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Disease prevention: How are we fairing?. 9 November 2007 Roscoe Taylor Director of Public Health Director, Population Health. Action across the continuum of prevention & care : example of type 2 diabetes. Preventable Environmental Health Hazards over Two Centuries (McMichael, 2006). - PowerPoint PPT Presentation
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Disease prevention:How are we fairing?
9 November 2007
Roscoe TaylorDirector of Public Health
Director, Population Health
Well population Screen those at risk People with newly diagnosed Type 2
diabetes
People with controlled diabetes
Primary Prevention
Vulnerable/at risk Identified Conditions Managed Conditions
Keep people well: Prevent movement to the
“at risk” group
Prevent progression to established disease and hospitalisation
Prevent/delay progression to complications and prevent re-
admissions
Good diet Physical activity Maintain healthy
weight Alcohol in
moderation Social factors
Treatment & acute care Continuing care & maintenance Self-management Crisis intervention
Well population Secondary Prevention/ Early detection Management & Tertiary Prevention
Overweight & obese Age >55 (>35 Indigenous
Australians) Family history Pre-diabetes (IGT, IFG) Hypertension Women with previous
gestational diabetes
Action across the continuum of prevention & care: example of type 2 diabetes
GlobalisationIndustrialisation Modernisation
Sanitation (infra-structure)
Food safety: laws, regulations
Smoke control: zoning, fines
19001800 2000
Infectious diseases
Obesity
Urban air pollution
Road trauma
Energy use and greenhouse gas emissions: climate change health impacts
Burden of disease (indicative only, not to scale)
Seat belts, drink-driving, road design
Clean air laws
Preventable Environmental Health Hazards over Two Centuries (McMichael, 2006)
Death and its causes
Top 10 Causes of Death* in Tasmania, 2004
2.5%
2.6%
2.7%
3.6%
4.2%
4.8%
5.3%
6.6%
16.8%
30.1%Cancers(all types)
Ischaemic heart disease
Cerebrovascular disease
Chronic lower resp diseases
Accidents
Diseases of nervous system
Diabetes mellitus
Diseases of arteries etc
Intentional self-harm
Diseases of digestive system
Source: ABS, Causes of Death, 2004, cat. no. 3303.0, Table 1.9
* as a % of total age standardised deaths
Avoidable Mortality Rate for Tasmanians Aged < 75 Years
226.8 213.9 192.6
173.3
0
50
100
150
200
250
300
1999-01 2002-04 2010 2015
Rat
e p
er 1
00,0
00 P
op
ula
tio
n TT Targets
Potentially avoidable deaths by socioeconomic status quintiles in Tasmanians aged under 75 years, 1999-2004
0
50
100
150
200
250
300
1999 2000 2001 2002 2003 2004
Rat
e pe
r 100
,000
Low Rest High
Rates are age-standardised to the June 2001 Australian population.
Social gradient & health
Michael Marmot argues convincingly that:
Low control over life&Social disengagement
…are the most powerful explanatory factors
Attributable Burden of DALY's - Australia 2003
0.2
0.6
0.7
0.9
1.1
2
2
2.1
2.3
6.2
6.6
7.5
7.6
7.8
0 2 4 6 8 10
Osteporosis
Unsafe sex
Air pollution
Child sexual abuse
Partner violence
Illicit drugs
Occupational hazards
Low fruit & Veg
Alcohol
Cholesterol
Inactivity
Body mass
Blood pressure
Tobacco
%These 14 risk factors explain 32.2% of Burden of Disease
AIHW 2007
The SNAPPs approach we use to address common risk
factors for chronic conditions
• Smoking
• Nutrition
• Alcohol
• Physical Activity
• Psychosocial
The challenge:Prevention strategies that
WORK at the Psychosocial level
Without taking the “PS” and socio- economic factors into account, strategies that focus on individual behavioural change probably won’t work, and even environmental measures will be less effective
What are we
to do about SNAPPs, and what still needs to happen?
“S” is for…..
Proportion of Tasmanians Currently Smoking
24.4%25.5% 25.4%
10%12%
15%
0
5
10
15
20
25
30
35
1995 2001 2004/5 2010 2015 2020
TT Targets
Source: National Health Surveys 1995, 2001, 2004/5; Tasmania Together (Revised) 2006
Australia: 1950-2000Smoking-attributed deaths: % of all deaths at ages
35-69
0
5
10
15
20
25
30
35
1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000
Year
Perc
ent
Males
Females
Smoking in Pregnancy
• Tasmania (2005): 27.6%
• NSW: 14.8%
• Tasmanian Public patients: 35.7%
• Private patients: 8.3%
• RR for Low Birth Weight Baby = 2.55
Self-Reported Tobacco Smoking Status During Pregnancy by Age, Tasmania 2005
13.5%17.1%17.5%
26.4%
43.8%
54.0%
< 20 20 - 24 25 - 29 30 - 34 35 - 39 40 +
DHHS, P erinatal Database No = 5,918
Proportion of Tasmanian Secondary School Students Currently Smoking* 1984-2005
0
10
20
30
40
50
1984 1987 1990 1993 1996 1999 2002 2005
Per
cen
t
Females 12-15 Years Males 12-15 Years
Females 16-17 Years Males 16-17 Years
*smoked within last 7 days; Source: Cancer Council, ASSAD Surveys
Try this on your next date!
Do health providers always ask their clients how many cigs they smoke, and advise them to quit?
“N” is for nutrition
Tasmanians Aged 18 Years and Over who are Overweight or Obese, 1989/90-2004/5
28.8% 30.5% 31.8% 30.0%25.0%
20.0%
10%
12.5%14.5%
17.1%
7.7%14.7%
0
10
20
30
40
50
60
1989/90 2001 2004/5 2010 2015 2020
Overweight Obese TT Targets
Source: ABS, NHS 1989/90 – 2004/5; Tasmania Together (Revised) 2006
Number of obese older people 1980 - 2000 (AIHW, 2003)
0
100,000
200,000
300,000
400,000
500,000
600,000
700,000
800,000
900,000
1,000,000
1980 1983 1989 1995 2000
Year
Num
ber
65+
55-64
Prevalence of chronic conditions by weight status in men (AIHW, 2003)
0
5
10
15
20
25
30
35
Diabetes Heart/Circulatorycondition
High bloodpressure
High bloodcholesterol
Men
Pre
vale
nce
(%)
healthy weight
overweight but not obese
obese
“Obese people should perform hard work, eat only once a
day, take no baths, and walk naked as much as possible.”
Hippocrates
quoted in Diabetes Care (2003) 26;11:3172-78)
In the modern era we have better solutions …
…..Sanitised tape worms!
We have to create supportive environments
Cool Canteen Accreditation program
Aims to help school canteens increase the availability of and promote safe and healthy food
and drinks
(*)
Creating Supportive Environments
Breastfeeding promotion
Aims to increase community
acceptance of and support for breastfeeding
Creating Supportive Environments
Nutrition Promotion
Funding for the Eat Well Tasmania Campaign to
promote enjoyable healthy
eating
Strengthening Community Action
Family Food Patch (peer educators) advocate for healthy eating at a local level.
Prevalence and consequence of Malnutrition in older people
• Malnutrition is common among elderly
• Malnutrition may lead to :– Higher risks of infection– Slow wound healing – Longer hospital stays– Poorer longer term health outcomes– Poor quality of life
Capacity Building
Healthy Settings
Community Development
Quality Improvements
The Action Steps of Mature Tastes Step 1: Use planning tool to identify, prioritise and plan to address key nutrition issues.
Step 2: HACC services action priorities.
Staff training Health PromotionNutrition Policy
Nutrition Screening
Menu changes
Step 3: Evaluation and further planning.
Some questions
• How would your service identify whether older patients were malnourished or at risk of malnutrition?
• Do you know whether malnutrition in your service’s older patients will be prevented by the care they receive when you discharge them?
Standard serves 1955 & 2001 (courtesy of Dept Human Nutrition, University of Otago)
1955Fries 72gCoke 200ml
2001Fries 205gCoke 950ml
Average number of food advertisements
0 2 4 6 8 10 12 14
Australia
UK
Greece
Germany
Netherlands
Norway TV3
Sweden TV4
Co
un
try
Average number of food ads per hour
And now we come to “A”, for
Alcohol….
We’ve come a long way…
Alcohol Related Harms
• Alcohol responsible for 4% of the global burden of disease (WHO)
• Alcohol causally related to 60 different medical conditions (Ridolfo & Stephenson)
• Alcohol causally related to a range of injuries, other social harms as well as hospital admissions
• As population consumption increases, harm also increases correspondingly
Tasmanian Population Response
• Under development – watch this space
• Establish a monitoring system allowing analysis of alcohol related trends
• Explore legislative change in support of safer drinking environments
• Focus on availability and marketing issues as a harm reduction measure
Tasmanian Targeted Response
• Focus on adult drinking as well as that of youth
• Strategies to build resilience in early childhood
• Strategies to address Foetal Alcohol Syndrome Disorder
• Explore introduction of workplace strategies
How does socio-economic status affect alcohol consumption?
“P” is for Physical Activity…
….the hardest of all
the risk factors,
to get moving?
Proportion of Population who do not Exercise Sufficiently* to Avoid Chronic Disease
69%71.5%69.6%
25%
45%
55%
0
20
40
60
80
100
1995 2001 2004/5 2010 2015 2020
TT Targets
*includes no exercise, sedentary, and low level exercise*includes no exercise, sedentary, and low level exercise
Source: ABS, NHS 1995, 2001, 2004/5; Tasmania Together, Revised, 2006Source: ABS, NHS 1995, 2001, 2004/5; Tasmania Together, Revised, 2006
Live Life Get Moving: Tasmanian Physical Activity Plan 2005 -2010
• Premier’s Physical Activity Council• Four action areas/goals:
– Participation– People– Policy– Places
• Coordinated action required across all 4 areas and across sectors
Some projects and strategies– Evidence-informed social marketing campaigns – Get Active program– Move Well Eat Well (Schools)– Good Fuel for Police (DHHS will be next!...)– ‘Healthy community framework’ for local
communities– Guideline development around land use planning
and the “Healthy By Design” Guidelines (PPAC and Heart Foundation)
– Monitoring and surveillance (major deficiency).
How do health services ensure that physical activity is seen as part of treatment?
Recent national events & Prevention
(weak) National Chronic Disease Strategy? Service Improvement Frameworks Abolition of NPHP (mod) Australian Better Health Initiative? COAG Human Capital Reform –
Diabetes± ANZ Food Regulation MinCo Resources diverted / wasted on
politically motivated mass media? Federal election
Summary
• To get good traction with prevention, strong Government intervention is needed….
…and bold interventions in the marketplace are called for…
Thank you for your time
What we don’t want DHHS to do for its clients?
The continuum of prevention and care
• Primary Prevention: protection of health by measures that eliminate or reduce the causes or determinants of departures from good health, control exposure to risk, and promote factors that are protective of health.
• Secondary Prevention: early detection of asymptomatic biological changes or asymptomatic disease, and prompt and effective intervention to address these departures from good health.
• Tertiary Prevention: measures to reduce or eliminate long-term impairments, disabilities and complications from established disease and prevent or delay subsequent events.
Supporting people with chronic conditions to change behaviour
• It is relatively easy to identify the risks that will increase a persons likelihood of developing a chronic disease, but working with people to change these risk factors is a challenge faced by all health practitioners.
• Easy to call it “Non compliance” … or are different tactics required?– Self management has been identified as an
essential key element in health systems that effectively address chronic disease
Self management
• Uses principles of both health promotion and risk reduction
• The person is at the centre of their own health care
• Builds skills and confidence
• Enhanced by supportive communities and health care providers
• Involves all levels of the health system
Supporting people to manage their own risk factors and chronic conditions
• Health Practitioners:– New skills to integrate into practice: Health coaching, Mentoring;
Flinders Partners in Health Tools to assess client’s self management skills
• For clients:– Community based programs: Stanford Chronic Disease Self
management Program; Condition specific education classes; peer led Diabetes cooking classes, exercise groups;
• For the System:– A coordinated model of care that supports clients to manage their
condition in partnership with health practitioners: i.e. the Chronic care Model
• Policy Level:– National Chronic Disease Strategy– Tasmanian Health Plan: Primary Health Care services
Prevention is not merely proactively applying a disease
model to what we do
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