In today's NYT, an extensive (and well done) news/feature appears on diabetes [link]. The article uses the toll of diabetes on individual patients - and it seems a few physicians as well - and its exceedingly high prevalence in New York City to frame the science of diabetes prevention and control. Tucked into the middle of the story was this nugget:
But Dr. Frieden, New York's health commissioner, says meaningful
prevention cannot be achieved at the city level. "I can urge people
until I'm blue in the face to walk and take the stairs and eat less,
and it won't make much difference," he said.
His emphasis is on
trying to better treat those who already have diabetes, an ambitious
goal in its own right. Most primary care doctors treat too many
patients to provide the attention that diabetics need, or to check for
the disease, he said. Specialists are scarce. And compliance among
patients is notoriously poor.
Even the most basic step in
controlling the disease - watching one's blood sugar - is too much for
many diabetics. Doctors recommend that two to four times a year,
patients take a so-called A1c test, which gauges the average sugar
level over the prior 90 days and is more revealing than daily at-home
measurements.
But in 2002 , the health department found that 89
percent of diabetics did not know their A1c levels. Of those who did,
presumably the most conscientious, four out of five had readings over
the level the American Diabetes Association says separates
well-controlled from poorly controlled diabetes.
Now I don't believe that the New York City Health Commissioner should necessarily set national health policy (or local ones outside his jurisdiction for that matter - no offense intended), but his comments are important to note in the context of national efforts such as the National Diabetes Education Program and its Small Steps. Big Rewards campaign to prevent Type II diabetes alongside its 'control' campaign Be Smart About Your Heart. As program designers and managers face the mandate to address diabetes among all the other public issues they confront, consider these statistics from NYC that has ...just three people and a $950,000 budget to outwit diabetes, a
disease soon expected to afflict more than a million people in the
city. Tuberculosis, which infected about 1,000 New Yorkers last year, gets $27 million and a staff of almost 400.
The use of social marketing cannot be seen just as a potential solution to a "problem," but also as a tool to assist decision-makers on where to focus limited resources. A key feature of social marketing, analysis of the competition, is a place to start. Competition in this case might refer to the competing interests and concerns for a piece of an agency's budget, priorities and needs of key constituencies and stakeholders, and the attentions and actions of other organizations. For example, I would be hard-pressed to argue for spending diabetes control and prevention dollars on an obesity program for children and teens if I know that several other organizations and millions of dollars are flowing into such efforts already. I might suggest a change in internal funding and staffing patterns to better match resources with (objectively?) defined needs and public health priorities (and prepare for the inevitable "We told you so." For those who don't remember, NYC was the site of a major reemergence of Tuberculosis several years ago which was blamed on official inattention to the control of the disease). Finally, no maybe first, I would look at the audiences that are affected - or potentially affected - by Type II diabetes (including health care providers and families), determine which ones are most open to behavior change now, and then focus what I have on working with those stakeholders, constituents and other external groups that are most critical to obtaining success. And for those already doing the work, take these measures of progress to heart from the national high blood pressure and cholesterol education programs. In the last 2 decades, the number of persons with
hypertension who are aware of their condition has increased dramatically. In
addition, the percentage of persons with hypertension who are on medication and
controlling their condition also has improved substantially, but
recent data indicate this trend is subsiding. Since 1978, average total
cholesterol levels among U.S. adults have fallen from 213 mg/dL to 203 mg/dL,
and the prevalence of cholesterol of 240 mg/dL or higher has declined from 26
percent to 19 percent
The message is "long-term, persistence." The behavior is that one doesn't necessarily chose between prevention, control and treatment outcomes, but rather sets priorities based on the patterns of the disease, its risk factors and sequelae (epidemiology); uses current and emerging information from the behavioral, medical and social sciences that are relevant to addressing the identified challenges; designs programs that are repsonsive and relevant to the attitudes, behaviors, readiness and values of the priority audiences; and positions the program in an environment where one is competing with others for resources and the audiences' time, attention and action.
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