question

1. Provide a clear brief description of literature search for evidenced-based interventions
2. Databases (CINAHL, OVID etc.) you searched. search terms used and rationale for search and selection decisions
3. Provide 4-5 evidence-based interventions that include screening, health promotion and disease management that you found in from your search.
4. At least two interventions must operate at the non-individual level (e.g., family, community, system, or policy level).
5. Outline systems thinking and the ethical principles that influence program and policy implementation and change.
6. Describe the ethical responsibilities of all healthcare providers to ensure interventions and changes in policy improve healthcare outcomes without causing harm or increasing disparities due to unintended consequences
7. Discuss how the healthcare system, healthcare policy and population-focused programs, impacts health equity both nationally and globally.
8. Discuss how you will identify, engage, and collaborate with stakeholders to implement change

answer

 

1. Evidence-based Interventions

The US Preventive Services Task Force (USPSTF) defines the aim of screening as “in an asymptomatic population, early detection and treatment of disease in order to improve the patients’ prognosis.” Screening is often an attractive preventive method because identifying persons at high risk before the disease develops can allow for a focused preventive intervention to avoid the disease. There are now four possible stages of preventive screening. The first is assessment of risk factors for disease to detect at-risk persons. This is followed by brief early detection, often of undiagnosed disease or risk factors, using simple tests. The next stage is early diagnosis and treatment of symptomatic disease or risk factors which were identified by routine medical examination. Patients may be diagnosable for disease but asymptomatic. Early diagnosis and treatment of screen-detected disease is the final step and usually involves additional diagnostic procedures to confirm the presence of disease and its level of progression. These interventions are designed to improve prognosis and increase cure rates for diseases that would have been more severely manifested if left until symptomatic detection to diagnosis, often with poor prognosis. Finally, screening also has the potential to decrease the burden of disease by identifying and treating diseases early in their course and thereby preventing disease complications. This will stop the disability stemming from complications and improve functional outcomes in the population. All of the above-mentioned stages will be types of treatments for disease identified by screening, with the first one, assessing risk factor, also being a type of health promotion. Changes in screening methods and diagnostic technologies have made the possibilities for early detection of disease much more feasible and will increase into the future with the development of new genetic markers for risk of future disease and gene-based therapies. As a result of the potential benefit of treatment at its earliest stages, there has been much activity and research in the area of disease screening. Target populations for screening intervention may be the entire population, specific age, sex, or risk-defined subgroups. The choice of which will depend on the disease characteristics, the potential benefit of screening, and the costs of screening to the target group.

1.1. Screening for Health Conditions

It examines a great variety of interventions frequently used to improve health condition, the various settings these interventions take place, for example schools, communities, medical settings, and also the diverse methodological strategies to study them. While we examine specific examples of each type of intervention, it is impossible to do justice to the full range of possibilities within each category. Our goal is to help both researchers and consumers of research better understand the complex options available towards the goals of improving health and reducing the burden of specific health conditions.

1.1. Screening for Health Conditions

The first definition of screening in the dictionary is “to test or examine for the presence of something (as a disease).” Screening tests are relatively simple and are designed to measure a specific attribute. They are often used on apparently healthy people in order to determine the existence of a risk factor for a given disease. In this paper, we adopt the WHO criteria for judging the worth of a screening programme, namely that it should be cost-effective, should be directed at a condition of public health importance, the facilities for diagnosis and treatment should be available, there should be a recognizable latent or early symptomatic stage, and finally that there should be a test acceptable to the population. This definition and the WHO criteria direct attention to considering the likelihood and severity of the health condition, and the ability to intervene in its natural history, should it be detected. Thus, assessment of risk factors for a disease is a form of screening, and if a health condition has no effective treatment, then a screening programme is not justified. Screening means looking for early signs of serious health conditions before symptoms develop. It is a systematic approach for identifying a sub-group of the population, usually for the purpose of detecting an undiagnosed disease in individuals without signs or symptoms. This is different from case-finding in high-risk individuals, which is a non-systematic opportunistic approach to diagnose a problem known to the patient or health worker. Both case-finding and screening are types of secondary prevention because they aim to find conditions at an early stage. The distinction between the two is becoming less clear, with case-finding now often being done by applying screening tests to selected high-risk groups. Primary prevention is the term used to describe activity that prevents a disease occurring at all. An example of this is the immunization of children to prevent infection with diseases such as measles and mumps, which can have serious complications when contracted in adult life. Although this is not an exaggerated example, in general, the screening process is a trade-off between the potential benefit of the early detection and treatment of disease and the harm caused to the individual as well as the financial and opportunity costs. High-quality economic analysis is therefore essential in determining the viability of a screening programme.

1.2. Health Promotion Strategies

These definitions incorporate several common concepts of health promotion. It is seen as a social process, not just individualistic. This is because it seeks to enable people to take control over their own health and have a say in the decisions affecting it. Health promotion places a positive view on health, going beyond a goal of preventing ill health, with the aspiration of an overall state of wellbeing. Finally, it is an investment for the future, aiming to improve the quality of life and health of the population.

Kreuter and De Rosa (2004) expand on the WHO definition by asserting that health promotion is an investment in the future of public health, aiming to enhance resources or positive health factors with the expectancy of lessening the likelihood of health issues occurring in the future.

This mirrors the Ottawa Charter (WHO, 1986), which is often regarded as the benchmark for health promotion, defining it as: “The process of enabling people to increase control over and improve their health…In this charter, the process of health promotion focuses on creating equitable access to the means of health for everyone.”

Health promotion is the process of enabling people to increase control over and improve their health. It moves beyond a focus on individual behavior towards a wide range of social and environmental interventions. Health promotion is a complex, ambiguous concept, and its definition has changed over time. It is widely agreed upon that there is no one ‘right’ interpretation of the concept. Many differing definitions have been developed, all with subtle differences; however, the core ideas remain constant. Peck (1993) provides an adaptation of the WHO definition: “Optimal health and wellbeing…through the collective efforts of individuals and societies.”

1.3. Disease Management Approaches

Disease management is the concept of reducing healthcare costs and improving quality of life for individuals with chronic conditions by preventing or minimizing the effects of the disease. The main focus is on the effects of the disease rather than the disease itself. The concept of disease management has evolved in response to changing epidemiological patterns and the rise of chronic disease as the major burden of illness, the growing awareness of resource constraints and the limitations of the healthcare system in most developed and developing countries. With an overall goal of improving health, the immediate specific goals of disease management cover a wide range of activities, at the level of the individual patient, the physician or healthcare professional, and the healthcare delivery system. These range from reduction of the severity of symptoms and functional limitations to minimizing the rate of progression of the disease, slowing or reversing damage to anatomic organs, and preventing unnecessary acute care hospitalization or use of the emergency room. High quality and high cost disease states are often targeted for disease management interventions. If guidelines for the condition exist, a good starting point is to compare physician practice patterns with evidence-based recommendations. This may uncover practice variation or practices not in line with evidence and identify areas for improvement in the quality of care. The identification of best practices is a key step in transitioning from a traditional approach of acute care to a more preventive treatment of disease. A further practice to identify specific patients, often those with high risk or high cost disease states, is through case management using specific case managers, often nurses, social workers, or allied health professionals. Finally, the fast-growing field of health information technology offers a possible means to enhance quality and efficiency of disease management through providing evidence-based information at the point of care, monitoring patterns of practice, and providing information to patients. This information looks at disease management as a long-term change in an approach to a given disease, rather than a specific intervention.

1.4. Non-individual Level Interventions

The individual level is chiefly concerned with changing individual health behaviours. Sometimes this is undertaken to reduce the chances of, or the impact of, a specific health problem. At other times, the intention is to bring about a general change in health behaviour with a view to improving the general level of health in the population. In general, individual level interventions are easy to define and implement. They normally have specific and easily measurable targets. The evidence on the effectiveness of the various possible interventions ranges widely. Often something that is known to be effective clinically is not so when applied in the community health field. This may require an innovative change to a proven intervention in order for it to be successful in a community setting. If the adverse health condition resulting from tobacco use is lung cancer, it is relatively straightforward to organize a lung x-ray screening program and then to develop services to treat the victimized individuals. At the end of a given period, the number of lung cancer cases within the screened population can be compared with the population not having been exposed to the screening program. An absolute decrease in lung cancer cases of the screened group indicates improvements in lung cancer outcomes and a high probability that screening contributed to the value. This example specifically compares the lung cancer results with the non-screened group; thus, it is a practical and inexpensive measure to study whether screening was effective.

1.5. Non-individual Level Interventions

For example, a new drug or surgical procedure for treating diabetes aimed to minimize complications may later be shown to be less effective for groups with a higher risk of complications from diabetes due to other medical conditions. While it can be argued that the clinical intervention is discriminatory, it is more likely that the research and choice of the clinical intervention has led to an avoidable excess of complications and disabilities among certain groups and thus increased disparity. This chapter deals with the more direct methods of reducing or eliminating disparity compared to the other interventions discussed, which are more likely to increase disparity in the short or intermediate term.

Population-based interventions are based on the principles and methods of public health and preventive medicine. Most (but not all) population-based health promotion and disease prevention programs direct interventions at the individual, interpersonal, and organizational level, and use policy and law as complementary strategies. Yet, some interventions are directed solely at the above systemic levels through the manipulation of the environment and/or the social and economic determinants of health. Frequently, these “downstream” interventions inadvertently choose or affect people disproportionately by race, ethnicity, national origin, or social class, and become a means to increase health and social disparities.

2. Systems Thinking and Ethical Principles

2.1. Understanding Systems Thinking

2.2. Ethical Principles in Program and Policy Implementation

2.3. Factors Influencing Change

3. Ethical Responsibilities of Healthcare Providers

3.1. Ensuring Improved Healthcare Outcomes

3.2. Addressing Unintended Consequences

3.3. Mitigating Disparities

4. Impact of Healthcare System and Policy on Health Equity

4.1. National Implications

4.2. Global Implications

5. Stakeholder Identification, Engagement, and Collaboration

5.1. Identifying Key Stakeholders

5.2. Strategies for Stakeholder Engagement

5.3. Collaborative Approaches for Change Implementation