Life Course Health Development: A Framework to Guide Research, Practice and Health Reform - PowerPoint PPT Presentation

View by Category
About This Presentation
Title:

Life Course Health Development: A Framework to Guide Research, Practice and Health Reform

Description:

for Women. Early. Intervention. Prenatal. Care. Primary Care. for Children. Age. White. African ... How to shift population risk curves and not just work at the ... – PowerPoint PPT presentation

Number of Views:423
Avg rating:3.0/5.0
Slides: 99
Provided by: jane256
Learn more at: http://webmedia.unmc.edu
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Life Course Health Development: A Framework to Guide Research, Practice and Health Reform


1
Life Course Health Development A Framework to
Guide Research, Practice and Health Reform
  • Neal Halfon, MD, MPH
  • UCLA Schools of Public Health, Medicine, Public
    Affairs
  • UCLA Center for Healthier Children, Families and
    Communities
  • MCHB-AIM Child Adolescent Policy Support Center

2
Goals of this Presentation
  • To review the evidence, importance and potential
    impact of the developmental origins of health and
    disease
  • To consider the strategic role that the emerging
    Life Course Health Development approach can play
    in
  • Advancing a progressive Health Policy Agenda
  • Enabling significant Health System Reform in the
    US

3
Presentation
  • Introduce Life Course Health Development
    Framework (LCHD)
  • Distinguish LCHD from Lifespan and Life-course
    approaches
  • Describe implications and applications of the
    LCHD model for
  • Health interventions
  • Organization and delivery of health services
  • Financing health services
  • Discuss relevance to child health policy
    development

4
Why Do We Need a New Framework?
  • Now more than ever there is a need to prioritize
    public expenditures and invest strategically
  • Many current policies are based on outdated
    norms, data, and approaches
  • Need to be able to communicate to policy makers
    why investments at key points in the life span
    are important and why more integrated approaches
    are necessary
  • Supports innovation in design, delivery and
    measuring outcomes that matter
  • Supports collaboration, cooperation, and
    communication

5
From Lifespan to LCHD
  • Lifespan models connect the dots- linking early
    life to later life
  • Life stage models periods of psychological
    development
  • Life-course models are concerned with patterns
    and pathways that connect the dots between early
    and later life
  • Life Course Health Development models-
  • Connect the dots
  • Describe the pathways or heath trajectories
  • Address the mechanisms that determine or
    influence health trajectories

6
(No Transcript)
7
LCHD
  • Where We Have Been

8
Figure 22. Life expectancy at birth and at 65
years of age by sex United States, 1901-2001
100
NOTE See Data Table for data points graphed and
additional notes.
Females
80
Life Expectancy at birth
Males
60
Life expectancy in years
40
Females
Life expectancy at 65 years
20
Males
0
Source Centers for Disease Control and
Prevention, National Center for Health
Statistics. Health, United States, 2004
1901
1910
1920
1930
1940
1950
1960
1970
1980
1990
2001
Year
9
Life Span
Health Span
Health / functional Status
Performance Span
0 years
20 years
80 years
10
Social/Nutritional/Epidemiological/ Developmental
Shift
  • Social Conditions dramatically changes over this
    time period
  • Nature, Array, and Prevalence of Risk, Protective
    and Health Promoting factors
  • Nutritional Conditions change- high sugar, high
    fat diets
  • Type, prevalence, distribution of acute and
    chronic disease changes dramatically
  • Developmental expectancies change
  • Capacity of Medical Care to intervene, modify
    risk and treat disease changes

11
The Evolving Health Care System
The First Era (Yesterday)
  • Focused on acute and infectious disease
  • Germ Theory
  • Acute Medical Care
  • Insurance-based financing
  • Reducing Deaths
  • Increasing focus on chronic disease
  • Multiple Risk Factors
  • Chronic Disease Mgmt Prevention
  • Pre-paid benefits
  • Prolonging Disability free Life
  • Increasing focus on achieving optimal health
    status
  • Complex Causal Pathways
  • Investing in population-based prevention
  • Producing Optimal Health for All

Health System 1.0
Health System 2.0
Health System 3.0
12
2004 National Research Council and Institute of
Medicine Report
13
IOM/NRC Definition of Childrens Health (2004)
  • Childrens health is the extent to which
    individual children or groups of children are
    able or enabled to (a) develop and realize their
    potential, (b) satisfy their needs, and (c)
    develop the capacities that allow them to
    interact successfully with their biological,
    physical, and social environments.
  • From Childrens Health, the Nations Wealth,
    National Academies Press, 2004.

14
Day Care
Community
Workplace
School
Relative Magnitude of Influence
Family
Individual

5 10 15 20 30 40 50 60 70 80
Age (years)
FIGURE 2 INFLUENCE OF HEALTH STATUS ACROSS THE
LIFE COURSE. Across the life course, the health
status of individuals is a function of endogenous
factors (genetic, physiological, psychological),
family influences, and a range of influences from
the immediate community (school and workplace),
and the larger community (neighborhood, city, and
nation). As illustrated in figure 2, the
relative influence of these factors changes as a
function of age. Adapted from Nordio S. 1978.
Needs in Child and Maternal Care. Rational
Utilization and Social-Medical Resources. Rivists
Italiana di Pediatria 43-20.
15
Health as a Developmental Process
  • Health is developmental
  • Health develops across the life course
  • Health development can be represented by health
    trajectories
  • Critical/ Sensitive periods
  • Gene - Environment Interaction have different
    impacts during different periods
  • Macro and Micro pathways delineate how toxic
    environment and risky families get under the skin

16
How Risk Reduction and Health Promotion
Strategies influence Health Development
FIGURE 4 This figure illustrates how risk
reduction strategies can mitigate the influence
of risk factors on the developmental trajectory,
and how health promotion strategies can
simultaneously support and optimize the
developmental trajectory. In the absence of
effective risk reduction and health promotion,
the developmental trajectory will be sub-optimal
(dotted curve). From Halfon, N., M. Inkelas,
and M. Hochstein. 2000. The Health Development
Organization An Organizational Approach to
Achieving Child Health Development. The Milbank
Quarterly 78(3)447-497.
17
Fig.
From Lamberts SWJ, van den Beld AW, van der lely
A. The endocrinology of aging. Science.
1997278419-424.
18
From Kuh D, Ben-Shlomo Y. A life course approach
to chronic disease epidemiology. New York Oxford
University Press. 1997.
19
Strategies to Improve Health Development
Trajectories
Back to Overall Model
Healthy Trajectory
At Risk Trajectory
Delayed/Disordered Trajectory
Graphic Concept Adapted form Neal Halfon , UCLA
20
Risk and protective factors
Risk Factors Child Family Community School
Protective Factors Child Family Community School
Outcome
Negative vulnerability
Positive resilience
21
Cumulative, Programming and Pathway Mechanisms
Influence LCHD
  • Three basic mechanisms influence LCHD
  • Cumulative - additive effect of multiple risks
    and protective factors, weathering
  • Programming - time specific influence of stimulus
    or insult during a critical or sensitive period
    on selection, adaptation, compensatory processes
  • Pathways-chains of (eco-culturally constructed)
    linked exposures that create a constrained
    conduit of gene-environment transactions

22
Cumulative SES (birth - 33 yrs) poor health, age
33
fair/poor health
4 5 6 7 8 9 10 11 12 13
14 15 16
best
worst
Lifetime SES score
Source Power et al, 1999
23
Birthweight and CVD OutcomesNurses Health Study
Curhan et al., Rich-Edwards et al.
24
(No Transcript)
25
Cumulative, Programming and Pathway Mechanisms
Influence LCHD
  • Three basic mechanisms influence LCHD
  • Cumulative - additive effect of multiple risks
    and protective factors, weathering
  • Programming - time specific influence of stimulus
    or insult during a critical or sensitive period
    on selection, adaptation, compensatory processes
  • Pathways- chains of (eco-culturally constructed)
    linked exposures that create a constrained
    conduit of gene-environment transactions

26
Poverty ECD
Parent- and Family-Level Predictors of Income
And Hardship ? Parent Work Status ? Job
Prestige ? Education Level ? Parent Marital
Status ? Race-Ethnicity
27
(No Transcript)
28
(No Transcript)
29
(No Transcript)
30
LCHD Childhood Antecedents of later Childhood
and Adult Health
Early social and material deprivation (financial,
educational, environmental)
Prior poor health, fetal nutrition, case-mix
Immunologic physiologic moderators
Current poor health/ premature mortality
Prior poor physical activity
Current poor physical activity
Prior adverse behavior
Current adverse behavior
Current social and material deprivation
Source van de Mheen et al, IJE 1998
From Starfield 02/03
31
LCHD New Approaches to Old Problems
32
Disease Progression
1 current practice 2 current capability 3
future capability
1
Symptoms
Cost
3
2
Years
Source Snyderman R. AAP presidential address
the AAP and the transformation of medicine.
Journal of Clinical Investigation.
2004114(8)1169-1173 (suppl)
33
Risk Assessment for Prospective Health
Risk assessment decision support
Late chronic
Symptoms
Cost
Early chronic
Low risk
High risk
Years
Wellness education and Internet and health
provider guided planning for all
Wellness education and Internet and health
provider guided planning for all
Individual-focused integrated provider systems.
Focus on quality of life and palliation at
appropriate late stages
Source Snyderman R. AAP presidential address
the AAP and the transformation of medicine.
Journal of Clinical Investigation.
2004114(8)1169-1173 (suppl)
34
(No Transcript)
35
LCHD and Birth Outcomes
White
Reproductive Potential
African American
Pregnancy
Age
36
LCHD and Birth Outcomes
White
Reproductive Potential
African American
Pregnancy
Age
37
Life Course Health Development
White
Poor Nutrition Stress Abuse Tobacco, Alcohol,
Drugs Poverty Lack of Access to Health
Care Exposure to Toxins
African American
Poor Birth Outcome
0
5
Puberty
Pregnancy
Age
38
LCHD AA White Birth outcomes
White
Primary Care for Children
Early Intervention
Prenatal Care
Prenatal Care
Internatal Care
African American
Primary Care for Women
Poor Birth Outcome
0
5
Age
Pregnancy
Puberty
39
Children Youth at Risk
4-6 Severe Disabilities 12-16 Special
Health Care Needs 30-40 Behavioral, Mental
Health Learning Problems 50-60 Good Enough
What are thriving ? 30 ? 40 ? 50 ?
40
How well is the 2.0 Child Health System
Performing?
41
The existing child health service system
  • Demand greater than services available
  • Families have complex needs - often beyond
    capability of any single service
  • Difficulty accessing services
  • Socio-economic gradient of access
  • Focus on treatment rather than prevention/early
    intervention
  • Episodic contact
  • Poor quality of Well Child Care

42
(No Transcript)
43
Transforming the Child Health System New
Paradigm vs. Old System
  • Child health system was designed for the first
    era of health care ( acute, infectious disease
    model)
  • It was upgraded a bit for the 2nd era, with more
    regionalization, chronic disease care
  • Ill equipped for this new era
  • Under-performing
  • Facing many new challenges

44
(No Transcript)
45
Optimal Health Development
Trajectory Optimizing Service Linkage Pathway
Lower Health Development Trajectory
Development
Pediatric Continuity
Network Connections
0
1
3
5
7
Years
46
Optimizing Trajectories Multisector Multilevel
Strategies
47
Systematic Data CollectionFor tracking Health
Development Trajectories
Preschool Assessment
Pediatric Early Child Assessment
Birth Certificate
School Readiness
  • Physical Wellbeing motor devt
  • Social emotional devt
  • Approaches to learning
  • Language devt
  • Cognition general knowledge

48
LCHD Key Economic Issues
  • Human health is the product of investments made
    across the life span
  • Rate of return on investments in childhood may be
    particularly advantageous
  • Rate of return can be thought of as a function of
    neural plasticity, and the efficiency with which
    environments and interventions can program
    development more broadly

49
Benefit-Cost Ratios for Longitudinal Studies
  • Perry Pre School
  • 17 to 1
  • Abecedarian Educational Child Care
  • 4 to 1
  • Chicago-Child Parent
  • 7 to 1
  • Elmira Prenatal/Early Infancy Project
  • 5 to 1

50
Rates of Return to Human Development Investment
Across all Ages
8
Pre-school Programs
6
School
Return Per Invested
4
R
Job Training
2
Pre-School
School
Post School
0
6
18
Age
Pedro Carneiro, James Heckman, Human Capital
Policy, 2003
51
(No Transcript)
52
Historical and Projected Components of Federal
Spending, 1962 2050
Source Congressional Budget Office
53
(No Transcript)
54
What does LCHD New Synthesis Provide to the
Discourse on Health System Reform?
  • Big Idea Forward looking
  • Integrative Framework
  • Connect up an increasingly balkanized field
  • Reframe for health system reform goals
  • Positions child/MCH in Vanguard of New Era in
    Health and Health Care Reform
  • New Rational for current and future activities

55
LCHD Framework Think Different!
  • Developmentally - in order to optimize outcomes
  • Population and upstream determinants of the
    outcomes that we want to achieve
  • How to shift population risk curves and not just
    work at the individual level
  • How to use alignment, connection, networking
    strategies to join up people, sectors, systems
    into a more functional approach - open source for
    a flatter health policy world
  • How to change the culture of the system we work
    in
  • To frame health in terms of its life long impacts

56
Conclusion
  • LCHD framework has an important role to play in
    understanding how multiple determinants of health
    interact across the life span and across
    generations to produce health outcomes
  • LCHD will become an increasingly important
    framework for guiding policy analysis,
    interventions, and solving medical conundrums
    like infant mortality difference.

57
Conclusion
  • LCHD will increasing be used to understand how
    multiple levels of gene environment transactions
    unfold in the process of human development to
    create risks, diseases, and different levels of
    health
  • LCHD will be used to guide new research efforts
    like the millennium cohort study in the US.
  • LCHD will be used to transform our notions of how
    to invest in the health capital of individuals
    and the nation.

58
UCLA Center for Healthier Children,
Families and Communities National Center for
Infancy and Early Childhood Health
PolicyAIM-MCHB Child and Adolescent Policy
Support Center
  • http.//healthychild.ucla.edu

59
Applying the Life Course Perspective in a
LocalMCAH Program
  • Cheri Pies, MSW, DrPH
  • Director, Family, Maternal and Child Health
    Programs

60
(No Transcript)
61
Overview
  • Background
  • Experience of one local MCAH program
  • Suggestions and tips for getting started and
    getting there
  • Sharing lessons learned

62
The Life Course Initiative
  • A 15-year initiative
  • Launched in 2005
  • Based on the Life Course Perspective and a
    12-Point Plan to close the Black-White gap in
    birth outcomes

63
Life Course Initiative Goals
  • Reduce health disparities overall
  • Optimize reproductive potential
  • Create a paradigm shift in MCH

64
Life Course Initiative Goals
  • To change the health of a generation

65
Our Road Map A 12-Point Plan
  • Improving Health Care Services
  • Strengthening Families and Communities
  • Addressing Social and Economic Inequities

66
Where is Contra Costa County?
67
Staff Education Content
  • Integrating the Life Course Perspective into
    their work
  • What are you currently doing that fits with the
    Life Course Perspective?
  • How can you integrate the Life Course Perspective
    into future activities?
  • Theory of the Life Course Perspective
  • Life Course Game
  • Life Course Initiative activities
  • A 12-Point Plan

68
The Contra Costa Experience
  • Conducted a series of interactive educational
    activities for staff
  • Engaged staff in identifying current and future
    activities
  • Created opportunities for staff to have their own
    A-ha! moment

69
The Contra Costa Experience
  • Established a Life Course Initiative Data Team
  • Conducted educational survey of Family, Maternal
    and Child Health Programs staff
  • Started to identify some intermediate outcomes
    for clients as possible measures of success (vs.
    long-term perinatal outcomes)

70
The Contra Costa Experience
  • Improved sense of well being, empowerment,
    resilience
  • Increase in social support
  • Decreased stress

71
The Contra Costa Experience
  • Increase in financial security and stability
  • Improved financial status

72
The Contra Costa Experience
  • Launched a financial education pilot project
    BEST Building Economic Security Today
  • Making the link between an increase in asset
    development (wealth) and health

73
Building Economic Security Today (BEST)
  • With Life Course Data Team, developed a logic
    model for an asset development pilot project
    BEST
  • Hosting Family Economic Success and Security
    training for 40 home visiting and WIC staff in
    October 2008
  • Viewing and discussing Unnatural Causes
  • Applying for grant funding for training and
    project from various sources

74
Getting Started
  • What is the story your local data are telling
    you?
  • What are you already doing that may fall under
    the Life Course Perspective?

75
Getting Started
  • Which community partners need to be on board from
    the start?
  • What could this paradigm shift mean for MCH in
    your community?

76
Getting There
  • Be prepared for skeptics (internal and external)
  • Have a plan fiscal and programmatic
  • Offer interactive educational sessions to
    community partners

77
Getting There
  • Lay the groundwork with higher-level management
  • Get ready to evaluate
  • Articulate and clarify the value of making this
    paradigm shift

78
Sharing Lessons Learned
  • Share your enthusiasm
  • Recognize and acknowledge what staff are already
    doing and build on this
  • Utilize the imagination and experience of staff
    to chart the course for the future

79
Sharing Lessons Learned
  • Engage the community of people whose lives you
    hope to touch
  • Have a long view
  • Recognize that change takes time

80
The skys the limit!
81
Communicating about the Life-Course Health
Development Model with State Legislators
  • for
  • CityMatCH NACCHO
  • By the
  • National Conference of State Legislatures
  • Martha King
  • October 16, 2008
  • Martha.king_at_ncsl.org
  • 303-856-1448

82
NCSL
  • National membership organization
  • 7,382 state legislators across the country
  • Thousands of legislative staff
  • Offices in Denver and Washington, D.C.
  • Goals
  • To improve the quality effectiveness of state
    legislatures
  • To promote policy innovation and communication
    among state legislatures
  • To ensure states a strong, cohesive voice in the
    federal system

83
Why Focus on State Legislatures?
  • Establish policies programs
  • Control the states purse tring
  • Enact requirements
  • Provide oversight
  • Provide leadership

84
Legislators Are Generalists
  • Agriculture
  • Corrections
  • Education
  • Health
  • Housing
  • Human Services
  • Labor
  • Transportation
  • Zoning . . .
  • Dozens of topics
  • A to Z
  • Hundreds of bills
  • Cant be experts in all

85
Health Issues by the Dozens!
  • Medicaid
  • Insurance/mgd care
  • Pharmaceuticals
  • Long-term Care
  • Health disparities
  • Uninsured
  • Health professions
  • Health Facilities
  • Environmental
  • Public health
  • SCHIP
  • Prenatal Care
  • Emergency services
  • Chronic diseases
  • Oral health
  • Injury prevention
  • Mental Health
  • Disabilities
  • Substance Abuse
  • etc. ...

86
Human Services Education Issues by the Dozens!
  • Child welfare
  • Home visiting
  • Child care
  • Abuse prevention
  • Hunger nutrition
  • Poverty issues
  • Etc.
  • Early childhood
  • Preschool
  • School success factors
  • Afterschool programs
  • School retention
  • No child left behind
  • Etc.

87
Overload!!
  • Going through all this information we have here
    is kind of like trying to drink from a fire
    hydrant. Colo. Rep. Mark Paschall
  • My seatmate told me this was a bad bill. I was
    going to vote no on it until I realized it was my
    own bill. Colo. Sen. Ray Powers

88
Competing For Legislators Attention
"Your topic"
A BLIP ON THE
POLITICAL RADAR
SCREEN
89
Your Strategic Role
  • The blip enlarger
  • For the Life-Course Health Development Model
    Issues
  • Raise awareness
  • Provide information resources
  • Provide tools to make a difference

90
Polling Question
  • Have you ever been involved in communicating
  • Life-Course" issues to state legislators in your
    state?

91
Getting Their Attention Barriers
  • Competing needs and demands
  • Budget issues competition
  • New legislators (20-25 turnover)
  • Lack of awareness/understanding
  • Relative size of the issue
  • Limited time resources
  • Complexity of cross-cutting "life course" concepts

92
Life-Course Where to Start
  • Consider Legislative Terminology
  • Life-Course Health Development Model
  • Health development trajectories
  • Interplay of biological, behavioral,
    psychological, and social protective and risk
    factors
  • Unlikely to resonate with state legislators
  • May sound overwhelming--where to start?
  • Translate message to their language and
    information needs

93
Translation Example
  • From this
  • "Maternal and child health programs that address
    preconceptional and interconceptional issues and
    needs are an important epidemiological approach
    to improving birth outcomes."
  • To this
  • "Promoting healthy pregnancies will save both
    lives and money. Here are some examples xxx"

94
Some Ideas
  • Life-Course Health Development Model
  • A way to address health needs in a more
    comprehensive and coordinated way
  • Health development trajectories
  • People's health needs and status should be
    considered over time
  • Interplay of biological, behavioral,
    psychological, and social protective and risk
    factors
  • Both negative and positive factors affect
    people's health--if we reduce the negative and
    increase the positive, health status will improve

95
Where Does "Life Course" Fit In?
  • Identify existing policies programs where these
    ideas may fit--especially the "protective
    factors"
  • Give specific examples
  • Communicate concisely
  • What will this cost? (and what are the costs
    associated with "risk factors"?)
  • Is there return on investment? If so, what? And
    when?

96
Consider the State Budget Process Cycles
  • Need to revise the following message
  • Public policy should include greater investments
    in children, womens health, community health,
    and improvement of social conditions for
    families.
  • What, specifically, can a state legislature do
    about this?

97
What policies programs are related?
  • Identify specific programs that relate to the
    "life course" concepts and be specific
  • Prenatal care
  • SCHIP Medicaid opportunities
  • Early childhood programs
  • Education
  • Social services
  • Preventive primary care
  • Promote health well-being

98
  • Questions and Answers
  • Thank you!
About PowerShow.com