match).

The reliability of Chinese version

WHOSAHPH

The general Cronbach's alpha of the Chinese version

WHOSATHPH was 0.938.

For each domains:

management and policy was 0.793;

patients assessment was 0.819;

patient information and prevention was 0.807;

healthy workplace was 0.785;

continuity and cooperation was 0.755.

The results showed that the Chinese version WHOSATHPH has high internal consistency and good language equivalence. But it still needs further large sample size research for the further validity test.

Self assessment of HPH development score mean

by China hospital leaders (ANOVA, SPSS.16)

Grade I Grade II Grade III Officer

and

other

TOTAL

Mean SD Mean SD Mean SD Mean SD

Number 11 9 21 2 41

Total means 144.82 48.2 158.67 32.1 154.19 33.6 148 152.7 37.1

management

policy

28.45 8.1 29.44 8.6 27.67 7.9 28 27.6 7.97

patient

assessment22.6 8.8 23.8 6.2 24.1 6.6 38 23.6 7.0

patient

information and

intervention

19.45 9.7 21.33 5.8 21.57 5.7 16 20.35 6.9

Develop healthy

workplace32 13.6 36.89 7.7 35.43 8.7 36 34.8 10.0

continuity and

cooperation26.18 11.8 30.22 6.1 28.43 7.4 30 28.22 8.4

China HPH development level

Total Grade1 Grade2 Grade3

shangha

i Hefei

Kunmi

ng

sha

ngh

ai

Hefe

i

Kunmi

ng

shang

hai

Hef

ei

Ku

nmi

ng

shan

ghai

Hef

ei

Kun

min

g

N 12 10 13 3 3 2 3 2 3 6 5 8

Total HPH mean

score 136.83 148.2 168.8

145

.3

132.

3 168.5 143.33

156.

5

165

.3 129.3

148.

2

170.

1

management

policy 22.67 29.4 33.92 25 29.7 34.5 23.33 29 36 21.17 29.4 33

patient assessment 34.33 26.2 45.23

38.

33 21.7 47 38 28 40 30.5 26.2 46.8

patient information

and intervention 18.83 23.8 23.31

20.

67 18.7 24.5 18.33 26 22 18.17 23.8 23.5

developa healthy

workplace 33.42 37.2 38

32.

33 33.7 38 33.33 37.5

39.

33 34 37.2 37.5

continuity and

cooperation 27.58 31.6 28.31 29 28.7 24.5 30.33 36 28 25.58 31.6 29.4

Self assessment of HPH development score mean

by China hospital leaders

Cities :

Shanghai HPH (N=15): 142.1 + 26.4

Hefei HPH (N=10): 162.3 + 40.0

Kunming HPH (N=15): 160.6 + 42.6

The mean Score of Self-assessment HPH by

China Hospital leaders

Grade III (N=21) Mean + SD: 154.19 + 7.3

Grade II (N=9) Mean + SD: 158.67 + 10.7

Grade I (N=11) Mean + SD: 144.82 + 14.54

The results indicated that Chinese hospital leaders

self-assessed a high HPH development level. China

Hospitals HP level didn’t present general statistic

significant difference in hospital size and in regions

with different levels of economic development.

Different Grades Hospitals:

Discussion

China HPH development feature

Groene Oliver found that Europe bigger hospitals

may have better possibilities to implement health

promotion standards than smaller ones in

European HPH development research. But in this

study, China’s HPH development level didn’t

show that HP level is related to hospital size or

economic development levels.

However, further large sample size research is

needed for more general results and conclusion

about China HPH development situation.

TCM and HPH

HP has always been China’s basic rule and policy with respect to health development because of HP value in TCM.

To handle the pressures resulting from the shortage of the health investment, China Health Ministry has to depend on TCM to provide accessible,

affordable, safe and

effective health services.

China Health Promotion Philosophy

A great doctor must concentrate and

aspirate his profession without any

selfish desire and lust when he treats

disease. He ought to have great

philanthropy and compassion

to people, and swears to rescue

Patient’s sufferings.

— Dr. Simiao Sun (541-682)

Golden Rules for Health Promotion

Dr. Simiao Sun ( 581-682)

To promote health, people should keep good life

style and life habits.

People should self perfect his personal quality,

don't touch the deleterious things. As long as

people self health promotion of his body and

spirit, he will not attach any disease neither his

body nor his mind. There is not any source to

produce disaster. It is the Golden Rule for health

promotion.

People, who well know the strategy of health promotion, focus on the prevention of disease. This is the Golden Rule of health promotion.

Therefore, when people practice the activities of health promotion, he not only focuses on medicine and nutrition, but also stressed on his behaviours.

Only when people have perfected his behaviours, he could have long well healthy life even without medicine.

Without quality healthy behaviours, people could not have long quality life; even he has the best medicine.

Golden Rules for Health Promotion

Long Health Life/ China HP culture and practice

China Famous TCM doctors all have a health long life. In the history, sixty

TCM famous doctors lived over 70 years old, most of them lived over 80

years old, a few of them even lived over 100 years old.

A famous TCM doctor who is 94

years old, he daily works time

is 10 hours.

A 90 years old Chinese lady who has

excellent health body with natural black

hair. She started to practise healthy daily

food style 60 years ago when she was

sick. Since she ate healthy food daily, she

never gets sick and always keeps health.

TCM integrates health philosophy, health value

and culture concerns into the social sciences

that advocates the disease prevention rather

than treatment, treats ailments in a timely way

before it becomes serious, stresses that

disease treatment should combine mental and

physical elements, emphasizes the harmony

between mind and body, man and society, as

well as man and nature. all of which match the

core principles of WHO HPH.

China HPH Developing Principles and StrategiesEmphasize the patients-center;

public benefits,

disease prevention,

(ex. Regular and free or cheap public

disease screening)

Primary healthcare service first.

Focus on school health education

and healthy lifestyle education.

Depend on the regular evaluation and inspection of medial service quality and security;

Emphasize health professional ethics;

Stress on the adaptive healthcare service development that matching the national/regional economic developing conditions.

Various evaluation and Competition

Shanghai HPH Practices Effect

In 2007, Shanghai health

expenditure per capital ranged

from $90 to $540, life expectancy

was 78.37/83.29( M/F) years,

infant mortality was 3/1000,

Maternal Mortality was

6.68/100000 given birth.

(Data source: Shanghai Health Ministry,

2008 Statistic Report).

Focus on HPH efficiency and close cooperation.

Stress on interactivity between patients, the public, and health professional workers.

Focus on the exchange

of successful world

experiences regarding

New theory, technology,

and management.

China

Undeveloped country, Gross national income per capita (PPP international $): 4,660

1.3billion population,

Polluted environment,

The USA

Developed Country

Gross national income per capita (PPP international

$): 44,070

0.3billion population

Healthy environment

Chinese doctor’s office

China HPH Developing Conditions

Chinese hospital crowded and noisy

waiting hallThe US hospital register center

U.S doctor’s office

The US. hospital ICU wardOne China best HPH teaching Hospital ICU ward

China National Health Education Activities and Far-ranging National HP Movement

Stress is put on the professional ethics and a spirit of

dedication. Emphasize the public, universal, and benevolent

value of health service and National HP movement.

USA Hospital Service Model is disease treatment

model but not health promotion model

The health care system relies heavily on private and not-for-profit

health insurance which drives the health care system in a

marketing business direction.

Over stress the money value and business

marketing role of the health service system;

It ignores the public benefit value and public

participation of health service.

Lessons learnt from the US failing in HPH practices

Over depend on advanced medical professional

services;

Ignores the national Pubic HP;

Ignores the important role of the entire society’s

(public) participation in the health promotion

movement;

Ignores fostering a healthy lifestyle and culture

development.

Lessons learnt from the US failing in HPH practices

Conclusions

Reliability

•The Chinese version WHOSATHPH has a high internal consistency and good language equivalence.

Value of HPH Development

•HPH development level may not be related directly to advanced and expensive medical equipment, the environment conditions and health expenditure's.•The hospital size might be not related to the HPH developing level.

Strategy of HPH

• Developing country ( or an economically undeveloped region) can develop high effective performance of HPH through national public participation movement. • Fostering a national HP value and culture is more effective and important than unique money investment for HPH developing.

Issues and suggestions for

HPH Development

Stress on healthy lifestyle

education since

childhood

National deversified health

promotion campaign and

government financial support

Synthesize Prevention and Treatment,

Primary and Advanced Medical Service.

Acknowledgement

University of Montreal

Department of Administration of Health(Farand Lambert, Régie Blais, et al)

Direction of International Relation( Yves Guay)

Fudan University (Fu Hua, Zhou Lei, et al)

Anhui Medical University ( Ma Ying, et al)

Kunming Medical University( Wan Chonghua, et al)

Montreal University Women Club.

Professor: Oliver Groëne and Jiqian Fang

China research cooperation partners for this research

Professor Fu Hua

(First Line, middle)

and his graduated

students (Shanghai)

Prof. Wan Chonghua

(Kunming)

Dr. Ma Ying`s

students

(Hefei)

The First Affiliated Hospital of Sun Yat-sen University

(Guangzhou)

The hospital where I had worked for seven years. Today, it has 2228 hospital

beds, has the most advanced medical equipment, is one largest hospital in

China.