12th WORLD

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12th WORLD PUBLIC HEALTH CONGRESS
ISTANBUL, TURKEY May, 2009
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A Qualitative Study on Health Policies for
Childhood Diabesity Prevention in the Dominican
Republic Helda Pinzon-Perez, Ph.D. California
State University-Fresno, USA David
Hernandez-Martich, Ph.D. Universidad
Iberoamericana, Dominican Republic Ammar
Ibrahim, MD INDEN, Dominican Republic
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Theoretical Framework

• Diabesity is also known as Obesity-Dependent
  Diabetes Mellitus. Overweight and obesity have
  been strongly linked to diabetes type 2 (Astrup
  Finer, 2000).
• Childhood diabesity is an increasing problem
  around the world.
• Research data on childhood diabesity is scarce.

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Definitions

• Authorship of this term- Shape Up America (2000)
• Anne Daly published an article in 1994 addressing
  diabesity as a deadly pentad disease.
• Obesity
• Non-Insulin dependent diabetes mellitus
• Hypertension
• Atherosclerotic cardiovascular disease
• Dyslipidemia
• Combination of these disorders of the metabolic
  system ought to be known as diabesity

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Theoretical Framework

• The dual epidemic of diabetes and obesity has
  become a major public health concern in the
  United States and around the world (Saljoughian,
  2007).
• The risk for diabesity is high for people from
  the Dominican Republic because of the existence
  of biologically-inherited genotype markers and
  the presence of dietary behavioral factors
  (Kazuyuki et. al, 2004).

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Theoretical Framework

• This genotypical increased risk is exacerbated by
  obesity. The prevalence of obesity in the
  Dominican Republic is worrisome, especially in
  women, with 26 being overweight and 12.1
  diagnosed as obese.
• The Dominican diet includes 39.5 fat, which is
  significantly higher than in the majority of
  developed countries (Kazuyuki et. al.).
• Health policy is an essential component in the
  prevention of this important public health
  problem.

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Location

• The Dominican Republic is an island located
  between the Atlantic Ocean and the Caribbean Sea.
  
• It is a part of the Lesser Antilles.
• The capital city is Santo Domingo and its
  territorial extension is 48,400 Km2.
• The Dominican Republic consists of 29 provinces
  and a national district.
• The economy is based on tourism and industrial
  activity (OPS, 2001).

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Location

• The total population in the Dominican Republic in
  2002 was 8,562,541 and in Santo Domingo was
  904,450 inhabitants, with a population density of
  175.9 inhabitants per km². The population growth
  between 1993 and 2002 was 1.8 (USAID OPS,
  2007).
• Instituto Nacional de Diabetes, Endocrinología y
  Nutricion (INDEN)
• Iberoamerican University- School of Medicine
• California State University- Dept of Public
  Health

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Health Care System

• Health services in the Dominican Republic are
  coordinated by the Dominican Department of Public
  Health and Social Assistance Secretaria del
  Estado de Salud Publica y Asistencia Social
  (SESPAS) .
• Services are offered at three levels central,
  regional, and provincial. Health promotion and
  disease prevention programs are coordinated at
  the central level and are centered on
  environmental health (OPS, 2001).
• The health system in the Dominican Republic is
  based on the philosophical premise that social
  assistance and security are undeniable rights of
  individuals that should be guaranteed by the
  Dominican Government.

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Health Care System

• Law 87-01 (May 9, 2001) created the Dominican
  System of Social Security Sistema Dominicano de
  Seguridad Social and established that the
  National Council of Social Security (CNSS)
  Consejo Nacional de Seguridad Social regulate
  the criteria and indicators to determine the
  populations qualifying for the Nationally
  Sponsored System Régimen Subsidiado.

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Purpose

• The qualitative study presented here involved the
  development of a proposal for health policy for
  diabesity in the Dominican Republic.
• This research endeavor provided the venue for
  health care personnel working at a tertiary level
  hospital in Santo Domingo to elicit health
  policies for childhood diabesity prevention.
• Some policy efforts in the Dominican Republic
  have historically been conducted to control
  diabetes, but additional efforts are currently
  needed to engage the health care sector in the
  prevention of childhood diabesity.

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Assessing the Needs
Determine present state of health
Identify existing programs
Compare health deficits
Deal with the problems
Validate the need
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Research Team

• Human Subjects Approval
• Dr. Ammar Ibrahim
• Dr. Aura Motta
• Dr. David Hernandez-Martich
• Dr. Helda Pinzon-Perez
• Literature Review
• Clinical Charts Review
• Incidence and Prevalence

• Focus Groups
• Nominal Group
• Data Entry
• Six medical students from Iberoamerican University

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TEAM AT INDEN

• Focus Groups
• Nutrition Psychology
• Residents
• Specialists
• Nursing

• Nominal Group
• Pediatrics Team

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Clinical Charts Review

• Sample selection
• Procedural aspects
• Short and clear
• Inter-rater Reliability

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Focus Groups

• Nutrition Psychologist (3)
• Specialists (10)
• Residents (10)
• Nurses (13)
• Pediatrics Team (4)

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Nominal Groups

• 4 to 5 Experts
• Knowledge and Experience
• Ranking the needs detected in the focus groups
• Determining priorities for action

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Data Analysis

• SPSS Quantitative Data
• NVivo- Qualitative Data

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Results

• Age 27 to 36 years old (n14 40.0), 37-46
  years old (n12 34.3 ), 47 and above (n7 20.0
  ), no data (n2 5.7). Most participants were
  middle-age adults between 27 and 36 years old.
• Gender Females (n30 85.7) Males (n5
  14.3). The majority of participants in the
  focus groups were females.
• Educational Level Graduate studies (n 18
  51.4) Bachelors degree (n10 28.5)
  Technical studies and High school (n6 17.1)
  no data (n2 5.7). Most participants in the
  focus groups had graduate studies.
• Professional Background General Practitioner or
  Resident (n9 22.5) Specialist (n 14 40),
  Licensed Vocational Nurse (n3 6.0) Nurse with
  BSN (n9 45.0). Most participants in the focus
  groups were professional nursing and medical
  practitioners with specialties in Endocrinology,
  Diabetology, and Nutrition.

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Results

• Policies proposed by the International Community
• Policies proposed by health care workers at INDEN

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Results-Handouts

• HOSPITAL AND HEALTH CARE SYSTEMS POLICIES
• SCHOOL AND COMMUNITY POLICIES
• ADVERTISING AND MARKETING POLICIES

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Implications for Practice

• The Adelaide conference made special emphasis on
  the inter-sectorial nature of health.
• According to this conference, developing health
  policies should involve economic, social,
  cultural, and educational considerations.
• In addition, the responsibility of industrialized
  nations in relationship to developing countries
  was also highlighted by the Adelaide Conference.
  
• This conference emphasized the ethical and social
  responsibility of developed nations to create
  health policies congruent with the needs of
  developing nations (WHO, 2006).

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Implications and Challenges

• Walt and Buse (2006) documented the need for
  further studies on assessing the impact of
  developing health policies that promote the
  governance goal of transparency and involve
  international cooperation, based on horizontal
  representation.
• According to Walt and Buse (2006), this
  representation needs to be based on the
  understanding that even within a group with
  similar ideas and interests, there could be
  dissenting voices.

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Implications and Challenges

• The international health promotion conferences in
  Ottawa, Jakarta, Adelaide, and Bangkok are also
  important frameworks for the recognition of the
  importance of health personnel in the enactment
  of health policies for diabesity prevention.
• These conferences recognized health as a
  fundamental right and a beneficial social
  investment.

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Implications and Challenges

• Provided scientific evidence of the
  cost-effectiveness dimension of healthy policy.
  Investing in health policies leads to short and
  long-term economic benefits, such as increased
  societal productivity and reduction of expenses
  associated with medical care (WHO, 2006).
• Childhood diabesity prevention should constitute
  a priority agenda for nurses since the increased
  risk for diabesity around the world has been
  documented from a genetic, behavioral, and
  cultural perspective.

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• Things to remember

PICTURES
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RESEARCH TEAM