Discussion Question 2 For Friday

RAJA JADELHACK, MSN, PHDC Abstract:

Close examination of the different healthcare systems and the present economic crisis worldwide suggests that all health organizations should re-evaluate the concept of health promotion and its relationship to cost-effectiveness. When choosing the most efficient and cost-effective system, each nation's healthcare system must seriously start to implement strategies for the change.

Health profes- sions, including nursing, must change their vision of education both in academic and practice settings, to focus on health promotion and illness prevention.

The key principle underlying this paper is to illustrate the importance of health promotion and cost-effectiveness being adopted by all health organizations worldwide, as well as to observe the experiences of selected counties in developing a health policy related to education in primary healthcare.

The paper will include a plan adopted by the General Nursing Directorate (GND) in the Kingdom of Saudi Arabia (SA), which contains a health promotion policy for the nursing administrations in all governmental primary healthcare centers in Saudi Arabia.

Key Words: Health Promotion, Nursing, Cost-Effectiveness HEALTH PROMOTION IN NURSING AND COST-EFFECTIVENESS H ealth promotion is a healthcare issue that should be a central focus for all national and international health organizations. A review of Uterature illustrates how cost is reduced when health promotion is implemented for thepubUc. This author will discuss selected examples of these research studies, which include several health components, and the chaUenges that the nursing profession might have to shift towards a health promotion approach rather than a curative approach.

DEFINITION The World Health Organization (WHO) defined health promotion as the process which enables people to improve control over the determinants of health and as a result to improve their own health.

Health promotion encompasses strategies that aUow populations to be healthy and enable them to make healthy choices. Health promotion is carried out by and with people, not on or to people. It improves the abiUty of individuals to take action for their Raja Jadelhack, RN, BSN, MSN, PhDc, is a Doctoral Student at Villanova University and is Nursing Director, feddah Region, Directorate of Health Affairs, Ministry of Health, Jeddah, Saudi Arabia.

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2 health, and the capacity of groups, organizations or communities to influence the determinants of health.

The health promotion process provides support for populations to become agents of their own health by their own actions and choices. Because of the multiple determinants of health, health promotion requires collaboration between the community, health professionals and other sectors (WHO, 2005).

The World Health Organization has also stated that cotintries need to develop poUcies and strategies that advocate for health promotion to be a part oftihe public health development agenda. There is a need to estabUsh functional partnerships, strong networks, and aUiances for promoting healtri that include private and public sectors, as weU as civil society groups, other than those traditionaUy engaged in healtri, in order to build a critical mass for health promotion in various settings (WHO, 2008) LITERATURE REVIEW Goetzel (2009) reported that in 2006 health spending in the United States (US) exceeded two trilUon (iollars. Of that total, three-fourths of that spending was directed toward treating chronic diseases. Almost two-thirds of growth in healthcare spending is attributable to American's worsen health habits, particularly the epidemic rise in obesity. The US healthcare delivery system favors paying for Summer 2012 treatment of chronic diseases rather than preventing them. There is growing recognition that for the US to continue to be an economic leader worldwide, supported by a healthy and productive workforce, attention needs to be diverted from cure of diseases and redirected towards health promotion and disease prevention. Goetzel concludes that prevention is a key element of comprehensive health reform strategy aimed at improving the health of Americans and reducing the social and financial burdens imposed by preventable illness. Moreover, a great amount of money can be saved by promoting riealth and educating the pub he on preventing many health problems such as obesity, which is an epidemic worldwid^ causing several preventable healthproblems (Goetzel, 2009).

The International Council of Nurses (ICN) (2009) reported that health-promoting actions performed by nurses working in diverse settings provide ideal opportunities for health promotion with a goal of creating healthy homes, schools, cities and workplaces.

Individually and through national associations, nurses, along with other healthcare providers, can be effective in paving the road for good health through health promotion.

According to Maurer and Smith (2009), pubhc health nursing evolved from visiting nursing and district nursing, and included home health nursing.

The term community health nursing came to be used in place of pubhc health nursing in the last decades of the twentieth centxiry. The beginning of the twenty-first century presents yet another transition, in that the terms community healtn nursing and pubhc health nursing are often linked together in community/public healm nursing, and there is a movement to return to the term public nealth nursing (Maurer & Smith, 2009).

Cost-effectiveness and health promotion are concepts that must be focused on by all healthcare professions.

The following are examples of several research studies which were (lone regarding this important health issue.

A study on smoking prevention and cessation among Dutch students was done to analyze cost- effectiveness of health promotion programs by Vigen, Baal, Hoogenveen, Wit, and Feenstra (2007). The analysis presented in this study showed that the school program to prevent smoking in adolescents is cost- effective. It is a common dilemma that health promoters are more interested in evaluating the process of program implementation and clinical outcomes rather than in analyzing programs' cost effectiveness, which is the main concern of health economist. For policy makers, cost-effectiveness is very important information, because investing in the promotion of pubhc health in the near term may result in large future health gains and saving in costs of care (Vigen et al., 2007).

Hagberg and Linholm (2006) conducted a review of the current knowledge concerning the cost-effectiveness of healthcare-based interventions aimed at improving physical activity. The conclusion of their study was that promotion of physical activity can be cost-effective with different methods and in different settings, but there remains a lack of evidence for specific methods in specific populations.

Price (2(JO6) made an important observation that there is a competition between health professionals focused on care and health professionals focused on prevention and health education for consumers and for revenue of healthcare.

Another study, done by Frick, MiUigan, White, Serwint, and Pugh (2005), performed an economic analysis, which is a tool available to facilitate efficient resource allocation. The authors mentioned that projects which save lives appeal to poHcymakers and the puDÜc, and health promotion programs that primarily afiect morbidity or quality or life require dociunentation of economic benefit to have a reason for implementing it.

Nurses often practice health promotion education in commtmities, which positively affects the communities' health. Examples of such efforts include breastfeeding education as cited by the following studies and authors (Pugh, Milligan, Frick, Spatz, & Bronner, 2002), hypertension prevention and control (Hill et al., 2003), coronary heart disease (Allen et al., 2002), obesity and diabetes control (D'Eramo-Melkus et al., 2004). Frick et al. (2005) observed that all of these examples are nurse administered and they represent public health interventions that are focused on changing health behaviors, particularly promoting positive health behaviors, relevant to morbidity (Frick et al., 2005).

A World Health Organization study was done by Mock, Kobusingye, Anh, Afukaar, and Arreola-Risa (2005) showed that motor vehicle accidents (MVAs) resulting in injury have become a major health problem globally, causing more than one milhon deaths each year.

Although MVA is usually aproblem of rich countries, 90% of deaths caused by MVA occur in poor countries.

Furthermore, rates of mortality caused by MVA are increasing rapidly in these poor countries; during the years 1975-1998, mortality rates of MVA were increased for instance by 79% in India, 237% in Colombia, 243% in China, and 384% in Botswana. During the same period mortahty attributable to MVA decreased in most of the countries with high income. In countries which are poor and with low income, MVA is the second leading cause of death for young adults of working age. Mock and associates stated tnat costs of treatment for these injuries result in high econonaic losses which can reach to 1-2 % of the gross domestic product in these countries (Mock et al., 2005).

Mock et al, (2005) also reported that there are many strategies which are low in cost that can enhance and control mjuries in the poor countries. All of these strategies require sufficient human resources, and in some cases, specific categories of human resource need to be developed. MVA can be prevented through training and education. In addition to human resource development, broader environmental and mobility management issues must be considered. Furthermore, they have noted that MVAs disproportionately burden poor populations, so they beheve tnat addressing issues of equahty is a necessary component of MVA control.

Vaccination, another mode of health promotion, also has a great effect on budgets and the economy of health organizations worldwide. Zhou et at. (2003) conducted an economic analysis of health promotion of Hepatitis B Vaccinations performed for Vietnamese- American children in Houston and Dallas between the years 1998-2000 to detect hepatitis B vaccination of Vietnamese-Americans children bore betweenl984- 1993.

Findings showed that the measurable impact of most pubhc nealth interventions is usually relatively small, and may often be statistically nonsignificant. In this instance, the interventions produced statistically significant increases in complete vaccination coverage.

In 24 months, 1176 (13.5%) completed the series of 3 Hepatitis B doses with media intervention and 390 (6.9%) with community mobüization. The impact of both education strategies was cost-effective as well as cost-beneficial. Nationwide in cities with relatively Journal of Cultural Diversity • Vol.

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2 Summer 2012 high concentrations of Asian and Pacific Islander populations (APIs), media education and community mobilization could be adopted to substantiaUy increase API childhood and adolescent hepatitis B vaccination coverage (Zhou et al, 2003).

Reardon (1998) stated that research data supporting the cost benefit of worksite Wellness programs is promising, although conflicted and Umited. Researching IBM's company health promotion program documented that interventions provided in a health promotion program at IBM led to significantly lowered employee risk factors such as high cholesterol levels and elevated blood pressure, which would in the long term prevent more costly care for heart disease.

The studies that have been reviewed have proved that health promotion is highly cost-effective.

F'opulation's needs for health services are rising due to several preventable health problems, such as, ot^esity, diabetes, hypertension, and other chronic diseases. By educating people about health promotion strategies, targeting pnysical activity, vaccination, safe driving, smoking, and many other growing health concerns, health workers can promote the health status of communities and populations. Increases in health expenditures make this a high priority for WHO and member nations to address through crianges in health poUcies to focus on health promotion and prevention all over the world.

As an example of how health promotion has been used as a focus for change in a program of nursing education is the University of Haifa. Moshe-Eilon and Shemy (2003) reported that the healthcare systems are complex anci are interdisciplinary nature, which requires that each team in the system should re-evaluate its framework as an independent discipline. All health care professions should know their contribution and must take into account the cost-effectiveness in order to prevent the overlap of functions that can cause extra burden on the financial resources of the health system. Moshe et al. (2003) also stated that there are rapid changes going on in the healthcare system, in general, as a result nursing should contribute in improving new and clear plans to fulfiU a vision that incorporates the importance of health promotion and cost-effectiveness. A good example is the nursing department at the Umversity of Haifa which developed a professional paradigm that was considered as the building blocks for health promotion, management, and research in nursing. Integration of the building blocks into the four-year baccalaureate degree program includes focus on the following: How to practice health promotion with students in the community setting; teach managerial nursing skuls at the baccalaureate level with appreciation of leveling; and nursing research, including both didactic teaching of basic research skiUs and implementation of a community project. The authors concluded that the current healthcare system is characterized by complexity and interdisciplinary teamwork. Each component of this system must demonstrate its unique contribution as mentioned earUer, and through their new curriculum plan they have demonstrated the potential contributions that nurses can meet.

This kind of health promotion education program is an excellent example for nursing education curricula.

In addition, schools of nursing need to identify clear strategies for measuring their programs outcomes.

In the health system of Saudi Arabia the Ministry of Health (2009) reported that the history of health Journal of Cultural Diversity • Vol.

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2 promotion in the Kingdom started in 1984 when primary i\ealth centers (PHC) were established in Saudi Arabia, and that the number of primary health centers reached in 2009 to 2,094. (MOH, 2009). Originally the PHCs focused on maternal and child care but ctarrently its goal is changed to include the whole population with aU levels.

Policies were derived from the MDH to increase the qiiaUty and numbers of primary health centers in SA. Furthermore, the policy included the international elements and principles of primary health centers which were reported by the WHO.

The Ministry of Health in Saudi Arabia devised a plan for greater health promotion focus in the area of public health from the period of 2007 to 2011; aU healthcare professions were included in the planning phase. The General Nursing Directorate (GND) plarmed on behalf of the nursing profession to address the foUowing main goals in the pubUc centers:

ic primary health care 1 Develop the nursing personnel resources in primary health centers.

2 Develop the nursing education programs in all primary health institutions.

3 Develop nurse leaders for primary health centers.

4 Improve the quality of nursing services through nursing education programs focused on quaUty.

5 Provide safe working environment for nurses.

Several steps were required before this action plan could be implemented starting in 2009.

The first step was to get an agreement of the project plan from the Minister of Health, and then a committee including a group of people for each goal was made to initiate the implementation phase, and subcommittees were created.

In regard to goal number 2, with its focus on nursing education, the plan was as foUows:

1 Initiation of a specialty program in community health nursing for nurses woridng in PHC.

2 Preparation of compulsory and basic in-service education programs.

3 Projection of a budget from MOH.

4 Preparation of faculty members specializing in public health nursing across the country.

5 Encouragement of all national nurses working in PHC to earn a baccalaureate degree in nursing (BSN) through creation of bridging programs and national and international scholarships.

6 Development of nurse leaders working in PHC.

7 Creation of a tool for evaluating the program, as weU as competency tests.

Beginrüng in year 2008, a complete educational package was prepared which included two types of programs, essential and compulsory, and nurse educators were trained to implement these courses at two regions out of twenty regions in the Kingdom as a pilot study, and then evaluate them. Then the plan is to expand the program to include all nurses working in PHC in the whole Kingdom of Saudi Arabia.

A policy statement of the compulsory implementation of the plan wül be offered by GND in MOH to two regions in Saudi Arabia, and then the other 18 regions wiU be notified when they are cleared by GND to start the program.

By examination of the GND's process of poUcy, planning and implementation, it is clear that it is a top-down approach which, reflects the foUowing set Surruner 2012 of important assumptions as mentioned by (Birkland, 2005):

Pohcies contain clearly defined goals against which performance can be measured, pohcies contain clearly defined pohcy tools for the accomplishment of goals, the policy is characterized by the existence of a single statue or other authoritative statement of pohcy, there is an " implementation chain" that starts with a policy message at the top and sees implementation as occurring through a chain, and finally policy designers have good knowledge of the capacity and commitment of implementers (p.l83).

The disadvantage of this approach is that emphasis on clear objectives without a consensus on what program goals are makes it hard to set a benchmark for program success and failure. One of the advantages of this approach is that MOH health system is not fragmented in Saudi Arabia; rather, healthcare is plarmed and dehvered only through MOH, which makes this approach highly suitable, whereas bottom- up models of pohcy can be more effective when there is no one system as in the United States healthcare system. It is possible to consider the CND pohcy as a synthesis approach because some of the members in the committee of planning were from the bottom part of the nursing system who work in primary healthcare centers.

CONCLUSION Looking at health and economic situations worldwide, it is evident that the use of resources for maximal benefit is crucial, and that greater attention should be directed towards health promotion. Previous studies have shown how cost-effective it is to re-evaluate the health systems and shift from an emphasis on cure to greater emphasis on promotion. AU health professions are challenged to develop a new vision to the future, and it is a great challenge for nursing educators as well to evaluate nursing curricula and teach future nurses according to the needs of the global health and the present economic situation worldwide. The planning process that is moving this agenda forward in the Kingdom of Saudi Arabia has been provided as an example of how the nursing profession can proceed.

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Pediatrics, 111(6).; 111(6 Pt 1): 1289-1296. doi: 10.1542/peds.lll.6.1289 Acknowledgment / wish to extend my sincere thanks to my advisor.

Dr. Nancy Sharts-Hopko, who encouraged me to publish and who, also, assisted me in revising and editing this paper.

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