I’m finishing up an online course on PHM, so I figured I’d publish my final paper here. It’s called “Addressing Healthcare Disparities in Tuscrawas County, Ohio” and the idea was to propose an intervention targeting a real population health indicator/social determinant of health that, if improved, would bring about an attendant improvement in a related population health outcome. Although I don’t have a track record of creating interventions like this, I hope it provides insight into how targeted, population-level interventions can work in the real world.
In this assessment and improvement activity, I will be focusing on outcomes and indicators of social determinants of health (SDOH) for residents of Tuscarawas County, Ohio. Members of my extended family live in the area, so I have a keen interest in how the county stacks up against national and state health benchmarks, along with strategies the population can employ to improve their collective health.
According to the website County Health Rankings & Roadmaps put together by the University of Wisconsin Population Health Institute and the Robert Wood Johnson Foundation — the high-quality data resource I chose to use for this project — Tuscarawas County ranks in the higher middle range in terms of “health outcomes” (higher 50%-75%) and in the lower middle range for “health factors” (lower 25%-50%) among counties in Ohio.1
For the assessment portion of this project, under the category of “population health outcomes” I chose to focus on the areas of adult obesity, teen births, and mammography screening. As far as “health indicators of social determinants of health” are concerned, I will zero in on the low scores earned by the county on the following measures: access to exercise opportunities, those residents who have attended some college, and those who are uninsured.
The outcomes in my list correspond to the SDOH that I chose such that, if each of the latter were improved, that action should bring about a corresponding improvement in each item’s related health outcome. To illustrate what I mean, take the outcome “adult obesity,” which I will further elaborate on later in this paper, for example: improving “access to exercise opportunities” to all adults in Tuscarawas County should in theory lead to a lower overall adult obesity rate. Adult obesity is an appropriate focal point for this discussion, since Tuscarawas’ percentage of obese adults ranks a bit higher than the state average (35% versus 34%, respectively), and well above the “Top U.S. Performers” (35% versus 26%, respectively).1
To provide context to the problem of adult obesity, in the article “A review of evidence-based strategies to treat obesity in adults” which appears in the journal Nutrition in Clinical Practice,the authors state the following: “In simplest terms, weight loss and maintenance depend on energy balance, and a combination of increased energy expenditure by exercise and decreased energy intake through caloric restriction is the mainstay of behavioral interventions.”2 The authors focus on lifestyle changes as the key ingredient to lowering adult obesity rates, which include “regular physical activity, healthy food choices, and portion control,” all of which require “ongoing support.”
When it comes to exercise, the authors of a separate literature review say that although all types of physical activity (PA) are associated with better health outcomes, “moderate to vigorous PA (MVPA) is considered especially crucial to the prevention of chronic disease and premature mortality.”3 But when one examines the level of participation in MVPA, one sees there is a disparity between those living in underserved communities versus residents of more privileged areas. One important reason for this difference is a lack of access to, and a perceived lack of safety in being able to use, exercise facilities in underserved areas.3 Since Tuscarawas County, Ohio underperforms both nationally and within the state on certain key SDOH measures like “access to exercise opportunities,” it is an appropriate setting for deployment of MVPA interventions.
For the racial and ethnic minority residents of Tuscarawas County, which make up less than 4% of the population, culturally-appropriate MVPA interventions should be tailored to different groups. As a case in point, the authors of the above-mentioned literature review cited The Body and Soul Health Initiative, a “24-week PA and dietary intervention targeting members of predominantly black churches.”3 Aimed primarily at African-American women, this program employed meetings to educate participants about diet and exercise, and were led by African-American staff members. The initiative resulted in a substantial improvement in participants’ minutes exercised over the course of 24 weeks.
When predicated on socioeconomic status (SES), the design of intervention strategies might look somewhat different. SES can be defined as “a combined measure of an individual’s income, education level and occupation.”4 The SES measure is most often inclusive of all members of a society, regardless of background. When looking at the health of low-SES communities, it is important to remember that although the terms “overweight” and “obese” are not interchangeable, they are not as divergent as one might think. Indeed, the WHO defines adults who are overweight as having a body mass index (BMI) greater than or equal to 25, and those who are obese have a BMI greater than or equal to 30.5
When evaluating ways to lower the adult obesity rate in low-SES communities, highly-structured programs involving goal-setting and accountability are likely essential. One study identified “goal setting, self-monitoring and goal review” as key ingredients of any community-based weight-loss program.4 In addition, in an article titled “Exploring Community-Based Weight Loss Initiatives, Retention, and Motivation,” the author notes that “due to the complex interplay of factors contributing to obesity, the International Obesity Task Force and the World Health Organization (WHO) recommend population-based community approaches that connect people, families, schools, and municipalities.”6
While some interventions target adults who are already obese, an alternate approach could involve focusing on adults who are at risk for becoming obese. According to the Mayo Clinic website, “Being overweight is a primary risk factor for prediabetes.”7 Since many overweight people are pre-diabetic, one qualifying factor for such a program could be community members who are prediabetic.
To ameliorate the effects of adult obesity in Tuscarawas County, Ohio, I would propose addressing the SDOH of limited access to exercise by establishing a cost-effective weight-loss program that targets overweight, pre-diabetic community members at risk for becoming obese through a combined exercise and healthy eating regimen. This program would incorporate goal-setting, self-monitoring, and accountability as crucial features. In addition, the initiative would have to be aligned with a local organization to facilitate buy-in by the maximum number of participants.
Such a program might look similar to the YMCA’s Diabetes Prevention Program (DPP). This national program promotes modest weight loss through healthy eating and regular physical activity.8 The program found that an intensive lifestyle intervention in line with its approach can reduce the development of diabetes by more than half in adults with prediabetes.9
The DPP is a one-year program consisting of weekly and monthly sessions in a group setting.10 These sessions are facilitated by coaches who lead small groups of adults. The overall goal of the program is that each participant sets out to lose 7% of their body weight while increasing physical activity each week. The program has achieved real-world success: nearly 30,000 people have attended at least one session, an average of 5.6% of participant’s body weight has been lost over the course of one year, and more than 2,775 lifestyle coaches have been trained to run the program.10
Eligibility requirements for my proposed intervention would track closely with those of the DPP. In line with WHO standards, DPP participants must have a BMI of greater than 25, with fasting plasma glucose levels between 100-125 mg/dL, 2-hour plasma glucose between 140-99 mg/dL, and a 1c between 5.7% and 6.4%. A previous diagnosis of gestational diabetes will suffice, but if no blood test is available, “a qualifying risk score based on a combination of risk factors” including family history and age can count toward eligibility.10 It is important to note that anyone already diagnosed with either type 1 or type 2 diabetes is unable to participate in the DPP, and people in those groups would be similarly ineligible to participate in my proposed intervention.
The goal of this intervention, much like the DPP, would be for each participant to lose at least 7% of their body weight. Participants would also be required to aim to increase their overall physical activity by 10 minutes each week.
Similar to some versions of the DPP, the program would be free contingent upon a physician referral.11 Participants in this intervention would meet in a mixture of group and one-on-one sessions with trained lifestyle coaches for 16 weekly core sessions.12 Coaches would instruct participants on how to make healthy food choices. In addition, the curriculum would cover effective exercise regimens, how to make more time for physical activities, and also how to manage their weight more effectively.
Program participants would be tasked with tracking their eating and exercise habits during this time, setting modest, attainable goals for each week. At the conclusion of the 16 weeks, as in the DPP, participants would be expected meet each month thereafter in a series of support sessions to ensure their continued progress. Participants and coaches would make a joint decision as to when the program would end for each individual, with the understanding that each participant would continue to be accountable to themselves for maintaining a healthy balance of good nutrition and exercise.
Organizations/Agencies/Systems/People Required to Perform the Intervention
Since no YMCAs in Tuscarawas County, Ohio currently offer the Diabetes Prevention Program, this intervention could be sponsored by the local government in a central location. The city of New Philadelphia, Ohio is the county seat, so I would propose setting up the counseling location there since it is geographically central to the area.
Due to COVID-19, at least for the time being, I would set up large-group counseling sessions over zoom but allow in-person, one-on-one meetings with lifestyle coaches — done in a safe manner in line with CDC guidelines — in a meeting room at the main branch library in New Philadelphia, Ohio. Participants would be given the option to go fully remote even for one-on-one meetings to bolster participation. Similarly, after the 16-week program concluded, I would ask lifestyle coaches to honor participants’ wishes to either do hybrid or fully remote one-on-one sessions in a way that conforms to CDC guidance.
The main challenge to uptake of this program, apart from inherent motivation issues with individual participants, would likely stem from the ongoing pandemic. There is no substitute for in-person counseling when it comes to overcoming deeply entrenched habits, so the physical distance imposed by remote coaching sessions may be insurmountable for some people. Consequently, placing extra emphasis on the value of personal accountability may be warranted.
To foster this accountability, it may be necessary to involve friends and family members when personal accountability becomes tenuous. Engendering the value of self-improvement is of paramount importance, and tactics to bring that about may vary from person to person, necessitating a tailored approach.
Other challenges may include wifi and internet connectivity issues in lower-SES communities that would make involvement in the remote aspect of this initiative challenging. Also, even though the USDA has found that by almost every metric it is more affordable to eat healthy foods versus unhealthy foods, it may be difficult to overcome the perception that eating healthy foods is more expensive.13 Relatedly, it may prove challenging to overcome preconceived notions about the time commitment involved with preparing one’s own meal as opposed to eating prepackaged or fast food. Finally, for any in-person components, it may be challenging for lower-SES participants to show up if public transportation is an issue in their local community.
Why the Intervention Should Work
This intervention should work in Tuscarawas County, Ohio because one of the prime social determinants of health at work there, namely a paucity of exercise opportunities and its attendant high adult obesity rate, can be mitigated by a program of guided exercise and healthy eating interventions. As long as thought is given to facilitating a hybrid (or fully remote) course of coaching sessions, and also a targeted approach to attaining buy-in from both attendees and their support networks, this plan should yield positive results.
One way to overcome the bandwidth issue might entail subsidizing wifi in participants’ residences for the duration of the pandemic. Additionally, ensuring transportation to and from one-on-one meetings (if a given participant opts for the hybrid option) would also bolster participation. This might involve distributing vouchers for Uber or arranging carpools for those participants who do not have reliable transportation.
- County Health Rankings & Roadmaps. Retrieved 1/26/22 from https://www.countyhealthrankings.org/app/ohio/2021/rankings/tuscarawas/county/outcomes/overall/snapshot
- Laddu D, Dow C, Hingle M, Thomson C, Going S. A review of evidence-based strategies to treat obesity in adults. Nutr Clin Pract. 2011 Oct;26(5):512-25. doi: 10.1177/0884533611418335. PMID: 21947634. [Link]
- Curr Sports Med Rep. 2016 Jul-Aug; 15(4): 290–297. doi: 10.1249/JSR.0000000000000276 [Link]
- BMC Public Health. 2018; 18: 967. Published online 2018 Aug 3. doi: 10.1186/s12889-018-5877-8 [Link]
- World Health Organization. Obesity and Overweight. Retrieved 1/26/22 from https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight#:~:text=For%20adults%2C%20WHO%20defines%20overweight,than%20or%20equal%20to%2030.
- Martinez, M. (2020). Exploring Community-Based Weight Loss Initiatives, Retention, and Motivation. UTHealth School of Public Health. [Link]
- Mayo Clinic. Prediabetes. Retrieved 1/26/22 from https://www.mayoclinic.org/diseases-conditions/prediabetes/symptoms-causes/syc-20355278#:~:text=Being%20overweight%20is%20a%20primary,your%20cells%20become%20to%20insulin
- YMCA. YMCA’s Diabetes Prevention Program. Retrieved 1/26/22 from https://www.ymca.org/what-we-do/healthy-living/fitness/diabetes-prevention
- Am J Prev Med. 2008 Oct;35(4):357-63. doi: 10.1016/j.amepre.2008.06.035. [Link]
- YMCA. YMCA’s Diabetes Prevention Program. Program Overview: How It Works. Retrieved 1/26/22 from http://divvy.cantaloupe.tv/storybooks/dd97cff8-5e7d-4968-9c71-d6e02b854a7c/embed/episode/7
- South Shore YMCA. Diabetes Management & Prevention. Retrieved 1/26/22 from https://www.ymcadc.org/programs/health-fitness/ymcas-diabetes-prevention-program/
- USDA. Carlson A, Frazao, E. “Are Healthy Foods Really More Expensive? It Depends on How You Measure the Price.” 2012. [Link]