International Congress Series 1267 (2004) 33 – 38
www.ics-elsevier.com
Establishing a disease prevention model Sandra Chambers * Southern Regional Health Authority, Union Bank, 5 Ward Avenue, Mandeville, Manchester, Jamaica
Abstract. Jamaica, as in many other developing as well as developed countries, has passed an era where the major causes of morbidity and mortality have shifted from the noncommunicable, infectious diseases. The leading causes of death in Jamaica in 1998 were due to cerebrovascular disease, diabetes mellitus, ischaemic heart disease, and hypertensive disease. It is well known that these diseases in many instances can be prevented through lifestyle changes, and can be detected early through routine screening examinations. However, the prevailing method of healthcare in Jamaica is one that focuses not on disease prevention, but rather on disease cure, such that patients do not present to a physician until they have developed signs and symptoms of a disease. Health care providers emphasize disease treatment, rather than prevention through health education. In 1996, the government of Jamaica, in an effort to place greater emphasis and awareness on the chronic and lifestyle-related diseases, entered into discussions with the government of Japan to establish a disease prevention (‘‘wellness’’) model in the southern region of Jamaica through joint technical cooperation. The goal of the project was to establish a model that would offer screening examinations, health education, counseling, and referral for further management for those found to be at risk for chronic and lifestyle-related diseases. It was important that services be geographically accessible and within the financial constraints of most Jamaicans. The project was implemented on June 1, 1998 and joint cooperation was to last for a 5-year period, ending May 31, 2003. D 2004 Elsevier B.V. All rights reserved. Keywords: Non-communicable diseases (NCDs); Lifestyle diseases; Wellness model; Health screening
1. Method of implementation The southern health region is divided into three parishes: Mandeville, St. Elizabeth and Clarendon. Manchester is the parish where the Southern Regional Health Authority’s office is located. The three parishes are largely rural and have a population of approximately 530,000 of which 130,000 are over age 30. While there had been other chronic disease prevention models developed in Jamaica, they were generally not as extensive as the services that the joint project sought to provide.
* Tel.: +1-876-625-2106; fax: +1-876-962-8233. E-mail address:
[email protected] (S. Chambers). 0531-5131/ D 2004 Elsevier B.V. All rights reserved. doi:10.1016/j.ics.2004.02.092
34
S. Chambers / International Congress Series 1267 (2004) 33–38
Therefore, in developing the current ‘‘wellness’’ model, several factors would need to be considered. 1. Which age group would be screened? 2. Where would the screening take place? 3. How would those individuals living in rural, geographically inaccessible areas be screened? 4. Would services be provided free or at a nominal cost? 5. What staff would be needed? 6. What equipment would be needed? 7. What would a screening exam entail and what tests would be offered? 8. How would data be collected? 9. How would advertising and promotion be done? 10. How would the program be extended? The Wellness project was conceptualized on paper approximately 2 years before the first patient was seen in February of 1999. From February 1999 to June 1999, a 3-month trial period was conducted where we sought to adapt what was on paper to an actual, real life situation. The first screening examinations were done at the Mandeville Comprehensive Health Center in the parish of Manchester. This is the largest non-hospital-based government clinic in the parish. It offers a wide range of medical services, including dental, maternal and child health, family planning, and curative services. The Wellness program began in the curative clinic where patients were already being seen for a number of different acute and chronic illnesses. As most chronic and lifestyle-related diseases tend to affect older individuals, we decided to start our screening examination at age 35, but would offer it for patients below age 35 with risk factors such as obesity, family history, and unhealthy lifestyle practices. During the trial period, patients were randomly selected from the curative clinic for a wellness screening exam, the only criteria being that they were age 35 years or older. The tests that were offered were height, weight, BMI, BP, random blood sugar, urine for sugar and protein, total cholesterol, and ECG. The cholesterol and blood sugar were non-fasting samples, as patients typically do not present to the clinic in a fasting state. As most Jamaicans were not in the habit of getting a general physical examination done, this was offered, in addition to breast and prostate examinations. Pap smears were not offered as patients were referred to the Family Planning Clinic for this service. The staff for the Wellness program initially included a public health nurse and a physician. It was the nurse’s duty to register the patient, measure the height, weight and BMI, draw the blood for laboratory testing, and do the ECG. The physician would do the medical exam, counseling and enter the data in a computerized database. During the trial period, we worked in close association with a Japanese nurse and doctor who offered assistance in setting up protocols and methods for screening that were suited to our Jamaican population and financial constraints. They also taught us how to use the equipment supplied by the Japanese government and set up the database. During the trial period, wellness examinations were offered only once weekly and only 5– 10 patients were seen on a given day. However, as the clinics got bigger, we realized we
S. Chambers / International Congress Series 1267 (2004) 33–38
35
would need more staff and so, a data entry clerk was employed. His job was also to do patient registration and keep inventory of all supplies and equipment. A medical technologist was employed for laboratory testing, a health educator for development of health education materials, and a nutritionist for counseling patients with obesity, uncontrolled or new onset diabetes mellitus and hypertension, and elevated cholesterol levels. As we introduced the Wellness program to our patients, we also wanted to introduce it to healthcare workers in our health department as well, as they would be vital in advertising and promoting the program in their communities. In March of 1999, we invited staff members from the Manchester Health Department to get a free Wellness examination. As part of their examination, we also conducted a health survey. The survey included questions of their perception of the current healthcare system, their concept of ‘‘wellness’’ and their own lifestyle practices and behavior. The Wellness clinic was offered free of cost in the initial 5 months of the program. During this time, however, a cost recovery analysis of each exam was done and based on our findings; it was decided to charge a nominal fee of JA$500 (equivalent to US$12). This was later increased to JA$600 in June of 2002 and is still the current price. This cost is much less than that of a private physician doing the same tests, and was in keeping with the goal of offering wellness preventive services at a nominal cost. As we began seeing more patients, there was a need for a Wellness Center that was separate and apart from the curative clinic. We needed to have a separate waiting area and examination rooms for those patients coming for a wellness examination. In October 1999, the Wellness Center was opened. It is a part of the Mandeville Comprehensive Health Center, but its primary role is doing screening examinations for chronic and lifestylerelated diseases. Patients are seen at the Wellness Center twice weekly and approximately 20 patients receive a screening examination on a given day. We wanted to make these screening exams easily accessible to the entire population in the southern region, not just those living in close proximity to our large health centers. In September 1999, we began our first mobile clinic in a rural community. The mobile clinic is done with the assistance of a bus (and driver) that is equipped with two examination beds, all the equipment needed to do a wellness examination, and our wellness staff. The same services are offered on the mobile units that are offered at the Wellness Center. Mobile clinics are conducted once weekly and take place at varying locations in a community, including business places, churches, schools, and small health centers. Initially, there was one mobile unit to cover the entire southern region, but as the program expanded into the parishes of Clarendon and St. Elizabeth, they were each given their own mobile unit through the generous donation of the Japanese government. In preparation for expansion into these two parishes, their medical staff was required to receive training from the Manchester Wellness and Mobile clinics. Advertising for the Wellness program has taken several forms. Initially, advertising was done when there was an official launch for the opening of the Wellness Center in October 1999. Formal advertising has taken the form of publicity by Community Health Aids (CHAs) who are healthcare workers offering health assistance to individuals in the communities where they live. Advertising for the program is also done by public health nurses who go into communities and speak informally about the program. Posters and flyers have been used, as well as a mobile public address system. We have had articles
36
S. Chambers / International Congress Series 1267 (2004) 33–38
printed in the local as well as the national newspaper, and we have invited members from the press to observe our program. Informally, and perhaps our major source of advertising is through word of mouth from patients who have already taken part in the Wellness program. We have had walkathons in different communities, and we have gone to health fairs where we have set up booths giving information about our program, as well as performing wellness examinations. We have also published yearly calendars that give information about the program. Currently, a Wellness examination includes: 1. A group health education session done by the health educator, nutritionist, physician or public health nurse. During this session, information is given on healthy lifestyle practices and behavior including nutrition and exercise. Control of current, existing chronic diseases and health maintenance through annual exams are stressed. 2. Registration—health and demographic information is taken on each individual patient, including prior existence of a chronic disease, lifestyle practices, and compliance with medications. 3. Height, weight, BMI, blood pressure measurements are taken. 4. Laboratory testing includes urine for protein and sugar, blood glucose, total cholesterol, hemoglobin. 5. ECG 6. Physical examination 7. Counseling 8. Referral for further treatment or follow-up by a physician. Referral is made to the cardiologist for patients with abnormal ECGs, to a primary care physician for those who need follow-up care and treatment and to the ophthalmologist, surgeon, or gynecologist if there are abnormalities found on the physical exam. Patients are also referred for pap smears, mammograms and PSA testing. Data are collected and analyzed using a computerized database. At each initial wellness screening exam, patients are given their test results in a pamphlet called the ‘‘Wellness Passport.’’ In addition to being a means of recording patients’ test results for 6 years, it also gives important health education information on such topics as hypertension, obesity, diabetes, cholesterol, height/weight/BMI, and the most recent edition of the pamphlet gives instructions on how to do a breast exam and encourages other cancer screening techniques. A paper copy of all wellness examinations is also kept at the health center, and patients are given a copy of all their results to take back to their physician for review. 2. Results A preliminary analysis of our data for the period September 1999 to June 2000 was done, and some important findings were noted. During this period 1190 patients were seen with the following results: Relationship between elevated BMI and abnormal ECG: (1) 790 (66%) had an elevated BMI (25 or greater);
S. Chambers / International Congress Series 1267 (2004) 33–38
37
(2) 386 (32%) had an abnormal ECG reading; (3) Of those with an abnormal ECG finding, 232 (60%) also had an elevated BMI. Relationship between elevated blood pressure and abnormal ECG: (1) 787 (66%) had an elevated blood pressure (WHO criteria class I or higher); (2) Of those patients with an abnormal ECG, 296 (77%) also had an elevated BP. Relationship between abnormal ECGs , BP, and BMI (1) Of those patients with an abnormal ECG (386), 30.6% had an elevated BP, 14.0% had an elevated BMI, and 46.1% had both an elevated BP and an elevated BMI. Relationship between abnormal blood sugars, BP, and BMI (1) Of those patients with an elevated blood sugar (160 patients), 21.9% had an elevated BP, 13.1% had an elevated BMI, and 59.4% had both an elevated BP and BMI. Based on these findings, we realized that if we developed a mass screening program where clients would get BMI and blood pressure checks, we would detect a large percent of our patients at risk for diabetes and heart disease. Those patients would then be educated and encouraged to get a full wellness examination. Thus, we needed to take the wellness model to the community level, and this required the input of the CHAs. 3. Mass screening program The original role of the CHAs was to form a bridge between services provided by the health department and the community. They were to identify the health needs of individuals in their communities, direct the individual to health facilities where these needs would be given attention, and follow up these individuals to make sure that desired results were met. In the disease prevention, wellness model, the CHAs would form a link between the Wellness program and the community. They would establish sites and times in their communities where individuals could get a BMI and BP readings (‘‘free check’’). They would also seek to empower and educate individuals and community leaders about healthy lifestyle practices and chronic diseases through liaising with the nutritionist, public health nurse, and health educator. Individuals found to be at risk would be referred for wellness examinations. The CHAs would also schedule and advertise mobile clinics coming to their communities. In preparing the community health aides for this community-based, mass screening program, they received appropriate training. They were given a textbook and lectures on the Wellness program. Its purpose and goal were outlined. The CHAs were educated in their role in the mass screening project and were shown how to use the equipment. They were taken into a busy section of town where they performed these free checks. A manual has been developed for their use that gives guidelines for the appropriate action to be taken based on the BP and BMI findings. Instructions include which patient to refer to the primary care physician for treatment and/or to the nutritionist and the wellness clinic. This community-based initiative has been established in 6 health centers in the parish of Manchester.
38
S. Chambers / International Congress Series 1267 (2004) 33–38
4. Summary The overall aim of the project was to improve the health status of the population in the southern region of Jamaica, with its main target being on the chronic and lifestyle- related diseases. However, the full impact of the Wellness program in the region may not be noted for some years to come. During the initial stages of the implementation of the program, a survey was conducted in the parish of Manchester that involved people’s awareness and behavior as it pertained to the non-communicable, chronic and lifestyle-related diseases. Approximately 2000 individuals were surveyed. In 2003, the survey was again repeated, and while studies are preliminary, it does show that people are involved in more health seeking behavior, such as getting regular BP checks. However, preliminary results also showed that we need to do a better job at advertising as many individuals were not aware that the Wellness program existed. In addition to providing easy access for disease prevention screening, the Wellness program has had some other positive impacts. Through this program, we have had joint collaboration in the field of public health between the Japanese and Jamaican governments. We have benefited from their technical assistance and their donation of equipment. The program has seen visits of specialists from Japan in the fields of laboratory medicine, information technology, and cardiology, who shared their knowledge and expertise. Health education is a primary focus of the Wellness program, and several health education materials have been developed. In addition to the ‘‘Wellness Passport’’ and calendars, we have developed health education videos that are culturally appropriate for our patients. They include obesity, diabetes, hypertension, exercise and nutrition. Patients watch these videos in the waiting area of the Wellness Center while they are waiting for their examinations. Brochures have also been developed by the wellness staff. Diabetes classes have also been very successfully implemented. Patients identified as diabetics during their wellness exam are invited to participate in the classes free of cost, which are taught by the nutritionist, public health nurse and physician. It is our goal in the Southern Regional Health Authority that this program be extended to other health regions of Jamaica and, possibly, to other CARICOM countries as well.
