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Many current policies are based on outdated norms, data, and approaches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

7. LCHD
Where We Have Been

8. Life expectancy in years
Figure 22. Life expectancy at birth and at 65 years of age by sex: United States,
100
NOTE: See Data Table for data points graphed and additional notes.
Females 80
Life Expectancy at birth
Males
Life expectancy in years 60 40
Females
Life expectancy at 65 years 20
Males
1901
1910
1920
1930
1940
1950
1960
1970
1980
1990
2001
Source: Centers for Disease Control and Prevention, National Center for Health Statistics. Health, United States, 2004
Year

9. Health / functional Status
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)
The Second Era
(Today)
Focused on acute and infectious disease
Germ Theory
Acute Medical Care
Insurance-based financing
Reducing Deaths
The Third Era
(Tomorrow)
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
Each era of health and health care represent major cultural shifts -each has it own logic, values, service delivery algorithms, system specification base on what the system is trying to achieve
Fight against disease- infectious disease, war on cancer and heart disease was not about waging health
like all cultural evolution- algorithms become more complex, broader, deeper and more functional ( finance algorithms, transportation algorithms, energy production)
Progress from one to the next represent quantum leaps forward where discovery necessitates new designs to produce new functionality
Structure of Scientific revolution – the imperative to shift often results when the friction under the old regime too great, run out of room,
We have all the elements of the paradigm shift
Orderly and planned or chaotic and reactive
Drip Incrementalism, gradual evolution doesn’t get you there – jolt, leap forward, new design,
Looking back at transition to First era- Flexner, 2nd era- science, MediCare, HMO,
Part of why Blue Sky Project was launched was not just because US health system is not performing up to snuff, and National Health Care Reform might be back on the table- ( HI is back on the table) but because new knowledge, new contexts are requiring that health algorithms be changed, upgraded, and transformed
This is happening all over the world
Health care operating systems are being upgraded and transformed to take advantage of new information, new health producing networks and to integrate and optimize health producing capacity of new technologies
New operating system (rather than patching the old system) and new algorithms
Come Back to what I mean
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 Children’s Health (2004)
“Children’s 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 Children’s Health, the Nation’s Wealth, National Academies Press, 2004.

14. Community Workplace School Family Individual 5 10 15 20 30 40 50 60 70
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 Needs in Child and Maternal Care. Rational Utilization and Social-Medical Resources. Rivists Italiana di Pediatria 4:3-20.

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 20
Health Development 40 60 80
Age (Years) HP RR
Risk Reduction Strategies
Health Promotion Strategies RR
Risk Factors
Optimal Trajectory
Trajectory Without RR and HP Strategies
Protective Factors HP
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 The Health Development Organization: An Organizational Approach to Achieving Child Health Development. The Milbank Quarterly 78(3):

17. Fig.
From: Lamberts SWJ, van den Beld AW, van der lely A. The endocrinology of aging. Science. 1997;278:

18. From: Kuh D, Ben-Shlomo Y
From: Kuh D, Ben-Shlomo Y. A life course approach to chronic disease epidemiology. New York: Oxford University Press

19. Health Development Trajectories
Strategies to Improve
Health Development Trajectories
Back to
Overall Model
Poverty
Lack of health services
Family Discord
Age
6 mo mo mo mo yrs yrs
Ready to learn
Pre-school
“Healthy” Trajectory
Health Services
Appropriate Discipline
Reading to child
“At Risk” Trajectory
Parent education
Emotional Health
Literacy
“Delayed/Disordered ” Trajectory
Birth
Early Infancy
Late Infancy
Early Toddler
Late Toddler
Early Preschool
Late Preschool
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
best
worst
Lifetime SES score
Source: Power et al, 1999

23. Birthweight and CVD Outcomes Nurses’ Health Study
Curhan et al., Rich-Edwards et al.

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. Child Social-Emotional
Poverty & ECD
Parent
Distress
Behavior
Investment
Child
Cognitive
Development
Physical
Child Social-Emotional
Family Income Poverty
Financial
Hardship
Parent- and Family-Level Predictors
of Income And Hardship
 Parent Work Status
 Job Prestige
 Education Level
 Parent Marital Status
 Race-Ethnicity
Neighborhood- and Community-Level Influences

29. Brains are built over time, a significant proportion is constructed during the early years of life, and the capacity for change decreases with age

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
Source: van de Mheen H, Stronks K, Looman CW, Mackenbach JP. Does childhood socioeconomic status influence adult health through behavioural factors? Int J Epidemiol 1998; 27(3):
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 1
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. 2004;114(8): (suppl)

33. Risk assessment decision support
Risk Assessment for Prospective Health
Risk assessment decision support
Symptoms
Late chronic
Cost
Early chronic
Low risk
High risk
Years
Personal lifestyle plan
Risk modification
Disease management
Personalized health plan
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. 2004;114(8): (suppl)

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
Age 5
Puberty
Pregnancy

38. LCHD: AA – White Birth outcomes
Primary Care
for Children
Early
Intervention
Prenatal
Care
Prenatal
Care
Internatal
Care
Primary Care
for Women
African
American
Poor Birth Outcome
Age 5
Puberty
Pregnancy

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

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

45. Trajectory Optimizing Service Linkage Pathway
Optimal Health Development
Trajectory Optimizing Service Linkage Pathway
Tutor
FRC
PED SR
FRC
PED
Lower Health Development Trajectory
Development
ROR
FRC
PED
Pediatric Continuity
NHV
FRC
PED
Network Connections 1 3 5 7
Years

46. Optimizing Trajectories: Multisector Multilevel Strategies
Health Development
Education
Health
Family
support
Child
Family
Neighborhood Services
Community
Policy
Social Welfare 20 40 60 80
Age (Years)

47. Systematic Data Collection For tracking Health Development Trajectories
Birth
1yr
4 ys
3 ys
2 ys
Preschool Assessment
Pediatric Early Child
Assessment
Birth
Certificate
School Readiness
Physical Wellbeing & motor dev’t
Social & emotional dev’t
Approaches to learning
Language dev’t
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 Ages8
Pre-school Programs 6
School
Return Per $ Invested 4 R 2
Job Training
Pre-School
School
Post School 6 18
Age
Pedro Carneiro, James Heckman, Human Capital Policy, 2003

52. Historical and Projected Components of Federal Spending, 1962 – 2050
Path is not sustainable.
One simple reason; interest costs begin to explode as the level of debt increases.
Source: Congressional Budget Office

54. Big Idea – Forward looking Integrative Framework
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 Policy AIM-MCHB Child and Adolescent Policy Support Center
http.//healthychild.ucla.edu

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

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
Theory of the Life Course Perspective
Life Course Game
Life Course Initiative activities
A 12-Point Plan
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?

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 sky’s the limit!

81. National Conference of State Legislatures
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

82. NCSL National membership organization: Goals:
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
At NCSL, we believe that strong legislatures help make strong states, and in turn, strong states make a strong nation. State legislatures are the forum for America's ideas, and NCSL strives to expedite the movement of those ideas in four primary ways:
NCSL can help you advance your ideas.
NCSL brings you the latest public policy ideas.
NCSL works to promote the exchange of ideas.
And NCSL takes your ideas to Capitol Hill.

83. Why Focus on State Legislatures?
Establish policies & programs
Control the state’s 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
Can’t be experts in all

85. Health Issues by the Dozens!
Medicaid
Insurance/mg’d 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. For the Life-Course Health Development Model Issues
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, women’s 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!