Capability and Clinical Success

Abstract

Better outcomes for chronic diseases remain elusive because success depends on events outside the control of the health care system: patients' ability to mange their health behaviors and chronic diseases. Among the most powerful infl uences on self-management are the social and environmental constraints on healthy living, yet the clinical response to these environmental determinants is poorly developed. A potential approach for addressing social determinants in practice, as well as planning and evaluating community responses, is the capability framework. Defi ned as the real opportunity to achieve a desired lifestyle, capability focuses attention on the material conditions that constrain real opportunity and how opportunity emerges from the interaction between personal resources and the social environment. Using examples relevant to chronic disease and behavior change, we discuss the clinical application of the capability framework. CASE HISTORYM rs R. is a 48-year-old Latina who suffers from type 2 diabetes mellitus, hypertension, dyslipidemia, and obesity. She has been regularly attending appointments at the practice for 3 years. Despite ongoing adjustment of her medications, her glycosylated hemoglobin level has never been less than 8.5%. Her history and refi ll intervals suggest that she takes her medications regularly. She has attended nutrition and diabetes education programs. Her physician, Dr M., initially believed that she was motivated to manage her illnesses but is growing increasingly frustrated by the lack of clinical progress. THE EPIDEMIOLOGICAL CONTEXTUnhealthy behaviors and the chronic diseases associated with them account for much of the morbidity and mortality in modern societies. Developing effective solutions is complicated by the burden of morbidity falling most heavily on those with the fewest resources. [1][2][3] Reducing these health disparities has proved especially diffi cult, with little progress during the past 20 years. 4,5 DISCONNECT BETWEEN PROCESS AND OUTCOME IMPROVEMENTSIn the struggle to manage chronic diseases, a growing number of clinical studies point to a disconnect between process-of-care improvements and clinical outcomes. [6][7][8][9] One reason for this disconnect is that success depends on events outside the control of the health care system: patients' ability to alter unhealthy behaviors and manage their diseases.6 The chronic care model therefore emphasizes the importance of patients as active partners. To promote patient participation, clinical strategies have broadened to include more holistic concerns, such as health literacy, [10][11][12][13] self-effi cacy, 14 16 These approaches represent important advances, and they have improved outcomes.12,17 Yet they are themselves limited in scope. They aim to enhance patients' confi dence, motivation, and problem-solving skills, but place less emphasis on evaluating whether the external environment offers real opportunities for change. 18 For example a review of the current national standards for diabetes self-m...

Communities of Solution: The Folsom Report Revisited

“…Community oversight is the essential to all Community of Solution programs, with local communities assuming the interest, capability, investment, and input into the endeavor. 43 Although modern examples are mostly health-system (or health-insurer) driven and focus on health care utilization outcomes, ideally the Community of Solution would originate organically from any reference point (school, geographic area, or community connected by a need) and demonstrate a broad health outcome.…”

Health Care Reform and Equity: Promise, Pitfalls, and Prescriptions

“…Potentially, this provision could foster innovative, community-wide solutions for care for underserved patients, including promotion of patient capability. 35 Success will depend on the strength of local partnerships and creation of sustainable models of primary care delivery that effectively coordinate use of community resources.…”

“…Potentially, this provision could foster innovative, community-wide solutions for care for underserved patients, including promotion of patient capability. 35 Success will depend on the strength of local partnerships and creation of sustainable models of primary care delivery that effectively coordinate use of community resources.ACA aims to transform health care quality (including primary care) through a series of small but potentially synergistic steps. 27 It promotes piloting of new care models, including medical homes, chronic disease management teams, and integration of medical and behavioral health care.…”

Practical Opportunities for Healthy Diet and Physical Activity: Relationship to Intentions, Behaviors, and Body Mass Index

“…In previous papers, we offered a theoretical 16 and empirical case 17 for examining health behavior using the capability approach, 18 a theory of social justice that focuses on people's opportunities to achieve the goals they value. Its proponents argue that opportunities are what societies should strive to equalize in promoting human well-being and in correcting deprivations and inequalities.…”