Special Report. Ecological Model

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1 Navigating the Sea of Diabetes Ann Albright, PhD, RD Editor s note: This article is adapted from the address of the American Diabetes Association (ADA) President, Health Care and Education, given in June 2008 at the association s 68th Annual Meeting and Scientific Sessions in San Francisco. A webcast of this speech is available for viewing at the ADA website ( under For Health Professionals and Scientists. Click on the icon for the 68th Scientific Sessions Presentation Webcasts. In reflecting on where we need to go in diabetes prevention and care and how to get there, I have chosen sailing, or more specifically, a boat, as a metaphor to give direction to my remarks. Although I am certainly not a sailor, sailing holds a special meaning for me. My late husband, Scott, loved sailing or certainly the idea of sailing and had a craftsman friend make a sailboat necklace for me. While Scott was ill, I wore the necklace every day to help us navigate through those rough waters. Our sailboat continues to help me live, work, and volunteer in diabetes. Our ultimate destination is a world free of the devastation of diabetes. This is our vision at the Division of Diabetes Translation at the Centers for Disease Control and Prevention (CDC). 1 I hope these words, from the nation s public health agency for diabetes, give voice to your vision as well. Our respective missions may be different, but I hope this vision will serve as the unifying destination we are all seeking. Because diabetes and pre-diabetes affect not only individuals, but also families, communities, and society, Ecological Model we need to take action in each of these arenas (Figure 1). 2 There are challenges and opportunities in each of these arenas for bringing us closer to a world free of the devastation of diabetes. The further out you move from individual to societal interventions, the more complex and multifactorial the approaches become and the longer it can take to achieve change. But the impact is more far-reaching. Individuals are crucial to achieving our vision, societal changes are crucial for achieving our vision, and so are the arenas (families, communities, organizations) in between. Importance of a Plan (Map) In navigating the sea of diabetes, it is important to have a plan or a map, 38 Diabetes Spectrum Volume 22, Number 1, 2009 Community and policy System, group, culture Family, friends, small group Individual The health of individuals is inseparable from the health of communities (Healthy People 2010) Figure 1. The ecological model of diabetes care. if you will, to provide direction and focus so you are not wandering aimlessly. Planning is important at several levels. I would like to comment specifically on the importance of both an organizational strategic plan and an individual treatment plan. You may say to yourself, I am not a planner, or, I know where I am going. But it is not enough for a single person to know the plan; others need to know it as well. Truly getting the upper hand on diabetes requires many people, many organizations, and many perspectives. A clear plan allows us to define what we are doing so others will know and provides a stronger foundation for building collaborations. Do you know your organization s strategic

2 BASIC SCIENCE Molecular/ physiological EFFECTIVENESS EFFICACY Ideal settings Real world settings Figure 2. The continuum of translation. EFFICIENCY AVAILABILITY Biggest effect on most people DISTRIBUTION Supply Diffusion of interventions plan? Is it more than a document that sits on the shelf? The American Diabetes Association (ADA) recently approved its strategic plan. It contains strategies and targets that will help us advance toward outcomes that are needed to meet the organization s mission: to prevent and cure diabetes and improve the lives of all those affected by diabetes. Please look at this strategic plan, which is available online at the ADA website (www. diabetes.org). 3 As health care providers, we play a pivotal role in helping people with and at risk for diabetes to develop individualized treatment plans. Without such plans, it is virtually impossible to achieve targets and successfully navigate the sea of diabetes. These plans must be jointly developed with people who have diabetes, and they need to own their plan. It is important to remember that course corrections are needed as we sail toward our vision. It is the norm not the exception that course corrections will be needed, and we need to remind ourselves and our patients of this. Having a plan and ongoing information that allows you to check the course and make necessary changes are key to ensuring that we do not wind up floating aimlessly through the sea of diabetes. Translation (Mainsail Catching the Wind) In our boat metaphor, I look at translation of science into practice as the mainsail and the wind that fills the sail, allowing us to make major headway in achieving our vision. What is translation? It can be confusing, partly because people use the term in various ways. I have found it helpful to think of translation in the following way: Translation is a form of research that seeks to answer questions that are directly applicable to real-world settings. Translation is also the act of transforming knowledge into action. It is helpful to look at the continuum of translation that moves from basic science to distribution (Figure 2). Basic biological research is a crucial first step, followed by efficacy trials that test hypotheses in ideal settings to show proof of concept. Effectiveness studies are done in real-world settings and offer important information about generalizability. The next steps to consider are efficiency, which seeks to identify ways to have the biggest effect on Diabetes Spectrum Volume 22, Number 1, 2009 the most people, and then availability, which is concerned about supply. The final step is distribution, which addresses diffusion of the intervention. All of these steps are necessary, and they build on each other. Although more basic research is certainly needed, as a country, we have made a much smaller commitment to the steps from effectiveness research through availability. Public health efforts are focused on the steps from effectiveness research to distribution. If we do not reach the higher steps, we have done a disservice to the important investment in basic and efficacy research. The creation of new knowledge often does not on its own lead to widespread implementation or impacts on health. 4 Government and taxpayers would like to see the benefits of tax dollars invested in health research by moving research into policies, programs, and practices. Knowledge translation can be approached in one of two ways: end-of-grant translation or integrated knowledge translation. In end-of-grant translation, researchers develop and implement a plan for making knowledge users aware of the knowledge that has been gained from their projects. In integrated translation, researchers and researchusers work together to shape the research process. Integrated knowledge translation should produce research findings that are more relevant to end-users. Glasgow and Emmons 5 described barriers to translation and the kinds of evidence needed to address and reduce them. The characteristics of the interventions are one type of barrier. Interventions that are intensive and very demanding for both staff and participants may prove efficacious but can lack generalizability and be difficult to apply to a broader population outside of a research setting. To increase translation, it is suggested that more effort be placed on examining the minimal level of intensity that is likely to produce meaningful change and not just the maximum level desired. In addition, the interventions may not be easily replicated by others because they are 39

3 A Health System for A Healthiest Nation: Health Protection for Life Public Health Network Health Protection: Health Promotion, Prevention, and Preparedness not packaged for easy implementation or there is no information about whether they can be successfully modified. Collecting additional process evaluation data when interventions are being tested may help identify permissible modifications. The other set of translation barriers described by Glasgow and Emmons are the characteristics of the target settings (e.g., schools and community-based health centers) that most often have very limited resources and the characteristics of the research design (e.g., small unrepresentative samples or failure to address issues important to local concerns). These barriers also influence the generalizability of the findings and make translation difficult. To overcome some of these barriers, it is important to consider the kinds of evidence that are necessary for translating research into practice. Because there are many different kinds of evidence, and each has its strengths and weaknesses, Glasgow and Emmons recommend integration of different kinds of evidence using mixed methods that combine the strengths of both quantitative and qualitative methods. 5 Paying attention to contextual issues (e.g., personal, social, and economic costs Healthcare Delivery System Disease Care Figure 3. The ideal health system is one in which health care delivery and public health are interconnected. of an issue) and connecting the multiple levels of influence that affect a health issue will enhance translation. The community-based participatory research method, in which research actively involves community partners in all components of the research study, can enhance study relevance and translation. The contributions of the community-based participatory research method not only occur during the research study and make findings more relevant for implementation, but also can build community capacity and provide benefits far beyond the duration of the study. Health System (Lighthouse) What else is needed to safely navigate the sea of diabetes? Lighthouses, which provide guidance and support are needed. Our health system should be a lighthouse, providing guidance and keeping us safe from rocky shores. The lighthouse needs to serve all people with and at risk for diabetes and the health care team. The health system that is a beacon of light is one in which the health care delivery system and the public health network interconnect (Figure 3). The health care delivery system takes the lead in diagnosis 40 Diabetes Spectrum Volume 22, Number 1, 2009 and disease care, while the public health network takes the lead in health protection, health promotion, prevention, and preparedness. In many instances, the health care delivery system and the public health framework should work hand in hand. How well have we been doing in improving diabetes quality measures and reducing complications with our current system (lighthouse)? We are making important progress, but we have much more work to do. It is certainly concerning that, in the United States in 2004, 63% of adults with diabetes reported poor mental or physical health at least 1 day in the past 30 days. 6 Data from the CDC show that processes of care (foot exams, flu vaccines, lipid testing, eye exams, and aspirin use) and outcomes (A1C, blood pressure, and LDL cholesterol levels) are showing improvements, except for blood pressure. 7 The age-adjusted prevalence of visual impairment per 100 U.S. adults with diabetes between 1997 and 2005 has declined. Trends in the incidence of complications, including cardiovascular disease hospitalizations, amputations, and end-stage renal disease among people with diabetes showed declines from 1980 to However, when looking at these data among the overall population, the trends are increasing. This is because the number of people with diabetes is increasing as a proportion of the overall population. What can we do to make our health system a brighter, more effective beacon? Many things are needed, but I would like to focus briefly on three: the Chronic Care Model; programs in which trained nonphysician health care professionals are given authority to make independent treatment decisions that follow protocols; and programs that involve community health workers. The Chronic Care Model includes creating partnerships between health systems and communities. 8 Communities need to be able to provide resources and policies that assist people in participating in healthy practices where they spend most of their time. The health system provides self-management support,

4 delivery system design, decision support, and clinical information systems. The Chronic Care Model includes a prepared proactive practice team. The work of Davidson et al. 9,10 has shown that when trained nonphysician health care professionals (under appropriate supervision) are given authority to make independent treatment decisions following protocols, patient outcomes are improved significantly compared to usual physician care. Finally, the Chronic Care Model includes informed, activated patients. One important way to help accomplish this is participation of community health workers. Community health workers provide a crucial bridge between communities and health care systems, providing support and reinforcing skills that help patients become better prepared to meet the demands of living with diabetes. 11,12 Health Disparities and the Rise in Diabetes Prevalence (Troubled Waters) Some who are navigating the sea of diabetes have a marooned or leaky boat. We continue to face significant health disparities in diabetes. These disparities are evident in the number of adults who have diabetes, with American Indians showing the highest prevalence, followed by African Americans and Hispanics/Latinos. 6 These racial/ethnic disparities persist among youth as well as adults. 13 Disparities are evident in risk factors for cardiovascular disease 14 and also in mortality from diabetes. 15 The mortality rate for men with and without diabetes is declining. The mortality rate for women without diabetes is declining, but for women with diabetes, the mortality rate has remained steady. In the quest for fulfilling the vision of a world free of the devastation of diabetes, we have come upon a looming danger an iceberg if you will. Let s not have the same outcome as the Titanic. We have a growing number of people on the cusp of entering the sea of diabetes. The approximate lifetime risk of the development of diabetes is 33% for men and 37% for women. The risk is 45% for African Americans and 48% for Latinos. The risk is 56% for those with a BMI of kg/m 2 and climbs to 72% for those with a BMI > 35 kg/m 2. 6 Various things are needed to address primary prevention, but one very helpful element is communityclinical partnership. Accessible options for physical activity and nutritious foods, along with support for maintaining healthy lifestyles, are needed in communities, where people spend most of their time. The clinical system is necessary for making diagnoses, referring people to community interventions, and providing ongoing medical follow-up. The challenges for diabetes prevention and control are sustaining and building on gains in control and gaining new resources for primary prevention. It is imperative that we do both and that new resources be obtained for primary prevention. Collaboration (Sharing the Sea) A discussion of navigating the sea of diabetes would not be complete without addressing collaboration and partnerships, and again, the metaphor of sailing offers insights. As we gain more people who are committed to achieving our vision of a world free of the devastation of diabetes, we have to share the water and position ourselves so we can really catch the wind and move forward. Wikipedia defines collaboration as interaction of knowledge and mutual learning between two or more people who are working together toward a common goal which is typically creative in nature. Collaboration is often assumed and not necessarily nurtured. It is helpful to consider that not all the ways we interact are collaborations or partnerships. We may be networking, which is exchanging information for mutual benefit; coordinating, which is identifying and aligning complementary resources; or cooperating, which is altering and sharing resources for a common goal. Collaboration is true synergy to co-create and achieve mutual benefit. Leadership (Wheel and Rudder) It is impossible to have effective collaborations and partnerships Diabetes Spectrum Volume 22, Number 1, 2009 without leadership. The wheel and the rudder on a boat provide a useful leadership metaphor. A leader is viewed by many as the person at the top. However, it is actually crucial to cultivate leadership throughout organizations. In John C. Maxwell s concept of 360 leadership, 16 leadership is a choice you make, not a place you sit. Serving leadership is an approach that I believe is a lynchpin to our success in achieving a world free of the devastation of diabetes. Jennings and Stahl-Wert 17 describe serving leaders as follows: Serving leaders run to great purpose by holding out in front of their teams a reason why that is so big that it requires and motivates everybody s very best. They upend the pyramid of conventional management and put themselves at the bottom. Serving leaders raise the bar of expectation by being highly selective in the choice of team members and by establishing high standards for performance. Serving leaders not only practice serving leadership, but blaze the trail by teaching serving leader principles and practices and, very importantly, by removing obstacles to performance. Finally, serving leaders build on strengths by arranging each person in the team to contribute what he or she does best. We are in a crucial time for diabetes, filled with both significant concerns and tremendous opportunity. Leadership matters most in times of uncertainty. 18 To navigate the sea of diabetes and achieve our vision of a world free of the devastation of diabetes, develop your serving leadership skills and teach them to others. There are many people to which I offer my thanks, gratitude, and love: My precious family who have my undying love; my dear colleagues and friends in the Division of Diabetes Translation at CDC, who are the best scientists and public health professionals around; my fellow principal officers Stewart Perry (Chair of the Board), Bob Garrett (Secretary/ Treasurer), and John Buse (President, Medicine and Science) and Chief Executive Officer Larry Hausner, who are the best boat mates you 41

5 could ever ask for; and all of you who have dedicated yourselves to helping people navigate the sea of diabetes. References 1 Centers for Disease Control and Prevention, Division of Diabetes Translation: About the program [article online]. Available from 2 McLeroy KR, Bibeau D, Steckler A, Glanz K: An ecological perspective on health promotion. Health Education Quarterly 15: , American Diabetes Association: strategic plan [article online]. Available from 011ADAStrategicPlan.pdf 4 Canadian Institute of Health Research: About knowledge translation [article online]. Available from html 5 Glasgow RE, Emmons KM: How can we increase translation of research into practice? Types of evidence needed. Ann Rev Public Health 28: , Centers for Disease Control and Prevention: National diabetes fact sheet: general information and national estimates on diabetes in the United States, Atlanta, Ga., U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Saaddine JB, Cadwell B, Gregg EW, Engelgau MM, Vinicor F, Imperatore G, Narayan KMV: Improvements in diabetes processes of care and intermediate outcomes: United States, Ann Intern Med 144: , Institute for Healthcare Improvement: Chronic Care Model [article online]. Available from Topics/ChronicConditions 9 Davidson MB, Castellanos M, Duran P, Karlan V: Effective diabetes care by a registered nurse following treatment algorithms in a minority population. Am J Manag Care 12: , Davidson MB, Karlan VJ, Hair TL: Effect of a pharmacist-managed diabetes care program in a free medical clinic. Am J Med Qual 15: , Witmer A, Seofer SD, Finocchio L, Leslie J, O Neal EH: Community health workers: integral members of the health care work force. Am J Public Health 85: , Norris SF, Chowdhury FM, Van Le K, Brownstein JN, Zhang X, Jack L, Satterfield D: Effectiveness of community health workers in the care of persons with diabetes. Diabet Med 23: , SEARCH for Diabetes in Youth Study Group: The burden of diabetes mellitus among U.S. youth: prevalence estimates from the SEARCH for diabetes in youth study. Pediatrics 118: , Imperatore G, Cadwell BL, Geiss L, Saaddine JB, Williams DE, Ford Ed, Thompson TJ, Narayan KMV, Gregg EW: Thirty-year trends in cardiovascular risk factor levels among U.S. adults with diabetes. Am J Epidemiol160: , Gregg EW, Gu Q, Cheng YJ, Narayan KMV, Cowie CC: Mortality trends in men and women with diabetes, 1971 to Ann Intern Med 147: , Maxwell JC: The 360 Leader. Nashville, Tenn., Thomas Nelson, Jennings K, Stahl-Wert J: The Serving Leader. San Francisco, Berrett-Koehler Publishers, Useem M: The Leadership Moment. New York, Three Rivers Press, 1998 Ann Albright, PhD, RD, is director of the Division of Diabetes Translation at the Centers for Disease Control and Prevention in Atlanta, Ga. She is President, Health Care and Education, of the American Diabetes Association. The findings and conclusions in this report are those of the author and do not necessarily represent the official position of the Centers for Disease Control and Prevention. 42 Diabetes Spectrum Volume 22, Number 1, 2009