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

2. THE ROLE OF HEALTH PROFESSIONALS COMMUNITY HEALTH Today we will talk about... Kaiser Permanentes Approach to Overweight and Obesity Community Health - An Evidence- Informed Approach The Role of Health Professionals in Community Advocacy

3. THE ROLE OF HEALTH PROFESSIONALS COMMUNITY HEALTH 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. THE ROLE OF HEALTH PROFESSIONALS COMMUNITY HEALTH 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? Health Professional Community Advocacy

5. THE ROLE OF HEALTH PROFESSIONALS COMMUNITY HEALTH I think were 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. The Epidemic of Overweight and Obesity www.discoveryhealthCME.com, N Engl J Med Vol. 352(11) March 2005, pp. 1138-1145 By 2040 all Americans will be overweight or obese.

6. THE ROLE OF HEALTH PROFESSIONALS COMMUNITY HEALTH JAMA, April 5, 2006, Vol 295, No. 13, 1549-1555 What is the trajectory of the obesity epidemic?

7. THE ROLE OF HEALTH PROFESSIONALS COMMUNITY HEALTH About Kaiser Permanente (KP) One of the nations 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. THE ROLE OF HEALTH PROFESSIONALS COMMUNITY HEALTH Kaiser Permanentes Approach to Overweight and Obesity Medical Office Visit Interventions Weight Management Interventions Environmental Changes

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

10. THE ROLE OF HEALTH PROFESSIONALS COMMUNITY HEALTH Community Health: An Evidence- Informed Approach

11. THE ROLE OF HEALTH PROFESSIONALS COMMUNITY HEALTH 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. THE ROLE OF HEALTH PROFESSIONALS COMMUNITY HEALTH 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 Ten Great Public Health Achievements 1900-99

13. THE ROLE OF HEALTH PROFESSIONALS COMMUNITY HEALTH 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 U.S. Tobacco Control Strategies N Engl J Med Vol. 350(3) 1/2004 pp. 293-301

14. THE ROLE OF HEALTH PROFESSIONALS COMMUNITY HEALTH 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 communitys unique assets and constraints Evaluate the project by using appropriate expertise Community Health - An Evidence-Informed Approach Pediatrics April 2005;115:1142-1147

15. THE ROLE OF HEALTH PROFESSIONALS COMMUNITY HEALTH 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 Which community PA interventions have good evidence?

16. THE ROLE OF HEALTH PROFESSIONALS COMMUNITY HEALTH Which community HEAL interventions have good evidence? Am J Health Promotion 2005;19(3):167-193 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

17. THE ROLE OF HEALTH PROFESSIONALS COMMUNITY HEALTH Which community PA interventions have insufficient evidence? http://www.thecommunityguide.org 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

18. THE ROLE OF HEALTH PROFESSIONALS COMMUNITY HEALTH 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. THE ROLE OF HEALTH PROFESSIONALS COMMUNITY HEALTH 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 Which worksite interventions have good evidence?

20. THE ROLE OF HEALTH PROFESSIONALS COMMUNITY HEALTH E ducation and Counseling - probably least effective (1) E nvironmental Changes and Policy (e.g., safe crosswalks) E nforcement 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 Injury Prevention Strategies

21. THE ROLE OF HEALTH PROFESSIONALS COMMUNITY HEALTH The Role of Health Professionals in Community Advocacy

22. THE ROLE OF HEALTH PROFESSIONALS COMMUNITY HEALTH Governors Summit on Health, Nutrition and Obesity – September 15, 2005 Pleasanton 2002Pleasanton 2006 Policy, Legislation and Environmental Change 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

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

24. THE ROLE OF HEALTH PROFESSIONALS COMMUNITY HEALTH 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. THE ROLE OF HEALTH PROFESSIONALS COMMUNITY HEALTH Advocacy Overview Advocacy Defined Identifying an issue Drawing attention to the issue Working towards a solution Advocacy Process 1.Organizing and coalition building 2.Finding information/research 3.Policy and strategy development 4.Mobilizing and communications Policy Link - www.policylink.org Physicians for Healthy Communities Section #3 pp. 4-6

26. THE ROLE OF HEALTH PROFESSIONALS COMMUNITY HEALTH 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 Step 1 - Organization and Coalition Building

27. THE ROLE OF HEALTH PROFESSIONALS COMMUNITY HEALTH 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 Step 1 - Organization and Coalition Building

28. THE ROLE OF HEALTH PROFESSIONALS COMMUNITY HEALTH 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 Policy Link - www.policylink.org Removing soda from school wont help me lose weight. The only exercise I ever get is walking upstairs to this vending machine.

29. THE ROLE OF HEALTH PROFESSIONALS COMMUNITY HEALTH 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. THE ROLE OF HEALTH PROFESSIONALS COMMUNITY HEALTH 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 Americas Youth http://www.shapingamericasyouth.com/ Step 2 - Finding Information and Research

31. THE ROLE OF HEALTH PROFESSIONALS COMMUNITY HEALTH 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 5 th, 7 th & 9 th Grades http://www.publichealthadvocacy.org Step 2 - Finding Information and Research – Data Sources

32. THE ROLE OF HEALTH PROFESSIONALS COMMUNITY HEALTH 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 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 Step 3 - Policy and Strategy Development

33. THE ROLE OF HEALTH PROFESSIONALS COMMUNITY HEALTH 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. THE ROLE OF HEALTH PROFESSIONALS COMMUNITY HEALTH Step 3 - Policy and Strategy Development - The Players Howard Taras, MD, FAAP, UCSD, Division of Community Pediatrics & School Health

35. THE ROLE OF HEALTH PROFESSIONALS COMMUNITY HEALTH 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. Step 3 - Policy and Strategy Development - The Players Howard Taras, MD, FAAP, UCSD, Division of Community Pediatrics & School Health

36. THE ROLE OF HEALTH PROFESSIONALS COMMUNITY HEALTH 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. THE ROLE OF HEALTH PROFESSIONALS COMMUNITY HEALTH 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 Step 4 - Mobilizing and Communications

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

39. THE ROLE OF HEALTH PROFESSIONALS COMMUNITY HEALTH Physicians for Healthy Communities Toolkit School Presentation Toolkit Speakers 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. THE ROLE OF HEALTH PROFESSIONALS COMMUNITY HEALTH 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. THE ROLE OF HEALTH PROFESSIONALS COMMUNITY HEALTH Step 4 - Mobilizing and Communications - Effective Speaking 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 Organizing Your Talk

42. THE ROLE OF HEALTH PROFESSIONALS COMMUNITY HEALTH 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. THE ROLE OF HEALTH PROFESSIONALS COMMUNITY HEALTH Step 4 - Mobilizing and Communications - Organizing Your Talk Key Point #3 - The Benefits Whats 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. THE ROLE OF HEALTH PROFESSIONALS COMMUNITY HEALTH Over 20% of children and 60% of adults in California are overweight. (CDC, www.chis.ucla.edu, www.publichealthadvocacy.org ) I think were 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) Step 4 - Mobilizing and Communications – Key Messages

45. THE ROLE OF HEALTH PROFESSIONALS COMMUNITY HEALTH Step 4 - Mobilizing and Communications - Effective Speaking CMA Foundation - Physicians for Healthy Communities Initiative 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

46. THE ROLE OF HEALTH PROFESSIONALS COMMUNITY HEALTH 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 Step 4 - Mobilizing and Communications - Media

47. THE ROLE OF HEALTH PROFESSIONALS COMMUNITY HEALTH 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 Childs School Your Place of Worship Your Clubs or Organizations

48. THE ROLE OF HEALTH PROFESSIONALS COMMUNITY HEALTH 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 Circle of Concern Circle of Influence The 7 Habits of Highly Effective People S.Covey

49. THE ROLE OF HEALTH PROFESSIONALS COMMUNITY HEALTH 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. THE ROLE OF HEALTH PROFESSIONALS COMMUNITY HEALTH 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 Possible Health Care Policy and Organizational Practices

51. THE ROLE OF HEALTH PROFESSIONALS COMMUNITY HEALTH CATCH - Community Access to Child Health One Pediatrician Can Make a Difference! Mission - to support pediatricians who work with communities to assure that children have medical homes and access to other needed health care services. The medical home. Local people can solve local problems using local resources. Pediatricians can make a difference in their communities. Experiences and successes can be shared. The CATCH Program Provides: Training Technical Assistance and Resources Funding Opportunities CATCH Program - 847-434-7085 catch@aap.org

52. THE ROLE OF HEALTH PROFESSIONALS COMMUNITY HEALTH 10 Tips for Health Professional Advocates 1. Choose Your Issue 2. Identify Solutions 3. Identify Supporters 4. Develop a Strategy 5. Frame Your Message 6. Educate 7. Mobilize Supporters 8. Testify 9. Dont Give Up 10. Vote! AAP Division of State Government Affairs – stgov@ aap.org

53. THE ROLE OF HEALTH PROFESSIONALS COMMUNITY HEALTH The normal physician treats the problem; the good physician treats the person; the best physician treats the community. Chinese proverb A Latina Born in the Year 2000 Has a 1 in 2 Lifetime Risk of Developing Diabetes - JAMA 290(14):1884 The Power of Storytelling

54. THE ROLE OF HEALTH PROFESSIONALS COMMUNITY HEALTH How ready am I to commit time to work on this issue as a community advocate? Who is in my circle of influence? What is one thing I can do in the next month? Health Professional Community Advocacy