UW School of Medicine and Public Health

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UW School of Medicineand Public Health

• Healthy Wisconsin Communities
• UW Cooperative Extension
• September 2009, Stevens Point, WI

Patrick Remington, MD, MPH
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Outline

• Metaphor
• Case study
• Population health frameworks
• Implications for UW Extension

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Part 1. Metaphor

• A small Midwestern city was located next to a
  river
• Although the river looked safe, people drowned
  nearly every day
• So the people decided to do something about it

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• One day, a man came by and was asked to help out
• But instead, he went upstream to see why the
  people were falling in the river

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• So he spent hours observing the bridges and river
  banks, learning why people ended up in the river
• He returned to the city, to tell all that he had
  learned
• Q What did they call him?
• An epidemiologist

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Epidemiology

• The study of the distribution and determinants
  of health and diseases, morbidity, injuries,
  disability, and mortality in populations

Friis, 1996
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LaCrosse, Wisconsin
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Case StudyLaCrosse, Wisconsin

• April, 2004
• Jared Dion, a 21-year-old UW-La Crosse student
  was missing for 5 days.
• He was pulled from the Mississippi River after an
  extensive search.
• QUESTION What was the cause of his death?

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A Serial Killer?
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Alcohol abuse?
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La Crosse Drowning Victim.40 Blood-Alcohol Level

• The cause of death is a freshwater drowning with
  alcohol intoxication as a contributing factor
• The Medical Examiner's says the blood alcohol
  level was .40
• However, police say the manner of his death is
  undetermined.
• Friends said Dion vanished from the downtown area
  where he and others had been drinking.

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Two years later Oct. 2006
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Part 2. Metaphor

• One day, a woman went with the man upstream from
  the city
• She wanted to see if she could prevent people
  from falling (or jumping) in the river

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Dont jump!
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• She returned to the city, to tell about all of
  the things that she had done
• They noticed that fewer people were drowning in
  the river
• Q What did they call her?
• A public health practitioner

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Disease Continuum
Health
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Disease Continuum

• Progression along continuum can be rapid
• Drinking and drowning
• Progression can take lifetime
• Poor diet and heart disease
• Smoking and lung cancer

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Preventable Causes of Death
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Preventable Causes of Death
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Preventable Causes of Death
Estimated for 2000 (see Mokdad et al, with
correction)
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What is the cause of this death?
Alcohol Abuse?
But what causes alcohol abuse (looking further
upstream)
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Alcohol task force gets close look at levee from
rivers sideBy JOAN KENT La Crosse Tribune

• Published - Wednesday, October 25, 2006
• You could hardly make out where the levee wall
  ended and the water began.And when someone
  shined a flashlight, you saw a sheer, straight
  wall into the Mississippi River, impossible to
  grasp.From the rocky riprap south of Pearl
  Street, there are no ladders on the river side of
  the levee until Main Street. And it was almost
  impossible to see the ladders north of Main
  because they are not lit.

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The Prevention Continuum
Health
Alcohol Abuse
Disease
Death
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40 Developmental Assets

• INTERNAL ASSETS
• Commitment to learning (e.g., homework)
• Positive values (e.g. integrity)
• Social competencies (e.g., resistance skills)
• Positive identity (e.g., self-esteem)

• EXTERNAL ASSETS
• Support (e.g., family support)
• Empowerment (e.g., service to others)
• Boundaries/expectations (e.g., high expectations)
• Constructive use of time (e.g., youth programs)

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Risk behavior prevalence by levels of
developmental assets
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• Adverse Childhood Experiences
• Dr. Rob Anda et al.
• Examines the health and social effects of ACEs
  throughout the lifespan
• Studied among 17,421 members of the Kaiser Health
  Plan in San Diego County

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Adverse Childhood Experiences 10 categories of
experience up to 18 years old -childhood abuse
emotional, physical, or sexual
-childhood neglect emotional or
physical -growing up with domestic
violence substance abuse (alcohol or
drugs) mental illness
parental discord crime
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Adverse Childhood Experiences Are Common

Household dysfunction
Substance abuse 27 Parental sep/divorce
23 Mental illness 17 Battered
mother 13 Criminal behavior
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Abuse Psychological
11 Physical 28 Sexual 21
Neglect Emotional
15 Physical
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The ACE Score Alcohol Use and
Abuse
Percent with alcohol related problem
Ever heavy drinker
Problem with alcohol use
Alcoholic
Married an Alcoholic
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Death
Scientific gaps
Conception
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What is the cause of this death?
The answer depends on your perspective (or how
far upstream you are willing to go)
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Public Health Diagnosis
Less education Alcohol ads Drink
specials Depression
Adverse Child Experience Peer
pressure Drinking in movies Poverty
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What can be done to prevent this from happening
again?
Health
Secondary Prevention
Risk Factors
Disease/Injury
Death
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Health Problem Analysis Worksheet
Indirect Contributing Factors
Direct Contributing Factors
Risk Factors
Health Priority
aka - NCAA Chart
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Health Priority A situation or condition of
people which is considered undesirable, is likely
to exist in the future, and is measured as death,
disease, or disability.
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Risk Factor A scientifically established factor
(determinant) that relates directly to the level
of a health problem.
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Direct Contributing Factor A scientifically
established factor that directly affects the
level of a risk factor.
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Indirect Contributing Factors A community
specific factor that directly affects the level
of the direct contributing factor.
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Outcome Objective The level to which a health
problem (priority) should be reduced.
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Impact Objective The level to which a risk
factor should be reduced.
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Impact Objective The level to which a risk
factor should be reduced.
Intervention Strategy Demonstrated to be
effective or used as national model and should
address an impact objective.
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Community Health Plan Worksheet
Outcome Objective
Health Problem
Risk Factor
Impact Objective
Contributing Factors
Proven Intervention Strategies
Barriers
Resources Available
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The Wisconsin Model
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Action Model to Achieve Healthy People 2020 Goals
Determinants of Health
Outcomes

• Behavioral outcomes
• Specific risk factors,
• diseases, and conditions
• Injuries
• Well-being and health-
• related Quality of Life
• Health equity

Interventions

• Policies
• Programs
• Information

Assessment, Monitoring, Evaluation Dissemination
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Substance Abuse a Life Course Approach
Adult YoungOlder
Adolescence
Infancy Childhood
Before birth
Increase in body fat with aging Age-related
declines in activity Established adult risky
behaviours Nutrition Pregnancy Environment Disp
arities
Obesity Growth Inactivity Nutrition Smoking
Adiposity rebound Growth
Mothers Nutrition IU Growth
Breast Feeding Physical Activity Nutrition Envir
onment
Environment
Environment
Parental Disparities
Parental Disparities
Parental Disparities
Biological risk? Atherosclerosis, hypertension,
insulin resistance ?Disease
Time
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The Rest of the Story
AP, 10/23/2006
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Dr. Remington, I appreciate your efforts with
your presentation, but please know you need some
updating on La Crosse specifically. Many of the
things you stated about La Crosse are simply
inaccurate. Please feel free to contact me if
you'd like to speak about this. Thanks, M.V.
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What you should know is that we are definitely
engaged in a variety of primary prevention
activities on campus as well as in the community.
UW-L takes a strong harm reduction
perspective, we work to empower students to
understand how drugs and alcohol work in an open
and honest way. Of the 19 recommendations you
mentioned, 16 of them have been implemented
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Operation River Watch is actually an amazing
student led, 100 volunteer organization with
students from all 3 institutions of higher
education participating. Volunteers patrol
from 11pm - 3am on Thursday, Friday, Saturday
nightsMany student organizations, sports teams,
fraternities, etc., will select an entire weekend
to volunteer. While patrolling they have radio
contact with the Police reserves if necessary.
My final thought is that we've had a TON of
community coalitions and open discussion on this
topic...we are far from being in denial and are
working toward change on every level. An
environmental approach is definitely where we're
at.
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Implications for UW Extension

• Work upstream
• Start early in life
• Consider the environment
• Use population health frameworks

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Working the Layers through UW Extension

• Four workshop tracks will be offered for breakout
  sessions
• Health Education Curricula and Resources
• Community and Economic Development to Promote
  Healthy Communities
• Health Education with Diverse Audiences
• Community Partnerships for Health Promotion