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© 2002 American Public Health Association
FIELD ACTION REPORT |
Robert L. Rhyne is with the University of New Mexico School of Medicine, Albuquerque. Philip A. Hertzman is with the Los Alamos Medical Center, Los Alamos, NM.
Correspondence: Requests for reprints should be sent to Robert L. Rhyne, MD, University of New Mexico School of Medicine, 2400 Tucker Ave NE, Albuquerque, NM 87131 (e-mail: rrhyne{at}salud.unm.edu).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONPARTNERSHIP ACTIVITIESCOMMUNITY HEALTH PROJECTSCONCLUSIONReferences |
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The Russian health care system historically has not relied on medical evidence to guide practice, uses centralized management, and is burdened by overspecialization. In 1999, a community health partnership was established between Sarov, Russia, and Los Alamos, NM, 2 cities linked by their nuclear weapons histories. Health problems addressed include asthma and diabetes, pediatric dental caries, low prevalence of breastfeeding, and adolescent drug abuse and sexually transmitted diseases.
A community-oriented primary care approach was adopted that includes (1) implementing a "train the trainers" strategy to educate health professionals and lay people, (2) adapting established clinical practice guidelines based on local resources, (3) restricting use of expensive or limited resources, and (4) securing commitments from local government for expendable supplies and medications.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONPARTNERSHIP ACTIVITIESCOMMUNITY HEALTH PROJECTSCONCLUSIONReferences |
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HEALTH CONDITIONS IN RUSSIA began to deteriorate in the late 1960s, and the fall of the Soviet Union in 1991 left a failing health service, a short supply of medications, a shrinking population with a decreasing life span, increasing mortality, and a declining birth rate.1–4 Health funding in Russia is only 3% of the gross national product, with less than 30% for primary care.5–8 The Russian health care system does not emphasize the use of evidence-based clinical practice, has a centralized management structure, and is burdened by a compartmentalized specialist-based system.
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Since 1992, the American International Health Alliance (AIHA) has sponsored programs to improve Russian health care through partnerships between US and Russian communities. The partnership between Los Alamos, NM, and its sister city, Sarov, Russia, a "closed nuclear city," began in 1996. In 1999, AIHA awarded the partnership a grant with the overall goals of (1) enhancing the health of children and (2) improving the treatment of chronic diseases in Sarov. Community-oriented primary care (COPC), a process that includes 5 logical steps to address problems in communities,9 was used to develop specific programs. In this preliminary report, we summarize the key aspects of the Los Alamos–Sarov medical partnership.
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PARTNERSHIP ACTIVITIES |
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TOPABSTRACTINTRODUCTIONPARTNERSHIP ACTIVITIESCOMMUNITY HEALTH PROJECTSCONCLUSIONReferences |
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At the beginning of the project, leadership teams from both communities met to prioritize objectives, which were to reduce adolescent risky behavior, improve dental health in children, encourage mothers to breastfeed, and improve treatment for patients with asthma and diabetes. Planning teams were then established for each objective.
An essential component of the project involved a "train the trainers" process. The Sarov leadership teams were trained in strategic planning methods and project intervention skills. They trained local health care providers, who in turn taught patients the skills. For example, an asthma self-care curriculum was developed for the Sarov asthma team that used established clinical practice guidelines.10 The Sarov physicians educated their patients about asthma self-care techniques. The key components of this approach were adapting clinical practice guidelines to locally available and affordable resources, designing a small pilot project, developing a patient education curriculum that includes knowledge and skills testing, defining specific process and outcomes measures, and modifying the program on the basis of lessons learned in the pilot project. We learned that programs requiring costly, expendable supplies could not be sustained; to promote sustainability, we restricted the use of expensive medications to sicker patients and sought funding from the municipal government for expendable supplies.
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COMMUNITY HEALTH PROJECTS |
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TOPABSTRACTINTRODUCTIONPARTNERSHIP ACTIVITIESCOMMUNITY HEALTH PROJECTSCONCLUSIONReferences |
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We initiated the following community health projects in Sarov.
Asthma Self-Care
Eighty-five adult and 30 pediatric patients with moderate or severe persistent asthma participated in a 6-month project. All patients attended an asthma school and demonstrated knowledge of their illness and skill in self-care techniques. Preliminary 4-month results showed fewer symptoms, emergency visits, hospitalizations, and lost school and work days; improved FEV1 (forced expiratory volume in 1 second); and increased patient satisfaction. The program has been expanded to include 195 patients.
Diabetes Self-Care
Fifty patients with uncontrolled type 2 diabetes mellitus were enrolled in a 6-month self-care project with the goals of reducing glycosolated hemoglobin levels by 1%, increasing the use of glucose self-monitoring by 80%, decreasing acute care episodes by 10%, and increasing patient satisfaction. The city government provided funds for glucose test strips.
Dental Health
Sarov dentists were trained at the University of New Mexico School of Dental Hygiene in techniques of dental prophylaxis; they then trained other local dentists. Subsequent training included 21 schoolteachers, 965 schoolchildren, and 60 parents. Dental examinations were performed on 111 children, aged 12 months to 7 years, in 3 Sarov schools. Preliminary results revealed that 47% of nursery children and 87% of kindergarten children had untreated caries in their primary teeth. The caries rate increased with age. The partnership team plans to negotiate for fluoride interventions in all nursery and kindergarten schools in Sarov.
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Breastfeeding
Initially, among breastfeeding mothers, only 40% breastfed their babies to 4 months of age. This figure increased by 10% after an educational program, which also resulted in an 8% increase in the number of mothers breastfeeding to 6 months and a 10% increase in the number breastfeeding to 1 year.
Adolescent Drug Abuse and Sexually Transmitted Infections
A variety of unhealthy behaviors were targeted, resulting in the following successes in just 1 year: the number of adolescent girls who sought medical attention from the gynecologist leading the educational effort increased from approximately 2000 to 6000, the number of abortions in adolescent girls decreased by 25%, smoking on high school grounds was banned, and a citywide peer educational program on substance abuse recruited senior student volunteers to conduct a "lifestyles" class on how to "make the right choices" when faced with peer pressure.
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CONCLUSION |
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TOPABSTRACTINTRODUCTIONPARTNERSHIP ACTIVITIESCOMMUNITY HEALTH PROJECTSCONCLUSIONReferences |
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We implemented improved models of care, based on established guidelines for asthma and diabetes, that resulted in demonstrable clinical improvements; we also implemented data collection systems that provide feedback information loops for monitoring quality of outcomes. Activities were initiated that have changed behavior in the areas of adolescent risky behavior, pediatric and adult dental health, and breastfeeding. These pilot activities can be expanded and replicated in Sarov and elsewhere.
Because of the many cultural and historical factors that influence the Russian health system, Sarov presents a unique environment for implementing COPC (Table 1
). Establishing a trusting relationship between the American and Russian teams is an essential first step in implementing a joint program of this type. The compartmentalization of health care delivery and a specialtyoriented system can hinder multidisciplinary cooperation and community involvement. Accurate characterization of community health needs may be difficult, owing to a lack of local data. And in a system that lacks evidence-guided clinical practice, designing methods to monitor process and outcome is challenging.
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Change in this regulated system is slow; however, collaboration with visionary leaders, like those in Sarov, and the tailoring of solutions to the current realities of Russian society are leading to steady progress. Involving local government and community leaders, adapting established clinical practice guidelines to local resources, using a "train the trainer" approach, and setting realistic goals are important components of a program that incorporates the COPC approach, and they can ultimately bring about beneficial changes in Russian health care.
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Acknowledgments |
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This work was supported by the American International Health Alliance, the US Agency for International Development, the Sarov Health Administration, and the Sarov City Duma Administration.
The authors wish to acknowledge Walter Wolford, DDS, for designing and standardizing the dental examination procedure and for supervising the collection of data on dental caries in children.
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Footnotes |
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Both authors participated in the work described and wrote and revised the report.
Accepted for publication August 8, 2002.
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References |
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TOPABSTRACTINTRODUCTIONPARTNERSHIP ACTIVITIESCOMMUNITY HEALTH PROJECTSCONCLUSIONReferences |
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1. Barr DA, Schmid RS. Medical education in the former Soviet Union. Acad Med. 1996;71:141–145.[Medline]
2. Chernichovsky D, Potapchik E. Genuine federalism in the Russian health care system: changing roles of government. J Health Policy Law. 1999;24:115–144.
3. Wines M, Zuger A. In Russia, the ill and infirm include health care itself. New York Times. December 4, 2000:A1.
4. Notzon FC, Komarov YM, Ermakov SP, Sempos CT, Marks JS, Sempos EV. Causes of declining life expectancy in Russia. JAMA. 1998;279:793–800.
5. Field MG. The health crisis in the former Soviet Union: a report form the "post war" zone. Soc Sci Med. 1996;41:1469–1478.
6. Tulchinsky TH, Varavikova EA. Addressing the epidemiologic transition in the former Soviet Union: strategies for health system and public health reform in Russia. Am J Public Health. 1996;86:313–320.
7. Barr DA, Field MG. The current state of health care in the former Soviet Union: implications for health care policy and reform. Am J Public Health. 1996;86:307–312.
8. Tillinghast SJ. Can Western quality improvement methods transform the Russian health care system? Joint Commission Journal on Quality Improvement. 1998;24:280–289.
9. Rhyne RL, Bogue R, Kukulka G, Fulmer H, eds. Community-Oriented Primary Care: Health Care for the 21st Century. Washington, DC: American Public Health Association; 1998.
10. Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma. Bethesda, Md: National Heart, Lung, and Blood Institute, National Asthma Educational and Prevention Program; 1997. NIH publication 97-4051.
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