Turning Issue Areas into Action

1. Turning Issue Areas into Action

2. The “Ecology” of Medical Care Green LA, et al. N Engl J Med 2001;344:2021-5.

3. Making Something Happen Perceptions of Data DATA Perceptions on Capacity to Solve the Problem Where the Action Is

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

5. 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 In a public statement to the media, she advocates that COUNTY funds be withdrawn from the PRIVATE company and that a volunteer ambulance service be started.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.

6. What’s the Problem? Don’t assumeyou 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

7. Childhood Obesity What is Known Regarding Childhood Obesity

8. A Review of Literature • Summations of Evidence for Findings in the Following Settings: • Surveillance • Clinical • Schools • Community • Education

9. 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

10. 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

11. Levels of Prevention Epidemiology “ At- Risk” Health Promotion Health Hazard Appraisal Primary Prevention Screening Secondary Prevention Early Diagnosis Tertiary Prev. Disease

12. 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)

13. Surveillance Need • It is suggested that there are three critical periods for the development of overweight in children • Intrauterine or early infancy • 5 to 7 years of age • Adolescence • Approximately one half of over weight school-age children and three quarters of overweight teenagers grow up to be obese adults (ADA Report)

14. 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)

15. 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

16. 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

17. 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

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

19. 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)

20. 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

21. 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 family- based interventions, involved behavioral counseling in which one or more family members accompanied the patient;

22. 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.

23. 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

24. 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

25. 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= OutcomeQuestionDo 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 DecisMak. 2007;7:16.

26. 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

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

28. Schools • Active Education: Physical Education, Physical Activity and Academic Performance RWJ Active Living Research – Research Brief 2009

29. 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.

30. 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

31. 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.

32. 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.

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

34. Group Activity • Design a PICO Intervention regarding childhood obesity in the school environment

35. Community • CDC Strategies July 24, 2009 MMWR

36. 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

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

38. Types of Policy Action Direct Indirect Monetary Provide Tax Purchase Subsidize Nonmonetary Prohibit Inform Require Implore O’Hare, M. “A Typology for Government Action” 1989

39. 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

40. 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

41. Activity • Fill out the Policy Quadrant trying to solve the following. Getting women to attend all their pre-natal care visits

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