Tag Archives: health behaviors

Public Health’s ‘Moonshot’ – Part 2: A Local Context

context-matters

Courtesy of Inspector Insight

 

In the first post of this series, I briefly described healthcare system expenditures, as a percent of GDP, for the U.S. and a number of OECD member countries. When coupled with population health outcomes data, the amount spent per person on healthcare in the U.S. seems excessive and arguably wasteful. Individual health behaviors, genetics and a broad range of social and environmental factors account for 90% of an individual’s risk for premature death. Addressing the factors outside the healthcare system, through a reallocation of spending into social services such as employment programs and supportive housing, may play a key role in improving population health outcomes.

Social determinants of health are “the structural determinants and conditions in which people are born, grow, live, work and age”. As such, a contextual understanding of communities and their history is critical to tackling deep-seated social issues. Below, I focus on the community of Durham, North Carolina for place-based contextual understanding.

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The Robert Wood Johnson Foundation (RWJF) is the nation’s largest philanthropic organization dedicated to improve health. RWJF’s focus, once solely on innovation in the healthcare system, has evolved to address the social and environmental factors as well in “building a culture of health.” Shifting the way society viewed health – from the absence of illness – was an integral part in this movement. It emphasized health as a resource for living fulfilling lives and collectively contributing to a competitive and thriving nation. It developed and strengthened relationships with key stakeholders and facilitated cross-sector collaboration. And it’s engaging leaders in communities.

In 2013, RWJF named six communities with its “Culture of Health Prize.” Distinct from its traditional grantmaking program, this prize awards $25,000 to communities for the work and successes they have already achieved. By shining a spotlight on a selected group of communities each year, RWJF is able to share lessons and first-hand knowledge with community leaders nationwide. Durham, North Carolina, was one of six communities selected for the Culture of Health Prize in 2014 for the work the Partnership for a Healthy Durham has done since 2004. The Partnership is just one example of community-engaged efforts to improve the lives of Durham residents. A few additional innovative models will be introduced in subsequent posts to illustrate social impact at the local level and offer ideas to accelerate their collective impact.

Durham

Approximately 250 miles southwest of our Nation’s capital, Durham is situated at the northernmost point of North Carolina’s Research Triangle, with Raleigh and Chapel Hill to its east and west, respectively. In its former life, the city was well-known for tobacco and textile production, but fast forward to 2017 and the “City of Medicine” is in a constant state of transformation. Durham was recently anointed as a destination for foodies, “The South’s Tastiest Town,” and boasts a vibrant and diverse culinary and social scene. A major factor in its Renaissance was a collective effort to attract entrepreneurs and catalyze innovation. Community and business leaders invested a significant amount of resources to revitalize downtown and its efforts appear to be paying off. Once described a “nascent startup scene” by Madrigal in the Atlantic, now exudes self-confidence with two Durham-based startups collecting back-to-back wins in 2014 and 2015 at Google Demo Day in Silicon Valley. The startup community has also made waves nationwide for its efforts to empower and nurture diversity; its epicenter, American Underground, a Google Tech Hub, houses 48.2% minority- or female-led companies thanks to initiatives like Code 2040 – a nonprofit organization that creates pathways to the technology industry for underrepresented minorities – and strong partnerships within the Research Triangle.

History

In the early 20th century, Durham had the most African American millionaires per capita than any other city in the U.S. Their success in finance and insurance was evident with a section of downtown named “Black Wall Street” (Forbes) and the city was also known as the “Capital of the Black Middle Class”. The Hayti District, an independent black community founded shortly after the Civil War, became a self-sufficient community and housed residents of all social class along with a variety of businesses, schools, library, hotel and a hospital. African Americans owned and operated over 200 businesses within the boundaries of the District. It flourished for decades through the 1940s until an urban renewal project in the 1950s tore through more than 200 acres in the heart of Hayti, displacing residents and businesses alike. The project was intended to ease commuting for suburban residents by realigning streets and construction of “the Durham Freeway”, NC-147.

Historically, urban regeneration or renewal served as a method for social reform in England to address substandard and unsanitary living conditions in rapidly growing industrialized cities. In the U.S., it came in the form of federal policies used to “reshape” American cities. The Housing Acts of 1949 and 1954 disbursed federal funding for cities to “acquire” areas identified as “slums” and were given to private developers to construct new housing. Additionally, the Federal Aid Highway Act of 1956 allocated 90% of federal funding to states to construct new highways that connected to the larger Interstate System. Large urban cities including New York, Chicago, Pittsburgh and Boston undertook urban renewal projects like Durham in the 1950s. While urban renewal projects generated economic development and improved quality of life in those cities, the destruction of neighborhoods left former residents in dire situations.

Poverty

A slow decline in manufacturing of textile and tobacco in Durham in the 1950s resulted in rising unemployment among working-class black residents due to segregation and discrimination. Coupled with urban renewal in the 1950s and 1960s and Civil Rights movements, the divide between whites and blacks grew. Sarah Willets of Indy Week describes an initial divide between affluent landowners and its workers even when the city was incorporated in 1869. An initial divide in opportunity which persists to this day.

“While some parts of Durham have single-digit and even less-than-1-percent poverty rates, in other neighborhoods, half the residents struggle to make ends meet.” — Sarah Willets, Indy Week

“We’ve always been taught the story of America is one of upward mobility. Durham very much embodies that. But some of the darker sides of the American story are here too.” — Justin Cook, Photographer, Slate Magazine

Photographer Justin Cook’s series, “Made in Durham” and various other pieces in the Indy illustrate what Willets captures in her story on Mayor Bell’s lasting dichotomous legacy – a thriving upward mobility amongst young professionals contrasted with historically African American neighborhoods that struggle with staggering rates of poverty and violence.

Alison Templeton, a research assistant at the UNC Center on Poverty, Work and Opportunity, released an update on urban poverty in Durham using current Census data in 2013. Templeton identified census tracts as “distressed” based on its performance compared to the state’s average on the following: per capita income, unemployment and poverty rates. 22% distressed census tracts in Durham County were identified in the report, which rose from 15% back in 2000. Other poverty-related statistics in Durham’s distressed tracts:

Poverty 46.7%
Child poverty 55.2%
Elderly poverty 25.6%
HS graduation 72.6%
Families led by Single Mothers 66.5%
Homeownership 27.6%

Poverty and the consequences of sustained poverty for individuals and communities significantly impact population health outcomes. Understanding historical context is a crucial first step in adequately addressing deep-seated social issues.

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Proactive Patriotism

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Millions across the country are breathing a sigh of relief after the Supreme Court ruled in favor of keeping the Affordable Care Act (ACA) in place.  The ACA was built on three fundamental pillars – non-discrimination of individuals with chronic conditions; a mandate that each individual purchase health insurance (paid or subsidized); and the creation of an online marketplace to purchase health insurance.  Many states opted out of creating online marketplaces, so the federal government stepped in and created them, resulting in millions of new enrollees.  The states who opted out were outraged that their residents were using state-appropriated subsidies to purchase health insurance from federally-created insurance exchanges.  And as you may or may not be aware, politics in Washington are no joke, especially around the ACA.  This case worked its way up to the Supreme Court and I wouldn’t be surprised if another part of the ACA is in contention at the highest levels in the next year.

In the real world, where people are dealing with real issues rather than politics, we can breathe a sigh of relief.  But let’s not forget that health and well-being is more than our interactions with the healthcare system.  Health insurance provides us with access to appropriate preventive and healthcare when we need it.  The key word I can’t stress enough is access.  And access, unfortunately, is not the magic bullet in the health and well-being equation.  It’s only a part of the solution.

What you do, or don’t do, on a daily basis adds up.  Your health behaviors, which include seeking health and preventive care, as well as your dietary habits, physical activity levels, stress management and substance use, among others all play key roles.  Genes do also play a part, but our behaviors are still within our control; it’s the one thing we can be accountable for.  When I worked at the Department of Health and Human Services (HHS), I had the privilege of working alongside then Acting Surgeon General RADM Boris Lushniak and his staff.  On many occasions, he led by example, encouraging acts of patriotism through individual accountability of our own health and well-being.  RADM Lushniak understood health from the macro-level all the way down to an individual’s health behaviors.

One of my responsibilities at HHS was lifestyle coaching.  I acted as an accountability partner for a handful of employees with specific health goals during a 12-week program.  We tackled many of the issues I outlined above – diet, physical activity and stress management.  I made sure to emphasize that changing behaviors is a gradual and continuous process.  Working with people on a 1-on-1 basis on changing their health behaviors was one of the most fulfilling things I’ve ever done.  The moment when someone understood health in a larger context is inspiring.  It’s one of the reasons why I started this blog.  My goal is to empower as many people as I can to see the bigger picture – that health and well-being is more than access and use of the healthcare system.  It’s about realizing that our health is our resource for living.  It’s about seeing our health as an investment, which needs daily attention.  It’s about “flipping a switch” on being proactive to our own health and well-being and being accountable to ourselves, families, communities and our nation.  We all need to be a part of this movement.  And it starts with each and everyone of us.

One tool that we can each leverage to improve our health is an app called Dacadoo.  Based on a handful of questions, you’re given a health score on a scale of 1-1000.  And as you add more data inputs – sleep, emotions, physical activity – your score fluctuates in real time.  It’s also compatible with various types of wearable technology.

Why is this a big deal?  Dacadoo quantifies the various components of an individual’s health behaviors and updates in real time when you do, or don’t do, health-promoting activities.  Think of it as a FICO score for your health.  Just as we would monitor and take steps to improve our credit score, we can also do for our own health.  I had a conversation with one of Dacadoo’s staff yesterday and I told him several times that I wished I had this when I provided lifestyle coaching at HHS.

With Dacadoo and other wellness apps, I believe our country is going in the right direction.  There’s a greater understanding that we can’t rely on the healthcare system to solve all our problems.  There’s a shift to being more proactive, rather than reactive.  Healthcare providers are now more versed in public health, health education and promotion.  If our country as a whole had a Dacadoo score, I’d say our score were improving incrementally.

But we have a lot more work to do.

“Efforts and courage are not enough without purpose and direction.” — John F. Kennedy

Public Health in Action – Communities Creating a Culture of Health

images I first heard about SEEDS through a community email listserv that my roommate sent me.  SEEDS frequently has volunteer opportunities throughout the year and I signed up for their most recent annual fundraiser, Pie Social.  It was such a fun event!  People donated all kinds of pies that day from sweet to savory to pizza – they were all there for everyone to enjoy.  One of the most inspiring aspects of that event was the community’s support.  Well-renowned chefs and residents alike spent hours to create delicious expressions of edible art.  And all the attendees were more than happy to splurge on various delicacies.  Veterans of the event even brought Tupperware to share their pie-riches with family and friends.

After volunteering, I wanted to learn more about SEEDS and was connected with another volunteer Prathima Kannan.  Here’s my interview with her…

Me: How did you end up doing the work that you’re currently doing?

Prathima Kannan: Right now, I work at Alamance County Health Department as a Registered Dietician for the Special Supplemental Program for Women, Infants, and Children (WIC) and also have a small nutrition private practice.  How I got here was a combination of interest and personal experience. During college and in my 20s, I struggled with my weight and nutrition. I chose to eat unhealthy foods; ate to cope with difficult emotions; ate mindlessly; and decided not to exercise most of the time. I dealt with the consequences of these choices: abnormal lab values and weight gain.  It was clear that these symptoms had a negative impact on my health, but less obvious were the negative impact on my self-esteem, social experiences and my work life.  I needed to make changes quickly and I revamped my diet, increased my physical activity levels, and changed my attitude towards living a healthy lifestyle—it doesn’t have to be drudgery.  I discovered that eating healthful foods can be delicious and that exercise can be enjoyable – all of which I had utterly dismissed in the past.   Though it all seemed too simple and straight-forward, it worked: today my lab values normalized and I feel radically different.  My own struggle with weight inspired me to help people change their lives through behavior modification, with particular focus on their diet. I found that health could be reversed through lifestyle changes, and since I wanted to help people on a community level, I chose to work at the Health Department. How did I find SEEDS? I went to graduate school at UNC Chapel Hill School of Public Health for Nutrition. I went into the program with an interest in growing food, gardening, nutrition and cooking and I wanted to find a place where I could combine these interests to help children or adults.   In the break room some students were talking about SEEDS and I also remember my Professors mention the organization in the context of increasing access to healthy food and improving community health through community gardening.  I made a mental note to follow up and started volunteering in 2014.  At SEEDS, I work with kids and I really wanted to show them that healthy living and prevention can be fun.

Me: What inspires you on a daily basis, especially when things get hard?

PK: What drives me is running into kind, friendly, helpful people anywhere in the word who work hard to realize their dreams or make a positive difference in the world.  Sometimes, after meeting a terrible person, I get jaded.  My spirits are immediately lifted after I run into someone great. Animals, especially wildlife, also inspire me. I admire their strength to keep going despite damage to their environment.  They are truly resilient.

Me: What do you think it will take for our healthcare systems to improve?

PK: Our healthcare system can improve in many ways.  One way that comes to mind is putting more holistic, preventive programs, individual care and initiatives in place, especially when dealing with diet-related chronic disease. Healthcare should be more coordinated as well. Physicians and other members of the healthcare team should really work more with registered dietitians, exercise physiologists, personal trainers, health psychologists and others to help a patient change behaviors/lifestyle instead of immediately writing a prescription.  Our healthcare system is too dependent on medicine and physicians for every diet-related health issue, and it’s not effective.  Despite the development of new medications, obesity and diabetes rates, for example, continue rise every year.

Me: Why do you think education is important?  Specifically, tie in your work with SEEDS on teaching kids about nutrition.

PK: Health education and health communication are key.  A quote I found from World Health Organization really resonates with me: “The focus of health education is on people and action.  In general, its aims are to encourage people to adopt and sustain healthful life patterns, to use judiciously and wisely the health services available to them, and to make their own decisions, both individually and collectively, to improve their health status and environment.” Excellent and accessible health education combined with health communication plays a huge role in whether or not someone will adopt positive health behaviors.  Children are faced with many choices that could affect their health on a daily basis.  Without being informed, it’s hard for a child to make smart, healthful decisions.  My goal at SEEDS is to encourage the kids I teach to take action and take control of their health after learning nutrition and healthful cooking skills.  After each lesson, I want them to eat more fruits and vegetables and know why they are beneficial; I want them to know how to eat healthfully when there are financial constraints or transportation and access issues to the best of their ability; I want them to make excellent health promoting decisions when faced with temptation like exposure to unhealthy foods at the supermarket, disease promoting internet and TV advertisements that are actually geared towards them, or possibly exposure to unhealthy eating habits of their peers or adults.

Me: What are the current needs in Durham (or where you live), as they relate to social determinants of health (i.e SES, poverty, access to care, transportation, safety, etc.)

PK: Reducing or eliminating health disparities is a current need.  Health disparities definitely exist in Orange County, NC. I see it every day.  Priority health issues in Orange County are access to health care, insurance and information; chronic disease/health promotion, exercise and nutrition; mental health and substance abuse; and injury.  This is based on the most recent Healthy Carolinians of Orange County’s Community Health Assessment.  The social determinants of these issues seem to be poverty, education level and whether or not someone lives in safe housing and in a health promoting environment (ie: Do they have access to a supermarket or farmers’ market? Do they live near a park or trail? Are there sidewalks?).  It is certainly known that people with higher incomes and more years of education who live in a healthy and safe environment tend to have better health outcomes and generally live longer.

Public Health in Action – Leveraging Health IT to Improve Outcomes

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In the broadest sense, Health Information Technology (HIT) is applying IT to health care in order to improve patient outcomes, quality of life and reduce health care costs.  The field is growing and fast.  By 2017, the field is predicted to yield over $30 billion.  And it’s not hard to find.  A recent visit to Apple’s app store can be overwhelming – even after filtering the apps down to “health.”

Healthcare providers, from hospital systems to individual healthcare professionals, as well as healthcare payers (consumers, government, insurance companies) have bought-in to the promising field.  Startups keep popping up.  Health is a primary focus in various innovation challenges.

In the bigger picture of improving our healthcare system, I think HIT has the potential if leveraged the right way.  I recently interviewed Dr. Ryan Shaw, professor at Duke School of Nursing on his thoughts about the field and its potential in improving our healthcare system.

Here’s Ryan!

Me: Tell us about your past experiences in work, research and academia and how it ties to your current role.  Also highlight your interests in the field of Health IT and what Health IT could lead to in terms of health outcomes.

Ryan Shaw: My undergraduate studies began in computer science and mathematics. After 2 years I switched into nursing. It’s a strange transition but I wanted to go into a career path where I felt I was making a difference in people’s lives. After becoming a nurse, I went back to school to get a masters in informatics at NYU while working as a nurse in NYC. This allowed to merge healthcare and the IT side.

At the end of my master’s program, Duke University just so happened to offer an Information Technology fellowship as part of a PhD program for nurses. I applied for the competitive program and received the fellowship. I ended up working for Duke’s Health Company “Duke Health Technology Solutions” while studying for a PhD at Duke.

Following that, I eventually landed a job as a Professor at Duke’s Nursing School. I love this job and it allows me to do both science and education. On the teaching side, I teach in our masters informatics program. On the research side I discover how to use novel technologies and their data to help patients’ self-manage chronic illness. This is exciting work and allow me to work with an interdisciplinary team of physicians, pharmacists, psychologists, nurses, and IT gurus.

Discovering knew knowledge that will be applied in healthcare is extremely rewarding. While working as a clinician I was able to impact each of my patients lives, research allows me to have a much broader reach of impacting many more lives and creates knowledge that other people will build upon. Our world is changing, and information technology is becoming an integral part of peoples’ everyday lives and thus their health as well. My team and I capitalize on this social change and leverage technology as a conduit to improve health. It’s really cool.

Me: What inspires you on a daily basis, especially when things get hard?

RS: Academia is tough. There are real no work hours and no day is ever complete. I could work 24/7 every day for a year and still have more to do. A lot of what you propose is rejected and people don’t value it. Grants that you work months on don’t get funded, manuscripts are rejected, and sometimes you sit in the office asking yourself if you really do make a difference. In discovering knowledge, there is often nowhere to go to look for an answer. Scientists create answers, we seek to answer the unknown and discover more. You need a thick skin and perseverance is of the most important traits needed.

I drive inspiration from my family, I work through stress by exercising (I run a lot and use to be big into triathlon), and view this video from Apple to get me going.

The video reminds me that innovators are the ones who change world and those who succeed are the ones who keep trying even when they fail.

Me: What do you think it will take for our society to view health more seriously?  As in, why is health lower in priority to careers and education and relationships?

RS: Honestly, health doesn’t come first for many people – and likely won’t ever. Families, safety and financial security usually come first. And in my opinion, that’s probably OK. We need to eat, pay our bills, and survive. These all impact our health. That’s not to say health isn’t important, it’s critical.

For people to take health more seriously, is really going to have to come from the top. In my opinion, there is too much focus on the individual and treatment of health. It’s really societal and public value. We need a greater investment in communities and public health. We’ve created infrastructure that supports poor habits. I think many people forget that physical infrastructure and urban planning are so important. If we make it easy to drive your car to the drive thru down the street, then that’s what people will do. We need sidewalks, urban planning that encourages walking, and a cultural shift that values these things. This is happening, but for so long we’ve focus on suburbs, building a society that is car centric, and making delicious food easy to get. It’s just so hard to change individual healthy habits when the structure around you suggests the opposite.

Me: What are some things/concepts/ideas/insights you’ve learned from your research that can help improve health outcomes in individuals and on a population-level?

RS: Some of the concepts we’ve learned is that technology needs to be designed with the end user in mind. A lot of technology and how it functions is useful for young people and techies. But those aren’t the people who are most in need. The people in need, and the most expensive people in healthcare, are those with chronic illnesses (obesity, diabetes, hypertension, etc.). These are the people that could benefit the most from novel technologies and their data – and they are of all ages, young and old.

We need technologies that truly fit into their daily lives and we need to create infrastructure in the care delivery system that is able to use newer technologies such as wearable devices. As of now, we don’t have this structure. But its possible. If all of our patients monitored their daily data, software could manage most people and guide them in self-management of health behaviors. If people don’t correct those behaviors, it could be bumped up to a nurse or pharmacist to help them. And then after that, it could be bumped up to a physician. This would allow for true population management and would be cost-effective. It would also allow physicians to have a better understanding of their patients’ day-to-day lives when they actually see them in the clinic. This may enhance medical decision making. Check out the article, Mobile Health Technology for Personalized Primary Care Medicine, that we wrote on this.

Me: What are the current needs in your city as they relate to social determinants of health (i.e. SES, poverty, access to care, transportation, safety, etc.)?  Social determinants of health are any factors that directly or indirectly affect health.  For example, being homeless could cause stress and malnutrition which could drastically affect one’s health.

RS: The Raleigh-Durham is certainly trying to address some of these social determinants of health. For example, transportation wise we are trying to get in light rail that will have stops next to low-income housing. The bus system is being revamped to meet more people’s needs.

In terms of access to care, the affordable care act has and is helping with a lot of this. But North Carolina chose not to expand Medicaid as much as many other states, to access to care is still an issue for many people.

The city of Durham is quite focused on measures to alleviate poverty and help with homelessness. There is more focus on adding in sidewalks so people don’t walk in the street for safety reasons, they’ve been building affordable housing, and are pushing measures that new development including a % of low-income housing.