Holistic Health Indicators:From Context to Application

CORE Group Spring 2016 Pre-conference Session

Sponsored by the Monitoring and Evaluation Working Group

and Medical Teams International

Steve Sethi, MD, MPHSenior Medical/Health Advisor

ssethi@medicalteams.org

Session Objectives

• Define holistic health, and differentiate it from multi-sectoralism

• Explain several concepts of holism, including shalom• Recognize the term transformational development • Describe health and wellness• Identify published evidence for improved outcomes

from holistic health interventions, and the need for research

• Name some examples of holistic health indicators

What is Holistic Health?

• People are multi-dimensional: more than physical objects, inseparable from social, emotional, spiritual being

• Isolated focus on physical needs low ROI (contributes to the perception of ‘wasted aid’)

• Development cannot simply be about economic advancement

• We have the opportunity to nurture richer, fuller lives:• Enlarging people’s choices and building human capabilities, enabling

them to live a long and healthy life, have access to knowledge, have a decent standard of living and participate in the life of their community and the decisions that affect their lives. (UNDP HDI)

• More likely to see lasting change in communities

Social Determinants of Health

• Recognize social determinants and root causes of poor health:• The circumstances in which people are born, live, work and age

• The systems put in place to deal with illness

• Shaped by a wider set of forces: economics, social policies, and politics

• Multisectoralism: every sector has the potential to affect health• E.g., finance, education, housing, employment, transport

• Government policies sometimes have contradictory aims

• Goal: reduce inequities• Addresses differences in communities, societies, institutions

• Not precisely focused on the individual’s experience

WHO: http://www.who.int/social_determinants/

Wider Determinants of Health

Whitehead, M. (1990). The concepts and principles of equity and health. WHO Regional Office for Europe.

Hancock, T., & Perkins, F., (1985). Health Education. Vol. 24, No. 1, pp. 8–10.

The Mandala of Health

Holism: broader concepts

• Broader than social determinants: the inner life, values, and human dignitythat make life worth living

• Values matter to people, often more than income or possessions, or even physical health at all costs

• Coping capacity - skills and assets to survive, respond, and recover

• Resilience: the flexibility to adapt to the challenges of life, and to have hopefor the future

• Relationships: the ability to relate positively to neighbors, the environment, God, self, and to one’s past and present, and to be accompanied in difficulty or death

• Community Capacity: Participation, Social cohesion, Sense of ownership, Collective efficacy, Resource mobilization (internal), Information equity, Critical thinking

Shalom/Transformation

• Early Jewish traditions:• Human beings are a living nephesh - a unity of body and soul• To be in right relationship with God, is to be in a state of shalom

(health-wholeness-peace)

• Shalom richly describes holistic health1: • Reconciled relationships, harmony with each other and environment,

fulfilment of one’s potential, adequate resources for life• Well-being / wholeness that results from all the above• Lived out in communities that demonstrate mutual concern for every

person and family.

• Foundational for FBO concept transformational development: “changed people and just and peaceful relationships.”2

1Evvy Campbell. Holistic Mission Occasional Paper No. 33.2Bryant Myers, Walking with the Poor. Orbis Books (1999).

What is health or wellness?

• WHO: “a state of complete physical, mental and social well-beingand not merely the absence of disease and infirmity.”

• Halbert Dunn: “wellness is an integrated method of functioning which is oriented to maximizing the potential of which an individual is capable.”1

• Well-being in population terms: “the presence of the highest possible quality of life in its full breadth of expression… good living standards, robust health, a sustainable environment, vital communities, an educated populace, balanced time use, high levels of civic participation, and access to and participation in dynamic arts, culture and recreation.”2

1Am J Public Health Nations Health. 1959 Jun; 49(6): 786–792.2 Canadian Index of Well-being. www.ciw.ca

Population measures of well-being

• Oregon Progress Board/Oregon Shines (1989) → Tracking Oregon’s Progress (2014): Healthy Economy, Healthy People and Communities, and Healthy Environment.

• Dutch Institute for Social Research: Life Situation Index

• Measuring Australia's Progress

• Melbourne Charter

• New Economics Foundation Happy Planet Index and National Accounts of Well-being

• Sustainable Society Index

• Bhutan’s Gross National Happiness

• UNDP HDI: life expectancy, education, income, and equality

Well-being

1 Bath University. Defining wellbeing. 2007.2 Brown, C., Alcoe, J. Journal of Holistic Healthcare. May 2010.

• Well-being in a social context: “a state of being with others where human needs are met, where one can act meaningfully to pursue one’s goals, and where one enjoys a satisfactory quality of life.”1

• Well-being in relational terms: how we relate inwardly to ourselves and come to understand ourselves through physical, mental, spiritual, and emotional levels, and how we relate outwardly to others, our community, and our environment.2

Salutogenesis

• What are the factors that support well-being?

• Antonovsky: Health is a continuum, not a dichotomy, between well-being, stress, and coping1

• Two positive mechanisms for responding to hardship and avoiding negative health outcomes:

1. Generalised Resistance Factors: social support, knowledge, experience, intelligence, financial resources, and traditions

2. Sense of Coherence: a positive way of viewing life and the ability to manage the stresses of living

• Comprehensible: things happen in an understandable and predictable way

• Manageable: you have the capacity to control and respond to events

• Meaningful: life is satisfying, worthwhile and full of purpose

1Antonovsky, A. Health, Stress and Coping. San Francisco: Jossey-Bass Publishers, 1979

Illness

• Conversely, if wellness is defined by high functioning in physical, social, mental, emotional, and spiritual levels, how do we define illness?

• Biopsychosocial Model (George Engel, 1977): pathology is influenced by biological, psychological, behavioral, and social factors.

• “Illness disrupts all of the dimensions of a relationship that constitute the patient as a human person, and therefore only a ‘holistic’ or biopsychosocial-spiritual model can provide a foundation for treating patients holistically.”1

1 Sulmasy, D. The Gerontologist. 2002: 42(s3); 24-33.

Evidence for Holistic Health

• Is there evidence that integrated projects are more holistically successful than single interventions?

• Do physical health interventions lead to improvement in community, economic or psychosocial indicators? Vice versa?

• Not a lot of data specific to health• Some studies with 2 outcomes (e.g., neonatal mortality and maternal

depression)

• FHI360 2014: systematic review (mostly 1-2 integrated interventions)

• Internal (unpublished) evaluations?

• Other holistic interventions are successful: • IFPRI 2014: Aspirations lead to behavior change in Ethiopia1

• J-PAL 2015: 6 RCTs of integrated livelihoods program1 Bernard T, et al. The future in mind: aspirations and forward looking behavior in rural Ethiopia. CSAE Working Paper WPS/2014-16. Oxford, UK: Centre for the Study of African Economies (CSAE).

FHI360 systematic review

• Prior data on observed links between determinants (e.g., more education = better health)

• Limited data on the impact of strategiesfor integrated development• 303 articles. 25 intervention types.• Single intervention multiple impact• Multi intervention single impact• Multi intervention multiple impact

• Conclusions: 13 types of integration positive, 9 mixed, 3 neutral

• Caveat: Combining standard single-intervention indicators may not reveal causation; “complex multi-layered models for development may require more nuanced and sophisticated measurement tools.”

FHI 360. Integration of Global Health and Other Development Sectors. (2014).

J-PAL 2015: Multifaceted program

• 6 RCTs in 6 countries over 2 years + 1 year follow up (10,495 participants)

• Interventions: Asset grant, training, support, life skills, short cash support, savings account, health information

• All outcomes significantly improved after 2 years

• Most improvements persist a year later

Banerjee A, et al. A multifaceted program causes lasting progress for the very poor. Science 2015 May; Vol 348(6236).

Indicators of Holistic Health

• Consensus on physical indicators already exists

• Need reasonable ways to measure and communicate changes in human dignity

• We are interested in a consolidated, standardized set of measures which shine a light on the fullness of human life.• Should at least reflect physical, social, mental and spiritual

aspects of health.

• What work has been done already?

Integra Foundation TD Indicators

• Service Indicators • Employment, pay, infrastructure, ethnic and gender equity

• Empowerment Indicators • Political and Social Influence (participation, successful lobbying,

women as owners/leaders, risk tolerance)

• Abundance Indicators • Income, living standards, investment

• Character Indicators • Faith identity and participation, volunteerism, care of children,

domestic violence, measures of corruption, environmental stewardship

Makonen Getu, Measuring Transformation. Transformation 2002 (19; 2: 92).http://neighborhoodtransformation.net/articles/workinggroup_files/Integra%20TransformationframeIA.doc

CRWRC Dimensions of Transformation

The Seven Dimensions of Transformation:1. Shared Vision

2. Sense of Community

3. Ownership

4. Leadership

5. Assets, Knowledge and Skills

6. Ongoing Learning

7. Shalom

http://bit.ly/1RRIGEr

Tearfund Learning and Impact Guide to Holistic Transformation

0

1

2

3

4

5Social connections

Personal Relationships

Living Faith

Emotional/Mental

Physical HealthStewardship

Material Assets &Resources

Capabilities

Participation/influence

• Wheel: a journey towards transformation.

• 9 Spokes: domains of holism:• Social connections, personal relationships,

faith, emotional, physical, stewardship, assets, capabilities, participation

• Each domain has 5 levels (avoiding to achieving).

• FGD for consensus on each domain, or HH survey

• Excel tools for data entry automatically create a radar plot

• Plots can be overlaid to show change from year to year

https://sites.google.com/a/tearfundfriends.net/evidence-effectiveness/home/evaluation-resources/tools-and-approaches/the-light-wheel

WV Compendium of Indicators for Measuring Child Well-being Outcomes

• 5 Domains of Change

• 6 categories of indicators for each domain• Education

• Household Resilience

• Caring for Others

• Emergence of Hope

• Community & Civic Participation

• Community & Social Sustainability

http://www.wvi.org/publication/compendium-english

WV TD Indicators: examples

• Increased sense of responsibility for others with mutual, reciprocal assistance

• Capacity to imagine community change

• The level of participation of community members, including children and youth, in implementation, supervision, and management of activities and community resources

• Increased level of trust within the community

• Development of life skills that lead to strategies to cope with or prevent emergency situations

• The extent to which internal resources are leveraged with and augmented by external resources.

Food for the Hungry Child Focused Community Transformation M&E Essentials

• Personal resilience score (depression score + generalized self efficacy score + social support seeking score)

• Perceived safety of children• Physical fights among children• OVC well-being score (CRS)• Intimate partner violence• Child attitudes towards IPV• Women’s social support outside the home• Children with close friendships• Women’s perception of divine will for women’s empowerment• Children with positive feelings about the future

Food for the Hungry (2012). FH CFCT Toolkit #7: CFCT Monitoring and Evaluation Essentials Manual.

MTI examples

• Afghanistan: • “warming” of community relationships due to public meeting places

for women, regular Shura meetings, and invitations to celebrations

• Cambodia:• % of Food Vendors operating a profitable business year round

• % women who think that wife-beating is justified for one of the 6 reasons cited in CDHS2010

• Guatemala:• % eligible families participating in Hambre Cero (a CCT program)

• # of church leaders trained in FP themes and committed to promotion of FP at community level.

MTI examples

• Mexico:• # of women that use adequate tools to resolve interpersonal conflicts (listen calmly,

speak calmly, attempt to resolve the conflict calmly)

• # of promoters that facilitate at least one peace education workshop.

• % of women that know at least three of their rights

• # of times women mentioned positive activities for the good of their community (participates in community work days or school work days, helps neighbors, assists in the organization of meetings, cares for the community in other ways)

• Haiti:• % of community members who would visit someone who had been treated for TB

• Myanmar • % of target villages who conducted village cleanup day in last 6 months

• # churches engaged in CH activities in majority-Buddhist communities

MTI examples

• Liberia• % of disadvantaged groups who attend Quality Improvement Team meetings

• % of female QIT members who report increased empowerment in communities with traditional gender roles

• % of HF clients who report being satisfied with services they received.

• # communities engaged in health construction activities

• Uganda

• # of churches with improved capacity to promote health behaviors

• # FBO leaders who provide psycho-social and spiritual support to affected families

• % of families in targeted communities affected by NS or HIV/AIDS who receive regular support from an FBO.

• # of families affected by HIV or Nodding Syndrome visited and offered psycho-social and spiritual support

Comments/Questions