Welcome to Engaging Consumers, Providers and Community in Population Health Programs. This is Lecture a. The objectives for this lecture are to identify population health programs's key constituents. Describe their constituencies's needs and goals. Analyze constituents's competing objectives to predict factors facilitating and inhibiting change. The PRECEDE-PROCEED Model was created by Green and Kreuter. PRECEDE talks about predisposing, reinforcing and enabling constructs in educational, ecological diagnosis and evaluation. So this is really talking about the identification of programs and constituents, and their values. The PROCEED part of the model is policy, regulatory and organizational constructs in educational and environmental development. This often deals with the program design itself. Here, we see a model adapted from the PRECEDE-PROCEED Model with permission. You'll notice that it starts in the upper right-hand corner with phase one being a social assessment where you make look at a community or population and make assessments about its quality of life, or lack thereof. For this example, let's say, we want to build bike lanes and increase the number of people biking to work. In phase two, you are going to try and quantify the issues in a more structured fashion doing what we call an epidemiological assessment or survey. This step is important, because later, we're going to develop research programs and goals that should change from the current to the desired state. It is advisable to bring in an epidemiologist at this stage. Those professionals will be very good at helping you to quantify and identify measures that you can use to both implement your program, and then monitor it thereafter. Ideally, they will draw on already existing and validated measures when available. Back to the bikes, the epidemiologists will identify some leading indicators, such as bike ownership, ongoing indicators, such as bike traffic on targeted thoroughfares. And lastly, outcomes, such as weight loss in the target population. Phase three is what we call the behavioral and environmental assessment. By behavioral, we're often talking about our constituents and their processes they go through in their day to day lives that are either facilitating better health or causing negative outcomes in their health and we also consider the environmental characteristics. In the bike example, we may want to know if the target population owns a bike or even knows how to ride. One common intervention these days is to put community bikes in place to promote increase ridership. Will that be needed in your community? Phase four is the educational and ecological assessment. So we'll actually look around in the environment for what are the predisposing factors to given behaviors, reinforcing factors and enabling factors. Again, we are primarily focused on the environment in this step. Hence, the ecological component. Lots of times, we have opportunities for educational interventions, which are the most defensible forms of public health as compared to other more invasive interventions where we forbid the target population to do something rather than learn how to take better care of themselves. No smoking regulations are a good example of an intervention where we would have hoped that education would have sufficed. Phase five is the administrative and policy assessment. This is where we ask whether we or our organizations, whether they be governments, health systems, insurance companies or other organizations in the community, are ready to engage in a new program or innovation. Here it is good to bring in both business and policy experts. Business people are necessary to determine if the program is adequately funded, administratively supported and sustainable. Policy experts also need to assess, if the program is likely to have support across elections. It is not unusual for one administration to support a program and for the next to cut it. Building support is essential. In the case of the increased bike lanes example, a new administration may prefer to put the money towards parks or some other activity. Having half built bike paths will not be a good outcome. If the answer to the phase five assessment is yes, we've completed the PRECEDE component of the model and can move to the lower half of the chart and work our way back in the other direction. That would be the PROCEED component. In phase six, you'll see that we'l have developed the program and we'll be implementing that program. Often, those programs are designed to modify or change the enabling, reinforcing and predisposing factors in the environment. For example, we may want people to bike to work more. So, we design a program that increases the number of bike lanes with the hope of reinforcing or enabling people to ride their bikes. We can then move into phase seven, our process evaluation. This is where we look at whether we got the environment changed in the way we wanted. Did we meet our target of adding 50 or 60 miles of bike lanes in our community? How many more bikes were sold in the community before and after the intervention? Phase eight is where we're actually going to start to go back to the population or individual themselves to asses the impact of the program we've implemented. Do we see people riding their bikes to work? We could put things like rumble strips in the roads that count every time a bike rolls over a particular intersection and we might see the impact in terms of our bike behavior. And ultimately in phase nine, we'll look at health outcomes. Do we see those people who are riding bikes having better health status? Have they lose weight? Is their cardiovascular function working better, etc? So, there's a quick overview of the PRECEDE-PROCEED Model. Let me go a little more in depth on each of these phases. So, phase one was the Social Assessment. This is the phase in which we identify the constituencies or target populations that have a stake in the issue, so we can try to get definitions in place around some of what we're trying to change since we're going to have to measure and study this implementation projects and you want to involve and engage members of the community as you do this. Oftentimes, studies will rely on self-reported data. So, you need to find out if the community members will be willing to share such information. Here's a list of some of the social indicators that health programs often seek to intervene on. Absenteeism from work or school are big ones. Of course, the more we get kids to go to school, the better off they tend to be. Discrimination in the workplace or in communities in general can be very problematic. Happiness, some countries actually measure the gross national happiness. For example, the government of Bhutan, a relatively small kingdom in the Himalayas measures happiness. And in other communities, you see things like riots as well as welfare and unemployment. So, you want to do those sorts of social assessments. You might then move into the Epi Assessment. This is where you're going to start getting into hard core types of data. Disability levels, we have something called activities of daily living or ADLs, which is a measure of people's ability to function and that's a very distinct epidemiology measure. Fertility is the number of children that women are having in a community. You may wish to reduce fertility, because they are unwanted pregnancies, et cetera or you may want to increase fertility in some other communities. For many years, China had a one-child policy, which was implemented to decrease fertility. And now, they're seeing that their population is not able to support itself in the way they'd like. So, they're hoping to increase fertility. Things like fitness, morbidity and mortality, these are all very specific epidemiological risk factors that you can measure. The third phase becomes a little more involved and also a little less clear in some respects, and this is the behavioral and environmental assessment. So now, we start to ask why people are unhealthy and what we can do to change that. And we might say, there are risk factors that are discretely linked to the second part of our behavioral assessment as you recall and that those risk factors are things like the lack of companies in a community to employ people. That would be a risk factor for unemployment. Those are fairly difficult to assess in some occasions. There are other behavioral features. Why are people having difficulty complying with healthy diets? Is there not the right type of food establishments in their community to make healthy choices? We hear about food deserts in some poor communities where the grocery stores simply do not maintain stocks of fruits and vegetables, etc. And lastly, the environmental features. Do we have the features available in our community to make for healthy living? Once you start to gather this information, you could put it into what we call a Prioritization Matrix and this really has two dimensions. The first dimension, which runs horizontally across the top of the matrix is the level of importance. With higher importance, over the left-hand column of the matrix and lower importance appearing over the right-hand column. You start the prioritization process by asking how valuable it is for us to change this health outcome, health behavior or health status feature in our community. You might take a health status feature like obesity and say that is a big problem, it leads to diabetes, which is a discrete health outcome and diabetes leads to premature death. Therefore, it's highly important to work on people's obesity and so you'll find the level of priority in the left had column of the matrix. The next step is to ask whether the health status feature is changeable or immutable. On the prioritization matrix, more changeable appears to the left of the top row and less changeable appears to the left of the bottom row. So if you decide that obesity is a changeable health feature, the level of prioritization will appear in the top row. And as we said earlier in the left-hand column under high importance, putting obesity in the upper left-hand box and giving it a high priority for program focus. On the other hand, take something that has little importance, for example, people's hair color. Maybe some study finds that natural blondes have more fun. Is hair color changeable? Yeah, hair color can be dyed, but we can't change it in point of fact genetically. So we made decide that the fun derived from being a natural blond is of low importance and that's not possible to change people's hair color, anyway. Putting that health feature in the no program box in the lower right-hand corner of the matrix to the right of not changeable and below low importance. And of course, you can imagine it might be a good exercise for you to think about different programs in your community that you might wish to pursue and then place them in these various boxes as an exercise. If for example, you want to work on a problem of low importance, but it is easy to change. The matrix would recommend a low priority for that intervention. On the other hand, if you have an important health status feature that's not very easy to change, the matrix would indicate priority only for an innovative program. Phase four is the education and ecological assessment. This is where we actually classify the factors in those matrices's elements that can influence behavior, including predisposing factors, such as people's awareness and knowledge. Reinforcing factors regarding feedback to the community and enabling factors and barriers, so we can enable a behavior or create a barrier to engaging in a behavior. For example, we don't want people drinking sugary sodas. In New York, Mayor Bloomberg very famously banned large open containers of soda from being sold creating a barrier to consuming large amounts of soda. Rewarding or reinforcing. We see more and more employers will penalize obese employees in their insurance programs etc. And so, you can think about these as important features to understand in your community. Phase five and this is no trivial matter. Do you actually have the will and the wherewithal in your community to pursue any program or the programs in particular that you may wish to engage in? This is where the precede part of this model typically ends. The PROCEED part starts with phase six or the implementation when you've actually started to select models, strategies and programs that you think may be effective in changing ultimately the health status of your community. Phase seven is the process evaluation and this is an ongoing feature of any program. You want to have real-time information, if at all possible on your ability to implement a program over time. If there are delays or shortfalls or other things that are slowing the complete implementation of a program, you may need to change course or take corrective action to ensure that the program is being implemented as intended. Phase eight is what you might call an intermediate outcome or impact evaluation. In this phase, you measure the short-term outcomes that you can actually see. These are physical tangible sorts of things that you hope are tightly correlated with the outcome that's desired in overall health status. You can actually have several layers of these. You can immediate impacts. Intermediate impacts and outcomes, and long-term outcomes, and any good program will have outcome evaluation, and a long-term sense built-in. This is an area where many programs actually do not allocate enough resources for funding to fully pursue the endeavor. Oftentimes, people rely on general mortality and morbidity in a community which can be difficult to ascertain, because people tend to move around. We might take the vital measures within a neighborhood. We might check symptoms appearing in our emergency rooms. Currently, there's something called the Zika virus, which is transmitted by mosquitoes that has been in the news a great deal and we may be looking for people who are presenting the symptoms of the Zika virus. Because if a pregnant woman has this particular illness, it's very likely that her child will be born with several birth defects that will be quite debilitating throughout that child's life as well as expensive to maintain. And so, those are the long-term outcome evaluations. This concludes lecture a of engaging consumers, providers and community and population health programs. So in summary, when engaging consumers, providers and communities, you really need to think about it as an end to end process that is iterative in nature. The PRECEDE-PROCEED Model may actually have multiple loops required before you get to a full blown program.
