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How Organizational Values Can Affect Responses to Chronic Disease Prevention and Management

Contents

I Introduction
II Overview of Centretown CHC and our model of care
III Challenges and tensions for Centretown CHC in addressing CDPM
IV What is Centretown CHC doing to address these challenges and tensions?
V Key learnings
VI Conclusion
VII References

-- submitted by Lise Labreque, Health Promoter, Centretown Community Health Centre

I Introduction

If you’ve been working in health promotion in Ontario in the past four years, you can’t help but have noticed that there is a big train moving through our sector. It is called Chronic Disease Prevention and Management (CDPM). It’s an express train, it’s moving very fast, and we’ve all had to jump on board…or else be left in the metaphorical dust!

You might be a health promoter, community developer, manager or executive director of an agency that works in the realm of CDPM. You feel pressured to deliver individual-focused strategies such as physical activity assessments, self-management programs, or nutritional counselling. Yet you know that the research is unequivocal – chronic diseases are not caused exclusively by biomedical factors and individual lifestyle choices, but are also due in large part to social, economic and structural factors (for a review of the evidence refer to the following in the references section: Butler-Jones, 2008; Public Health Agency of Canada, Centre for Chronic Disease Prevention and Control, 2006; Health Nexus and the Ontario Chronic Disease Prevention Alliance (OCDPA), 2008; Raphael, 2007). You see poverty eradication and health equity as the long-term solution to chronic diseases.

Does this describe your situation? As health promotion practitioners we are often faced with such dilemmas. Perhaps your personal values clash with the agency where you work, or with the communities that you serve. Maybe your agency’s value of and work in community capacity building is “in tension” with your funders’ request for data on individual interventions. While we may claim to be neutral or objective in our work, the reality is that values influence the decisions we make as front-line workers, as managers, executive directors and boards, and as funders.

The purpose of this article to describe how one agency, the Centretown Community Health Centre (CHC) has taken on this challenge of balancing our organizational values with the larger context in which we deliver services. More specifically, our experience with CDPM.

II Overview of Centretown CHC and our model of care

Located in downtown Ottawa, Centretown CHC, like all other CHCs in Ontario, follows a model of health that values and recognizes the impact of the social determinants on health, believes in whole-person care, and focuses on community as well as the individual. We provide free primary health care services, including health promotion, illness prevention and treatment, chronic disease management, and individual and community capacity building.

The CHC model of care is based on eight attributes. We provide services that are comprehensive, accessible, client-and community-centered, inter-professional, integrated, community governed, inclusive of the determinants of health, and grounded in a community development approach. At Centretown CHC, services are offered either on-site, through home-visiting, or through outreach at drop-in and recreation centres, housing cooperatives and other community locations. Centretown CHC just celebrated its 40th anniversary and is one of the oldest CHCs in the province.

III Challenges and tensions for Centretown CHC in addressing CDPM

Despite our holistic approach to health, even we are challenged to address CDPM in a broad-based, holistic manner. Some of the challenges and tensions we face are:

Where to focus our efforts? In the past two years there have been many CDPM opportunities for CHCs, for example: quality improvement initiatives such as the Quality Improvement and Innovation Partnership (QIIP) (see OHPE Bulletin 612 for an overview of QIIP) and the Improved Delivery of Cardiovascular Care (IDOCC) program; staff training on diabetes self-management, offered through our Local Health Integration Network (LHIN); and funding for physical activity programs and other lifestyle-focused approaches through the Ontario Ministry of Health Promotion.

Convincing decision-makers that CDPM efforts need to go beyond individual interventions.With the many CDPM opportunities listed above, how can we convince decision-makers (e.g., policy makers, politicians, and funders) of the link between our socio-environmental efforts (such as advocacy, community development, leadership development, and capacity building) and CDPM, and the need to invest equally in both of these areas?

How to comprehensively evaluate our full spectrum of CDPM work? We are faced with two inter-related tensions. First, we see the trend for funders who want to track accountability of CDPM efforts through both indicators at the individual / clinical / biomedical level (e.g., client blood glucose levels, number of clients who have been referred to physical activity in the past six months, or number of pap tests conducted) and through indicators for outcomes only. Such measures of effectiveness overlook the fact that in health promotion, the process of how and with whom we do our work, and the context in which individuals live are equally important indicators to track in order to fully interpret successful “outcomes.”  

Second, over-and-above individual indicators, we also want to look at indicators for community and system level change such as those for community capacity building, shifts in public policies, civic participation, partnerships and collaboration, and changes in social infrastructure.  

IV What is Centretown CHC doing to address these challenges and tensions?

In the past year, Centretown CHC has taken several steps to address these challenges.

Laying the foundation

We have created an internal CDPM Action Team with a representative from all teams, whose role is to provide leadership for CDPM within the centre. We have developed a CDPM Conceptual Framework, to clearly articulate how we are addressing CDPM at the individual and systems/organizational levels. We are presenting our CDPM Conceptual Framework to all staff in order to get everyone “on the same page,” to create buy-in, and to ensure common messaging about our social determinants of health (SDOH) approach to CDPM.

Building our capacity

We are taking steps to build our internal organizational capacity to address CDPM:

  • Developing a system to track and monitor CDPM activities on a quarterly basis.
  • Participating in the QIIP and other quality improvement projects for our primary care team.
  • Training staff in the “Stanford” Chronic Disease Self-Management Program.
  • Familiarizing ourselves with the recent CDPM literature and working with tools such as Health Nexus’ Primer to Action or the Canadian Public Health Association’s Tool for Strengthening CDPM.

Taking systems-level action

We are participating in system-level efforts such as:

  • Sharing our expertise and learning from others through the Champlain LHIN Diabetes Community of Practice network and the LHIN CDPM Collaborative.
  • Creating food security policies in partnership with a grass-roots food-security advocacy group and academics and researchers at the University of Ottawa.  
  • Participating in the City of Ottawa’s Community Development Framework initiative, a large community and systems-level effort with a goal to create healthy and safe environments and provide accessible, integrated and holistic services to communities in need.

Reframing our work

We have been in the business of CDPM for 40 years; we’ve just have been calling it something else – primary health care! Our physicians, nurses, nurse practitioners, dietitians and health promoters still continue to provide individual-level CDPM primary care to our clients.

Yet at the same time we are trying to be more explicit about the fact that other staff are ALSO doing CDPM – such as our community developer who is working with the “City for All Women Initiative”, the goal of which is to increase capacity of women from diverse communities to participate and have a voice in the municipal decision-making process, or our social workers who provide counselling on how to cope with the emotional aspects of chronic diseases.  

Measure Our CDPM performance and successes more comprehensively

We have made a commitment to measure our CDPM efforts in a more comprehensive way, even if our funder is not asking us for this information. In the coming year we will identify indicators at the community and / or systems level that we can easily track and monitor.

V Key learnings

Following are some of our key “learnings” and reflections from our work in CDPM: 

  • Ensure solid foundation — through articulating common values, goals, language and messaging.
  • Acknowledge and celebrate the CDPM work that is already being done by many different providers and programs in the centre.
  • Seize opportunities when they are presented to us – even if they mean more work or even if they are individual or behavioural / lifestyle focused. Just “go for it”, see what we can learn from it and draw lessons that can be applied in the community and socio-environmental contexts.
  • That said, take it slowly! Take time to reflect on what these new experiences are like – for staff, clients and participants. Are these new opportunities meeting the needs of those at highest-risk of chronic diseases? Are there other interventions that might better meet the needs of our communities?
  • Continue to emphasize that health promotion is not just about individual, lifestyle programs.

Remember that measurement of health promotion is not just about outcomes, but also about process and context.

VI Conclusion

It hasn’t always been comfortable for us to take this stance on CDPM. There have been – and will continue to be – internal and external tensions. However, as Dennis Raphael so passionately states, “…there are two issues to be faced by health promoters in Canada. The first is to confront the continued dominance of lifestyle and behavioural approaches to health promotion among practitioners and the understandings held by the media and public concerning the sources of health and illness. The second problem is to have those who recognize the importance of the social determinants of health take an explicitly political approach as a means of moving the health inequalities agenda along.” Our decision to write this article is one step towards taking up this call to action.

VII References

Butler-Jones, D. (2008). Chief Public Health Officer’s Report on the State of Public Health in Canada 2008. Ottawa: Government of Canada. Retrieved July 9, 2009 from: http://www.phac-aspc.gc.ca/publicat/2008/cphorsphc-respcacsp/index-eng.php.

Centre for Chronic Disease Prevention and Control. Public Health Agency of Canada. Chronic Disease. Ottawa. [Last Updated: 2006-11-07. Accessed July 9, 2009]. Retrieved from: http://www.phac-aspc.gc.ca/ccdpc-cpcmc/index_e.html

Health Nexus and the Ontario Chronic Disease Prevention Alliance (OCDPA). (2008). Primer to Action: Social Determinants of Health, Toronto.

Raphael, D. (2007). Poverty and Policy in Canada: Implications for Health and Quality of Life. Toronto: Canadian Scholars’ Press Inc. In M. O’Neill, A. Pederson, S. Dupéré, & I. Rootman (Eds.), Health Promotion in Canada: Critical Perspectives (2nd Ed.) (pp. 317-329), Toronto: Canadian Scholar’s Press.