Science & Research

Making a difference

Dr. Patricia Martens leads a team of researchers who are working to build a better health-care system

Dr. Patricia Martens
Dr. Patricia Martens
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Bio: Dr. Patricia Martens

About the Manitoba Centre for Health Policy

Winnipeg Health Region
Wave, Summer 2011

Dr. Patricia Martens likes to tell a story that serves as a kind of "aha" moment for her.

It was the early 1990s, and Martens, who is now the Director of the Manitoba Centre for Health Policy at the University of Manitoba's Faculty of Medicine, was working on her master's degree in epidemiology and needed to develop a research project.

As she mulled over her options, she settled on a subject that was near and dear to her heart: the importance of breastfeeding in infant health.

It was a subject she knew well.

As a new mom in the late 1970s, the former high school teacher had become a passionate supporter of breastfeeding, first as a provincial leader with La Leche League Canada (Steinbach area) in 1984, and then as Manitoba's first international board-certified lactation consultant in 1987.

Through her work in this field, Martens knew that breastfeeding rates in First Nations communities were much lower than the national average. The Canadian average at the time was 75 per cent, but at Sagkeeng First Nation community, for example, only about 40 per cent of new moms were choosing the breast over the bottle.

Martens could see that she might be able to make a difference in these communities. If she could do some research to find out why rates were so low, she might be able to come up with ideas to boost breastfeeding rates.

That's when she went to work. In short order, she obtained a student fellowship through the National Health Research and Development Program (NHRDP). Then she plotted out her approach, one that would include seeking help from First Nations leaders.

"I went to the Assembly of Manitoba Chiefs as well as First Nations and Inuit Health to ask how to go about engaging communities in this research," she explains. "And they were very supportive, since breastfeeding was considered to be a very special mother/child relationship that had strong roots in Aboriginal culture. They also helped me identify the local health contacts so that I could explain what I wanted to do."

For Martens, the chance to finally move beyond planning conferences on breastfeeding and helping women individually to leading a research project like this one was a dream come true. Dr. Kue Young, a professor in the Community Health Sciences Department at the U of M's Faculty of Medicine, agreed to be her master's supervisor.

She began in 1992 with her master's research on the predictors of breastfeeding in Hollow Water, Sagkeeng, Little Black River and Long Plains. Her early research, based on chart findings and interviews, uncovered basic barriers to breastfeeding: many of the expectant moms thought their breast milk would be "no good" or that they wouldn't produce enough milk.

Moving further into her PhD work in the late 1990s, with her supervisor, Dr. Patricia Kaufert, also in the Community Health Sciences Department, Martens then contacted each community to see who would be interested in working with her to determine what kinds of programs could possibly address the issues identified in her earlier research. It turned out that Sagkeeng - an Ojibway community of 3,000 people, about 125 kilometres northeast of Winnipeg - was more than willing to work with Martens.

And so, in 1997, she designed a study to see what could work to address the problem of low breastfeeding rates. Working closely with the Sagkeeng Health Centre, Martens evaluated several programs that the community put into place. These included a video and booklet for prenatal teaching that the community produced, a new way for the health nurse to teach pregnant women about the importance of breastfeeding, and a new maternity hospital policy at the local Pine Falls Hospital.

But Martens believes the real key to the project's success was initiating a peer counselling program. "We also hired young moms from the community to work alongside the health nurse with the new moms as postpartum home visitors," says Martens.

The results were remarkable: "We were able to increase the community's breastfeeding rates to 70 per cent, which is astounding with such a minimal program. And it not only increased the initiation rate, but the duration rates - the length of time the babies were breastfed - went even higher than the Canadian average," says Martens.

The change in breastfeeding rates in Sagkeeng First Nation is important. Research shows that babies who are breastfed tend to have stronger immune systems, are less susceptible to infections and less likely to become obese. Martens herself was involved in a study recently that showed breastfed babies were also 50 per cent less likely to develop Type 2 diabetes.

Clearly, babies born at Sagkeeng over the last 10 years are beneficiaries of this research. Thanks in part to the work done by Martens, the health-care providers and the community leaders, they can expect to lead healthier lives.

But there is another beneficiary of this research project and others like it: the health-care system. Indeed, many experts say the continued sustainability of Manitoba's health-care system will depend to a degree on the ability of researchers like Martens and her colleagues at the Manitoba Centre for Health Policy to continue finding ways to enhance the delivery of care and improve overall the health and well-being of the population.

For Martens, the Sagkeeng project affirmed something she already knew: health research, especially when done in collaboration with others, has the power to change people's lives for the better. It would not be long before she would take her enthusiasm for this type of work to MCHP as a research scientist in 1999. By 2004, she would become its director.

Today, sitting in her office on the fourth floor of the Brodie Centre at the University of Manitoba's Bannatyne Campus, it's clear Martens remains passionate about her role at MCHP.

"It's not an easy job," says Martens. "It takes energy, but it's fulfilling."

One look at her daily calendar - booked months in advance - tells the story. After driving in from her rural home that she shares with her husband, Gary Martens, her days and evenings are filled with meetings, teaching classes, supervising graduate students, travelling to conferences and managing the dayto- day needs of what is - in reality - a multi-million-dollar corporation.

As for her leadership style, Martens remains true to the idea of collaboration. "People who come into this workplace are pleasantly surprised that there's a lot of camaraderie and collaboration and sharing of knowledge," she explains.

She describes MCHP, a research unit of the Department of Community Health Sciences in the Faculty of Medicine at the University of Manitoba, as an informal, egalitarian environment. "We work a little differently than most research scientists who might work in isolation. We start at the very beginning of a project with researchers and lots of support people. We meet weekly for two years putting together this work, and it's really fun… often it's not the research scientists who come up with the idea that day; maybe it's the data analyst or the research co-ordinator or the office support person… as a result of a lot of people contributing, you end up with a strong product."

Martens is quick to point out that the workplace environment didn't change under her leadership. Rather, she inherited a workplace culture that has been constant since MCHP was originally established in 1990 by Les and Noralou Roos - names that are synonymous with health research in Manitoba.

It is an unlikely research environment in that there's ne'er a white lab coat or a foaming beaker to be found. Instead, in a comfortable, relaxed office setting, a staff of 60 statisticians, data analysts, support staff, researchers and students pore over numbers, charts and graphs. ("In-thetrenches research," says Martens.)

For most of us, those same images would read as easily as the hieroglyphics on an ancient scroll. But for the staff at MCHP - all specialists in population health-based research - those patterns are as precious as the gold nuggets of the Treasure of the Sierra Madre. Each notation tells a never-ending story about the health of Manitobans and clearly illustrates which factors - including health care, health programs, income, education, employment and social circumstances - are affecting those outcomes.

The genius of the Rooses is that they understood the value of this "repository" of information. And for the past 21 years, MCHP has carefully developed and maintained (and guarded) this comprehensive population-based data repository on behalf of the provincial government for use by the local, national and international research community.

In other words, from the moment we are born until we die, our lives are tracked each time we visit a doctor, or go to the hospital, or go to school, or get involved with social services or social housing. Each and every transaction is recorded in one of the 97 databases that make up the repository. That information, used strictly for research, has been "anonymized," which means that all names and addresses have been completely removed for privacy, and only a number remains.

"We don't know who the people are, but once we have all the ethics and privacy approvals, we can link the data together to answer really interesting questions," says Martens. "For instance, what is the physical and mental health of people living in social housing compared to the rest of the population or compared to other low incomes but not in social housing? Is it better?"

It seems a simple idea. After all, under a universal health-care system, provincially, each person is allotted a specific health-care number - an obvious tracking tool. But, only a few other provinces ever created a centre for population based research - using as its foundation an administrative health data base. Manitoba was unique when MCHP was formally established, and maintains a leading-edge status in the richness of the data, unsurpassed throughout Canada (and internationally) today.

"So the really visionary people - like Les and Noralou Roos, who started it - just did a fabulous job of positioning us with a world-class opportunity of having an academic centre with scientists with academic freedom so that when we find something, it's going to be reported. At the same time, we have our feet in the reality of what are the questions that have to be asked so that we can have a healthier province or city," says Martens. "I do a lot of speaking across Canada and internationally because so many other provinces and countries want to have something like the MCHP."

Another unique aspect to MCHP is its close association with the provincial government and with regional health authorities. However, as Martens explains, as close as the relationship is, it is also separate. Certainly, it's a fact that the provincial government provides MCHP with roughly half its yearly funding of $4 million in grants. In exchange, MCHP provides the government with five major research projects a year (known as "deliverables," the topics are decided upon by Martens and the Ministry of Health). But MCHP still maintains its autonomy as a research unit within the university - not as a government agency. And all of this deliverable research becomes public when the report is finished.

"When I travel, I often am working with governments and local universities to show how we are set up - to show how we are responsive to government, but at the same time maintaining that sense of neutrality and academic integrity in research so that it's situated outside of government," says Martens.

Further, the arrangement also offers an unprecedented perk for MCHP. "What other scientist in Canada has the privilege of doing a report and then talking directly to the minister of health who can actually implement it?" says Martens.

Over the years, the "deliverables" have dug into the kinds of questions necessary to effectively manage a provincial healthcare system - with health-care costs at the top of the agenda. One example of how MCHP research helps guide government policy involves a recent report on the Healthy Baby Program, conducted by Dr. Marni Brownell, a senior scientist at MCHP.

The Healthy Baby Program was introduced in 2001 to enhance the health of vulnerable babies by offering an income supplement and/or community programs for low-income mothers and families. The government was taking a big risk - offering cash instead of food vouchers.

"This report is so interesting," says Martens. "The government wanted to know if the program was working - and the big question was what kind of difference could a maximum supplement of $81.41 a month make?"

Well, as it turns out, it makes a huge difference - not only for the moms and newborns, but in terms of projected hospital costs, says Martens.

"For those receiving the income supplement, (Brownell) found a reduction in low birth weight rates, a reduction in preterm birth rates (which are expensive to the system) and a huge increase in breastfeeding rates," says Martens. The conclusion is that participation in the Healthy Baby Program appears to be associated with healthier outcomes for some of Manitoba's most vulnerable babies. Other examples of studies that have helped inform government decisionmaking include:

  • Hospital Funding with the Health-Care System (Black 1991)
  • An Assessment of How Efficiently Manitoba's Major Hospitals Discharge Their Patients (Brownell, Roos 1992)
  • The Direct Cost of Hospitalizations in Manitoba (Finlayson 2009)
  • An Initial Analysis of Emergency Departments and Urgent Care in Winnipeg (Doupe 2008)
  • Using Administrative Data to Develop Indicators of Quality Care in Personal Care Homes (Doupe 2006)
  • Patterns of Health Care Use and Cost at the End of Life (Menec 2004)
  • Pharmaceutical Use in Manitoba: Opportunities to Optimize Use (Raymond 2010)

The list goes on. But, there are also reports of a different nature, of concern to the researchers and to those who decide health-care policy. For example, last year, MCHP researchers Dr. Tim Hilderman, Director of the U of M's Community Medicine Residency Program, and Dr. Alan Katz, Associate Professor in the U of M's Community Health Sciences Department, completed the Manitoba Immunization Study - one of the most comprehensive analyses of the province's immunization programs ever performed.

Covering an eight-year period from 2000 to 2008, the study focused on childhood and adult immunizations. Among the questions asked: How many were getting their shots? Are the rates consistent province-wide? Are people-at-risk getting full protection? The study also attempted to determine if there was any link between vaccinations and rumoured side-effects like paralysis, brain swelling and blood that doesn't clot. On that last question, Martens is clear. "It's pure bunk," she says. "Our study and others have proved no adverse effects at all."

Overall, the researchers delivered a "good news, troubling news" kind of report. The good news is that children's immunization rates have remained steady over the years. And Martens is especially buoyed by the immunization rates for chicken pox, which many parents discount as a simple childhood disease.

"I love this little diagram," she says as she turns to a page in the report. "You can see as chicken pox immunization has increased, the hospitalization of very sick chicken pox cases has gone down - and to me that's a fabulous finding, because those are really, really sick kids."

There were, however, a couple of trouble spots in the adult population. It appears that the rates for flu shots for those over 65 are going down. That is not a good trend, say the researchers. A comparison of nursing home death rates between those who did and didn't have a flu shot indicated that seniors who get the shot live longer than those who don't.

But of most concern in the report is that only six per cent of pregnant women are getting the flu shot. The researchers can only guess at the reasons: it may be that women think the shot will harm the fetus, and if that is the case, it will be up to doctors to step up to the plate to make their pregnant patients aware of the benefits of getting a flu shot.

One of the best examples of how MCHP works with regional health authorities to serve provincial interests involves one of Martens' earliest projects after joining the organization in 1999.

At the time, Martens was put in charge of the annual MCHP Rural and Northern Health Care Days, and later began the annual MCHP/WRHA Health Care Days. The events enable MCHP researchers to present completed reports to a gathering of up to 200 high-level planners, CEOs, frontline health workers and regional health authority board members.

Up until 1999, the outcome of the event had always been predictable: the scientists presented; the audience listened. The problem was that the research was not being put to use, in part because communication between the RHAs and MCHP was limited.

Martens thought there should be a change in format. So, in 1999 she introduced the first round-table session. The challenge was to create a more communicative experience.

"Before, it was more a didactic teaching style, but with my teaching background, I said, 'Let's make it a more conversational round table with the RHAs.' So after a careful explanation of how to read the graphs and charts, the scientists sat at the tables with people from the small regions and looked at the data together."

That day was both unnerving and invigorating.

"In fact," says Martens, "they were very candid with, 'That was a stupid way to divide up our region,' or, 'Why don't you do it this way?' or 'Why don't you run this health indicator with something we really need to know?'"

On the other hand, the researchers were surprised by how much they learned from the RHAs. "After that wonderful interactive experience, I wondered why we weren't including the RHAs at the beginning of our regional reports, instead of at the end - and then maybe we could avoid some of these mistakes. And so, continues Martens, "that's how we started The Need to Know Team."

The team got off to a running start in 2001 through a Canadian Institutes of Health Research five-year team grant for university-community alliances. It was a case of being in the right place at the right time. With a mandate to put knowledge into action, CIHR was advocating knowledge translation, which was a burgeoning new field of research.

Today, there are many definitions of knowledge translation, but the fundamental concept - as described by CIHR - is to "bring users and creators of knowledge together during all stages of the research… to yield beneficial outcomes for society."

Since its inception, The Need to Know Team has proved to be one of the most successful models of knowledge translation in action in Canada, and very possibly stands alone as a model for public policy researchers in North America and beyond. The team's work was recognized nationally in 2005 when it was awarded the $20,000 CIHR Health Research Knowledge Translation Award for Regional Impact. "It was like getting an Academy Award," says Martens.

But, of course, there is more to the team's model than simply discussing research projects once a year in small groups. Building on the concept of involving the RHAs in the research process from start to finish, Martens devised a model where all RHAs can choose up to two senior people in their regions to come to work at MCHP three times a year, for two days at a time. The goal is to have members of the RHAs and Manitoba Health work together with MCHP researchers to create new knowledge of relevance to the RHAs. Built into the process is an attempt to understand each other's points of view and language, and, ultimately, to put the research into action.

The result is that the RHAs have gained new understanding of how research is done, while the researchers have learned about the hard realities of day-to-day decision-making in the Regions.

A prime example of the team's knowledge translation in action is a 2004 report entitled Mental Illness in Manitoba: A Guide for RHA Planners. The report was developed with input from the RHAs, and rather than toss the report into a back cupboard, many of the RHAs used the report to examine how their programs were performing. Manitoba Health, in particular, used it specifically to:

  • Develop a provincial suicide prevention strategy;
  • Create a new mental health and addiction data system;
  • Look at needs in the area of access to psychiatrists;
  • Look at the need for collaboration between mental health and primary health initiatives.

Even after taking over as Director of MCHP in 2004, Martens still finds time for her own research projects.

In 2007, for instance, she looked at the prevalence of mental illness in personal care homes. She found that 75 per cent of residents had a diagnosed mental illness when admitted (which could be anything from depression to substance abuse to anxiety disorders or schizophrenia), and within the residents overall, 87 per cent had some form of mental illness. Given Manitoba's aging population, these numbers will only increase over the next two decades. "This really put into the limelight the need to put more psychiatric nurses into personal care homes," says Martens. "So out of that, Manitoba Health supported an initiative to hire psychiatric nurses in all personal care homes in the province."

In another report, Martens and her team, in collaboration with Dr. Harvey Chochinov, a distinguished professor of psychiatry at the U of M, studied whether women living with schizophrenia were getting access to appropriate cancer screening - like mammograms or pap tests - which most women take for granted. The study showed that if the women had continuity of care - in other words, if they were seeing one doctor for the majority of their visits - their rates were close to average. However, if the women were receiving care from a "patchwork quilt" of physicians, their screening numbers were low.

A suggested solution was that in order to reach women with severe mental illness, mental health specialists - psychiatrists, in particular - may have to take a broader approach to clinical care to ensure their female patients received preventive screening services.

Breastfeeding, of course, is always high on Martens' project list. In 2007, Martens and her research assistant, Linda Romphf, published an article entitled Factors Associated with Newborn In-Hospital Weight Loss in the Journal of Human Lactation. It won an award as the most useful article of the year for hospital nurses. In studying full-term newborns' weight loss in hospital after birth, the report compared the weight loss of breastfed babies to that of bottle-fed babies. The breastfed babies lost around five or six per cent of their weight, which is to be expected, given the fact that babies are over-hydrated before birth, and lose some of that weight after birth. But, unlike what you would expect, the fact that bottle-fed babies lost less weight was not a good thing.

"The bottle-fed baby might, in fact, be over-consuming milk," says Martens, "so they need to approximate the experience of the breastfed babies to the bottle-fed ones so that they are getting the very small physiologically-appropriate amounts of milk in the first couple of days."

The article suggested that post-natal nurses rethink what is the proper amount of formula to feed babies in the early days, because an over-fed baby, even in small amounts in the first couple of days of life, could set the child up for potential overweight or obesity in later life. "Hospitals are now looking at their protocols for non-breastfed babies to ensure they are recommending appropriate fluid amounts in feedings," says Martens.

Now in her seventh year as the director of MCHP, Martens continues to build on the success of the organization. Under her leadership, staff has increased, and the organization is expanding research into various areas, such as social housing and the use of intensive care.

Responsible for attracting grant money to MCHP, Martens and a national team recently landed a large grant to look at prescription drug safety and effectiveness.

"Our data can actually pick up surprising things that might not have been picked up before, because we have all the pharmaceutical data but we also have the hospitalizations. So we are going to be involved in a cross-Canada study linking certain drugs in the market to certain effects - whether they be good or bad at a population level - way beyond what the drug companies could ever have studied," says Martens.

Once again, the one-time school teacher is out to show how research, especially when done in collaboration with others, can make a differerence in people's lives.

Dolores Haggarty is a Winnipeg writer.

Wave: Summer 2011

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Wave is published six times a year by the Winnipeg Health Region in cooperation with the Winnipeg Free Press. It is available at newsstands, hospitals and clinics throughout Winnipeg, as well as McNally Robinson Books.

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