Following a bit repetitive of other posts but never mind!
Health and wellbeing, extra care etc!
I have recently completed a short on line course presented by John Hopkins University Bloomberg School of Public Health about “Health for All”. I really enjoyed this course as it filled a critical gap in my understanding and also enabled me to review my core values. I came across this paper last week.
“TIME TO THINK DIFFERENTLY[1]
By Edward Steinfeld, AIA, Arch.D., Director, IDeA Center, University at Buffalo, SUNY
In this installment in our design for aging guest writers series, Edward Steinfeld, AIA, Arch.D., discusses the need to practice “community design for aging”.
Since the 1960s, there has been a steady increase in the development of environments built specifically for older people including retirement housing, continuing care retirement communities (CCRCs), memory care centers, and assisted living facilities. This occurred because economic development made long life more common. But while this demographic shift was occurring, enormous growth in suburban sprawl created low-density communities, and health care for elders evolved into a facility-based model. Now, the only places designed to accommodate old age are specialized facilities and neighborhoods separated from the rest of the population. Is this a new form of segregation? Does it reflect “ageism” in American society?
Perhaps the best example of this segregation is The Villages, an age-restricted community north of Orlando where 75,000 people have settled. On one hand, The Villages demonstrates that communities designed to be age friendly will attract older residents. On the other hand, The Villages and smaller versions of retirement meccas offer a disturbing vision of the future. Unlike government entities, they do not have a representative government; they are privately owned, modern versions of company towns. When residents commit to living in such communities, they give up a measure of autonomy and control and become “consumers” of services rather than citizens of a community and all that implies.
What would happen if even larger numbers of affluent elders picked up and moved to communities like The Villages—that is self-contained “active living communities” and CCRCs on the fringes of traditional towns and cities—leaving behind those with lower incomes and poorer health? Active older people contribute greatly to our society as productive workers, volunteers, caregivers (for both other elders and youth) taxpayers, and jurors. Their collective wisdom is a valuable resource for communities. As the population ages, we cannot afford to have too many withdraw from being citizens of traditional communities, especially if they leave the burden of caring for all those in great need to the rest us. Furthermore, the architecture that results is formula driven with an emphasis on the short term.
There is evidence that there is latent desire for other options. The surveys done on preferences for housing in old age indicate that substantial majority of middle-aged people want to “age in place” (see for example, Keenan, 2010). Demonstrating this preference, urban areas are attracting residents in their 50s because they provide walkable, mixed-use living opportunities that are more amenable to aging in place (Karp, 2008). In addition, the high cost of long-term care and the general dislike of institutional living is driving a renewed interest in home care and innovative methods for delivering care to elders who do not require relocation to a geriatric facility.
While demand for age-restricted settings may continue to be strong for some groups in the older population simply due to the rapidly increasing numbers of elders, a major focus for “design for aging” should be on rethinking existing communities in response to the maturation of society. We need to start planning and designing communities that will keep elders engaged in productive life, provide affordable housing options, insure safety and security, offer attractive leisure time pursuits, encourage diverse social opportunities, and support age related changes in abilities and health. We need to practice community design for aging. The Atlanta Regional Commission’s (ARC) Lifelong Community Design Initiative, featured in another article on this website, is one of the first efforts to really look at how to redesign existing communities and serves as a good model.
How do we transfer the knowledge about design for aging to this much larger and more complex problem? I believe the answer is by practicing universal design. Many design professionals think universal design is a new buzzword for accessible design or ADA compliance. Earlier definitions and publications about the concept did not help to overcome this perception because they were too focused on design to support function. But it is actually a radically different concept. Universal design applies all the lessons learned over the last 50 years about human-centered design to all environments, products, and services. It is not the province of technical specialists or experts in a specialized building type.
“Universal design is a process that enables and empowers a diverse population by improving human performance, health and wellness, and social participation.” (Steinfeld and Maisel, 2012). In other words, universal design is design for universal benefits, including, but not limited to, benefits for elders. In addition to compensating for deficits in function like accessibility in housing, it includes reducing health threats like air and water pollution, encouraging walking by building sidewalks and safer street crossings, and promoting social participation like providing opportunities for intergenerational social contact.
Designing settings for elders alone leads to socially unsustainable communities. For example, there are limited opportunities for a retiree to find a part time job in The Villages. One resident, a retired professional musician, confided to the author that there were so many amateur musicians willing to do gigs for free that he could not find enough paid work to keep himself busy. As a professional, he felt that his skills were not valued if people were not willing to pay him for performing. What will happen when most residents of The Villages reach their 80s and 90s? Who will provide health care? Who will play golf? Who will shop in the stores?
Design for diversity makes sense, even in the context of aging. People age at different rates along several dimensions at once, based on their biology, life experiences, personality, and social interaction style. We all are familiar with this phenomenon. At my university there is a 92-year-old professor who is still teaching a class while many of our much younger colleagues retired in their mid 60s or earlier for health reasons or to pursue other interests. These individual differences make the older population one of the most diverse segments of society. Yet places like The Villages, assisted living facilities, and CCRCs offer limited lifestyle choices. For example, almost all the homes in The Villages are single-family detached dwellings on cul-de-sacs. Practically everyone gets around by car or golf cart. Although there are interesting places to walk and congregate, getting to them requires a vehicle.
So, where do we start? Basically, we need to get stakeholders involved in community planning and design to think in universal design terms so that everything they do offers potential for the older generations. This is a process of innovation because it is a new way of thinking. The best way to spread an innovation is through personal contacts in a peer network. If you want to get a doctor to adopt digital record keeping, for example, convince another doctor she respects to adopt it first. Early adopters who are respected by their peers spread the innovation (Rogers, 2003). Organizations like the American Architectural Foundation and the AIA Knowledge Community on Aging can serve as change agents to recruit early adopters, not just in the architectural community, but also in the communities of clients and government.
Health for all
I came across a thought provoking website about what is happening in Canada.[2]
“The key feature of primary health care reform is a shift to teams of providers who are accountable for providing comprehensive services to their clients.
There is a growing consensus that family physicians, nurses, and other professionals working as partners will result in better health, improved access to services, more efficient use of resources, and better satisfaction for both patients and providers.
Such teams are well positioned to focus on health promotion and improving the management of chronic disease. This team approach, along with telephone advice lines, facilitates access to primary health care services after-hours, reducing the need for costly emergency room visits.
Other technologies can support information-sharing among providers so that Canadians need not repeat their health histories or undergo the same tests for every health care professional they see.
In these ways, all aspects of personal care are brought together in a coordinated way.
Presently, relatively few Canadians access primary health care services in this way. All provinces and territories are implementing plans for primary health care reform, with funding support from the federal Primary Health Care Transition Fund. Each jurisdiction is undertaking its own approach but some common areas of focus have emerged:
- the creation of primary health care teams and organizations which are responsible for providing comprehensive services to their clients (including coordination with other levels of care);
- the creation or enhancement of telephone advice lines to provide 24-hour first-contact services;
- improvements in the management of chronic diseases (which account for a large portion (40-70% according to various estimates) of health care system costs);
- a greater emphasis on health promotion and illness/injury prevention;
- voluntary participation by providers and patients alike;
- capacity-building in evaluation, so that system performance may be monitored; and
- an explicit focus on change management activities to support all of the above.
Comment
I understand these two matters to be examples of seriously thinking through issues comprehensively, from a person centred, whole system, ecological approach.
The health for all course referenced the Healthy Cities Movement.[3]
“The Healthy Cities movement has been in process for almost 30 years, and the features needed to transform a city into a healthy one are becoming increasingly understood. What is less well understood, however, is how to deliver the potential health benefits and how to ensure that they reach all citizens in urban areas across the world. This task is becoming increasingly important because most of the world’s population already live in cities, and, with high rates of urbanisation, many millions more will soon do so in the coming decades.”
I disagree with the above – we do know what to do and how to do it. The course started by taking us back to Alma-Ata!
Declaration of Alma-Ata
International Conference on Primary Health Care, Alma-Ata, USSR, 6-12 September 1978
“The Conference strongly reaffirms that health, which is a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity, is a fundamental human right and that the attainment of the highest possible level of health is a most important world-wide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector.”[4]
One of the things I loved about the course was its continual reinforcement of health as being as not even primarily a personal matter, but one of ensuring just equal societies and communities.
Census-Based, Impact-Oriented (CBIO) Methodology[5]
“Historically, the Census-Based, Impact-Oriented (CBIO) methodology is an outgrowth of a tradition of prospective, longitudinal field studies of mortality, fertility and migration in relatively small, defined communities which began in the 1950s under the leadership of Dr. John Gordon, then Professor of Epidemiology at the Harvard University School of Public Health. Several classic studies have resulted from this approach, led by others now well known in international public health:
- Dr. John Wyon, leading the Khanna studies in India (Wyon and Gordon, 1971)
- Dr. Carl Taylor, leading the Narangwal studies in India (Kielmann, et al, 1983, Taylor, 1973)
- Drs. Warren and Gretchen Berggren leading community-based studies in Haiti through Hospital Albert Schweitzer (Berggren, Ewbank, and Berggren, 1981)
- Dr. Henry Perry undertaking rural health programming in Bolivia (Perry, et al, 1998)
The CBIO methodology is an approach to health care service provision that allows local health care providers to better understand, more effectively treat, and accurately measure outcomes and impacts for the most commonly found causes of unnecessary suffering, sickness and death within their communities. What do we mean when we say “better understand”? The common approach to PHC provision traditionally is to establish facility-based health services in a particular location(s), with the assumption that well established clinical protocols and treatments will be applicable to all those who enter for care. Unfortunately, this may be true part of the time, but we have found many different causes of illness and death, and these vary considerably from country to country, department to department, even community to community. Thus, learning about the unique patterns of local illness and death, and their underlying causes is necessary to a complete diagnosis and effective treatment within the CBIO approach.
When we say “more effectively treat”, we mean that most health providers will assume that the public will seek out their services when needed. We have found this assumption also is not well founded. Of course, when one has a physical accident, like a broken bone or an infected tooth, symptoms may be so obvious (and painful!) that care will be sought immediately. However, families are unaware of many signs and symptoms of their illnesses, or will postpone treatment to ‘see if it gets better by itself.’ Further, many families who know they have a health problem do not believe they are entitled to, nor believe they are able to pay for local health services. Or, they may not trust those services to effectively treat their problems, or they fear that they will be treated badly by the health staff. The CBIO approach attempts to systematically overcome these common barriers to effective health care treatment by: learning about the local causes of illness and death; creating strategies that directly address those causes; and by proactively seeking out ‘high risk’ families, providing targeted and appropriate health education messages and treatment. This ultimately creates an informed service population who will actively seek health care when it is necessary to do so.
When we say “accurately measure outcomes and impacts” we mean that the CBIO approach allows us to more precisely measure program results than almost any other strategy. How is this so? By developing and maintaining a census of the targeted service population, we have the basis, the mathematical ‘denominator’, against which all services received and outcomes achieved will be compared. For example, we will know exactly how many women of reproductive age (WRA; usually 15 – 49 years of age) are in our population, we will know what kinds of services they received, and we can quite accurately estimate the service coverage received, and further, compare this with any behavioral outcomes of interest to us (through service data or through periodic household surveys). This is a much more accurate approach than, say: depending upon clinic usage data and disaggregated national census data to generate coverage estimates. It is better because clinic data measure only women motivated and able to seek out clinic services, ignoring all the other women who did not receive services for whatever reasons. And, because such facility-based outcome results are based on (most likely) out-of-date or inaccurate census projections, these calculations may result in systematic under or over reporting of coverage.
The situation in facility-based PHC may even be worse for indicators such as immunization coverage, which often is measured by counting the number of doses distributed (whether or not they are received), or by counting ‘heads’ of children who receive the doses (whether or not the immunizations are timely, or that the children actually need that particular immunization) and divided, again, by an often unreliable projection of the childhood population. Of course, surveys could be used to more accurately estimate the proportion of children who received their immunizations appropriately (if child immunization cards are in systematic use locally), but then that data would not be useful for local programs to target those who have missed their immunizations, or those who are ready to begin.
Advantages of the CBIO Approach
We have already mentioned some of the most important reasons to consider the CBIO approach to community-based PHC provision. A more complete listing of reasons will include:
- Scarce resources are precisely targeted to local causes of illness and death through the assessment of local health needs and the use of census data.
- Many more people will be reached in a timely manner with appropriate education and treatment because of proactive outreach and communication activities, based upon census data and the use of community maps.
- CBIO health providers frequently develop a closer working relationship with ‘high risk’ families since they see them regularly, resulting in more trust of the health program, and better acceptance of important health messages.
- Traditional non-users of health services (who frequently are the sickest within a community) are sought out, making health care access and treatment more equitable and creating greater impact.
Measurable outcomes in areas where the CBIO approach has been used are more precise than many other methods, and usually demonstrate remarkable results that would not have been realized through facility-based PHC alone.
Why is Equity of Health Care an Issue?
Equity of health care access and use is actually a huge, though too often overlooked concern of public health. We are concerned that individuals and families who are less well educated, with fewer resources available to them, with weaker social ties, with inferior social status, and the like do not believe they have the right to decent health care, and in many cases, are passively or actively discouraged from using public services.
All individuals of a society should be able to receive basic health services that allow them to survive and thrive, contributing to the overall wellbeing of their families, communities and nation. Even within small rural communities that appear homogeneous to the casual observer, we find individuals and families who are less well educated, with fewer resources available to them, with weaker social ties, with inferior social status, and the like. These families simply do not believe they have the right to decent health care, and in many cases, are passively or actively discouraged from using public services. Further, clinicians often are the last to understand the many perceived and real barriers of these families, do not leave their health facilities to seek out this information, and do not know what they do not see. We believe overcoming these biases and barriers is an important responsibility of the health care system, in order that families may thrive in a setting free of prejudice and inequality.
The CBIO health approach focuses on serving all members of the project communities. “The reach is tremendous,” says Judy Gillens of FOCAS. She explains, “The most important thing [about the CBIO approach] is that you can capture all the people within your community; you can catch those who are on the fringe[s of health care].” Henry Perry, who helped found the CBIO approach, asserts that it takes a “deep philosophical commitment to improving the health of a population” in order to engage in the method. In Perry’s opinion, organizations that use CBIO need to be prepared for a long-term commitment, and they must be committed to demonstrating improvements.”
The GLA is in a very important position to enable real long lasting change for all. The principles and solutions have been worked out, it is a matter of implementation.
A critical change will be the development of a new role – that of the community health worker. This role is similar to that of the competent support and care worker, but with important differences. They will be working in a clearly defined geographic area, as part of a clearly defined team that has overall responsibility for the health and well being of a community. Communities, families and individuals will have developed and be implementing person centred life plans – they will know where they have come from, where they are, where they wish to be.
It will become impossible to propose an older persons housing scheme by the Thames that it has hoped people will move to, and will have no evidence of specialist and universal design.
The people of a community will have discussed together options, and with facilitating professionals, proposed solutions and brought together required resources. But to do this requires people who know their communities in detail – community health workers.
Urban planning and policy is never only about agreeing a structure or group of structures in a place. It is about habitat, about creating structures and systems that enable.
