If you have a few moments, I am putting up a piece that will potentially be published in the Innovation Learning Network’s ( @HealthcareILN ) most awesome annual report, Insights 2012 ( you can see the 2011 version here).
I am not a fan of closed peer review, I am one of open peer review, and since ILN happily doesn’t follow the Ingelfinger Rule, I am posting a draft of my piece here. Can you help me by letting me know:
- Do you understand it?
- Does it help you understand social determinants of health?
- Would it help someone who’s not close to this topic understand it better?
- Does the visual thinking approach connect well?
Please add your ideas / improvements / corrections / random and organized thoughts in the comments. Thank you!
Changing Behavior: Thinking visually about social determinants
For ILN Insights 2012 (draft, rev 4, 8/21/12) • Ted Eytan, MD MS MPH
The Visual Thinking Journey
At the 2011 Innovation Learning Network InPerson meeting, my group was having trouble ideating until an ILNner came by and said, “try using drawings in addition to words.” Instantly our world opened up. Departing, he recommended the book “Back of the Napkin,” by Dan Roam.
I read that as well as the follow-up book by Roam, “Blah Blah Blah: What To Do When Words Don’t Work.” And a few months later,, I was inspired to use some of these visual techniques to lay out a different kind of behavior change – from thinking about the individual’s lifestyle choices to thinking about a society’s choices that make populations healthy or not.
We are relying too much on modifying a person’s individual choices to improve health. I see it when we talk about mobile apps, challenges and games that don’t address the “causes of the causes” of a person’s behavior that are the social determinants of health.
So let’s dive in!
WHO: Many citizens, few health professionals
If you look visually at a health system, like this example based on Kaiser Permanente, you can see that we are out-personned. There isn’t enough people working in health care to reach every person we serve to guide their daily choices. People and organizations outside of health care are needed to improve health.
HOW MUCH: What we measure should matter to people and society
The above figure (licensed under the Open Government License v1.0) is from the groundbreaking Marmot report, published in 2010 (See: Now Reading: Why a focus on lifestyle behavior change may not improve health: The Marmot Review | Ted Eytan, MD). It shows that the vast majority of the English population will never make it to retirement age without some form of disability from illness or another reason.
That’s a more meaningful, measurable goal for a person and a society – the ability to lead a long, healthy life, regardless of background.
Let’s condense all those dots
We’ll show the “spread” from healthiest to unhealthiest using smooth bars. Let’s also keep track of our own staff separately. Health care staff should be as healthy or healthier than the people they are serving, right? As best we can tell today, they are as healthy as the members they are serving, no more, no less.
WHAT: The Results We Want
There are two alternate futures. The future we want is the one where everyone is healthier. There is less of a disparity between the most healthy and the least healthy. Our staff shows even greater health gains, leading our members.
The future that scares us is the one where the most advantaged are much healthier, the least advantaged are only a little healthier.
HOW: Proportionate Universalism
“To reduce the steepness of the social gradient in health, actions must be universal, but with a scale and intensity that is proportionate to the level of disadvantage. We call this proportionate universalism.” (Marmot review)
Making investments at all levels (individual, family, community, AND society)
We should invest across all of these areas to be successful. Working at the family, community, and society level is much harder, unfortunately.
Investing too much at the level of the individual: Lifestyle Drift
Mobile apps that remind us to record our calories or promote competition among our friends are designed to change our individual choices. Why do we focus our attention here? Probably because it feels less complicated.
Part of the explanation for this emphasis lies with the comparative ease of identifying action to address behavior, rather than the complexity of addressing social inequalities shaping such behaviors. This has led to the seemingly less challenging route of lifestyle interventions – this tendency has been described as ‘lifestyle drift’. (Marmot review)
Putting it all together, The tomorrow we want
Using the visual thinking approach, this is the one image that includes the WHO/WHAT and HOW of behavior change and social determinants to improve health.
If we spend the right amount of time at the individual level as well as the societal level, people at all levels of the health gradient will improve their health, and the gap between them will decrease. We will model the improvement in our own workforce.
Putting it all together – The tomorrow we don’t want
If we invest poorly, and do what seems easiest, we’ll get the outcome we don’t want. The most advantaged, who didn’t need as much help in the first place, will get healthier. The least advantaged may or may not get healthier. Our workforce will not achieve greater health gains. Our costs, and more importantly their costs (money, time, lives) will not be manageable. That will make all of us unhappy.
Let’s go from cartoon to reality, because we’re not trying to fix a cartoon – we’re trying to fix this…
Data and images from present day Washington, DC
- We need to understand the role of health care in improving health; we cannot do it alone •
- We need to have a measurable goal in mind – not just pounds lost or blood pressure lowered, but longer, healthier life, and less inequality between the most healthy and the least healthy
- When we talk about innovating in health, we need to think beyond individual interventions – this is in the scope of health care and a health care Innovation Learning Network.
“(We were taught) first, that we were not in the business of giving patients health. That our responsibility was to treat the excesses of human folly or the misfortune caused by human genes or frailty. Second, that we were not in the business of preventing death. Third, we were to intervene only if we were certain that we would make a difference. Otherwise we would simply watch and hope that tincture of time would make a difference…If we violate these three rules … we end up with unrealistic expectations from health care, much futile care, high health care costs and poor health.” – from Baicker K, Chandra A. The Health Care Jobs Fallacy. New England Journal of Medicine. 2012;366(26):2433–2435
All of the images used in this piece are below, with a few bonuses.