Transcript Document

Turning Issue Areas into Action
The “Ecology” of Medical Care
Green LA, et al. N Engl J Med 2001;344:2021-5.
Making Something Happen
DATA
Perceptions of
Data
Perceptions on Capacity to
Solve the Problem
Where the Action Is
Adding Research to the CHIP Model—CHIP to CHIRP
(McGinnis PB. Family & Community Health.2010)
Problem Solving Activity
The 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In a public statement to the media, she advocates that COUNTY funds be withdrawn from the PRIVATE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 Obesity
What 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 Prevention
Epidemiology
Health
Promotion
Primary
Prevention
“ At- Risk”
Health Hazard
Appraisal
Screening
Early Diagnosis
Disease
Secondary
Prevention
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 infancy
2. 5 to 7 years of age
3. Adolescence
• Approximately one half of over weight schoolage 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
Adding Research to the CHIP Model—CHIP to CHIRP
(McGinnis PB. Family & Community Health.2010)
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 Defined
dietary counseling/nutrition education—
dietary counseling included
the prescription of a specified caloric
and/or nutrient content per
day; nutrition education involved
providing more general information
on foods, shopping, and nutrition to
promote healthful eating;
● physical activity counseling/education—
physical activity counseling
included the prescription of a specified
amount and/or type of physical
activity; physical activity education
involved providing more general information
on physical activity for
health and included providing
physical education in schools;
sedentary activity counseling/education—
same as above but addressed
sedentary activities such as
television watching and video game
playing;
● behavioral counseling —involved
counseling on self-monitoring of
diet and physical activity, cue
elimination, stimulus control, goal
setting, action planning, modeling,
limit setting, and other behavior
modification strategies;
● family counseling —specific to familybased interventions, involved
behavioral counseling in which one
or more family members accompanied
the patient;
Interventions Defined
● parent training— specific to
family-based interventions, involved
behavioral counseling targeted at
parents to improve their parenting
skills, including limit setting, role
modeling, and positive
reinforcement;
● parent/family involvement —
specific
to school-based studies, included
providing parents with information
on healthful diet and
activity behaviors for their families;
● physical activity environment—
specific to school-based
interventions,
included making changes to the
physical environment and to the
structure of physical education
classes to promote physical activity;
● school food environment—specific
to school-based interventions,
included
making policy and school
food service changes to promote
healthful 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.
Question
Do standing desks help reduce Body Mass Index among middle
school children?
Concepts
Standing 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
Question
Do standing desks help reduce Body Mass Index among middle school
children?
P= middle school children
C= traditional (seated) desks
I= standing 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
Adding Research to the CHIP Model—CHIP to CHIRP
(McGinnis PB. Family & Community Health.2010)
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 ResearchResearch 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 the
provision of nutrition education.
Regulations regarding nutrition and physical activity practices in child-care settings
are limited and vary widely among and within U.S. states.
Many preschool children enrolled in child care are not meeting recommendations
for physical activity. Child-care practices and policies relating to 1) the amount
of time allocated for physical activity; 2) required training and supportive staff
behaviors; and 3) appropriate physical settings for play have the potential to
influence physical activity levels.
Pre School (Cont)
There is some evidence of a relationship between use of informal child-care
arrangements (e.g., relative care) and increased risk for obesity. Research
examining the relationship between children’s weight status and use of formal
child-care arrangements (e.g., licensed family child-care homes, child-care
centers, Head Start programs) has produced mixed results.
Opportunities for parent education and involvement may be limited in many childcare
settings, and only a few studies have examined parent perceptions relevant to
nutrition and physical activity environments.
Existing evidence indicates the following may be successful strategies for promoting
healthy eating and physical activity in child-care settings: integrating opportunities
for physical activity into the classroom curriculum; modifying foodservice practices;
providing classroom-based nutrition education; and engaging parents through
educational newsletters or activities. At this time, it is not clear which combinations
of specific strategies are effective for reducing obesity among preschool children.
Adding Research to the CHIP Model—CHIP to CHIRP
(McGinnis PB. Family & Community Health.2010)
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
Adding Research to the CHIP Model—CHIP to CHIRP
(McGinnis PB. Family & Community Health.2010)
Types of Policy Action
Direct
Monetary
Provide
Purchase
Nonmonetary Prohibit
Require
O’Hare, M. “A Typology for Government Action” 1989
Indirect
Tax
Subsidize
Inform
Implore
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.