Healthy IslandsJanuary 1, 2011

OUTLINE• Healthy Islands: Mission & Goals• Ecological Framework• Food System Model• Interaction Framework Availability Accessibility Interaction

• Social Communication Strategy• Monitoring & Interventional Framework• MAPPS Framework

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HEALTHY ISLANDS: MISSION & GOALS• Mission: Healthy Islands will improve the health and quality of life of

the populations of island communities

• Goals Address the crisis of non-communicable diseases Ensure the community has access to a healthy food supply Ensure community members live in a health-promoting environment Develop the capacity of the health workforce Improve the health literacy of the population Empower community members to make healthy decisions Provide the community with a financially sustainable health system Institutionalize the program with an organization and governance model

capable of ensuring long-term viability

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ECOLOGICAL FRAMEWORK• The NCD Plan will translate into a portfolio of interventional projects• Projects will be targeted to specific areas of the ecological framework

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ECOLOGICAL FRAMEWORK

INDIVIDUALS

SOCIAL NETWORKS & GROUPS

COMMUNITY SYSTEMS

COMMUNITY TIERS & SYSTEMS

ECOLOGICAL FRAMEWORK

FOOD SYSTEM : EXCHANGE MODEL• The food system can be represented using a set of models that describe

actors, their roles and their various kinds of interactions

FOOD SYSTEM : TIERS• The food system can be represented as a series of tiers comprised of

interconnected markets

FOOD SYSTEM : VALUE CHAIN

FOOD SYSTEM : ACTOR ROLES• The (simplified) food system model consists of a series of

interconnected markets • Actors may play multiple roles within the various markets

• Farm producers provide raw materials to Food Makers• Food Makers produce food for Food Sellers• Food Sellers sell food to Food Consumers

FOOD SYSTEM : ACTORS

FOOD SYSTEM STRATEGY

FOOD SYSTEM STRATEGY

AGRICULTURAL MARKET

AGRICULTURAL MARKET

AGRICULTURAL MARKET

AGRICULTURAL MARKET

• With a farmer’s market, the farmer handles transportation to the marketplace

• With a farm stand, the consumer purchases food at the farm site

FOOD SYSTEM EXAMPLES• Farmer’s markets and farm stands represent two

highly simplified food systems; the farmer and consumer transact directly with each other

AGRICULTURAL MARKET

FOOD SYSTEM EXAMPLES• Another simple food system has roles for farmers and

consumers, with an intervening set of distributors for transportation; there is no intervening food manufacturer

• Fresh produce does not involve manufacturing or processing of foods

FOOD SYSTEM EXAMPLES• Various arrangements may exist between food sellers

such as grocery stores and supermarket chains and farmers

AGRICULTURAL MARKET

FOOD SYSTEM EXAMPLES• Schools and restaurants are two types of food

service establishments

AGRICULTURAL MARKET

AGRICULTURAL MARKET

FOOD SYSTEM : INTERMEDIARIES• The food system may include additional

intermediaries that handle distribution, warehousing and transportation functions

• Food wholesalers are sometimes present

FOOD SYSTEM: LOCAL VS EXTERNAL MARKETS• The food system may include agricultural producers

or food makers from within the local region or located externally

FOOD PRODUCTION MARKET

FOOD PRODUCTION

FOOD SYSTEM: SUPPLY CHAIN• The food system generally includes complex supply

chain arrangements between food companies and the manufacturers of various food production inputs

FOOD PRODUCTION

HOME PREPARATION

FOOD SERVICES MARKET

FOOD SYSTEM : ACTORS

• The conceptual food system with the community can be mapped to a physical marketplace with consumers and providers are defined locations

• Spatial interaction becomes an important factor in the physical market• Actors have to negotiate distance in order to transact within the

marketplace

FOOD SYSTEM: CONCEPTUAL TO PHYSICAL MARKETS

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FOOD SYSTEM: COMMUNITY SETTINGS

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INTERACTION: COMMUNITY SETTINGS• The community setting plays a key role in shaping the lived experience

of community members • Each community member occupies and transitions between various

settings during the course of any given day• Settings offer health promotion opportunities in terms of nutrition and

physical activity

Settings

•Homes (own home, others’ homes)

•Work sites

•Schools, after-school settings

•Child care settings

•Health and social welfare settings

•Other community-based settings(e.g. community centers, churches)

•Recreational sites

•Retail settings

•Restaurants, fast-food venues

•Food stores

INTERACTION FRAMEWORK : SUMMARY• The interaction framework applies to the dynamic interactions between

the community member and various resources within the community.• The resource may be another community member or a physical

resource such as food to be consumed• The framework provides a model for understanding the various

ecological factors that influence the ability of community members to engage in various activity

• A key concern is understanding how ecological factors influence interactions between geographically separated actors and resources

INTERACTION FRAMEWORK• Interactions between actors and resources involve several dimensions• Individual dimensions relate the aspects of the actor participating in

the interaction• Other interaction dimensions involve aspects of the external

environment, which mediate between the actor and the resource

ACCESSIBILITY• Accessibility plays a key role in community member activities where

interaction involves distance between the actor and the resource

ACCESS: CLIMATE AND GEOGRAPHY• The climate and geography of the region may influence the interactions

between the actor and resource

ACCESS: TRANSPORTATION NETWORK & MODALITIES• Transportation networks and the transportation options available to the

actor directly shape the accessibility of a given resource

RESOURCE AVAILABILITY AND ALTERNATIVES• Resource availability is independent from accessability• Availability relates to whether the desired resource is present at a

given location, as well as what alternative options are available

AVAILABILITY: SELECTION FACTORS• Multiple selection factors influence the actor’s choice of location and

selection of resource from available alternatives

AVAILABILITY: OTHER DIMENSIONS• More complex aspects of resource availability include the proximity of a

given resource at a given location to other desired resources or locations

INTERACTION: PROXIMITY AND TIMING• The ecological framework is focused on understanding the lived

experience of community members in terms of how their time is spent engaged in their daily activities and interacting with the various community settings.

• The community member’s day can be viewed in terms of the physical settings they occupy as well as the activities they engage in

INTERACTION: PROXIMITY AND TIMING• Proximity and timing dynamically shape the interaction between actors

and resources

INTERACTION: INDIVIDUAL DIMENSIONS• Individual dimensions influence the interaction between actors and

resources

SOCIAL COMMUNICATION STRATEGY: SUMMARY• Health promotion activities should leverage social networks Social networks provide a set of trusted relationships and communications

channels that can enable rapid dissemination of health promotion information

The social communication strategy should leverage the multiple, overlapping networks and social groups that each community member belongs to

Using multiple social communication channels raises the likelihood of reaching every community member

Relying on multiple social communication channels provides an opportunity to mutually reinforce health promotion information from independent sources

Multiple social communication channel reduce the likelihood of community members receiving inaccurate or incomplete health promotion information

The social communication strategy supports an efficient train-the-trainer approach to disseminating health promotion information

A successful social networking strategy will require strong commitment to health promotion from the trusted leadership of the various social groups

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SOCIAL NETWORK AND GROUP TYPES• Types of social groups/networks available Family: immediate/nuclear, extended kinship networks

Extended social networks: friends and acquaintances

Work groups

Community groups• Youth groups

• After-school activity groups

• Sports teams

• Volunteer groups

• Church groups

• Other neighborhood or village groups

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SOCIAL GROUP INTERFACES• The divisions of roles within a social network/group enables efficient

dissemination of health promotion information Groups may have multiple interfaces based on member roles

Group interfaces serve as a coordination point for dissemination of health promotion information

Health promotion Information may be tailored to specific group member roles

Group members playing a communications coordination role may further tailor or customize the health promotion information

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KINSHIP NETWORKS• Kinship Networks Kinship covers relationships between community members based on descent

(‘consanguinity’) and marriage (‘affinity’)

Descent networks are based on genetic relationships (immediate/nuclear and extended families)

Affinity networks describe abstract social patterns of relationships that are not based on genetics

Different cultures have differing kinship systems and terminology

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•Individuals are genetic offspring of a single union.

•Individuals may form various types of unions – with various degrees of formal significance in terms of legal or religious recognition.

•An individual may form multiple unions, giving rise to multiple sets of offspring.

•An individual may form a union with someone with offspring from an earlier union.

EXTENDED FAMILY NETWORKS• Extended Family Networks extending beyond the community member’s immediate family may

be wide-ranging and complex

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EXTENDED SOCIAL NETWORKS• Extended Social Networks Community members may participate in a wide-ranging set of informal

relationships with others in the community

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ORGANIZED COMMUNITY GROUPS• Organized Community Groups Community members may participate in organized groups with varying types

and degrees of formal group organization, membership structures and roles, and forms of participation

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WORK GROUPS• Work groups Community members may participate in the formal or informal economies

through membership in various work groups

Work groups and subgroups have various types and degrees of formal group organization, membership structures and roles, and forms of participation

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METHODOLOGY: PROBLEM ANALYSIS

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CAUSAL WEB: MACRO-ECONOMIC SYSTEM

CAUSAL WEB: FOOD MARKETS

CAUSAL WEB: BUSINESS PERFORMANCE

CAUSAL WEB: WORKFORCE HEALTH

STRATEGIC DRIVERS, GOALS AND OBJECTIVES

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TACTICAL, OPERATIONAL AND EXECUTION PLANS

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PATIENT CARE EXAMPLE

PATIENT CARE EXAMPLE

PATIENT CARE EXAMPLE

PATIENT CARE EXAMPLE

PATIENT CARE EXAMPLE

MONITORING AND INTERVENTION : GROUPS

MONITORING AND INTERVENTION : SYSTEMS

MONITORING AND INTERVENTION : ENVIRONMENT

MONITORING AND INTERVENTION : ENVIRONMENT

MONITORING AND INTERVENTION : INTEGRATED

INTERVENTIONAL STRATEGY• Based on the MAPPS Framework Media Access Point of Decision Information Price Social Support Services

• Communities Putting Prevention to Work (CPPW) MAPPS is currently the framework for the CDC’s CPPW initiative

• Best-Practices Framework Evidence-based interventions drawn from the peer-reviewed literature and

expert synthesis Communities and states have found these interventions to be successful in

practice

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MAPPS FRAMEWORK• Focused on chronic diseases (non-communicable diseases) Target conditions: obesity, diabetes and cardiovascular disease Responsible for 7 of 10 deaths Vast majority of serious illness-related disability Greatest contributor to healthcare expenditures (75%)

• Addresses key risk factors Lack of physical activity Poor nutrition Tobacco use (out of scope – addressed elsewhere)

• Specific goals Decrease overweight/obesity prevalence Improve nutrition (e.g. increased fruit/vegetable consumption, reduced salt

and trans-fat) Increase levels of physical activity

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STRATEGIES AND INTERVENTIONS• High-Level Strategies Strengthen healthcare infrastructure

Reduce costs through prevention Advance public health across the lifespan Reduce health disparities Reduce risk factors Prevent and/or delay onset of chronic disease Promote wellness

• Intervention Approach Policy, systems and environmental change Communities and schools Positive behavior change related to nutrition and physical activity

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MAPPS: MEDIA

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Interventions : Media

Nutrition Physical Activity

Media and advertising restrictions consistent with federal law

Promote healthy food/drink choices Counter-advertising for unhealthy

choices

Promote increased activity Promote use of public transit Promote active transportation

(bicycling and walking) Counter-advertising for screen time

MAPPS: ACCESS

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Interventions : Access

Nutrition Physical Activity

Promote healthy food/drink choices Healthy food/drink availability Limit unhealthy food/drink

availability Reduce density of fast food

establishments Eliminate trans-fat through

purchasing actions, labeling initiatives, restaurant standards

Reduce sodium through purchasing actions, labeling initiatives, restaurant standards

Procurement policies and practices Farm to institution, including

schools, worksites, hospitals and other community institutions

Safe, attractive accessible places for activity

City planning, zoning and transportation

Require daily quality PE in schools Require daily physical activity in

afterschool/childcare settings Restrict screen time (afterschool,

daycare)

MAPPS: POINT OF PURCHASE/PROMOTION

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Interventions : Point of Purchase/Promotion

Nutrition Physical Activity

Signage for healthy vs. less healthy items

Product placement & attractiveness Menu labeling

Signage for neighborhood destinations in walkable / mixed-use areas

Signage for public transportation, bike lanes/boulevards.

MAPPS: PRICE

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Interventions : Price

Nutrition Physical Activity

Changing relative prices of healthy vs. unhealthy items (e.g. through bulk purchase / procurement / competitive pricing)

Reduced price for park/facility use Incentives for active transit Subsidized memberships to

recreational facilities

MAPPS: SOCIAL SUPPORT AND SERVICES

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Social Support & Services

Nutrition Physical Activity

Support breastfeeding through policy change and maternity care practices

Safe routes to school Workplace, faith, park,

neighborhood activity groups (e.g., walking hiking, biking)