Community based approaches to preventing diabetes and heart disease Maximilian de Courten, Brian Oldenburg

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1 Copenhagen School of Global Health Community based approaches to preventing diabetes and heart disease Maximilian de Courten, Brian Oldenburg Monash University University of Copenhagen

2 Outline: 1. What are Community Based Intervention (CBI) for NCD control & prevention? 2. Rationale for CBI in NCD control & prevention 3. What is the experience from evaluating them 4. What are the issues around evaluation 5. Monitoring CBI 6. Community Readiness

3 Community-based prevention programs can be defined as being integrated and comprehensive, and not limited to medical care settings. use multiple interventions, targeting change among individuals, groups, and organizations, and they often incorporate strategies to create policy and environmental changes.

4 The role of the community in health intervention projects community as setting for interventions, community as target of change, community as agent with developmental capacity, and community as resource with a high degree of ownership and participation. These categories are proposed to illustrate the difficulties in summarizing results across the array of community-based projects.

5 Effective public health interventions The most effective public health strategy for prevention & control of NCDs is thought to involve a 3-tiered approach, incorporating one-on-one interventions for high-risk individuals, community-wide interventions that attempt to change social norms and improve environments, and policy-level efforts that also help modify the social and political environments. This strategy is inspired by the Ottawa Charter concepts.

6 What is the Rationale for Integration of NCD Prevention and Control into Communities? The lack of a cure The costs (burden) of complications The efficacy and the strategy of prevention

7 CBI programmes Community-based intervention programmes can be defined as being integrated: across risk factors and diseases, across services and disciplines, and comprehensive across levels of prevention and care, and are not limited to clinical care settings

8 Community in CBI CBI programmes systematically involve engagement of community leaders, social networks, media, and direct education of the general population. This encourages and confers community involvement and ownership.

9 Health Status and Relevant Intervention Healthy Individuals Early Disease Established Disease Complications & Death Exposure to Risk Incidence & Prevalence of Disease, and its Clinical Control, Complications, Mortality Distribution, operations, and utilisation of health services across the population Primary Prevention Early Detection and Good Clinical Control Health Systems Improvement: Effectiveness, Efficiency, Access, Equity...

10 Components of NCD Programmes Coordinating body; Info on risk & prevalence; Adequate & rational resourcing Direction & Infrastructure Changing Environments Changing Lifestyles Reorienting Health Services Policy, Social, Cultural, Economic, and Physical factors that determine behaviour Knowledge, attitudes, beliefs, practices that affect risk exposure Clinical Mgt Guidelines; Community-based care; Training, equipping, auditing

11 Health Promotion and CBI Community-based intervention programmes have a strong focus on health promotion and use multiple interventions to create supportive environments, to promote behavioural change among individuals and groups, and to re-orient health services.

12 Community-based Services Consumer Action Support for development of Diabetes Association, Cancer Society... Primary Health Care Guidelines for clinical management of obesity, diabetes, hypertension, and palliative care for terminal cancer Training, equipping, and auditing of community-based service Reference Centres and Pathways Centre of clinical excellence for training and referral in Diabetes, CVD, Cancer Centre for Evaluation support

13 The importance of community capacity Community capacity can represent: a necessary condition, an indispensable resource, and a desired outcome for community interventions. Health Promotion Activity Community Capacity Population Health Outcome

14 Community Based Trials Past Experience

15 The Tribulations of Community-based Trials A number of well-conducted, large-scale trials involving entire communities under enormous efforts testing the capacity of public health interventions to change various forms of behaviour related to NCDs have often ended in disappointment. Generally, the size of the effect has been meagre in the relation to the effort expended. [Susser, M 1995]

16 The Tribulations of Community-based Trials - 2 A more recent review of the success of community based interventions demonstrated their difficulties in achieving a population level impact and also difficulties in evaluating them [Merkel 2003]. In other words we not only don t know what works but also don t quite know how to find out.

17 Reasons explaining the lack of strong intervention effects for CB interventions Methodological Issues Low statistical power Design and sampling issues Magnitude of Effects Limitations of the Intervention Length of the intervention Insufficient tailoring Low level of community penetration Limited ecological reach

18 Reasons explaining the lack of strong intervention effects for CB interventions Limitations of Theory Type III error: the inability to detect an effect due to inappropriate methods The Influence of Secular Trends

19 Evaluation techniques for CBI Useful evaluations of comprehensive CBI use a variety of approaches to collect and analyze data from many sources and to disseminate findings to diverse audiences, including practitioners, community members, funders, policy makers, and other researchers.

20 Scope of Evaluation Effective evaluations do more than collect and analyze data; they also make it possible for community stakeholders to use the information to continuously improve programs and policies.

21 Evaluating health promotion programs Health issue Goal Outcome evaluation Determinants Objectives Impact evaluation Actions on priority determinants of the issue Strategies Process evaluation

22 To monitor vs evaluate Monitor: to watch, keep track of, or check usually for a special purpose Evaluate: to determine the significance, worth, or condition of usually by careful appraisal and study Encyclopaedia Britannica

23 Selecting SMART Indicators Specific: clear and precise Measurable: amenable to intervention Achievable: realistic Relevant: to the health issue, the population and to the organization Time specific: time frame for achieving change in indicator

24 Monitoring Guidelines Indicators are they SMART? What are the key questions that the monitor should answer Being strategic, rather than following every single intervention component within a program Bigger picture questions eg sustainability, who is missing out What information do we need in order to answer these questions? How will we get this information who, when, how? Planning for analysis, reporting and dissemination Budget being realistic: what can we afford to do; what does the key organization expect for its investment?

25 Understanding communities readiness to change

26 Exploration of communities Where and when should we invest effort to get social change? Is there a natural order of change? when are conditions conducive to change? what changes might a community accept? how might this change over time? Which communities should we work with first? Steps to consider as part of assessing cost-effectiveness

27 Perspective: Tobacco control advocate Assumes current epidemiological knowledge Extrapolate individual change theory to communities Communities self governing local state national varying size from few thousand to many millions

28 Health Agendas project (Victoria, Australia, 2000) Tobacco not on main agenda for most influentials in health seen as a side issue Need to link to active agendas, or Need external advocacy to generate interest No long-term strategic agenda

29 Characteristics of tobacco control in AUS Concern comes largely from epidemiology intellectual not emotional concern issue lacks urgency Need for emotional engagement issue personalized role in larger agenda Victims rarely become advocates for change smokers deeply conflicted passive smokers less so reliance on health groups to advocate Little influence outside of health

30 Neighbourhoods (parks, open spaces, recreation facilities) 37 Physical Availability, access, quality, facilities, lighting Economic Costs to users, local govt budget allocations Policy Green space requirements in suburbs, policy orientation towards participation, carfree areas Socio-cultural Perceptions of safety, community value/ownership of spaces, cultural attitudes to exercise

31 Readiness to change At any given time: there is variability in readiness to change therefore effort to enact change varies required action varies Alternatives for action: wait until they are ready shape interventions to readiness

32 Diffusion of Innovations: 41 Stages in Adoption Knowledge--Become aware Persuasion--Purposively acquire more information Decision--Reach a decision about the value of the innovation (Go/No Go) Implementation--Put innovation into practice Adoption--Continue or not continue Source: Everett M. Rogers (1995). Diffusion of innovations (4th ed). New York: Free Press.

33 Key types of influence Decision makers involved rarely initiators Bureaucrats supportive need to be supportive Elites support mainly from health groups powerful opponents General public supportive, but not passionate

34 Possible positions Active advocates Supporters Accepters Passive opponents Active opponents

35 What is the Community Readiness Model? Is a model for community change that integrates a community s culture, resources, and level of readiness to more effectively address an issue. Allows communities to define issues and strategies in their own contexts. Builds cooperation among systems and individuals. Increases community capacity for prevention and intervention. Encourages and enhances community investment in an issue. Can be applied in any community (geographic, issue-based, organizational, etc.). Can be used to address a wide range of issues. Is a guide to the complex process of community change.

36 Purpose of the CR Model Matching an intervention to a community s level of readiness is absolutely essential for success. Interventions must be challenging enough to move a community forward in its level of readiness. However, efforts that are too ambitious are likely to fail because community members will not be ready or able to respond. To maximize chances for success, the Community Readiness Model offers tools to measure readiness and to develop stage-appropriate strategies.

37 Process for Using the Community Readiness Model

38 6 Dimensions of Readiness Community Efforts: To what extent are there efforts, programs, and policies that address the issue? Community Knowledge of the Efforts: To what extent do community members know about local efforts and effectiveness of those efforts? Leadership: To what extent are appointed leaders and influential community members supportive of the issue? Community Climate: What is the prevailing attitude of the community toward the issue? Is it one of helplessness or one of responsibility and empowerment? Community Knowledge about the Issue: To what extent do community members know about the causes of the problem, consequences, and local implications? Resources Related to the Issue: To what extent are local resources people, time, money, space, etc. available to support efforts?

39 Stages of Community Readiness STAGE 1 No Awareness 2 Resistance 3 Vague Awareness 4 Preplanning DESCRIPTION Issue is not generally recognized by the community or leaders as a problem (or it may truly not be an issue). At least some community members recognize that it is a problem, but there is little recognition that it might be a local problem. Most feel that there is a local problem, but there is no immediate motivation to do anything about it. There is clear recognition that something must be done, and there may even be a committee. However, efforts are not focused or detailed. 5 Preparation Active leaders begin planning in earnest. Community offers modest support of efforts. 6 Initiation Enough information is available to justify efforts. Activities are underway. 7 Stabilization 8 Confirmation/ Expansion 9 High Level of Community Ownership Activities are supported by administrators or community decision makers. Staff are trained and experienced. Standard efforts are in place. Community members feel comfortable using services, and they support expansions. Local data are regularly obtained. Detailed and sophisticated knowledge exists about prevalence, causes, and consequences. Effective evaluation guides new directions. Model is applied to other issues.

40 Using the Assessment to Develop Strategies To be successful, any effort toward making change within a community must begin with strategies appropriate to its stage of readiness To move ahead, readiness on all dimensions must be at about the same level focus your efforts on strategies that will increase the community s readiness on the lower scoring dimensions.

41 Ways the Community Readiness Model Can Be Used - 1 Program Evaluation: The evaluation of multi-component, community-wide efforts is challenging when measuring complex changes over time. The CRA helps to assess the overall effectiveness of efforts giving insight into key outcomes (such as shifts in community norms, support of local leadership, etc.).

42 Ways the Community Readiness Model Can Be Used - 2 Development organizations: The CRA model can be used to quickly assess whether or not proposed projects stand a chance of success in a given community to implement successfully.

43 Ways the Community Readiness Model Can Be Used - 3 Research: Research on community-wide program effectiveness frequently involves intervention and control communities. The CRA allows to match communities by stage of readiness. Longitudinal changes can also be documented by serially conducted CRAs.