“Talk Back”Studies in Community

Health “Public Health is the science and art of preventing disease, prolonging life, and promoting health and efficiency through organized community efforts”

(Winslow, 1920)

)

Public Health Approach

Public HealthModel

Medical Model

Versus

Key Terms

Community Health – health status of a defined group of people, and the actions

and conditions to promote, protect, and preserve their health

Public Health– actions that society takes collectively to ensure that the

conditions in which people can be healthy can occur; may be at national, state, or local level

Community Nutrition in Action 5th ed. by Boyle & Holben

Key Terms

Population Health– health status or health outcomes of a population. This

includes the:• distribution of health outcomes within a population• health determinants that influence distribution of health• policies and interventions that impact the determinants

“Fulfilling society’s interest in assuring conditions in which people can be healthy” (IOM report,

1988)

Distribution of health outcomes

USA spends > 17% of its GDP on health but performs low in quality, access, efficiency, equity, and health outcomes.

In 2006, • Over 43.8 million Americans were uninsured• 8% of adults did not receive needed medical care• 10% received delayed care• 9% indicated they did not fill prescriptions because

of cost

Obesity - common, serious, and costly• Obesity-related conditions include:

– heart disease– Stroke– Type 2 diabetes– Certain types of cancer

• Est. annual medical cost in U.S.A. – Overall cost $147 billion in 2008 – Per individual, annually cost $1,429

higher than those of normal weight. • ~75% of Americans

are overweight or obese

• Over one-third of U.S. adults are obese.

Healthy People 2010 – released in 2000

• How have we done?– Obesity continues to rise– Little progress on physical activity– Some progress on calcium intake– Health disparities continue– Little or no improvement in dietary fat intake or

consumption of fruits, vegetables, and whole grains

Health Determinants

Determinants of Health

Health starts where we live,

learn, work,

and play.

Policies and interventions

Public Health in the US

~Mission~Promote physical and mental health and

prevent disease, injury, disability

~Vision~Healthy People in Healthy Communities

Public Health seeks to…

• Prevent epidemics and the spread of disease

• Protect against environmental hazards

• Respond to disasters

• Prevent injuries

• Promote healthy behaviors

• Assure the quality and accessibility of health services

What Is Healthy People 2020?

■ A national agenda that communicates a vision for improving health and achieving health equity.

■ A set of specific, measurable objectives with targets to be achieved over the decade.

■ These objectives are organized within distinct Topic Areas.

Key Features of Healthy People

■ Creates a comprehensive, strategic framework that unites health promotion and disease prevention issues under a single umbrella.

■ Requires tracking of data-driven outcomes to monitor progress and to motivate, guide, and focus action.

■ Engages a network of multidisciplinary, multisectoral stakeholders at all levels.

■ Guides national research, program planning, and policy efforts to promote health and prevent disease.

■ Establishes accountability requiring all PHS grants to demonstrate support of Healthy People objectives.

Evolution of Healthy People

Target Year 1990 2000 2010 2020

Overarching Goals

• Decrease mortality: infants–adults

• Increase independence among older adults

• Increase span of healthy life

• Reduce health disparities

• Achieve access to preventive services for all

• Increase quality and years of healthy life

• Eliminate health disparities

• Attain high-quality, longer lives free of preventable disease

• Achieve health equity; eliminate disparities

• Create social and physical environments that promote good health

• Promote quality of life, healthy development, healthy behaviors across life stages

# Topic Areas 15 22 28 39*

# Objectives/Measures 226/NA 312/NA 467/1,000 >580/1200

* With objectives

1. Access to Health Services

2. Adolescent Health*

3. Arthritis, Osteoporosis, and Chronic Back Conditions

4. Blood Disorders and Blood Safety*

5. Cancer

6. Chronic Kidney Disease

7. Dementias, Including Alzheimer’s Disease*

8. Diabetes

9. Disability and Health

10. Early and Middle Childhood*

11. Educational and Community-Based Programs

12. Environmental Health

13. Family Planning

14. Food Safety

* New Topic Area for 2020

Healthy People 2020 Topic Areas / National agenda

15. Genomics*

16. Global Health*

17. Healthcare-Associated Infections*

18. Health Communication and Health Information Technology

19. Health-Related Quality of Life*

20. Hearing and Other Sensory or Communication Disorders

21. Heart Disease and Stroke

22. HIV

23. Immunization and Infectious Diseases

24. Injury and Violence Prevention

25. Lesbian, Gay, Bisexual and Transgender Health Issues*

26. Maternal, Infant and Child Health

27. Medical Product Safety

28. Mental Health and Mental Disorders

* New Topic Area for 2020

Healthy People 2020 Topic Areas (continued)

29. Nutrition and Weight Status

30. Occupational Safety and Health

31. Older Adults*

32. Oral Health

33. Physical Activity

34. Preparedness*

35. Public Health Infrastructure

36. Respiratory Diseases

37. Sexually Transmitted Diseases

38. Sleep Health*

39. Social Determinants of Health*

40. Substance Abuse

41. Tobacco Use

42. Vision

* New Topic Area for 2020

Healthy People 2020 Topic Areas (continued)

Community Case Study 1 - • Setting: National Healthy

Mothers, Healthy Babies Coalition

• Trigger: Grant opportunity for MCH Title V funding

• Local Agency’s goal: To improve maternal inter-conceptual Nutrition

National Healthy Mothers, Healthy Babies Coalition (HMHB) is an American non-profit organization founded in 1981 in response to the US Surgeon General’s conference on infant mortality.

…”develop, enhance and expand State Title V MCH data capacity to allow for informed decision making and resource allocation that supports effective, efficient and quality programming for women, infants, children and youth, including children and youth with special health care needs. ”

The funding source’s

objective…

Integrate Healthy People 2020 as a guide Community Program development

http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=26

Preconception Health and BehaviorsHP2020 Goals

• MICH-14 Increase the proportion of women of childbearing potential with intake of at least 400 µg of folic acid from fortified foods or dietary supplements

• MICH-15 Reduce the proportion of women of childbearing potential who have lower red blood cell folate concentrations

• MICH-16.2 Increase the proportion of women delivering a live birth who took multivitamins/folic acid prior to pregnancy

• MICH-16.5 Increase the proportion of women delivering a live birth who had a healthy weight prior to pregnancy

Nutrition Education: Linking Research Theory and Practice. Slides: Isobel R. Contento, Ph.D, CDN & Pamela Koch, Ed.D, RD

Strategies directed at mediators of food choice and diet-related action

Food behaviors/practices

- Fruits and vegetables- Breastfeeding

- Resource management

Food behaviors/practices

- Fruits and vegetables- Breastfeeding

- Resource management

Conceptual Framework for Theory-Based Nutrition Education: A Logic Model

Motivational mediators Why to take

action

- Risks and concerns

- Benefits

- Attitudes

- Preferences- Self-efficacy- Social norms

Environmental mediators

- Interpersonal and social support

- Institutional/community actions- Policies, systems, and food environment

Improved health

Decreased disease risk

Decreased food insecurity

Improved health

Decreased disease risk

Decreased food insecurity

Action mediators How to take

action

- Action plans- Knowledge- Food skills- Self-

regulation skills

- Personal agency

Inputs

• People

• Time

• Materials

• Money

• Space

• Partners

• Needs assess-ment process

• People

• Time

• Materials

• Money

• Space

• Partners

• Needs assess-ment process

Intervention activities

• Conduct classes

• Facilitate groups

• Develop product resources

• Work with families

• Work with community partners

• Work with media

• Work with policy makers

Intervention activities

• Conduct classes

• Facilitate groups

• Develop product resources

• Work with families

• Work with community partners

• Work with media

• Work with policy makers

OutcomesOutputs: Theory-Based Intervention

Food system impacts

Food system impacts

Societal impactsSocietal impacts

HMHB Activity – develop a rough outline of a program plan that would fit both your

agency’s and the grant funder’s goals

1. Primary Prevention – to promote healthy behaviors / health promotion

2. Target audience – low income postpartum women who are at high risk of short inter-conceptual period.

3. HMHB goal – Increase inter-conceptual period to 2 years, establish a healthy weight prior to pregnancy, increase the proportion of women who took multivitamins/folic acid prior to pregnancy.

4. MCH Title V Grant goal – to prospectively evaluate a community-based MCH health intervention to provide quality data to allow for informed decision making and future resource allocation.

HMHB Activity

1. Clarify your goal statement for the grant request.

2. Outcome objective(s)?

3. Process objectives(s)?

4. Structure objectives (s)?

Make the objectives S.M.A.R.T.

(Specific, Measurable, Achievable, Relevant, Time-bound)

HMHB Goal: __________________________1. Outcome objective:

How do you plan to measure pre and post program health or

nutritional outcome?

2. Process objective(s): Level of InterventionLevel 1: Build awarenessLevel 2: Change lifestyleLevel 3: Create a supportive environment

3. Structure objective(s):What are the inputs you need to make this happen?

INPUTS ACTVITIES OUTPUTS OUTCOMES IMPACT

Staff / people

Time

Materials

Space

Partners

Money

Community Case Study 2 – WIC Breastfeeding Promotion

• Trigger: Biannual program planning cycle• Local Agency’s program objective: By 2016,

increase the % of African American infants who are still being breastfed at 6 month recert from 18% to 22% (equal to the rate of Caucasian infants)

• Existing program component: Breastfeeding Peer Counselor Program

• Strategy: Improve evaluation of breastfeeding promotion activities establishing quality date to allow for better decision making and resource allocation

WIC Breastfeeding Promotion Activity

Process Objective: To design three high quality evaluation methods of breastfeeding promotion activities that can be implemented no later than 10/1/2014.

1. Formative evaluation

2. Process evaluation

3. Impact evaluation

4. Outcome evaluation

5. Structure evaluation

6. Cost-Benefit analysis

Community Case Study 3 – Head Start & Child Obesity

• Trigger: Local Head Start program solicited your assistance after identifying 53% of their 4 year olds were at or above the 85% BMI for age. They are requesting you design a culturally-appropriate family-based intervention.

• Cultural considerations: Of 50 families, 47% are Hispanic. 29% are African American. 24% are Caucasian. All are at or under 130% of poverty level.

• Assignment: What strategies could you use to best design a “culturally appropriate” intervention?

Community Engagement

• The building of ongoing, permanent relationships between agencies and individuals for the benefit of a community.

• Focus is on moving the community towards positive change.

• Differs from community organizing in that its usually addressing a stalled or stagnant position.

Let’s Move! – 2010 initiative with 5 pillars

1. Create a healthy start for children

2. Empower parents and caregivers

3. Providing healthy foods in schools

4. Improving access to healthy affordable foods

5. Increasing physical activity

2012 Improved Nutrition Standards for School Meals

• Ensuring students are offered both fruits and vegetables every day of the week;

• Substantially increasing offerings of whole grain-rich foods;

• Offering only fat-free or low-fat milk varieties;• Limiting calories based on the age of children

being served to ensure proper portion size; and

• Increasing the focus on reducing the amounts of saturated fat, trans fats and sodium.

Community Engagement – “moving forward on a stalled initiative”

• In Georgia, kids resisted the loss of their beloved fried chicken.

• In New Mexico, whole-wheat tortillas went straight to the trash can.

• In Tennessee, after schools replaced familiar flaky white biscuits with a whole-grain variety, one official reported a “severe amount of rejection.”

How can we engage the “community” of school lunch recipients?

https://www.youtube.com/watch?feature=player_profilepage&v=4BpvihkVRGU#t=0

https://www.youtube.com/watch?v=xt1eb8lfOpQ&list=PLUE0faBef-IGe5yHce4fjMdnAjrzo__Ms

https://www.youtube.com/watch?v=Xul5kqhm_QM

https://www.youtube.com/watch?v=FpyGlw5cDb4

Relationship Between

Patient/Client/Group & Dietetics

Professional

-

Nutrition Diagnosis Ø Identify and label problem Ø Determine cause/contributing risk

factors Ø Cluster signs and symptoms/

defining characteristics

Nutrition Assessment Ø Obtain/collect timely and

appropriate data Ø Analyze/interpret with

evidence - based standards

Ø

Ø Identify risk factors Ø Use appropriate tools

and methods Ø Involve

interdisciplinary collaboration

Screening & Referral System

Outcomes Management Sys tem

Ø Monitor the success of the Nutrition Care Process implementation

Ø Evaluate the impact with aggregate data Ø Identify and analyze causes of less than

optimal performance and outcomes Ø Refine the use of the Nutrition Care

Process

NUTRITION CARE PROCESS IN

COMMUNITY

Ø Document

Nutrition Monitoring and Evaluation Ø Monitor progress Ø Measure outcome indicators Ø Evaluate outcomes Ø Document

Nutrition Intervention Ø Plan nutrition intervention

· Formulate goals and determine a plan of action

Ø Implement the nutrition intervention · Care is delivered and actions

are carried out Ø Document

Document

How can we use NCP when the patient is a community?

A.D.I.M.E.A. – Assess your Community

oCommunity Needs Assessmento Analysis of cause of problemso Identify existing resources o Seek to quantify unmet need

Steps in a Community Needs Assessment

• Clarify the target population • Set the scope of the assessment• Collect the data

– Local demographics, local morbidity & mortality data– Local surveys and screenings as resources allow– State and National data (compare / extrapolate)

• Analyze and interpret the data• Report the findings to stakeholders• Set priorities and choose a plan of action

Tools: National Nutrition Monitoring and Related Research Program (NNMRRP)

• Established by Congress in 1990 • Implementation by USDA and DHHS • Over 50 surveillance system monitor and

assess the dietary, nutritional, and related health status of the population

5 areas of national data collection

• Nutritional status and nutrition-related health measures

• Food and nutrient consumption• Knowledge, attitudes, and behavior assessments• Food composition and nutrient data bases• Food supply determinations

2010 Cengage-Wadsworth

2010 Cengage-Wadsworth

National Health and Nutrition Examination Survey (NHANES)

• Representative sample of non-institutionalized civilian population ages 2 months and older

• Dietary intake (one 24-hour recall)• Body composition• Biochemical analyses of blood and urine• Bone density• Dietary and health behaviors• Collects data at household, family, and individual level

NHANES

• Data used to develop reference standards for nutritional status• update CDC growth charts

• National prevalence's of diseases• Trends in nutrition status

2010 Cengage-Wadsworth

2010 Cengage-Wadsworth

“What We Eat in America Survey”

• Dietary interview component of NHANES• Individuals in households, one sample with all

levels of income, another of low-income households

• One-day and 3-day food intakes of individuals (1-day recall, 2-day record)

• Times of eating occasions• Sources of food eaten away from home

2010 Cengage-Wadsworth

Total Diet Study (TDS)

• Eight age groups, infant through elderly• Assesses for nutrients and contaminants in

foods• Estimates levels of 11 essential minerals•Collects and analyzes foods from retail

markets in urban areas• Assesses additives and contaminants

• e.g exposure to mercury from fish & shellfish

2010 Cengage-Wadsworth

Behavioral Risk Factor Surveillance System (BRFSS)

• Annually since 1984 • Telephone survey of adults 18 y.o. and older

• Demographic information• Height, weight• Smoking, alcohol use• Weight control practices• Diabetes• Preventable health problems• Cholesterol-screening practices, awareness, treatment• Food frequencies for dietary fat, fruit, and vegetable

consumption

LOCAL SOURCES:Personal Health Data:

• Vital statistics• Epidemiology• Disease registries• Health screening

• Hospital discharge data

• University research

• Health program evaluation data

Data on local concerns & resources:

• Health resource inventory• Public forums• Polling• Focus Groups

• Information from private & non-profit providers

• Special methods- MAPP

• Mobilizing for Action through Planning & Partnerships

MAPP – 4 Assessments

• Community Themes and Strengths• Local Public Health System• Community Health Status • Forces of Change

• In both clinical practice and community settings• Issues with liability, confidentiality (HIPPA, CLIA)• Will the data be assessed on aggregate? • Follow-up when positive risks identified

Local Health Screenings

Health Impact Assessment (HIA)“A combination of

procedures, methods, and tools

by which a policy, programme or project may be judged as to its potential effects on the health of a population, and the distribution of

those effects within the population.”

WHO, European Centre for Health Policy. Gothenburg Consensus Paper, Health Impact Assessment- main concepts and suggested approach. Brussels, 1999.

The purpose/function of HIA is to:

• Inform and influence the decision maker• Help address inequalities in health.• Promote collaborative effort.• Place public health on the agenda• Reduce conflict between stakeholders• Encourage sustainable development

Examples of where HIA has been used.– Urban traffic pattern changes.– Local school policy to implement safer routes to

school.– Building an out-of-town shopping center requiring

more vehicular traffic.– Assessing the common agricultural policy.

Think DETERMINANTS OF HEALTHThis tool has potential for RD / Urban Planner collaboration. More info at www.who.int/hia.

Are basic needs being met in your community?

Health Equity

“Equity in health implies that ideally everyone

could attain their full health potential

and that no one should be disadvantaged

from achieving this potential

because of their social position

or other socially determined circumstance.”

Whitehead, M. & Dahlgren, G. (2006)

62Assess the disparity or equity among your population subgroups…

Food Security Survey 2010

Household food security is access at all times to enough food for an active healthy life for all household members.

Quick History of Food Assistance Programs

• 1930s Great Depression – government distribution of food commodities

• 1939 Experimental Food Stamp program, (became permanent in 1964)

• 1946 National School Lunch Act• 1972 WIC established • 1996 Welfare Reform – Welfare to Work

5 programs account for 94% of USDA’s expenditures

for food assistance

• FSP / SNAP – Supplemental Nutrition Assistance Program (entitlement)

• NSLP – National School Lunch Program

• WIC – Supplemental Nutrition Program for Women Infants and Children

• SBP – School Breakfast Program

• CACFP - Child and Adult Care Food Program

How does your community’s usage of these programs compare?

Possible NCP Diagnostic Codes

NC-3.3 Overweight/obesity

NC-3.4 Unintended weight gain

NB-1.1 Food and nutrition-related knowledge deficit

NB-1.2 Unsupported beliefs / attitudes about food or nutrition related topics.

NB-1.7 Undesirable food choices

What data can you get?

Community P.E.S. Statement

(P): Obesity related to

(E) societal system supporting undesirable food choices, physical inactivity, and nutrition-related knowledge deficit as evidenced by

(S) NHANES and BRFSS data and local school data indicating continuing increase prevalence of mean population adult BMI > 30 and child BMI / Age ≥ 95%.”

I: Health Promotion / Disease Prevention

• Focus on lifestyle (behavior) change to work toward optimum health by…

• Design and implement a health promotion intervention which to promoting health and preventing disease by …

Three types of prevention efforts:

• primary prevention – preventing disease by controlling risk factors

• secondary prevention – detecting disease early through screening and other forms of risk appraisal

• tertiary prevention – treat and rehabilitate people with illness or injury

M/E: Monitor and evaluate…

• Design your evaluation strategy and tools as you initially plan your program

• Consider what information you need to collect to justify your program (and your budget)

• Take time to verify and validate your assessment tools

• Integrate your reports to your funding source(s) as part of your “M/E”

Be a Interdisciplinary PH team player…

NursesEpidemio-logists

Dietitians &

Nutritionists

Dentists

Dental Hygienists

Social workers

Administra-tive

Profession-

als

Doctors

Environmental

Health Inspectors

Nurse Practi-tioners

Health Promoter

Program Planners/Evaluator

s

Community Nutrition Competencies1. Mange nutrition care for population groups across the

lifespan

2. Participate in nutrition surveillance and monitoring

3. Conduct outcome assessment and evaluation of community-based programs

4. Participate in community-based research

5. Consult with agencies on food access for populations

6. Develop and deliver health promotion projects

7. Participate in food and nutrition policy development

8. Provide training and facilitate community capacity building

© 2013 Cengage-Wadsworth

Practice Settings of Community Dietitians and Public Health Nutritionists

Trends impacting Community Nutrition• An aging population • Generational diversity• Increasing ethnic diversity• Increasing demands for health services /

cost containment / privatization• Environmental challenges• Risks of multidrug resistant bacteria• The promise of nutrigenomics

http://www.youtube.com/watch?v=KJ6_ymvQxBk

What will be our futurein roles in population

health?

Think outside the square!