Preliminary Needs Assessment
Health Risks Associated with not Doing Desired Behavior
Associated health outcomes. Infectious disease rates are higher (Odds Ratio = 1.88) among those diagnosed with autism, which may include bacteria, viruses, fungi, and parasites (Lewin Group, 2013). Neurological disorders affect the autism population at a higher rate (24.06 times) than what is observed in compared neurotypical groups (Lewin Group, 2013; Matson, 2016, p. 28; Richdale & Schreck, 2009). Co-occurring psychiatric conditions are common (70%) among those diagnosed with autism (Simonoff et al., 2008). Metabolic dysfunction is prevalent (4.38 times higher) in the autism community when compared to the neurotypical population (Lewin Group, 2013). Not surprisingly, autoimmune disorders are reported at a higher rate (Odds Ratio = 1.75) when compared to controls (Lewin Group, 2013). Gastrointestinal disease is prevalent in autism (Odds Ratio 4.45) and may include gastritis, duodenitis, reflux, diarrhea, constipation inflammatory bowel disease, lymphonodular hyperplasia, permeability, and abnormal carbohydrate digestive enzyme activation (Lewin Group, 2013; Matson, 2016, p. 12; Randolph-Gips, 2011). Allergies are found to be scientifically higher in autism (Odds Ratio 2.23) and are due mainly to food exposures (Chen et al., 2013b; Lyall, Van de Water, Ashwood, Hertz-Picciotto, 2015). Autism mortality rates are higher (two – six times) than what is observed in the neurotypical community and are due in large part to epileptic related deaths (Gillberg, Billstedt, Sundh, & Gillberg, 2010; Mouridsen, Bronnum-Hansen, Rich, & Isager, 2008).
Proven Methods to Minimize Risk
Education. Providers should be informed of the unique health factors and outcomes associated with autism. Clear descriptions of the critical pathways and molecular functioning within this population should be fully detailed. Health care practitioners will gain crucial information on epigenetics and the importance of prevention strategies, which may derail vital biomedical treatment strategies. An evidence-based biomedical approach in providing care will be fundamental in minimizing all the negative associated risks and outcomes.
Biomedical protocols. Biomedical strategies begin with credible laboratory reports, which result in metabolic balancing. Typically, the majority of the necessary labs and treatment outcomes are not covered by insurance providers, which creates an increased financial burden on the patient population and their caregivers; however, progressive legislation such as the Autism and Co-Occurring Medical Conditions Awareness Act found within the Illinois legislature promotes coverage for the diagnosis and treatment of underlying medical conditions that otherwise go unfunded (Illinois General Assembly, 2016).
Associated health risks. Laboratory tests, which analyze plasma zinc and serum copper ratios could lead to confirmation of imbalances, which would result in appropriate supplementation. Iron deficiency anemia may be confirmed with the use of a complete blood count, iron test, reticulocyte count, and ferritin level test and could aid in the balancing of this essential mineral (WebMD, n.d.). There is some controversy in neurotransmitter analysis; however, a noninvasive method for the use of therapeutic protocol development may include Positron Emission Tomography (PET) or urine and saliva testing (Finnema et al., 2015; Marc et al., 2011). It is not advised to administer serotonin reuptake inhibitors among those diagnosed with autism due to their ineffectiveness among this population (Samer et al., 2013; Williams, Wheeler, Silove, & Hazell, 2010). An alternative approach to the treatment of the neurotransmitter system may include amino acid therapy, which may include N-acetylcysteine (Nikoo et al., 2015). Interestingly, elevated pyrroles steal the necessary cofactor enzymes required for the production of neurotransmitters and might contribute to the underlying cause of dysfunction among a subgroup of autistic individuals. Laboratory findings of elevated kryptopyrroles in the urine could lead to effective vitamin and mineral supplementation to mediate the root cause of neurotransmitter dysfunction (Talty & Dahlitz, 2013). Oxidative stress may be determined by evaluating biomarkers in the blood, which might be treated using methylcobalamin injections (75 μg/Kg 2/day for three months) and folinic acid (400 μg for three months; Frye et al., 2013). Other treatment strategies that may resolve oxidative stress include tetrahydrobiopterin, dimercaptosuccinic acid, betaine, and vitamin E (Rossignol & Frye, 2012). Chronic neuroinflammation may be reported using a three-dimensional cell culture that measures the mRNA expression of cytokines, chemokines, and i-NOS. Another method of documenting neuroinflammation includes immunoblotting, which could analyze MAP kinase pathway activation (Monnet-Tschudi et al., 2011). Most conventional therapeutic protocols in the reduction of chronic neuroinflammation are rooted in the treatment of Alzheimer’s disease; however, antioxidant and cannabinoid therapy has resulted in the reduction of neuroinflammation among the autistic patient population (de Ceballos, 2015; Yang, Hondur, & Tezel, 2016). Genetic polymorphisms can be measured at birth using the hill prick test. Mutations may be mitigated by supplementation of essential cofactor enzymes, which tune-up defective pathways and metabolic functioning (Oberg et al., 2015). Autoimmunity can be evaluated by serology reports, which document neuro-autoimmune makers (Elamin & Al-Ayadhi, 2014). There is a void in the literature in proven therapies regarding autism autoimmunity. Laboratory findings of undermethylation could include plasma or serum analysis of methionine concentrations or elevated levels of homocysteine (Frustaci et al., 2012; Hart, 2012). Similar to treatment in polymorphisms, providers can tune up cofactor enzymes with vitamin and mineral supplementation, which results in improved pathway and metabolic functioning (Hart, 2012). A Smith-Lemli-Opitz syndrome (SLOS) test may be beneficial in detecting dysfunctional cholesterol metabolism, which might result in cholesterol supplementation (Aneja & Tierney, 2008; Wang, 2014). The presence of nagalase activity could indicate a nonspecific immune system dysregulation and might be treated with Gc protein-derived macrophage activating factor (Bradstreet, Vogelaar, & Thyer, 2013). A laboratory finding of dysbiosis may include stool sample analysis, which could result in the treatment of antimycotic and probiotic therapy (Hsiao et al., 2013; Kantarcioglu et al., 2016).
Associated health outcomes. Autism associated health outcomes have well-established treatment strategies among conventional medicine. The issue regarding these underlying co-morbidities is the lack of diagnostic investigation by providers, which would result in effective therapies.
Description of Target Community
Kentucky census report. It was estimated in 2015, that 4,425,092 individuals reside in the state of Redacted (United States Census Bureau, 2015). Of that, 23.9% are minors under the age of 18 years, which describes 1,057,597 individuals (United States Census Bureau, 2015).
The total population of Redacted, Redacted includes 62,479, with a higher population of females (51.6%) than males (48.4%; City Data.com, 2016). It is reported that there are 13,476 children under the age of 19 living in Redacted, which captures a higher majority (38.6%) of children between the ages of 15 to 19 years (Infoplease, 2016). The majority of the population is white (72.4%); however, other races are reported, such as black (15.2%), Hispanic (6.6%), and Asian (3.7%; City Data.com, 2016). The most common industry in this community is manufacturing (City Data.com, 2016). Currently, there are eight hospitals in the area, which administer care to the autism population (City Data.com, 2016).
Autism population. The prevalence of autism spectrum disorder (ASD) is estimated at 1 in 68 children (Centers for Disease Control and Prevention [CDC], 2012). According to the CDC’s prevalence rates, there are 198 ASD patients in the Redacted city limits, who are presumably served by 20 pediatricians practicing within the target area. The state of Redacted may have 15,553 children diagnosed with autism according to the CDC’s prevalence rate, who are presumably managed by 864 practicing pediatricians. The CDC reports that males are affected by ASD at a rate four times what is observed in the female population (Centers for Disease Control and Prevention [CDC], 2012). According to the reported sex distributions of autism, it could be noted that 50 female and 148 male children reside in the city limits of Redacted. The sex distribution of the entire state of Redacted could account for 3,888 female and 11,665 male children. Very little is known about the distribution of ASD severity among this population or the rate of autism among specific age ranges among the minor population.
Description of Health Promotion Program
Clinic focus. Each quarterly session will include a one-hour presentation of new knowledge, guest speakers, and a question and answer section. There will be a minimum of two guest speakers who are currently practicing biomedical protocols within the autism population or an experienced specialist in a scientific field relating to the neuro-immune disease. These providers will outline case studies regarding therapeutic outcomes, which were developed from specific biomedical protocols. The specialists in ASD biomedical literature may include interdisciplinary professionals in epigenetics, systems biology, gut microbiology, nutrigenomics, metabolomics, neuroscience, gastroenterology, environmental science, and immunology.
Financial proposal. It is advised that a foundation should be formed to aid in the funding of quarterly biomedical clinics, neurobiology research, and family life biomedical resources for affected families. The future goal for the foundation’s vision would include hands-on problem-based learning in the form of provider rotations through a functional medicine clinic, which utilizes biomedicine. Clinical simulation practice frameworks and simulation-based mastery would then replace previous quarterly biomedical clinics located at the Redacted.
Participant sampling. Convenience sampling will be used in gathering the program participants. A professional invitation addressed to all 20 pediatricians in the local community will be mailed three weeks before the initial start date of the program. The preliminary clinics will provide the testing ground for a future expanded program. If financial recourses are available and pediatrician support is realized, invitations will gradually develop with the intent to capture all board certified pediatricians (864) in the state of Redacted.
It is reported that CBL adds value to the didactic teaching method (Nair, Shah, Seth, Pandit, & Shah, 2013). Guest speakers who are familiar with the material and have case study experience will be asked to participate in the program clinics. The primary advantage of CBL methods includes increased attention, logical thinking, clinical reasoning, and improved interested in the study topic (Nair et al., 2013).
Meeting the objective. The program is broken down into four primary biological functional systems, which include neurological, immune, toxicological, and gastrointestinal. It is important to note that these systems often intersect; however, the foundational knowledge offered during that quarterly clinic will be rooted in a particular biological system. The complete program includes 20 quarterly clinics over the course of five years. Each clinic will focus on the biomedical approach in addressing one autism associated health risk (AHR) and one associated health outcome (AHO; Appendix A). The health risk and outcome presented during the clinic will relate to one another. The program instruction will focus on a medical evidence-based approach in the diagnosis and treatment protocol for each AHR and AHO within the study population.
Future goals. The proposed future of the program, which would include the hands-on and didactic teaching of biomedical protocols among those diagnosed with autism within the clinical setting would presumably expand upon the learning enjoyment of those participating in the program (Solymos, O’Kelly, & Walshe, 2015). The program development would have to rely on increased financial support to aid in provisions of additional staff, increased instruction time, and funding for a specialized operational clinic focused on neuro-immune disease.
The Health Belief Model
Increase perceived susceptibility. The program will clearly outline the risk ratios of all associated factors and outcomes relating to the diagnosis of autism. The statistical significance of co-occurring pathology and system disturbances will be demonstrated through credible peer-review recourses and systematic reviews. This will help pediatricians realize the risk ratio of co-morbidity among the autism population (Kreuter, Lezin, Kreuter, & Green, 2003, p. 127).
Increased perceived severity. The health promotion program will undoubtedly demonstrate the increased mortalities and morbidities associated with the untreated and unrecognized co-occurring conditions among ASD patients. Presumably, this will aid in the providers understanding that the untreated overlapping conditions diminish the patient's quality of life, function in society, and unnecessarily reduces the individual’s life expectancy (Kreuter et al., 2003, p. 127).
Remove perceived barriers. The program will process the treatment pieces together for easy clinical use and understanding, which may remove perceived barriers between providers and evidence-based medicine (Kreuter et al., 2003, p. 128). The educational clinics are broken down into four primary systems, which include neurological, immune, toxicological, and gastrointestinal to help facilitate ease of understanding. A web page would be crafted to structure the best practice approach to diagnosing and treating this population based on evidenced-based medicine. The clinics would serve as a base for discussion of the diagnostic markers, treatment strategies, and interdisciplinary guest speakers who may offer their experience by reporting on real clinical cases.
Add perceived benefits. A provider’s primary goal is to improve the health and well-being of their population, which may be an ideology to capitalize on for added perceived benefits of the program (Kreuter et al., 2003, p. 128). It would benefit the autism community if providers came together and reported the gains or possible losses associated with the evidence-based treatment strategies. This shared knowledge in the greater landscape of scientific and medical understanding might be rewarding for those pediatricians who choose to participate in functional medicine.
Importance and Changeability Matrix and Health Promotion matrices/Tables
Objective and Community
The Targets for Change
Behavioral. The behavioral risk factors towards this health promotion objective include absence in comorbidity screening, philosophy of autism, and inactivity in gaining relevant knowledge. Many providers simply do not screen for comorbidity in autism, which is called diagnostic overshadowing. This could be in part due to the difficulties the patient may have in communicating with their providers; however, this behavior is in part due to the physical symptoms being attributed to the behavioral diagnosis of autism rather than a separate medical occurrence worthy of treatment. The philosophy of autism could be defined by some as primary psychiatric without prevalence of medical comorbidity. Those that identify with this philosophy believe strongly in preserving autism neurodiversity even if that behavior means neglecting medical treatment. Lastly, some providers are preoccupied with pediatric care far-removed from the disease of autism, which separates the provider from evidence-based knowledge and valid treatment within this population.
Environmental factors. The environmental risk factors include the proximity of diagnostic laboratories, lack of compounding pharmacies, lack of insurance coverage, obstruction from interdisciplinary teams to provide integrative medicine, and reduced scheduling time during patient evaluation and treatment strategy objectives. There are a limited number of laboratories that can phenotype and properly evaluate the molecular deficits in those diagnosed with autism. This occurrence may provide some obstruction between diagnosis and treatment strategy. Secondly, some areas lack compounding pharmacies, which can be commissioned in designing personalized nutraceuticals based upon relevant lab reports. Further, insurance coverage of essential diagnostic laboratory test and follow-up treatment protocols are largely deigned by providers, which add an unnecessary burden on autism families. The third environmental risk factor includes the lack of enthusiasm that specialty providers may have in the treatment of this population. Lastly, the scheduling time to ensure proper evaluation of all potential prevalent comorbidities must be lengthy and mediate the possibility of diagnostic overshadowing.
Shorten the List
Determine Factor Importance
Identifying the Causes
Generating Predisposing, Reinforcing and Enabling Factors
Reinforcing factors. Insurance providers typically do not cover the diagnosis and treatment of ASD co-occurring conditions. Interdisciplinary teams may not be cooperative in implementing integrative care.
Enabling factors. It is easier for pediatricians to maintain the status quo. Marginalizing ASD patients to psychiatry consultations is the tradition.
Building the Program, Spreading the Message
Policy, Regulatory, and Environmental Actions
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