Title: Life Course Health Development: A Transformative Framework To Improve Childrens Health
1Life Course Health Development A Transformative
Framework To Improve Childrens Health
- Neal Halfon, MD, MPH
- UCLA Schools of Public Health, Medicine, Public
Affairs - UCLA Center for Healthier Children, Families and
Communities - National Center for Infancy Early Childhood
Health Policy - MCHB-AIM Child Adolescent Policy Support Center
CityMatCH 08, Albuquerque September 21, 2008
2Goals 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 progression Health Policy Agenda
- Enabling significant Health Systems Reform in
the US
3Take home Points Power of LCHD
- Life Course Health Development (LCHD) is
different than a life course approach - LCHD integrating framework
- Connecting the disparate parts of MCH
- Connecting MCH to rest of health and human
development - Leverages MCH and Positions and Prioritizes MCH
policy - Provides a new Operating Logic for Transforming
the Health System - Powerful analytic model for solving MCH problems
4From 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
5Reasons to link Health and Human Development
across the life span
- Health policy needs to better reflect our
knowledge of what influences health development
across the life course - The converging goals of medicine and public
health requires a framework that can integrate
personal and population health production models - The dynamics of health production need to be
understood in era of genomics driven medicine - The developmental origins of disparities need to
be better understood
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7LCHD
8Figure 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
SOURCE Centers for Disease Control and
Prevention, National Center for Health
Statistics, National Vital Statistics System.
Life Expectancy at birth
Males
Centers for Disease Control and Prevention,
National Center for Health Statistics. Health,
United States, 2004
60
Life expectancy in years
40
Females
Life expectancy at 65 years
20
Males
0
1901
1910
1920
1930
1940
1950
1960
1970
1980
1990
2001
Year
9Life Span
Health Span
Health / functional Status
Performance Span
0 years
20 years
80 years
10Social/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 - Types, prevalence, distribution of acute and
chronic disease changes dramatically - Developmental expectancies change
- Capacity of Medical Care to intervene, modify
risk and treat disease
11The Evolving Health Care System
The First Era (Yesterday)
- Focused on acute and infectious disease
- Germ Theory
- 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 2.0
Health System 1.0
Health System 3.0
122004 National Research Council and Institute of
Medicine Report
13IOM/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.
14LCHD
- Defines Health as a developmental process
- Builds upon Ecological and Transactional models
of Life Span Development - Utilizes a rapidly Expanding Evidence Base
- Life Course Chronic Disease Epidemiology
- Neurobiology
- Early Intervention Research
- Economics of Human Capital Formation
- Gene-Environment/ Social Epidemiology
15Health as a Developmental Process
- Health is a developmental process
- 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
environments and risky families get under the skin
16How 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.
17Fig.
From Lamberts SWJ, van den Beld AW, van der lely
A. The endocrinology of aging. Science.
1997278419-424.
18From Kuh D, Ben-Shlomo Y. A life course approach
to chronic disease epidemiology. New York Oxford
University Press. 1997.
19Strategies to Improve Health Development
Trajectories
Back to Overall Model
Healthy Trajectory
At Risk Trajectory
Delayed/Disordered Trajectory
Graphic Concept Adapted form Neal Halfon , UCLA
20Risk and protective factors
Risk Factors Child Family Community School
Protective Factors Child Family Community School
Outcome
Negative vulnerability
Positive resilience
21LCHD
22Adverse childhood events and adult depression
Odds Ratio
Adverse Events
Chapman et al, 2004
23Adverse childhood events and adult ischemic heart
disease
Odds Ratio
Adverse Events
Dong et al, 2004
24Adverse childhood events and adult substance abuse
Dube et al, 2002
Dube et al, 2005
Self-Report Alcoholism
Self-Report Illicit Drug Use
25LCHD
- Actionable Mechanisms for Intervention
26Cumulative, 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
27Cumulative 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
28LCHD
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31Life Course Chronic Disease Epidemiology Barker
Hypothesis
- Affiliation MRC Environmental epidemiology unit
in South Hampton - Design Historical Cohort
- Key Finding Fetal growth and development, and
other factors, in first year(s) of life related
to cardiovascular and other chronic disease in
the fifth and sixth decade
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35Barker HypothesisBirth Weight and Coronary Heart
Disease
Age Adjusted Relative Risk
Rich-Edwards 1997
36Birthweight and CVD OutcomesNurses Health Study
Curhan et al., Rich-Edwards et al.
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38Smoking During Pregnancy Offspring Obesity
Pooled AOR 1.46 (1.33, 1.59)
Oken et al., unpublished
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40Odds ratio of obesity breast versus formula fed
0.87 (95 CI 0.85, 0.89)
Owen et al, Pediatrics , 2005 (From Gilman)
41LCHD
- Programming leads to Latent Effects
Long time horizons between exposure and outcomes
42Cumulative, 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
43Poverty ECD
Parent- and Family-Level Predictors of Income
And Hardship ? Parent Work Status ? Job
Prestige ? Education Level ? Parent Marital
Status ? Race-Ethnicity
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47LCHD 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
48LCHD New Approaches to Old Problems
49How are LCHD concepts being used
- Health System Reform (US)
- Adays Reinventing Public Health
- Breslows 3rd Era of Health and Health Care
- Snydermans Future Medical/Health System analysis
- Health System Reform ( Intl)
- UK Acheson Report, Sure Start, Health
Development Agency - Canada CIAR, Major Measurement Strategy focused
on curve shifting across the life course - WHO- ECD initiative, Commission on Social
Determinants of Health
50Disease 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)
51Paradigm Shift
Source Snyderman R. AAP presidential address
the AAP and the transformation of medicine.
Journal of Clinical Investigation.
2004114(8)1169-1173 (suppl)
52Risk 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)
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54LCHD and Birth Outcomes
White
Reproductive Potential
African American
Pregnancy
Age
55LCHD and Birth Outcomes
White
Reproductive Potential
African American
Pregnancy
Age
56Life 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
57LCHD AA White Birth outcomes
White
African American
Primary Care for Children
Early Intervention
Prenatal Care
Prenatal Care
Internatal Care
Primary Care for Women
Poor Birth Outcome
0
5
Age
Pregnancy
Puberty
58LCHD FrameworkService Delivery System
Applications
- Health Services
- Moving from health maintenance to health
development organizations - Integration strategies for newly engineered
health systems - Vertical Primary, Secondary, Tertiary
- Horizontal Biological, Behavioral, Social, Env.
- Longitudinal Life-course/Lifespan
59Source Wise PH. The transformation of child
health in the United States. Health Affairs.
23, No. 5 (2004) 9-25.
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61Changing Pattern of Childhood Morbidity
- Increase in chronic health problems (10-14)
- Greater recognition of mental health problems
(15-20) - Greater appreciation of role and impact of
developmental health problems learning,
language (10-17)
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63Children 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 ?
64How well is the 2.0 Child Health System
Performing?
65The 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
66The existing child health service system
- Fragmented service delivery
- Different sectors (health, public health,
population health, civic) - Different funding streams
- Different cultures
- Lack of co-ordination
- Narrow programmatic criteria for eligibility
- Variable understanding of child health issues
- Local community generally has limited
accountability or responsibility
67How do we get the health system that children
need?
- Incremental vs. Transformational
- Reforms
68Transforming 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
69Child Health 3.0 the New Improved approach
- Integrated and comprehensive approach -
broadbanding of services to achieve curve
shifting outcomes - Greater flexibility of services and improved
coordination at local community level - Increased community and consumer participation
- Prevention, health promotion, early
intervention, developmental optimization focus - Focus on outcomes through improved systems
performance - Innovative funding and accountability
arrangements
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71Transformation Framework
72Transformation Framework
73NUMBER OF CHILDREN
FUNCTION
74Universal Curve Shift
Low income
Median
High income
NUMBER OF CHILDREN
FUNCTION
VULNERABLE
75Includes Physicians, dentists Schools Child Care
POLICY
COMMUNITY
NEIGHBORHOOD SERVICES
Education
FAMILY
CHILD
Child Health
Family Support
76Pediatric Office 2.0
Preventive Care
Acute Care
Pediatric Office
Chronic Care
Developmental Services
7718 month visit
- Pediatric Care 2.0
- C.D Disability
-
- Screen 4-6 w/ disability
- Screening tools Pathway
- Pediatric Office connected to Regional Center
- Pediatric Care 3.0
- Optimize Developmental Health
- I.D 30-40 developmental risk
- Screening tools Pathway
- Pediatric Office connected
- Child care
- Many other programs
- Coordination
- Regional center
78DS Community Services Pathway
Evaluation (IDEA Sector
Screening Pediatric Services Sector
Surveillance Community Services and Resource
Sector
Assessment Peds/HPlan/PHSector
IDEA Regional Center for Developmental Disabilitie
s
Mid-Level Assessment Center
Preventive Care
Other Specialized Services
Acute Care
Developmental Services
Chronic Care
COORDINATION CENTER
Child Care/Family Resource Center
Program
Surveillance
Program
79Optimal Health Development
Trajectory Optimizing Service Linkage Pathway
Lower Health Development Trajectory
Development
Pediatric Continuity
Network Connections
0
1
3
5
7
Years
80Optimizing Trajectories Multisector Multilevel
Strategies
81Early Childhood System Building Blocks
Desired Outcomes at School Entry
A.
Family Capacity and Function
Emotional / Social / Cognitive Development
Physical Health Development
Trajectory of Child Development and Family
Function
B.
C.
Child Health Services
82Early Childhood System 2.0 Building Blocks
Desired Outcomes at School Entry
A.
Family Capacity and Function
Emotional / Social / Cognitive Development
Physical Health Development
B.
Universal Preschool
Head Start Family Literacy
Early HS
Family Resource Centers
C.
Early Care Education
Family Support Services
Child Health Services
83Child Health Services Building Blocks
Desired Outcomes at School Entry
Family Capacity and Function
Emotional / Social / Cognitive Development
Physical Health Development
.
Child Health Services
84Child Health Services Building Blocks
Desired Outcomes at School Entry
Family Capacity and Function
Emotional / Social / Cognitive Development
Physical Health Development
.
Child Health Services
85Early Childhood System 3.0
Desired Outcomes at School Entry
Family Capacity and Function
Emotional / Social / Cognitive Development
Physical Health Development
.
Assessment
Health Center
Screening
ECE Center
Family Resource Center
Surveillance
Co-located or virtually connected service centers
creating new pathways
86Systematic 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
87What 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
88Take home Points Power of LCHD
- Life Course Health Development (LCHD) is
different than a life course approach - LCHD integrating framework
- Connecting the disparate parts of MCH
- Connecting MCH to rest of health and human
development - Leverages MCH and Positions and Prioritizes MCH
policy - Provides a new Operating Logic for Transforming
the Health System - Powerful analytic model for solving MCH problems
89LCHD 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
90UCLA 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