XI. STRATEGIES FOR IMPROVING DIABETES CARE D iabetes is a chronic illness that requires continuing medical care and patient self-management education to prevent acute complications and to reduce the risk of long-term complications. Diabetes care is complex and requires that many issues, beyond glycemic control, be addressed. A large body of evidence exists that supports a range of interventions to improve diabetes outcomes. These standards of care are intended to provide clinicians, patients, researchers, payors, and other interested individuals with the components of diabetes care, treatment goals, and tools to evaluate the quality of care. While individual preferences, comorbidities, and other patient factors may require modification of goals, targets that are desirable for most patients with diabetes are provided. These standards are not intended to preclude more extensive evaluation and management of the patient by other specialists as needed. For more detailed information, refer to Bode (Ed.): Medical Management of Type 1 Diabetes (1), Burant (Ed): Medical Management of Type 2 Diabetes (2), and Klingensmith (Ed): Intensive Diabetes Management (3). The recommendations included are diagnostic and therapeutic actions that are known or believed to favorably affect health outcomes of patients with diabetes. A grading system (Table 1), developed by the American Diabetes Association (ADA) and modeled after existing methods, was utilized to clarify and codify the evidence that forms the basis for the recommendations. The level of evidence that supports each recommendation is listed after each recommendation using the letters A, B, C, or E.

Standards of Medical Care in Diabetes

During the past 20 years there has been a dramatic increase in societal interest in preventing disability and death in the United States by changing individual behaviors linked to the risk of contracting chronic diseases. This renewed interest in health promotion and disease prevention has not been without its critics. Some critics have accused proponents of life-style interventions of promoting a victim-blaming ideology by neglecting the importance of social influences on health and disease. This article proposes an ecological model for health promotion which focuses attention on both individual and social environmental factors as targets for health promotion interventions. It addresses the importance of interventions directed at changing interpersonal, organizational, community, and public policy, factors which support and maintain unhealthy behaviors. The model assumes that appropriate changes in the social environment will produce changes in individuals, and that the support of individuals in the population is essential for implementing environmental changes.

An Ecological Perspective on Health Promotion Programs

This article summarizes an extensive literature review addressing the question, How can we spread and sustain innovations in health service delivery and organization? It considers both content (defining and measuring the diffusion of innovation in organizations) and process (reviewing the literature in a systematic and reproducible way). This article discusses (1) a parsimonious and evidence-based model for considering the diffusion of innovations in health service organizations, (2) clear knowledge gaps where further research should be focused, and (3) a robust and transferable methodology for systematically reviewing health service policy and management. Both the model and the method should be tested more widely in a range of contexts.

/pdf/diffusion-of-innovations-in-service-organizations-systematic-232yz0xxv2.pdf

Diffusion of Innovations in Service Organizations: Systematic Review and Recommendations

Lincoln, Yvonna, and Egon Guba, "Postpositivism and the Naturalist Paradigm," pp. 14-46 in Yvonna Lincoln and Egon Guba, Naturalistic Inquiry . Beverly Hills, CA: Sage, 1985.*

Building Leadership Effectiveness This program encourages leaders to develop practices that transform values into action, vision into realities, obstacles into innovations, and risks into rewards. Participants will be introduced to the five practices of exemplary leadership: modeling the way, inspiring a shared vision, challenging the process, enabling others to act, and encouraging the heart Coaching & Communicating for Performance Coaching & Communicating for Performance is a highly interactive program that will give supervisors and managers the opportunity to build skills that will enable them to share expectations and set objectives for employees, provide constructive feedback, more effectively engage in learning conversations, and coaching opportunities. Skillful Conflict Management for Leaders As a leader, it is important to understand conflict and be effective at conflict management because the way conflict is resolved becomes an integral component of our university’s culture. This series of conflict management sessions help leaders learn and put into practice effective strategies for managing conflict.

기독교 사역과 Leadership

The enormous growth in worksite health promotion programs during the past 20 years has been accompanied by increased concern with methods and strategies for improving and maintaining program quality. Approaches to quality control include the development of certification and/or licensure programs for worksite professionals and accreditation procedures for academic programs. Golaszewski and his colleagues in their article on "Role Delineation for the Position of Director of Worksite Health Promotion Programs" have performed a valuable service to the profession through their multimethod study of the job requirements and skills necessary for directors of worksite health promotion programs. ~ Given the importance of developing quality control mechanisms for worksite programs, we think that it is important to reflect on some of the issues about the role of the director and about the recommendation for certification made by the authors. Specific issues addressed in this commentary include: 1) the importance of planning for the future, and 2) who benefits from certification and licensure. It is apparent from the literature reviewed by the authors that there was a shift in competencies required of worksite health promotion directors in the 1980s. Worksite directors were increasingly expected to have broad competencies in program development and implementation, combined with good organizational, leadership, and management skills. In short, worksite directors became recognized as managers as ~riuch as service deliverers. Just as there was an apparent shift during the 1980s in competency requirements, the decade of the 1990s may well witness even more dramatic changes with health care reform. By focnsing their methodology on competency requirements for cnrrent worksite directors, there is the risk of developing standards and programs to meet cnrrent, rather than future, needs. Thus, an important component of the development of job standards and skill requirements should be a view of the future. In rapidly changing jobs, basing job requirements and skills on current practices--particularly if linked to licensure and certification--runs the risk of formalizing current standards, which can be extremely difficult to change or adapt to new circumstances. Linked to the need for a view of the future is the emphasis in the authors’ findings on bnsiness, program, and hmnan resource management. While management skills are an obvious requirement for worksite health promotion program directors, it is only fair to ask, "Management for what?" Is a program director simply a manager of health promotion services to employees, or is there some larger view of the purpose, nature, and extent of health promotion in worksites. It is onr contention that an important area of expertise is neglected and, in fact, never mentioned in this article-a public health perspective. From a public health perspective, worksites are important community settings for providing health promotion services and creating social enviromnents that are supportive of healthpromoting behaviors. Thus, we wonld argue that an important requisite for directors of worksite health promotion programs is a view of their role in fostering and maintaining the health of employees and their families, as well as contributing to the health of the communities in which their organizations are embedded. If worksite health promotion programs are to be publically supported through tax deductions and other mechanisms under national health insurance, they should include improvements in health stares as important goals and objectives. Sociologists of the professions have viewed the development of professions from both fnnctionalist and conflict perspectives. 2-4 From a functionalist perspective, professions serve to provide society with a way to handle major needs, for example health or education. Professional standards assure quality and are a way to link education and skills to the market place. On the other hand, when viewed from the conflict or power perspective, professional standards serve to control entry to the market and arise from the economic self-interest of the professional group. As one might expect, the justification for role delineation, certification of professionals, and accreditation of university degree programs by professional organizations is typically presented from the functionalist perspective. ~’~

R,eflections on Certification

The enormous growth in worksite health promotion programs during the past 20 years has been accompanied by increased concern with methods and strategies for improving and maintaining program quality. Approaches to quality control include the development of certification and/or licensure programs for worksite professionals and accreditation procedures for academic programs. Golaszewski and his colleagues in their article on \"Role Delineation for the Position of Director of Worksite Health Promotion Programs\" have performed a valuable service to the profession through their multimethod study of the job requirements and skills necessary for directors of worksite health promotion programs.~ Given the importance of developing quality control mechanisms for worksite programs, we think that it is important to reflect on some of the issues about the role of the director and about the recommendation for certification made by the authors. Specific issues addressed in this commentary include: 1) the importance of planning for the future, and 2) who benefits from certification and licensure. It is apparent from the literature reviewed by the authors that there was a shift in competencies required of worksite health promotion directors in the 1980s. Worksite directors were increasingly expected to have broad competencies in program development and implementation, combined with good organizational, leadership, and management skills. In short, worksite directors became recognized as managers as ~riuch as service deliverers. Just as there was an apparent shift during the 1980s in competency requirements, the decade of the 1990s may well witness even more dramatic changes with health care reform. By focnsing their methodology on competency requirements for cnrrent worksite directors, there is the risk of developing standards and programs to meet cnrrent, rather than future, needs. Thus, an important component of the development of job standards and skill requirements should be a view of the future. In rapidly changing jobs, basing job requirements and skills on current practices--particularly if linked to licensure and certification--runs the risk of formalizing current standards, which can be extremely difficult to change or adapt to new circumstances. Linked to the need for a view of the future is the emphasis in the authors’ findings on bnsiness, program, and hmnan resource management. While management skills are an obvious requirement for worksite health promotion program directors, it is only fair to ask, \"Management for what?\" Is a program director simply a manager of health promotion services to employees, or is there some larger view of the purpose, nature, and extent of health promotion in worksites. It is onr contention that an important area of expertise is neglected and, in fact, never mentioned in this article-a public health perspective. From a public health perspective, worksites are important community settings for providing health promotion services and creating social enviromnents that are supportive of healthpromoting behaviors. Thus, we wonld argue that an important requisite for directors of worksite health promotion programs is a view of their role in fostering and maintaining the health of employees and their families, as well as contributing to the health of the communities in which their organizations are embedded. If worksite health promotion programs are to be publically supported through tax deductions and other mechanisms under national health insurance, they should include improvements in health stares as important goals and objectives. Sociologists of the professions have viewed the development of professions from both fnnctionalist and conflict perspectives.2-4 From a functionalist perspective, professions serve to provide society with a way to handle major needs, for example health or education. Professional standards assure quality and are a way to link education and skills to the market place. On the other hand, when viewed from the conflict or power perspective, professional standards serve to control entry to the market and arise from the economic self-interest of the professional group. As one might expect, the justification for role delineation, certification of professionals, and accreditation of university degree programs by professional organizations is typically presented from the functionalist perspective. ~’~

Reflections on Certification

https://ajph.aphapublications.org/doi/pdfplus/10.2105/ajph.93.4.533

20 .W arner KE. Selling Smoke: Ciga- rette Advertising and Public Health.

\n \n \n To assess self-reported financial strain and persistence in asking treatment- and medication-related questions in relation to medication nonadherence.\n \n \n \n Data were analysed from a cross-sectional study of adults with diabetes, hypertension or both in central Texas in 2013. Measures of medication nonadherence in the past 12 months, financial strain and patients' persistence in asking treatment- and medication-related questions were identified. Medication nonadherence resulting from cost, transportation or work was compared with medication nonadherence resulting from other reasons. Binary and multinomial regression models were fitted to identify factors associated with medication nonadherence among the respondents.\n \n \n \n In the bivariate model, medication nonadherence from any cause was significantly associated with financial strain, not asking questions about treatments or medications, and all demographic characteristics. However, in the multinomial model, medication nonadherence resulting from cost, work or transportation was only associated with not asking medication-related question about financial strain, lack of health insurance, age and gender. This was true for nonadherence resulting from other reasons except that ethnicity was significant while gender was not.\n \n \n \n While removing financial strain could aid medication adherence, clinicians should also encourage patients to be persistent in asking questions about their medications until they understand the purpose for taking them. Our findings have implications for empowering patients to be more proactive in enhancing their adherence to medications.\n

The effect of health-related information seeking and financial strain on medication nonadherence among patients with diabetes and/or hypertension in central Texas

We wish to thank Rabin for observing that “[h]ealthy aging begins with the fetus, not the adult.” Clearly, community-based public health programs must take into account health and health-related issues throughout the life span and focus on strengthening communities to support the health of all age groups.

We will respond to several inferences that might be drawn from Rabin’s letter. First is the implication that health comes from participating in lifestyle programs. Second is the notion that educating children is the pathway to good health. Third is the implication that our approach allows individuals to comfortably and permanently “change.”

Our view is that communities are more than mere settings for delivering individually oriented lifestyle change and health promotion programs. Instead, we believe that (1) many of the social forces that produce health and illness are experienced within communities (whether geographic communities, communities of identity, or relational communities); (2) communities are important resources for addressing health and healthrelated issues; (3) substantive, sustainable improvements in population health require addressing the social forces that produce illness, including social and economic disparities; and (4) building and strengthening communities is an important outcome of public health activities, irrespective of their effects on health status. As a result, we think that the delivery of direct services to individuals and participation in programs are only 2 of the numerous and varied goals of health promotion programs.

Educating children (and adults) is important for every society. Nonetheless, health education in the narrow sense of conveying information about the benefits and costs of behaviors is a limited approach to addressing the present and future health needs of communities. To effectively advance the health of children, we need to better ensure safe and healthy environments, access to quality health care, smoke-free schools, enforcement of policies on motor vehicle restraints, and development of effective drug and violence prevention strategies. Moreover, we would suggest that in controversial societal issues, for example, adolescent pregnancy, when there is no consensus about who is to blame for the problem and who is responsible for the solution, our society tends to choose educational strategies over strategies that address more fundamental causes.

Certainly, change—be it societal or individual—is uncomfortable. Creating a healthy society is not about seeking comfort or permanence, although sustainability of our efforts is an important goal. Rather, creating a healthy society is about seeking social justice and contributing to a peaceful and equitable world.

Kenneth R. McLeroy

Papers

R,eflections on Certification

Reflections on Certification

20 .W arner KE. Selling Smoke: Ciga- rette Advertising and Public Health.

The effect of health-related information seeking and financial strain on medication nonadherence among patients with diabetes and/or hypertension in central Texas

Mcleroy et al. respond