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Esteban Cruz, MD Director, Community Initiatives Kaiser Permanente Southern California

Community Health The Role of Health Professionals. August 12, 2006 Los Angeles, CA . Esteban Cruz, MD Director, Community Initiatives Kaiser Permanente Southern California. Today we will talk about. Kaiser Permanente’s Approach to Overweight and Obesity

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Esteban Cruz, MD Director, Community Initiatives Kaiser Permanente Southern California

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  1. Community Health The Role of Health Professionals August 12, 2006Los Angeles, CA Esteban Cruz, MD Director, Community Initiatives Kaiser Permanente Southern California

  2. 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

  3. 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

  4. Health Professional Community Advocacy • 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?

  5. The Epidemic of Overweight and Obesity “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.” “By 2040 all Americans will be overweight or obese.” www.discoveryhealthCME.com, N Engl J Med Vol. 352(11) March 2005, pp. 1138-1145

  6. What is the trajectory of the obesity epidemic? JAMA, April 5, 2006, Vol 295, No. 13, 1549-1555

  7. 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.

  8. Kaiser Permanente’s Approach to Overweight and Obesity • Medical Office Visit Interventions • Weight Management Interventions • Environmental Changes

  9. Fetus Fetus Preventing: Infants Infants • SGA • LGA Promoting: Toddlers Toddlers • Breastfeeding Diagnosing: Children Children • Early Adiposity Rebound Increasing: Adults Adults • Physical Activity Decreasing: Increasing: • TV Viewing • Physical Activity • Sweetened Decreasing: Beverage • Portion Size Consumption Encouraging: • Weight The Permanente Journal/ Summer 2003/ Volume 7 No. 3 pp. 6-7 Maintenance A Longitudinal Approach to Preventing Overweight

  10. Community Health: An Evidence-Informed Approach

  11. Are overweight children a personal or community issue? 1,068 random sample CA residents, telephone survey 10-11/2003 http://calendow.org/caobesityattitudes/index.htm

  12. Ten Great Public Health Achievements 1900-99 • 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

  13. U.S. Tobacco Control Strategies • 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 N Engl J Med Vol. 350(3) 1/2004 pp. 293-301

  14. Community Health - An Evidence-Informed Approach • 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 Pediatrics April 2005;115:1142-1147

  15. Which community PA interventions have good evidence? • 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

  16. Which community HEAL interventions have good evidence? • 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 Am J Health Promotion 2005;19(3):167-193

  17. 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 http://www.thecommunityguide.org

  18. 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

  19. Which worksite interventions have good evidence? • 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 http://www.thecommunityguide.org

  20. Injury Prevention Strategies • 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

  21. The Role of Health Professionals in Community Advocacy

  22. Policy, Legislation and Environmental Change Pleasanton 2002 Pleasanton 2006 • 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 Governor’s Summit on Health, Nutrition and Obesity – September 15, 2005

  23. The Role of Health Professionals in Community Advocacy JAMA January 7, 2004 - Vol. 291, No. 1 pp. 94-98 • Provide quality care to individual patients in regular practice. • Improve the system of care delivered by group/organization. • Provide quality care to uninsured patients. • Improve insurance coverage, after-hours care and geographic distribution of services. • Environmental change in local schools and communities to address tobacco, injury prevention, and obesity. • Public policy to address same issues.

  24. 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. e328-346 Pediatrics Vol. 115 No. 4 April 2005, pp. 1142-1147

  25. Advocacy Overview • Advocacy Defined • Identifying an issue • Drawing attention to the issue • Working towards a solution • Advocacy Process • Organizing and coalition building • Finding information/research • Policy and strategy development • Mobilizing and communications Policy Link - www.policylink.org Physicians for Healthy Communities Section #3 pp. 4-6

  26. Step 1 - Organization and Coalition Building • 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

  27. Step 1 - Organization and Coalition Building • 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

  28. 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.” Policy Link - www.policylink.org

  29. Step 2 - Finding Information and Research • Use the internet • Contact individuals and organizations • Access public records and proceedings • Conduct polling and surveys • Review completed research Policy Link - www.policylink.org

  30. Step 2 - Finding Information and Research • 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/

  31. Step 2 - Finding Information and Research – Data Sources • 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

  32. Step 3 - Policy and Strategy Development • 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 • 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 Policy Link - www.policylink.org

  33. 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

  34. Step 3 - Policy and Strategy Development - The Players Howard Taras, MD, FAAP, UCSD, Division of Community Pediatrics & School Health

  35. Step 3 - Policy and Strategy Development - The Players • 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. Howard Taras, MD, FAAP, UCSD, Division of Community Pediatrics & School Health

  36. 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 Policy Link - www.policylink.org

  37. Step 4 - Mobilizing and Communications • 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 Policy Link - www.policylink.org

  38. Step 4 - Mobilizing and Communications – Knowledge & Skills • Subject Matter Expertise • Prevention and Health Promotion • Population Management • Public Health Strategies • Skills • Leadership and Influence • Advocacy Strategies • Public Speaking and Media Events

  39. 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 – cmaulhardt@cmanet.org – 916-551-2874

  40. 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

  41. Step 4 - Mobilizing and Communications - Effective Speaking Organizing Your Talk • 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

  42. 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) CMA Foundation - Physicians for Healthy Communities Initiative

  43. 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 CMA Foundation - Physicians for Healthy Communities Initiative

  44. Step 4 - Mobilizing and Communications – Key Messages • 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)

  45. Step 4 - Mobilizing and Communications - Effective Speaking 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 CMA Foundation - Physicians for Healthy Communities Initiative

  46. Step 4 - Mobilizing and Communications - Media • 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 Policy Link - www.policylink.org

  47. 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

  48. Circle of Circle of Influence Concern 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 The 7 Habits of Highly Effective People S.Covey

  49. 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

  50. Possible Health Care Policy and Organizational Practices • 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

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