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Center for Healthier Children, Families & Communities Life Course Health Development: A Framework to Guide Research, Practice and Health Reform Neal Halfon,

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Presentation on theme: "Center for Healthier Children, Families & Communities Life Course Health Development: A Framework to Guide Research, Practice and Health Reform Neal Halfon,"— Presentation transcript:

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

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

4 Center for Healthier Children, Families & Communities Why Do We Need a New Framework? Now more than ever there is a need to prioritize public expenditures and invest strategically 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 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 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 innovation in design, delivery and measuring outcomes that matter Supports collaboration, cooperation, and communication Supports collaboration, cooperation, and communication

5 Center for Healthier Children, Families & Communities From Lifespan to LCHD Lifespan models – connect the dots- linking early life to later life Lifespan models – connect the dots- linking early life to later life Life stage models – periods of psychological development 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 models – are concerned with patterns and pathways that connect the dots between early and later life Life Course Health Development models- Life Course Health Development models- Connect the dots Connect the dots Describe the pathways or heath trajectories Describe the pathways or heath trajectories Address the mechanisms that determine or influence health trajectories Address the mechanisms that determine or influence health trajectories

6 Center for Healthier Children, Families & Communities

7 Center for Healthier Children, Families & Communities LCHD Where We Have Been

8 Center for Healthier Children, Families & Communities Figure 22. Life expectancy at birth and at 65 years of age by sex: United States, NOTE: See Data Table for data points graphed and additional notes. Life Expectancy at birth Life expectancy at 65 years Year Males Females Males Source: Centers for Disease Control and Prevention, National Center for Health Statistics. Health, United States, Life expectancy in years

9 Center for Healthier Children, Families & Communities Health / functional Status 0 years20 years80 years Life Span Performance Span Health Span

10 Center for Healthier Children, Families & Communities Social/Nutritional/Epidemiological/ Developmental Shift Social Conditions dramatically changes over this time period Social Conditions dramatically changes over this time period Nature, Array, and Prevalence of Risk, Protective and Health Promoting factors Nature, Array, and Prevalence of Risk, Protective and Health Promoting factors Nutritional Conditions change- high sugar, high fat diets Nutritional Conditions change- high sugar, high fat diets Type, prevalence, distribution of acute and chronic disease changes dramatically Type, prevalence, distribution of acute and chronic disease changes dramatically Developmental expectancies change Developmental expectancies change Capacity of Medical Care to intervene, modify risk and treat disease changes Capacity of Medical Care to intervene, modify risk and treat disease changes

11 Center for Healthier Children, Families & Communities The Evolving Health Care System The First Era (Yesterday) The Second Era (Today) The Third Era (Tomorrow)  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 Center for Healthier Children, Families & Communities 2004 National Research Council and Institute of Medicine Report

13 Center for Healthier Children, Families & Communities 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 Center for Healthier Children, Families & Communities 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. Relative Magnitude of Influence Age (years) Family Individual Community Workplace School Day Care

15 Center for Healthier Children, Families & Communities Health as a Developmental Process Health is developmental Health is developmental Health develops across the life course Health develops across the life course Health development can be represented by health trajectories Health development can be represented by health trajectories Critical/ Sensitive periods Critical/ Sensitive periods Gene - Environment – Interaction have different impacts during different 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 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 The Health Development Organization: An Organizational Approach to Achieving Child Health Development. The Milbank Quarterly 78(3): Trajectory Without RR and HP Strategies 020 Health Development Age (Years) HP RR Risk Reduction Strategies Health Promotion Strategies Optimal Trajectory Protective Factors HP RR Risk Factors

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. A life course approach to chronic disease epidemiology. New York: Oxford University Press

19 Center for Healthier Children, Families & Communities Birth Early Infancy Late Infancy Early Toddler Late Toddler Early Preschool Late Preschool Age 6 mo 12 mo 18 mo 24 mo 3 yrs 5 yrs Ready to learn Strategies to Improve Health Development Trajectories “At Risk” Trajectory “Delayed/Disordered ” Trajectory “Healthy” Trajectory Back to Overall Model Parent education Emotional Health Literacy Reading to child Pre-school Appropriate Discipline Poverty Lack of health services Family Discord Graphic Concept Adapted form Neal Halfon, UCLA Health Services

20 Center for Healthier Children, Families & Communities Risk and protective factors Risk Factors Child Family Community School Protective Factors Child Family Community School Outcome Negative vulnerability Positive resilience

21 Center for Healthier Children, Families & Communities Cumulative, Programming and Pathway Mechanisms Influence LCHD Three basic mechanisms influence LCHD Three basic mechanisms influence LCHD Cumulative - additive effect of multiple risks and protective factors, weathering 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 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 Pathways-chains of (eco-culturally constructed) linked exposures that create a constrained conduit of gene- environment transactions

22 Center for Healthier Children, Families & Communities Cumulative SES (birth - 33 yrs) poor health, age 33 % fair/poor health Lifetime SES score bestworst Source: Power et al, 1999

23 Center for Healthier Children, Families & Communities Birthweight and CVD Outcomes Nurses’ Health Study Curhan et al., Rich-Edwards et al.

24 Center for Healthier Children, Families & Communities

25 Center for Healthier Children, Families & Communities Cumulative, Programming and Pathway Mechanisms Influence LCHD Three basic mechanisms influence LCHD Three basic mechanisms influence LCHD Cumulative - additive effect of multiple risks and protective factors, weathering 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 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 Pathways- chains of (eco-culturally constructed) linked exposures that create a constrained conduit of gene- environment transactions

26 Center for Healthier Children, Families & Communities Poverty & ECD Parent Distress Parent Behavior Parent Investment Child Cognitive Developmen t Child Physical Developmen t Child Social- Emotional Developmen t 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 Family Income Poverty Financia l Hardshi p

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30 Center for Healthier Children, Families & Communities LCHD: Childhood Antecedents of later Childhood and Adult Health From Starfield 02/03 Source: van de Mheen et al, IJE 1998 Early social and material deprivation (financial, educational, environmental) Prior poor health, fetal nutrition, case-mix Immunologic & physiologic moderators Prior adverse behavior Prior poor physical activity Current poor health/ premature mortality Current poor physical activity Current adverse behavior Current social and material deprivation

31 Center for Healthier Children, Families & Communities LCHD: New Approaches to Old Problems

32 Center for Healthier Children, Families & Communities Disease Progression SymptomsCost Years = current practice 2 = current capability 3 = future capability Source: Snyderman R. AAP presidential address: the AAP and the transformation of medicine. Journal of Clinical Investigation. 2004;114(8): (suppl)

33 Center for Healthier Children, Families & Communities Risk Assessment for Prospective Health Source: Snyderman R. AAP presidential address: the AAP and the transformation of medicine. Journal of Clinical Investigation. 2004;114(8): (suppl) SymptomsCost Years Risk assessment decision support Low riskHigh risk Early chronic Late chronic Personal lifestyle planRisk modificationDisease management Personalized health plan 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

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35 Center for Healthier Children, Families & Communities LCHD and Birth Outcomes Pregnancy White African American Reproductive Potential Age

36 Center for Healthier Children, Families & Communities LCHD and Birth Outcomes Pregnancy White African American Reproductive Potential Age

37 Center for Healthier Children, Families & Communities Life Course Health Development Poor Nutrition Stress Abuse Tobacco, Alcohol, Drugs Poverty Lack of Access to Health Care Exposure to Toxins Poor Birth Outcome 05 Puberty Pregnancy Age White African American

38 Center for Healthier Children, Families & Communities LCHD: AA – White Birth outcomes Prenatal Care Poor Birth Outcome 05 Pregnancy Puberty Internatal Care Primary Care for Women Early Intervention Prenatal Care Primary Care for Children Age White African American

39 Center for Healthier Children, Families & Communities 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 Center for Healthier Children, Families & Communities How well is the 2.0 Child Health System Performing?

41 Center for Healthier Children, Families & Communities The existing child health service system Demand greater than services available Demand greater than services available Families have complex needs - often beyond capability of any single service Families have complex needs - often beyond capability of any single service Difficulty accessing services Difficulty accessing services Socio-economic gradient of access Socio-economic gradient of access Focus on treatment rather than prevention/early intervention Focus on treatment rather than prevention/early intervention Episodic contact Episodic contact Poor quality of Well Child Care Poor quality of Well Child Care

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43 Center for Healthier Children, Families & Communities 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) Child health system was designed for the first era of health care ( acute, infectious disease model) It was upgraded a bit for the 2 nd era, with more regionalization, chronic disease care It was upgraded a bit for the 2 nd era, with more regionalization, chronic disease care Ill equipped for this new era Ill equipped for this new era Under-performing Under-performing Facing many new challenges Facing many new challenges

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45 Center for Healthier Children, Families & Communities 01357Years Trajectory Optimizing Service Linkage Pathway NHVFRC PED RORFRC PED SRFRC PED Tutor FRC PED Pediatric Continuity Network Connections Development Optimal Health Development Lower Health Development Trajectory

46 Center for Healthier Children, Families & Communities Optimizing Trajectories: Multisector Multilevel Strategies Health Development Age (Years) Social Welfare Familysupport Education Health Family Neighborhood Services Community Policy Child

47 Center for Healthier Children, Families & Communities Systematic Data Collection For tracking Health Development Trajectories School Readiness 5 ysBirth1yr4 ys3 ys2 ys Pediatric Early Child Assessment Birth Certificate Preschool Assessment Physical Wellbeing & motor dev’t Social & emotional dev’t Approaches to learning Language dev’t Cognition & general knowledge

48 Center for Healthier Children, Families & Communities LCHD Key Economic Issues Human health is the product of “investments” made across the life span 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 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 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 Center for Healthier Children, Families & Communities Benefit-Cost Ratios for Longitudinal Studies Perry Pre School Perry Pre School $17 to $1 $17 to $1 Abecedarian Educational Child Care Abecedarian Educational Child Care $4 to $1 $4 to $1 Chicago-Child Parent Chicago-Child Parent $7 to $1 $7 to $1 Elmira Prenatal/Early Infancy Project Elmira Prenatal/Early Infancy Project $5 to $1 $5 to $1

50 Center for Healthier Children, Families & Communities Rates of Return to Human Development Investment Across all Ages Return Per $ Invested Age R 6 Pre- School SchoolPost School Pre-school Programs School Job Training 18 Pedro Carneiro, James Heckman, Human Capital Policy, 2003

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52 Center for Healthier Children, Families & Communities Historical and Projected Components of Federal Spending, 1962 – 2050 Source: Congressional Budget Office

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54 Center for Healthier Children, Families & Communities What does LCHD New Synthesis Provide to the Discourse on Health System Reform ? Big Idea – Forward looking Big Idea – Forward looking Integrative Framework Integrative Framework Connect up an increasingly balkanized field Connect up an increasingly balkanized field Reframe for health system reform goals Reframe for health system reform goals Positions child/MCH in Vanguard of New Era in Health and Health Care Reform Positions child/MCH in Vanguard of New Era in Health and Health Care Reform New Rational for current and future activities New Rational for current and future activities

55 Center for Healthier Children, Families & Communities LCHD Framework: Think Different! Developmentally - in order to optimize outcomes Developmentally - in order to optimize outcomes Population and upstream determinants of the outcomes that we want to achieve 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 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 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 How to change the culture of the system we work in To frame health in terms of its life long impacts To frame health in terms of its life long impacts

56 Center for Healthier Children, Families & Communities 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 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. LCHD will become an increasingly important framework for guiding policy analysis, interventions, and solving medical conundrums like infant mortality difference.

57 Center for Healthier Children, Families & Communities 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 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 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. LCHD will be used to transform our notions of how to invest in the health capital of individuals and the nation.

58 Center for Healthier Children, Families & Communities 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

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

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 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,

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? ç Establish policies & programs ç Control the state’s purse $ tring $ ç Enact requirements ç Provide oversight ç Provide leadership

84 Legislators Are Generalists ç Dozens of topics: A to Z ç Hundreds of bills ç Can’t be experts in all ç Agriculture ç Corrections ç Education ç Health ç Housing ç Human Services ç Labor ç Transportation ç Zoning...

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

86 Human Services & Education Issues by the Dozens! Õ Child welfare Õ Home visiting Õ Child care Õ Abuse prevention Õ Hunger & nutrition Õ Poverty issues Õ Etc. Õ Early childhood Õ Preschool Õ School success factors Õ Afterschool programs Õ School retention Õ No child left behind Õ 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 "Your topic" A BLIP ON THE POLITICAL RADAR SCREEN Competing For Legislators’ Attention

89 Your Strategic Role The “blip enlarger” For the Life-Course Health Development Model Issues ç Raise awareness ç Provide information resources ç 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 ç Competing needs and demands ç Budget issues & competition ç New legislators (20-25% turnover) ç Lack of awareness/understanding ç Relative size of the issue ç Limited time & resources ç 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!


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