1 Amman January 12, 2016 Presentation Health Education and Advocacy Experiences from Jordan This document is confidential and is intended solely for the use and information of the presenter. 2 Health Education The Jordan Breast Cancer Program Health Advocacy The Health Care accreditation Council Interlinkages and Impact Outline 3 Health Education The Jordan Breast Cancer Program Health Advocacy The Health Care accreditation Council Interlinkages and Impact Outline 4 A few Definitions in the world of Health Education Health promotion aims to help people to live healthy lives. It involves increasing peoples knowledge and awareness, enabling them to take action to improve their health, and ensuring that their circumstances allow them to make healthy choices. Health promotion includes: Health education Developing personal skills Strengthening community action Reorienting health services Building healthy public policy Creating supportive environments Health Promotion Information, education and communication Information, Education and Communication (IEC) in health programs is an important tool that aims to increase awareness, change attitudes and bring about a change in specific behaviors. IEC means sharing information and ideas in a way that is culturally sensitive and acceptable to the community, using appropriate channels, messages and methods. It is therefore broader than developing health education materials, because it includes the process of communication and building social networks for communicating information. IEC interventions involve the active participation of the target audience and adopt channels, methods and techniques that are familiar to their world view. Health Education Health education is a social science that draws from the biological, environmental, psychological, physical and medical sciences to promote health and prevent disease, disability and premature death through education-driven voluntary behavior change activities Health education is defined by the Jordan Ministry of Health as "any combination of learning experiences designed to pre-dispose, enable, and reinforce voluntary adoption of behavior conducive to health". Health education aims to increase knowledge and awareness and is an important component of health promotion. 5 Health education takes on the lead to change a certain behavior in a strategic, systematic and targeted manner Supported by the latest knowledge from research (medicine, sociology, psychology). A systematic, comprehensive and consistent activity. Adapted to age, gender, education and particular health, mental or social problems of an individual or community (school, entreprise, city). Encourages personal investment of an individual. Respects environment of an individual. Guiding into action Informing people Motivating people 6 Health education occurs in different settings for many purposes; however, the process of what health educators do is the same SettingPrimary MissionWho is Served?What kind of Services SchoolEducationChildren/ adolescents Unintentional injuries, Child abuse and neglect, Substance abuse, personal health and hygiene WorksiteProduce goods and services; Make a profit (if applicable) Consumers of products and services Physical activity and fitness Nutrition and weight control Stress reduction Worker safety and health Blood pressure and/or cholesterol education and control Alcohol, smoking and drugs HospitalsTreat illness and traumaPatientsIn the hospital, direct patient education is part of ongoing patient care and is typically delivered by nurses and physicians Group health education on such topics as diabetes and prenatal care are also provided Community primary care setting Prevent, detect, and treat illness and trauma Patients Family planning Nutrition Breast feeding Health DepartmentChronic and infectious disease prevention / control Public Non communicable diseases School health Mental health Voluntary health agencies Prevention and control targeted disease/condition Public Supportive of the last two examples 7 Health educator focus on the stages of change that a community or individual will go through 8 Assess the barriers Health education is part of an overall health promotion process that is trying to impact individual or community behavioral change Design and implement service provision Define and Understand the health problem III III Design and implement Health education plan III Evaluate and assess impact Services Knowledge attitude Enabling environment IV Back to the drawing board Regulatory approach Service approach Educational approach Remarks Approaches in Public Health V 9 Follow all the steps to design and implement a successful health education plan Establish the program Involve key stakeholders Identify target audiences Conduct a formative assessment Segment target audiences Define behavioral change objectives Design the strategy, plan and evaluation of the program Monitor and evaluate Implement Pretest all tools Develop communication tools and activities 10 The communication / education plan is not only about the media channels that are used Communicator Knowledgeable, effective, responsive, trained, trustworthy, influencer Message Target specific, age, culture, sensitive, comprehensible, action oriented, designed properly Audience Defined, understood, receptive, reachable, influenced by Channels Accessible, trustworthy, combination, 11 Modes of communication can be grouped into three categories MassGroupIndividual T.V Radio Press Films Health magazine Posters Health exhibition Lectures Film and charts Group discussion Panel discussion Symposium Workshop Individual and family sessions Door to door outreach Clinic based education 12 All of which should be identified and measurable from the beginning 13 Health Education The Jordan Breast Cancer Program Health Advocacy The Health Care accreditation Council Interlinkages and Impact Outline 14 Assess the barriers First we define the problem Design and implement service provision Define and Understand the health problem III III Design and implement Health education plan III Evaluate and assess impact Services Knowledge attitude Enabling environment IV Back to the drawing board V 15 Breast cancer is the most common cancer among females and continues to grow on a yearly basis Ten Most Common Cancers Among Jordanian Females JNCR New Cases of Breast Cancer JNCR Primary Site Cumulative Number of Cases years Number of Cases 95% % from all cases 28.5% 32.7% 35.3%36.2% ASR 29.4 ASR 35.2 ASR 39.2 ASR per 100,000 16 Jordanian females are inflicted with the disease at a young age when they are at the peak of their productivity Distribution of Breast Cancer Cases by Age Group JNCR 2005 Age Percentage of Breast Cancer Cases Average Age Specific Incidence Rate (ASIR) Per 100,000 Females JNCR Years Number of Cases Ave Crude Incidence Rate = 22.8/100,000 *Median age in developed countries = 65 years 57% 17 At the onset of JBCP, Breast Cancer used to be detected at late stages when the survival rate and treatment success are not promising Stages of Breast Cancer in Jordan based on KHCC Experience b4 JBCP Stage II, 23.70% Stage 0, 0.50% Stage III, 56.20% Stage % Stage IV, 12.90% N=550 Direct Correlation of Survival to Stage of Detection Stage of disease at Detection Percent of Survival 18 Assess the barriers Then we look at barriers Design and implement service provision Define and Understand the health problem III III Design and implement Health education plan III Evaluate and assess impact Services Knowledge attitude Enabling environment IV Back to the drawing board V 19 Awareness and services on breast cancer early detection and screening were limited, diagnosis focused and not institutionalized Mammography Services Lack of availability and accessibility to screening services Unequal distribution of services across the Kingdom No asymptomatic screening policy; only referred symptomatic patients accepted Cumbersome regulations to screening Quality Assurance Lack of protocols and standard operating policies and procedures (SOPs) to run the units No certification program to set the standards for the mammography units No monitoring and evaluation of performance of health providers regarding guidelines for breast screening Public Awareness Negative attitudes towards subject of breast cancer (many females prefer not to know) added to cultural barriers & social taboos that extend beyond the female herself leading to fears of being ostracized by husband, family, or society Need for more individualized and one-on-one activities in order to change behavior that require large outreach efforts Lack of awareness, buy-in & action of key- informant & service providers supporting screening Capacity Building Lack of female technicians trained in mammography and recruited to serve the facilities Absence of training facilities (other than KHCC) in Jordan to accommodate for training of technicians and radiologists Incomprehensive academic curricula that do not mandate mammography as a required course for technicians Training manuals have not yet been implemented 20 Assess the barriers Then we design the program Design and implement service provision Define and Understand the health problem III III Design and implement Health education plan III Evaluate and assess impact Services Knowledge attitude Enabling environment IV Back to the drawing board V 21 Thus the Jordan Breast Cancer Program was set up in early 2007 to down stage the disease and decrease morbidity and mortality To improve availability and accessibility of screening services across Jordan, especially to those with low income and those residing in remote areas with little access to healthcare services; To increase the knowledge of the public on the benefits of breast cancer prevention and to change the attitude and behavior of the target population to seek early detection services; To establish national unified protocols and guidelines that cover all processes of a comprehensive early detection and screening program. These guidelines will include best practice and quality assurance guidelines on training, medical equipment, diagnosis, and referral systems; To improve healthcare personnel education and training; and To evaluate the impact of the program by collecting data for surveillance and epidemiological analysis to record and measure success of early detection. To improve availability and accessibility of screening services across Jordan, especially to those with low income and those residing in remote areas with little access to healthcare services; To increase the knowledge of the public on the benefits of breast cancer prevention and to change the attitude and behavior of the target population to seek early detection services; To establish national unified protocols and guidelines that cover all processes of a comprehensive early detection and screening program. These guidelines will include best practice and quality assurance guidelines on training, medical equipment, diagnosis, and referral systems; To improve healthcare personnel education and training; and To evaluate the impact of the program by collecting data for surveillance and epidemiological analysis to record and measure success of early detection. Program Objectives Program Goals To reduce morbidity and mortality from Breast Cancer by early detection and screening; To shift the current state of diagnosis of Breast Cancer from its late stages (III- IV), to diagnosing Breast Cancer at its earliest stages (0-II) where the disease is most curable, survival rates are highest, and treatment costs are lowest; To reduce morbidity and mortality from Breast Cancer by early detection and screening; To shift the current state of diagnosis of Breast Cancer from its late stages (III- IV), to diagnosing Breast Cancer at its earliest stages (0-II) where the disease is most curable, survival rates are highest, and treatment costs are lowest; 22 Assess the barriers We look closely at the health education part Design and implement service provision Define and Understand the health problem III III Design and implement Health education plan III Evaluate and assess impact Services Knowledge attitude Enabling environment IV Back to the drawing board V 23 JBCP designed core strategic areas to work on and developed an action plan with prioritized activities Accessibility, Availability and Usability Developing Human Resources Public Awareness and Health Education Quality Assurance Strategy and Data Targeted Awareness Activities March Campaign Campaigns October Development of Information & Communication Toolkits JBCP Hotline promotion 24 The Jordan Breast Cancer Program follow a very rigorous and scientific approach in designing their educational campaign Step One: Research Step Two: Planning Phase 2.1: Setting A Goal 2.2: Identify Target Group Who / where are they (demographics)? How do they obtain daily information? Who are their role models? What are their current perceptions, knowledge, needs, wants, preferences, and behavior in relation to the issue addressed by the campaign? What prevents them adopting the alternative behavior promoted by the campaign? What would motivate them to adopt the promoted behavior? 2.3: Developing the Campaign Message /Slogan and Design A good message is simple and clear. A good message is true and credible. A good message gives a reason. A good message is understandable. A good message is, convincing. A good message is acceptable. 2.4: Developing the Campaign Action Plan Step Three: Implementation phase Step Four: Follow upMonitoring Step Five: Reporting and Evaluation 5.1: October Campaign report 5.2: National Survey to assess the campaign 25 The health education plan includes several channels of communication for awareness and targeted goals Audiovisual activities (TV, Radio, Printed media (newspapers, magazines) Outdoor branding (bridges, wall units, billboards, mupies, lamp-posts) Social media and E-Media (FB, Twitter, instagram, Websites) Mass Awareness IEC Material distribution (flyers, shower cards, booklets, bookmarks, bank inserts) Lectures Road-shows. ( malls, schools, health centers, universities) Open days. (auditioning performances) Outreach Free CBE Discounted mammogram for all women Free mammograms for underprivileged women Screening 26 Provision of services is coupled with raising awareness among the public and driving the demand towards early detection Clinical Breast Exam Year # of Beneficiaries Mammograms Year Women Outreach 15,3775,9859,392SBEs train 19,3995,98513,414Attendance 1, ,445Lectures JBCPTotalMoH 27 Assess the barriers Then we monitor and evaluate before going back to the drawing board Design and implement service provision Define and Understand the health problem III III Design and implement Health education plan III Evaluate and assess impact Services Knowledge attitude Enabling environment IV Back to the drawing board V 28 In less than two years experience, preliminary indications from KHCC data already show a shift in staging of the disease Stages of Breast Cancer in Jordan based on KHCC Experience before program Stage II, 23.70% Stage 0, 0.50% Stage III, 56.20% Stage % Stages of Breast Cancer in Jordan based on KHCC Experience after program Stage II, 41.32% Stage I, 8.90% Stage IV, 17.35% Stage III, 24.20% Stage % Stage IV, 12.90% 3.42% unknown N=550N=438 29 Year after year the message matures and changes to build on the successes of the year before and address the challenges that are still faced (1) 2006 Early detection saves lives 2010 We screeneddid you? 2009 At 40 we screen 2011 Encourage her to screen 2007 Female: a mammogram helps you 2008 Detection means safety 30 Year after year the message matures and changes to build on the successes of the year before and address the challenges that are still faced (2) 2012: promise to Screen 2013: Screen we are all with you 2014: Lets go, your health is more important 2015: stay in my life 31 Health Education The Jordan Breast Cancer Program Health Advocacy The Health Care accreditation Council Interlinkages and Impact Outline 32 Advocacy is to promote or reinforce a change in policy, program or legislation rather than providing support directly to clients or users of services, advocacy aims at winning support from others. Assess the barriers Design and implement service provision Define and Understand the health problem III III Design and implement Health education plan III Evaluate and assess impact Services Knowledge attitude Enabling environment IV Back to the drawing board V 33 In many ways, advocacy, like any other program, follows a series of steps to arrive at the intended goal Process Identify the need or the problem Gather data to document the need or problem Identify decision-makers Gather support Develop recommendations to address the need or problem Make the case Pitfalls Failing to effectively communicate needs to healthcare providers Taking an all or nothing approach Not being willing to try a service or program Focusing on unproductive approaches in the healthcare process Not documenting everything Areas of Advocacy Leadership development Coalition building Networking Political Lobbying Promoting legislative change Briefing media Counteracting opposition Stakeholders Beneficiaries Decision makers Allies and partners Resistant groups (Adversaries) 34 Advocacy has specific techniques and tactics Advocacy techniques and tactics Audience/Stakeholder Category BeneficiariesPartnersAdversariesDecisionmakers Sensitization Mobilization Dialoguing Debating Negotiating Lobbying Petitioning Pressuring 35 Advocacy in health care is critical at the policy level and for sustainability purposes Why Individual & institutional health actions have spillover effects Citizens expect government to satisfy physical, economic & psychological needs Protecting public health involves moral judgments that acquire legitimacy thru political debate Healthy population is vital to economic growth & social order How Measure public priorities/opinions: Measure media coverage: Find priorities of legislators: Categorize the salience of issue: Identify key political decision makers Which organization? Who? When and how? When Documentation of scientifically & socially credible threat Agreement on who or what is responsible for the problem Social views about affected populations Health is a political issue Who Individual Professional Interest group Lobbyers Academia community 36 Health Education The Jordan Breast Cancer Program Health Advocacy The Health Care Accreditation Council Interlinkages and Impact Outline 37 Although Jordan fairs well on many health indicators, the in depth reality of services in Jordan was challenging Weaknesses No data related to patient safety No P&Ps &/or clinical guidelines Reporting culture Lack of enforcement of Regulations and Safety regulations No medical liability law Lack of continuous credentialing and privileging system tied to continuous education Impact of crisis in the region and load on the healthcare system. 38 So the Health Care Accreditation Council (HCAC) was established in an effort to address some of the challenges members form a National Accreditation Committee was approved Donor support for government of Jordan on accreditation First draft of Jordanian Hospital standards was published Establishment of HCAC Surveyor training started ISQua accredits the hospital accreditation standards 1st edition Primary Health Care Standards NQSGs launched ISQua accredits Surveyor Certification Course ISQua accredits HCAC First group of accredited hospitals Centers of Excellence First Edition Breast imaging Units Standards Medical Transport Standards Diabetes Standards & Cardiac Standards Launched 2006 Piloting in Hospitals Official partnership with Ministry and stakeholder PHCs accredited Strategic plan MOH ISQua Reaccredits HCAC 1 st Change Day Mandatory accreditation law drafted Change Day rd Quality Conference 39 Through the provision of two types of services Functions Accreditor Enabler Consultant Development Training and Certified Courses Preparedness Consulting for Quality Mock Surveys Accreditation Surveyor Development Standards Development Education and ConsultationDepartment ConsultationDepartment Surveys and Standards Development Department Surveys and Standards Development Department Firewall 40 So today, HCAC is not just an accreditation body, it is a nonprofit institution with the aim to raise the quality of health services MissionObjectivesComponents Continuous Quality Improvement and Patient Safety Safe health care Quality services Empowered providers Patients NGOs Government Intl Orgs Health Professionals Trainers & Academics Private Sector Stakeholders Decision Makers Patients & Families Health Professionals Institutions Supportive environment Accreditation Consultation Capacity Building Research 41 works on different levels to support quality improvement and patient safety Awareness Education Research 2 Courses Healthcare Certified Quality Practitioner Healthcare Certified Clinical Risk Manager Healthcare Certified Executive Leadership Healthcare Certified Infection Preventionist pledges 42 and runs National Quality and Safety Goals every other year YearGoals 2009 Identify Patient Correctly Improve Safety of High Alert Medication Ensure Correct-Site, Correct-Procedure, Correct-Patient 2010 Ensure compliance with hand hygiene best practice All Medical Record Entries must be Timed, Dated, and Signed 2011 Clear and Interactive Communication During "Hand Over Improve the Safety of Multiple Dose Vials (MDV) Use Safe Management of Central Lines to Minimize Infection and complications Patient fall Appropriate use of prophylactic antibiotics in surgery Reduce the risk of catheter associated urinary tract infections 2013 Improve Pain Management Medication Reconciliation Zero Tolerance for Workplace Violence Remarks It is part of HCACs CSR Goals are developed in a consultative manner Goals are selected based on the: Potential of happening Potential impact Applicability to all sectors Applicability to all types of people Uniquely Jordanian Solutions are possible Goals must be: Valid Reliable Clear Realistic Measurable. Institutions apply voluntarily and have to demonstrate: written and implemented evidence based policy/guidelines In-service training for relevant staff Documented evidence of implementation Monitoring of the compliance With positive results Certification is awarded for one year 43 The accreditation initiative has had several impacts at the macro and micro levels in Jordan Macro Develop the expertise of quality and patient safety -8 Certified Consultants -35 Certified Quality professionals -27 Certified Infection Control professionals -14 Certified Risk Management -26 Leadership & Management Instill at the institutional level progress, change and improvement -17 hospitals accredited four in the pipeline -90 PHC accredited 27 in the pipeline Have a body to advocate, focus and push the agenda (become a line item in the MOH Budget) Raise level of awareness of the importance of the subject matter & develop services to ensure buy in Address needs of the country & region and respond to emerging issues Improve health care quality through standards Stimulate the management of health services to focus on quality and patient safety Improve professionals understanding and skills on quality improvement strategies and "best practices" Management and Leadership Committee Medical Record Committee Infection Control (IC) & Environmental Safety Committee Quality Improvement & Client Safety Committee Radiation Safety Medication management Infection Control ContinuityMedical RecordOverall Safety Institutional Patient and Employee Satisfaction Housekeeping Increased the professionalism of care providers Increased sense of responsibility towards the clients Improved communication and cooperation with client/ families Improved the level of medical services provided to clients Enhanced the confidence in the care Minimized/prevente d incidents caused by the health care process 44 The evidence of the impact of HCAC accreditation is being generated but still needs more years of implementation 45 Accordingly the government has taken many strides to institutionalize accreditation Ministry of Health His Majesty King Abdullah II bin Al Hussein initiative for at least one accredited hospital in each governorate New private hospitals law indicates accreditation to be accomplished within 5 years from publishing Accreditation targets identified and specific in Ministry of Health strategic plan Jordan 2025 indicates accreditation as a requirements for hospitals In response to a directive of His Majesty, the Prime Minister commissioned the Ministry of Health to draft a law for mandatory accreditation for all health sector in Jordan Senate has requested accreditation of institutions to follow medical liability law Recent Steps Establishment of Central Accreditation Steering Committee Headed by General Secretary Support quality management directorate with staff and other resources Assign quality coordinator in all health directorate Establishment of medical record committee Quality and accreditation on MoH strategic plan for 2014 2017 46 Health workers have a very positive view of the role of accreditation on improving the work of health centers "The accreditation had a positive effect on my health center" The following department or service was mostly effected Courtesy of Health Systems Strengthening Project II implemented by Abt Associates and funded by USAID Mean Scores for 1st & 2nd Collaboratives Patient Satisfaction Surveys Through the PHC Lens 47 Upward trends in several areas in accredited vs. non-accredited PHCs have been noted Courtesy of Health Systems Strengthening Project II implemented by Abt Associates and funded by USAID Through the PHC Lens 48 Sometimes pictures are worth a thousand words (before) 49 Sometimes pictures are worth a thousand words (after) Look alike medication Sound alike medication 50 So how did health care quality and patient safety become a political issue through the advocacy steps? Why Individual & institutional health actions have spillover effects Citizens expect government to satisfy physical, economic & psychological needs Protecting public health involves moral judgments that acquire legitimacy thru political debate Healthy population is vital to economic growth & social order How Measure public priorities/opinions Measure media coverage Find priorities of legislators Categorize the salience of issue Identify key political decision makers Which organization? Who? When and how? When Documentation of scientifically & socially credible threat Agreement on who or what is responsible for the problem Social views about affected populations Health is a political issue Who Individual Professional Interest group Lobbyers Academia community 51 Health Education The Jordan Breast Cancer Program Health Advocacy The Health Care accreditation Council Interlinkages and Impact comparison Outline 52 Health education and health Advocacy are similar yet different in many ways however always aiming at improved health Health Education Goal: Change attitudes, Beliefs, values and Behavior of individuals or group of individuals Advocacy Goal: Actively supporting a cause, and trying to get others to support it as well Process Similarities. Identify, segment audiences. Undertake research to clarify issues. Develop strategies & messages. Monitor and evaluate Although there is a good deal of overlap between health education and advocacy, advocacy activities tend to be more deliberately persuasive and campaign oriented. 53 Comparing the JBCP and the HCAC programs AdvocacyHealth education aims to gain wider support ensuring educates individuals and the community about the existence and benefits of JBCP regular screening for women for the early detection of breast cancer Importance of early detection through regular exams and successful treatment HCAC Improving patient safety and quality in health care Patient rights, patient safety tools, 54 whether it is a health education issue or an advocacy issue, the systematic targeted approach is the same Under- standing situation and needs Acquiring skills Implement -ing behavioral change Requiring change Doing it over and over Doing it willingly embedding behavioral change in day to day life 55 JBCP is a bottom up participatory approach to inducing change in a the health of a population Public Awareness Development of Services Capacity Building Stable Funding legislation JBCP Public Awareness Stable funding Legislation Capacity Building Service provision HCAC Awareness and Education Advocacy 56 However, many education and advocacy efforts in health in the region are not institutionalized What's working? Many national programs driven by government or NGO that have positive impact on health Diabetes Healthy lifestyles Family planning Vaccination Road accident Several advocacy efforts working such as quality and patent safety, family protection and safety, women rights Drivers include NGOs, donor organizations and to a lesser extent government Good capacity for health promotion Challenges Continuity vague Not legislated Funding dependent Not coordinated Working in silos Advocacy is not well used as a science for change Politics / policy are government driven Lack of data Academia not involved in overall design of policy 57 Therefore a more concerted effort will be more cost effective and impactful for the success of advocacy and health education Awareness Experience/ Experiential Expansion Consolidation capacity Maturity phases Pre-existing Individuals Community Professionals Government Implementers Civil society providers academia champions media Donors educators