Turning Issue Areas into Action. Green LA, et al. N Engl J Med 2001;344:2021-5. The “Ecology” of...

Turning Issue Areas into Action

Green LA, et al. N Engl J Med 2001;344:2021-5.

The “Ecology” of Medical Care

Making Something Happen

DATAPerceptions ofData

Perceptions on Capacity toSolve the Problem

Where the Action Is

Adding Research to the CHIP Model—CHIP to CHIRP(McGinnis PB. Family & Community Health.2010)

Problem Solving ActivityThe baby was wrapped and waiting. She squirmed and perspired from the fever as well as the warm bunting. Her mother, Josina, began to cry. Why didn't the ambulance come? The baby was so sick.This sort of thing happened often in the Hispanic settlement that sat on the southwest edge of Laketown. People say an elderly women waited three hours for an ambulance last Wednesday.When her neighbors finally got her to the hospital, she was dead on arrival. Last month a stroke victim had called for help using the emergency number. He was told he would have to call his physician because he had no cash for the ambulance when it arrived.Laketown is a medium sized city (10,000) located in a rural area. Because of its two large factories, it has attracted workers from a variety of cultures. They live in ethnic settlements, throughout the city. Laketown now has divisions of Black, Caucasian, Hispanic and Asian groups. The Hispanic people are the least wealthy.Within the last few weeks a heated discussion has erupted in the community over the efficiency of the PRIVATE ambulance service.June Moreno, a social worker in the public assistance agency, has charged that the ambulance service was responsible for the death of an elderly Hispanic woman. She also thinks the ambulance service purposefully delays response to low income and minority areas.In a public statement to the media, she advocates that COUNTY funds be withdrawn from the PRIVATE company and that a volunteer ambulance service be started.Walter Carpenter, a prominent farmer and major stockholder in the private ambulance firm is furious with Moreno's charges. Moreno calls representatives from each settlement to a meeting. Carpenter also attends.

What’s the Problem?

• Don’t assume you know what the problem is without understanding the cause

• Don’t assume you know what is causing the problem without confirming it (use your data!)

• Don’t assume people are the problem• Don’t jump to countermeasures without

having a deep understanding of the problem

Childhood ObesityWhat is Known Regarding

Childhood Obesity

A Review of Literature

• Summations of Evidence for Findings in the Following Settings:– Surveillance– Clinical– Schools– Community– Education

Method

• Searched for manuscripts and documents which systematically reviewed the evidence presented in a variety of peer-reviewed research journals

• Present the overall findings based on settings for the delivery of the service

• Highlight areas on the CHIP to CHIRP model

Levels of Prevention

• Tertiary Prevention – interventions to slow down or reverse the increase in BMI

• Secondary Prevention – prevention efforts including the identification and intervention of asymptomatic children who are at risk for overweight

• Primary Prevention – prevention efforts occurring before individuals are overweight

Levels of PreventionEpidemiology

“ At- Risk” Health HazardAppraisal

HealthPromotion

PrimaryPrevention

Screening

Early Diagnosis

Disease

SecondaryPrevention

Tertiary Prev.

Surveillance

• Although BMI is a measure of relative weight rather than adiposity (fat), it is recommended widely for use among children and adolescents to determine overweight and is the currently preferred measure

• BMI may have limited validity for racial / ethnic minorities (Whitlock et al)

Surveillance Need

• It is suggested that there are three critical periods for the development of overweight in children

1. Intrauterine or early infancy2. 5 to 7 years of age3. Adolescence• Approximately one half of over weight school-age

children and three quarters of overweight teenagers grow up to be obese adults (ADA Report)

Clinical

• Limited research is available on effective, generalizable interventions for overweight children and adolescents that can be conducted in primary care settings or through primary care referrals (Whitlock et al)

• Recommendations include application of behavioral choice theory (Epstein et al)

QI Strategy: PDSA Cycles• Plan

– Define the objectives– Identify questions to be answered– Make predictions of the outcomes– Plan for change (who, what, when,

where)• Do

– Implement action (document problems, observations)

• Study– Analyze and compare the data to

predictions– Summarize findings– Move to implementation or return

to planning phase• Act

– Spread the process or change

What are we trying to accomplish?

Make sure the aim or objective is SMART

• Specific: What is the goal? Be precise in your description

• Measurable: Monitor the progress over time by describing what is being measured

• Actionable: Understand and overcome barriers• Realistic: Know your resources, team ability and

attention to achieving the goal• Timely: Establish a target date; set interim

milestones if necessary

Activity -CCO Measures

• Follow up After hospitalization for Mental Illness– Discharges fro members age 6> who were

hospitalized for treatment of selected mental health disorders and had an outpatient visit within 7 days of hospitalization

Position of the American Dietetic Association

• Reviewed only programs that included an outcome measure of weight status or adiposity (body weight, BMI, skinfold thickness, percent body fat)

Definitions

• Dietary Counseling / Nutrition• Physical Activity Counseling / Education• Sedentary Activity Counseling / Education• Behavioral Counseling• Family Counseling• Parent Training• Parent / Family Involvement• Physical Activity Environment• School Food Environment

Interventions Defineddietary counseling/nutrition education—dietary counseling includedthe prescription of a specified caloricand/or nutrient content perday; nutrition education involvedproviding more general informationon foods, shopping, and nutrition topromote healthful eating;● physical activity counseling/education—physical activity counselingincluded the prescription of a specifiedamount and/or type of physicalactivity; physical activity educationinvolved providing more general informationon physical activity forhealth and included providingphysical education in schools;

sedentary activity counseling/education—same as above but addressedsedentary activities such astelevision watching and video gameplaying;● behavioral counseling —involvedcounseling on self-monitoring ofdiet and physical activity, cueelimination, stimulus control, goalsetting, action planning, modeling,limit setting, and other behaviormodification strategies;● family counseling —specific to family-based interventions, involvedbehavioral counseling in which oneor more family members accompaniedthe patient;

Interventions Defined● parent training— specific to family-based interventions, involved behavioral counseling targeted at parents to improve their parentingskills, including limit setting, rolemodeling, and positive reinforcement;● parent/family involvement —specificto school-based studies, includedproviding parents with informationon healthful diet andactivity behaviors for their families;

● physical activity environment—specific to school-based interventions,included making changes to thephysical environment and to thestructure of physical educationclasses to promote physical activity;● school food environment—specificto school-based interventions, includedmaking policy and schoolfood service changes to promotehealthful eating.

What Works

• Two specific kinds of overweight interventions: a) multi-component, family based programs for children age 5-12 years and b) school-based programs for adolescents

• Multi-component programs include behavioral health counseling, promotion of physical activity, parent training/modeling, dietary counseling /nutrition education

Break down your question into concepts. These will be the building blocks of your

evidenced-based project.

QuestionDo standing desks help reduce Body Mass Index among middle school children?

ConceptsStanding desks, school furniture, body mass index, middle school, children, adolescents

Consider This Before You Begin

With some research questions PICO1 may help identify concepts for your literature search and project design.

P=Population

I= Intervention

C= Comparison

O= Outcome

QuestionDo standing desks help reduce Body Mass Index among middle school children?

P= middle school children I= standing desksC= traditional (seated) desks O= reduced Body Mass Index

1. Schardt C, Adams MB, Owens T, Keitz S, Fontelo P. Utilization of the PICO framework to improve searching PubMed for clinical questions. BMC Med Inform Decis Mak. 2007;7:16.

Reviewing Published Documents

Research Articles usually have the following sections:

Abstract: A short summary of the study and its findings

Introduction: Provides background and rationale for doing the study

Methods: Describes how the research carried out the study

Discussion: Provides and assessment of possible meanings and implications

References: Citations to other sources upon which the study was based

Schools

• Active Education: Physical Education, Physical Activity and Academic Performance

RWJ Active Living Research – Research Brief 2009

Schools

Studies consistently show that more time in physical education and other school-based physical activity does not adversely affect academic performance.

In some cases, more time in physical education leads to improved grades and standardized test scores.

Physically active and fit children tend to have better academic achievement. Evidence links higher levels of physical fitness with better school attendance and fewer disciplinary problems.

Pre-School / After School

• Preventing Obesity Among Preschool Children: How Can Child-Care Settings Promote Healthy eating and Physical Activity?

Source: RWJ Healthy Eating Research and Active Living Research- Research Synthesis October 2011

Pre- School

Research in child-care settings has identified opportunities to improve the nutritional

quality of foods provided to children, mealtime behaviors of caregivers, and theprovision of nutrition education.

Regulations regarding nutrition and physical activity practices in child-care settingsare limited and vary widely among and within U.S. states. Many preschool children enrolled in child care are not meeting recommendationsfor physical activity. Child-care practices and policies relating to 1) the amountof time allocated for physical activity; 2) required training and supportive staffbehaviors; and 3) appropriate physical settings for play have the potential toinfluence physical activity levels.

Pre School (Cont)There is some evidence of a relationship between use of informal child-carearrangements (e.g., relative care) and increased risk for obesity. Researchexamining the relationship between children’s weight status and use of formalchild-care arrangements (e.g., licensed family child-care homes, child-carecenters, Head Start programs) has produced mixed results. Opportunities for parent education and involvement may be limited in many childcaresettings, and only a few studies have examined parent perceptions relevant tonutrition and physical activity environments. Existing evidence indicates the following may be successful strategies for promotinghealthy eating and physical activity in child-care settings: integrating opportunitiesfor physical activity into the classroom curriculum; modifying foodservice practices;providing classroom-based nutrition education; and engaging parents througheducational newsletters or activities. At this time, it is not clear which combinationsof specific strategies are effective for reducing obesity among preschool children.

Group Activity

• Design a PICO Intervention regarding childhood obesity in the school environment

Community

• CDC Strategies July 24, 2009 MMWR

Community Strategies

• Strategies to Promote Availability of Affordable Healthy Food and Beverages

• Strategies to Support Healthy Food and Beverage Choices

• Strategy to Encourage Breastfeeding• Strategies to Encourage Physical Activity or

Limit Sedentary Activity• Strategies to Create Safe Communities that

Support Physical Activity

Types of Policy Action

Monetary

Direct Indirect

Nonmonetary

ProvidePurchase

ProhibitRequire

TaxSubsidize

InformImplore

O’Hare, M. “A Typology for Government Action” 1989

Types of Action by Quadrant

Direct / Monetary - Can provide service itself or purchase goods from private sector

Indirect / Monetary - Can enact commodity and excise taxes, tariffs, fines, quotas, fees, pricing systems. Can also provide compensation, subsidies, payments, vouchers, grants loans, tax credits, exemptions, insurance or similar mechanisms

O’Hare, M. “A Typology of Government Action” 1989

Types of Action by Quadrant

Direct / Non-Monetary - Can prohibit or restrict by rules, regulations, standards, quotas, licensing, and deregulation. Can also require through similar types of actions

Indirect / Non-Monetary - Can provide educational, informational and promotional efforts to modify behavior

O’Hare, M. “A Typlogy for Government Action” 1989

Activity

• Fill out the Policy Quadrant trying to solve the following.

Getting women to attend all their pre-natal care visits

Education / Knowledge

• We have yet to find a comprehensive evaluation of multiple education intervention in comparison with each other. We are continuing to search.

Turning Issue Areas into Action. Green LA, et al. N Engl J Med 2001;344:2021-5. The “Ecology” of...

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