An Integrated Public Health Approach in Managing Chronic Diseases

An Integrated Public Health Approach in Managing Chronic Diseases

Introduction

What is a Public Health, or population approach?

It is an approach to health that aims at improving the health of the entire population, so as to reduce determinants of health, as well as health inequalities among population groups. It makes use of a multi-sectoral team working towards a common goal to improve the health of individuals. It looks at a broad range of factors and conditions that have a strong influence on people’s health.

An underlying assumption of a Public Health approach is that reductions in health inequities require reductions in material and social inequities. The outcomes or benefits of the public health approach, therefore, extend beyond improved population health outcomes to include sustainable and integrated health systems, increased national growth and productivity, and strengthened social cohesion and citizen engagement.

A Public Health approach also uses evidence-based decision making; it applies multiple strategies to act on the determinants of health; it collaborates across levels and sectors; it employs mechanisms to engage citizens; it increases accountability for health outcomes.

There are THREE Sessions in this unit.

Study Session 1: Public / Population health approach

Study Session 2: Public health strategies for the prevention of NCDs

Study Session 3: Planning and implementation of health interventions

Unit 3 - Session 1

Public/Population Health Approach

In this session we will look at some of the approaches that have been utilised to prevent chronic non communicable diseases. The approaches that will be discussed are public health approach, population approach and common risk approach.

Contents

1.  Learning outcomes of this session

2.  Readings

3.  Public Health approach in the prevention and management of chronic diseases

4.  Population approach to chronic no communicable diseases

5.  Common risk approach to chronic non communicable diseases

6.  Basic principles of chronic disease control intervention.

1 LEARNING OUTCOMES OF THIS SESSION

2 READINGS

There is one reading for this session.

3 Public Health Approach to prevention and management of chronic diseases

Public health principles provide a useful framework for continuing to investigate and understand the causes and consequences of chronic non communicable diseases and for preventing NCDs, through primary prevention programmes, policy interventions and advocacy. The Public Health Approach seeks to address the underlying risk factors that predispose individuals to NCDs.

Public Health approach has four steps:

Public health approach aims to provide the maximum benefits to a large number of people; therefore it focuses on the population and not on individuals.

4 POPULATION APPROACH TO CHRONIC NON COMMUNICABLE DISEASES

This approach assumes that if the disease is normally distributed then everyone has some disease. Assuming that one needs to reduce the occurrence of the diseases then this problem needs to be approached in two ways namely:

1.  Target all the population to reduce everyone’s risk

2.  Target a sub population i.e. those at high risk of getting the condition

Rose (1992) suggest that in this case a whole population based approach is appropriate as the risk factors affect all those who live in that society and thus it is more effective to target the whole population.

Figure 2: Distribution of risk for cardiovascular disease, and high-risk and population-

based management strategies

Source: (Erhardt, Moller & Puig, 2007).

In this session we look at the different approaches that can be used to reduce the burden of chronic NCDs. Erhardt, Moller & Puig (2007), suggest that there are advantages and disadvantages to these approaches. Read the article and then answer the questions in the task that follows.

READING

Erhardt, L., Moller, R., Puig, J.G. (2007). Comprehensive Cardiovascular Risk Management – what does it mean in Practice? Vascular Health Risk Management, 3(5): 587-603

5 THE COMMON RISK APPROACH TO THE PREVENTION OF CHRONIC NON COMMUNICABLE DISEASES

As highlighted in Unit 1 session 3 and Unit 2 session 1, many of the NCDs share common risk factors. These risk factors are themselves a result of factors beyond the individual’s control. The underlying concept in the common risk factor approach is that controlling a small number of risk factors may have a major impact on a large number of diseases at lower cost, greater efficiency and effectiveness than disease specific approaches.

Figure 3: Common Risk factor Approach

Source: Watt, 2005 (Modified from Sheiham & Watt, 2000)

6 BASIC PRINCIPLES OF CHRONIC DISEASE CONTROL INTERVENTION

There are a number of approaches that can be used in an effort to reduce chronic NCDs. However, approaches need to be integrative so that they encompass many aspects so as to have maximum benefits.

There are basic principles to chronic disease control and intervention. Brownson et al (1998) proposed the following 10 principles of chronic disease control intervention:

a.  Comprehensive approaches that address the economic, social and political roots of health and sickness have proven to be more effective than traditional education approach.

b.  Changes in underlying community norms are another key to widespread and long-term improvements in health.

c.  Community-based approaches that target the whole population will contribute the most to reducing chronic disease mortality.

d.  A chronic disease control programme will be more effective if the at-risk population is actively involved in the prioritisation, development and implementation of all intervention activities.

e.  A chronic disease control programme will be more effective if community organizations (such as schools, churches, social clubs) are actively involved in developing and implementing the intervention.

f.  Chronic disease control interventions should build on traditional practices and cultural norms.

g.  Clearly defined objectives are essential for planning and implementing effective interventions.

h.  Intervention strategies should be selected based on the needs of the specific at-risk population.

i.  Multiple intervention strategies will increase the effectiveness of health programmes.

j.  Effective interventions require evaluation and the appropriate adjustment of strategies.

Based on these principles, the key concepts of chronic disease control interventions can be enumerated as:

·  Strategies focused on community norms

·  Community-based approach targeting the whole population

·  Active involvement of the priority population

·  Active involvement of the community organizations

·  Clearly defined objectives

·  Strategies based on the needs of the priority population

·  Multiple intervention strategies

·  Ongoing evaluation

7 SuMMARY

In this session we looked at the different approaches to prevention of chronic non communicable diseases. All these approaches have their advantages and disadvantages; therefore there is a need to weigh up certain factors (cost, applicability, etc) before deciding on an approach. In the next session we will look at some of the strategies that have been used to prevent chronic non communicable diseases

8 REFERENCES

Brownson, R.C., Schmid, T.L., King, A.C., Eyler, A.A., Pratt, M. & Murayi, T. (1998). Support for Policy Interventions to Increase Physical Activity in Rural Missouri. American Journal of Health Promotion, 12(4): 263-266.

Watt RG. (2005). Strategies and Approaches in Oral Disease Pprevention and Health Promotion. Bulletin of the World Health Organization, 83 (9): 711-718

Sheiham, A. & Watt, R.G. (2000). The Common Risk Factor Approach: a Rational Basis for Promoting Oral Health. Community Dent Oral Epidemiol, 28: 399–406.

Unit 3 - Session 2

Public health strategies for the prevention of NCDs

Introduction

As highlighted in Unit 1 Session 3, non communicable diseases have multiple risk factors. In many developed countries strategies have been utilised in an effort to combat the burden of chronic non communicable diseases (NCDs). Furthermore, studies have shown that chronic NCDs can be prevented and controlled through comprehensive and integrated actions. These actions include the following interventions:

·  policy decisions;

·  laws and regulations;

·  taxation and pricing;

·  improving the built environment;

·  advocacy;

·  screening (workplace, schools and communities)

·  clinical interventions at health facility levels.

In this session we will look at population based strategies for chronic NCDs and the focus will be on risk factors such as physical activity, diet (nutrition) and smoking. Because we will be looking at population based approaches, we will focus on structural or environmental prevention strategies that have been utilised in different countries in an effort to curb the burden of chronic NCDs.

Session contents

1. Learning outcomes of this session

2. Readings and references

3. Food environment

4. Built environment

5. Tobacco control

6. Session summary

Timing of this session

There are three readings and four tasks in this session. It is likely to take you up to three hours to complete.

1 LEARNING OUTCOMES OF THIS SESSION

2 READINGS

There are three main readings for this session, which focus on smoking, food environment and built environment.

3 FOOD ENVIRONMENT

Poor dietary intake has been linked with many NCDs. However, dietary intake is influenced by many factors and some of these factors are beyond the individual’s control. Therefore interventions need to deal with the causes of poor dietary intake. A paper by Igumbor and colleagues (2012) illustrates how big food cooperation’s impact on the food environment and how this then leads to problems such as obesity which in turn is one of the major risk factors of chronic NCDs. This paper further suggests that in order to intervene and influence the food environments especially in developing countries there is a need to engage policy makers, as trade agreements have an influence on locally available foods.

In different places public health strategies to prevent NCDs by improving the food environment have been employed, and include:

1.  Salt reduction: Salt consumption is associated with high blood pressure, which is one of the main risk factors for strokes and heart diseases. Reduction in salt in processed foods and other food items has been used in some countries, especially those in Europe. Most of the strategies for salt reduction are actions taken by government in partnership with the food industry and non-governmental organisations and the strategies included food reformulation, consumer awareness initiatives and labelling actions.

2.  Reduction of trans fat: Trans fatty acids, also known as trans fats, have been linked to the development of cardiovascular diseases. Foods such as meat and dairy products naturally contain trans fats. However, there are artificial trans fats that result from the hydrogenation of oils - the addition of hydrogen to oil in order to make it a solid. Often food manufactures add trans fat to food to stabilize it, increase the shelf life and add texture. The removal of artificial trans fat has been one of the strategies used in places like the United States and South Africa (see article by Igumbor et al, 2012).

3.  Nutrition Labelling: Nutrition labeling, sometimes referred to as food labeling, is one on of the strategies that have been utilized in many countries to force the food industry to declare the composition of their food items. It is hoped that by disclosing or declaring the composition of food items, the public will be supplied with relevant information that will allow them to make informed and healthy choices when selecting food.

Read the following paper, and then answer the question in Task 1.

READING

Igumbor, E.U., Sanders, D., Puoane, T.R., Tsolekile, L.P., Schwarz, C. & Purdy, C. (2012). Big Food: the Consumer Food Environment, Health and the Policy Response in South Africa. PLos Medicine, 9(7).

Task 1: Think about possible policy changes to address NCDs.

Reflect on the policy responses of the South African government to the obesogenic environment. What can the government do in your own country to respond to the unhealthy food environment?

4 BUILT ENVIRONMENT