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Issue 56 | The Network: Towards Unity for Health (TUFH) Community Approaches and Population Health

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Dear Reader,

"You have to have a big vision and take very small steps to get there. You have to be humble as you execute but visionary and gigantic in terms of your aspiration. In the Internet industry, it's not about grand innovation, it's about a lot of little innovations: every day, every week, every month, making something a little bit better."

This sentiment from early tech entrepreneur Jason Calacanis refers to building companies in an age of rapid growth, unexpected change, and a regulatory environment trying to keep pace. This quote also perfectly frames the current state of our global health ecosystem. The articles of our 56th edition, curated by The Network: Toward Unity for Health (TUFH), detail the link between small steps and collective aspiration and impact. Our second edition with TUFH in as many months, highlights the pioneers in community approaches and population health who are incorporating societal and environmental factors into health services to create a more equitable and accessible health care ecosystem around the globe. 

This edition, “The Network: Towards Unity for Health (TUFH) Community Approaches and Population Health,” features initiatives that are at once small steps and gigantic visions for the promise that these innovations hold for moving into the future of health care today. Leveraging blockchain technology to improve elderly care, incorporating social accountability to drive rural health outcomes, implementing community-driven population health innovations, and confronting income, nutrition, and health inequality for single mothers and their families are among the many out-of-the-box practices we are excited to feature in our latest edition. 

The focus on Community Health as prioritized by TUFH, highlights the most effective approaches to serve and engage remote and rural, indigenous, migrants and refugees, women, and elderly populations. While Population Health seeks to raise awareness of the importance of investing in health workforce education and is oriented towards meeting the needs, performance measurement, and the impact of innovation in advancing the policies, strategies, and approaches that must be aligned to improve the quality, relevance, equity, and cost effectiveness of the delivery of health services. The authors of this edition are the practitioners and health innovators who work tirelessly to drive change little by little to make things better for all people. These programs create a patchwork tapestry that together shows a unified picture of the potential of the thriving global health ecosystem.  


To bridge the gap between good intentions and government or institutional transformations, organizations such as TUFH have a critical role in serving as the link and connector between global policy organizations and local change agents such as policymakers, institutions, and associations who are doing the groundwork. The work of TUFH and its partner organizations advances the dialogue and grow global consensus, expand the capacity of local innovators, and create platforms for interprofessional education to be shared. To achieve quality and equitable health care we must continue to take small steps with little innovations every day, every week, and every month to make things a little bit better for all people around the world.

Yours in Innovation,

Nicholas Torres and Tine Hanson-Turton, Co-founders

Mike Clark, President and Alescia M. Dingle, Managing Editor

Article Summaries 

Blockchain: A Late Arrival into Elderly Care

Samar A. Ahmed, MD, JMHPE, FAIMER Fellow, Ain Shams University Faculty of Medicine

The idea proposed in this article is the creation of a system for the development and certification of home caregivers who are capable of providing primary service care in elderly patients' houses. These patients are a population who suffer constant health events that require multiple hospital visits that can be reduced and thereby reduce the cost that is endured by the patients and the health system. The proposed solution would be to make the home care accessible through an application that can arrange for ordering of specialized patient caregivers upon request provided that they have received proper training, certification, and registration in their local university hospitals. These caregivers will be certified and offered a recertification program every six months to make sure there is a continuous improvement process. The use of blockchain technology will be important to allow for the registration and selection of care based on a point system that is acquired by these home caregivers.


Facility and Community-Based Services for Rural Region by Medical School with Concept of Social Accountability

S. CHHABRA, Emeritus Professor Obstetrics Gynecology, Ex. Dean, Mahatma Gandhi Institute of Medical Sciences, Sewagram Officer on Special Duty, Dr. Sushila Nayar Hospital, Utawali, Melghat, Amravati Chief Executive Officer, Aakanksha Shishugruha, Kasturba Health Society, Sewagram, Wardha 442 102, Maharashtra, India

The Melghat region of Maharashtra has high maternal, perinatal, infant, and child morbidity and mortality compared to the rest of Maharashtra, India. Kasturba Health Society, Sevagram which runs Mahatma Gandhi Institute of Medical Sciences, took the initiative to change this scenario. After struggle for almost a year with government, change took root beginning January 1, 2012 with help from a philanthropist. With guidance, the support of MGIMS of KHS, Sewagram, the team offered 24-7 services including Caesarean sections, minor and major gynecological procedures, and cataract surgeries performed regularly and surgical cases, all by camp approach. While trying to do whatever we could, many difficulties came and solutions were found with the realization that community-based services, community motivation, mobilization, and behavior changes were essential. Steps were taken. Nurse midwives provide community-based antenatal services with advocacy of  intranatal, postnatal, neonatal, and child care, that started with 52 villages served by four nurse midwives and grew to seven nurse midwives serving 140 villages within 10-85 kilometers from the health facility. There are monthly meetings for monitoring, feedback, advice, and planning. General diagnostic therapeutic camps have been become an annual event. In March 2012, the facility served 226 patients; in February 2013, there were 1036 patients; in February 2014, 1107 patients; in February 2015, 1883 patients; in February 2016, 2197 patients; and in 2017, 268 differently abled patients were provided with supports and aids including hearing aids, crutches, calipers, and surgeries for Cleft lip and Cleft Palate. In 2018/2019, there were a total of three camps held monthly with 2,665 beneficiaries. A medical institute as backbone can do a lot for communities in rural, remote regions by sending health providers in rotation and taking care of health providers everyday life needs until the time there are a sufficient number of providers who take interest in the health of rural remote communities.


Working Together with Adults: An Implementation, Interprofessional Education in Geriatric Care

By Daniel Richard Kambey, FITRIANA, Amandha Boy Timor Randita & Ayuningtyas Satya Lestari 

The elder population is increasing in developed and developing countries. The high number of elderly in the future will give positive and negative effects. A high elderly population will become a national burden if the elderly suffer health problems. The aging population have high demands of comprehensive care. Effective team-based health care through interprofessional collaboration among health care providers is important to face the complexity of health problems in the elderly to improve their quality of care and patient outcomes. Interprofessional collaborative practices should be initiated in the undergraduate phase through Interprofessional Education (IPE). This study used a qualitative approach to explore the effectiveness of IPE in geriatric care through a short-course of an IPE program. The study shows that there were several advantages of the course of IPE learning in geriatric care from the students’ perspectives. The students were able to demonstrate collaboration in assessment, planning, and intervention for improving elderly health. The students can improve their communication skills among health care students from other professions. However, there were challenges of IPE implementation in geriatric care that this article will explore further.


Going the Extra Mile: Rural Health Recruitment Resource

Christine Franklin, Psychologist

This article focuses on "The Extra Mile: The Essential Guide for Health Professionals Going Bush," a text which brings together much of the important information required to work effectively in the rural or remote context. The article through examination of theories from the book helps to address workforce issues and support the transition of health professionals to rural practice.


Promoting a New Era of Innovation in Public Health Practice: An Introduction to the Concept of a Community Population Health Practice System Approach to Promoting Success in Resource Strapped Communities

Joseph B. Hawes, MD, MPH Senior Public Health Consultant CEO Fusion Health Solutions Washington, DC and Ann S. Goldman, PhD., MPH Director of Education Programs Department of Epidemiology the Milken Institute School of Public Health The George Washington University Washington, DC

The challenge we truly face as public health practitioners is the need for us to open a new book on public health practice rather than simply turning another page in the same old book. In the old book the description of an innovative approach is simply another chapter on a new way of doing the same old thing. Moreover, the old book’s ending is always the same -- no improvement in the fate of families and children living in poor communities. The new book is about providing the existing public health practice system the capacity to do its job. Doing so, by complementing it with a community population health practice system. This article introduces the 1996 W.K. Kellogg Foundation and The Robert Wood Johnson Foundation, Turning Point Collaborating for a New Century in Public Health Partnership Model, which originated this concept. It also provides a glimpse into more than four decades of accumulative practice experiences of applying adaptation of the TP model within different health care systems at national, state, tribal and community levels that nurtured its development. This article is meant to stimulate the generation of new ideas about how can we take the next step in overcoming the challenges that have plagued and prevented us from achieving our goal as public health practitioners -- that of protecting and promoting good health outcomes for the most vulnerable members of our society.


Breast Cancer Education, Screening and Treatment: Innovations from the Community Up in Rural Haiti

Prof. Judy Lewis, University of Connecticut, Farmington, CT, USA; Dr. Bette Gebrian, Executive Director, Grand'Anse Health and Development Association, Jeremie, Haiti

Chronic noncommunicable diseases represent a major and unaddressed problem in the global south. Rural Haitians have very limited access to health care and there are few statistics available for breast cancer in countries where even births and deaths are poorly recorded. What is documented is that the fatality rate is high because women enter care too late. The Grand’Anse Health and Development Association working with the Haitian Ministry of Health, University of Connecticut, and other organizations has been providing outreach for community education, screening, and basic treatment for breast cancer for the past four years. Working through local churches has been very effective, 250-300 women are screened each year. Research has focused on program operation and improvement, women’s knowledge and beliefs, and men’s awareness of health and breast cancer. Understanding and engaging community resources and perspectives is critical to addressing neglected diseases such as breast cancer.


Care for Older People in Malawi: A Situation Analysis

Charles Nyasa (BSc. PT, Honours)1, Anthony Mwakikunga (PhD. Anatomy)1, Enock Chisati (MSc. Ex Phys & Spo)2 1. Division of Anatomy, Department of Biomedical Sciences, University of Malawi College of Medicine, Blantyre Malawi 2. Department of Physiotherapy, University of Malawi College of Medicine, Blantyre, Malawi Corresponding Author: Charles Nyasa (BSc. PT, Honours). Division of Anatomy, Department of Biomedical Sciences, University of Malawi College of Medicine, Private Bag 360, Blantyre Malawi

According to the National Statistics Office, the population of older people in Malawi is rising and projections show that this will only increase. Considering the well-known potential and contributions of older people, this is an advantageous resource necessary for development of the nation. Evidence suggests that most people poor people in Malawi continue to live in poverty, have poor nutritional and health states, have no home or shelter, and are often abused. There is a need for the nation of Malawi to prepare for this surge in population aging, particularly, through implementation of policies and programs that position older people more favorably in the society so as to cultivate their potential for long term gains. However, high quality information on health characteristics and current social circumstances of older people in Malawi is scarce and this hinders adequate targeting and proper allocation of resources. This piece of writing is a descriptive situation analysis on the wellbeing and health-related quality of life of older people in Malawi. It is a first step and part of an ongoing research study evaluating functional capacity, health related quality of life and physical activity behavior among community-dwelling older Malawians.


Early Childhood Development Center Malnutrition Program

Stephen Odiwuor, final year Bachelor of Medicine and Bachelor of Surgery Student, Jomo Kenyatta University of Agriculture and Technology

Malnutrition is one of the major issues of public health importance among the developing countries because it contributes a lot to child mortality and disability adjusted life years. The current approaches being used to screen for malnutrition do not involve the early childhood development (ECD) education and daycare teachers, they mainly focus on screening for malnutrition at the household level. The ECD center program gives a different approach to the screening and prevention of severe acute malnutrition (SAM). The approach focuses on increasing the number of children that would be screened for SAM using one MUAC tape. The impact will be measured by analyzing the data in the data entry book and the Data from the ECD centers can be used to influence policies.


A Method for Rural Hospitals to Create Countywide and Multicounty Community Health Needs Assessments 

Harry Perlstadt, PhD, MPH, Michigan State University, E. Lansing, MI; Debra Rusz, M.A., Michigan State University, E. Lansing, MI; Travis Fojtasek, Ph.D., Fojtasek Consulting, Jackson, MI; Kay Balcer, B.S., Balcer Consulting & Prevention Services, Harbor Beach, MI, and Darcy Czarnik Laurin, B.S., Thumb Rural Health Network, Midland, MI.

This article describes a methodology that enabled eight non-profit hospitals and three local health departments to generate hospital, countywide, and multicounty health needs assessments in the three adjacent rural counties of Huron, Sanilac, and Tuscola, Michigan, USA. The Community Health Needs Assessment (CHNA) mixed methods approach resulted in 1,758 usable surveys, 56 individuals participating in hospital-based focus groups, and interviews with 14 stakeholders conducted during 2016. Surveys were distributed by community organizations and returned at central collection boxes or in prepaid envelopes. Links to an online survey were included in press releases and distributed by hospitals and service providers. Participants were asked about the availability and delivery of health services, barriers to care, and health concerns about youth, adults, and seniors. To eliminate duplication for county and regional analyses, respondents who lived in a multi hospital service area were assigned to one hospital based on utilization and proximity. Adjustments were made for selection bias given the non-probability sampling design. Survey respondents, focus groups, and stakeholders identified the same six top issues of concern in their county: cost of health insurance; cost of medications for elderly; not enough specialists; not enough primary care physicians, cancer in adults, and jobs with livable wages. This approach provided a set of reasonably accurate, interpretable data enabling each hospital to establish its own priorities and implementation strategies as required by the Affordable Care Act. In addition, the hospitals, county agencies, community groups, and regional authorities could utilize the data and work together to improve population health and health care delivery.


A Multi-Disciplinary Intervention to Promote Health and Well-Being in Disaster Situations and Vulnerable Communities in Mexico: A Proposal from University Health Professionals

By Ana Paula Wirth, Andrés Quintero Leyra, Nestor Emmanuel Ramírez Lugo & Jesús Abraham Hernández Cruz

Social determinants of health can shorten healthy life expectancy by longer than other risk factors, such as high blood pressure or obesity. Therefore, organized efforts are needed to diminish health inequalities and promote the overall well-being of vulnerable populations. Aliis Vivere is a group of students from different backgrounds, such as medicine, psychology, social work, anthropology, amongst others, which engages in solidarity action to promote health and well-being of all, no matter of age, gender, origin, socioeconomic status, or any other condition. The group conducted a participatory health census in marginalized and vulnerable communities, as well as communities facing disaster situations, in order to identify major health challenges and offer appropriate assistance to promote physical, social and psychological well-being. The aim of this project is to expand these actions to other communities and implement a series of longitudinal interventions, designed and planned with the health census. Our goal is to have an impact from an intersectoral and interprofessional point of view with divided responsibilities amongst the main stakeholders: the government, academia, civil society and, as a central component, the community itself.


Confronting Inequality Through Access to Income for Single Mother Families

Regis Shema

This article focuses on the mission of a project aimed at improving the standard of living of various vulnerable people that will empower single mothers to have a seat at the decision-making table by enhancing their public speaking, knowledge, and skills through students who are providing training to single mothers about conflict resolution.


Improvement Course in Child Development and Development for Primary Health Care Professionals

By Phd. Alessandra Vitorino Naghettini, Medicine School Professor; Phd. Bárbara Souza Rocha, Nursing School Professor; Phd. Natália Del Angelo Aredes, Nursing   School Professor; Phd. Maria Goretti Queiroz, Dentistry  School Professor; Phd. Ida Helena Carvalho Francescantonio Menezes, Nurtition School Professor; Phd. Thais Rocha Assis, Medicine School Professor; Nurse Maria Aparecida de Oliveira Rodrigues, Primary Health Unit; Prof. Sebastián Leite Pinto, Medicine School Professor; Phd. Lusmaia Damaceno Camargo Costa, Medicine School Professor; Phd. Eliane Terezinha Afonso, Medicine School Professor; Dr. Marla  Moreira Avelar, Clinical Hospital Physician; and Dr. Beatriz  Ferreira Carvalho, Clinical Hospital Resident Doctor

An experience report on the creation of a child development and growth (GD) course for primary health care professionals (PHC), proposed to meet the demands of continuing education in areas far from major cities. The critical points of the theme generated from the construction of the groups through two guiding questions: 1.) Multiprofessional team: What needs to improve in the care of the child in the Primary Health Care Unit (PHC), and 2.) What are my challenges for the follow-up of the growth and development in the PHC, whose responses were analyzed using the strategic planning tool (5W3H). The target audience was 150 health professionals from the multiprofessional team including doctors, nurses, dentists, psychologists, nutritionists, speech therapists, physiotherapists, dental surgeons, and physical educators who worked in the health units of the region. From the analysis of the critical points, the following projects were proposed: a.) Survey about situational diagnosis and comprehensiveness of the unit about children and their families, b.) Training in physical examination of the child and evaluation of neuropsychomotor development, c.) Elaboration of a regional protocol for care of the child with care flow, and d.) Empowerment of community health agents on the importance of growth and development assessment.