Presentation on theme: "Life Course Health Development: A Framework to Guide Research, Practice and Health Reform Neal Halfon, MD, MPH UCLA Schools of Public Health, Medicine,"— Presentation transcript:
1Life Course Health Development: A Framework to Guide Research, Practice and Health Reform Neal Halfon, MD, MPHUCLA Schools of Public Health, Medicine, Public AffairsUCLA Center for Healthier Children, Families and CommunitiesMCHB-AIM Child & Adolescent Policy Support Center
2Goals of this Presentation To review the evidence, importance and potential impact of the developmental origins of health and diseaseTo consider the strategic role that the emerging Life Course Health Development approach can play inAdvancing a progressive Health Policy AgendaEnabling significant Health System Reform in the US
3Presentation Introduce Life Course Health Development Framework (LCHD) Distinguish LCHD from Lifespan and Life-course approachesDescribe implications and applications of the LCHD model forHealth interventionsOrganization and delivery of health servicesFinancing health servicesDiscuss relevance to child health policy development
4Why Do We Need a New Framework? Now more than ever there is a need to prioritize public expenditures and invest strategicallyMany current policies are based on outdated norms, data, and approachesNeed to be able to communicate to policy makers why investments at key points in the life span are important; and why more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 necessarySupports innovation in design, delivery and measuring outcomes that matterSupports collaboration, cooperation, and communication
5From Lifespan to LCHDLifespan models – connect the dots- linking early life to later lifeLife stage models – periods of psychological developmentLife-course models – are concerned with patterns and pathways that connect the dots between early and later lifeLife Course Health Development models-Connect the dotsDescribe the pathways or heath trajectoriesAddress the mechanisms that determine or influence health trajectories
8Life expectancy in years Figure 22. Life expectancy at birth and at 65 years of age by sex: United States,100NOTE: See Data Table for data points graphed and additional notes.Females80Life Expectancy at birthMalesLife expectancy in years6040FemalesLife expectancy at 65 years20Males19011910192019301940195019601970198019902001Source: Centers for Disease Control and Prevention, National Center for Health Statistics. Health, United States, 2004Year
9Health / functional Status Life SpanHealth SpanHealth / functional StatusPerformance Span0 years20 years80 years
10Social/Nutritional/Epidemiological/ Developmental Shift Social Conditions dramatically changes over this time periodNature, Array, and Prevalence of Risk, Protective and Health Promoting factorsNutritional Conditions change- high sugar, high fat dietsType, prevalence, distribution of acute and chronic disease changes dramaticallyDevelopmental expectancies changeCapacity of Medical Care to intervene, modify risk and treat disease changes
11The Evolving Health Care System The First Era(Yesterday)The Second Era(Today)Focused on acute and infectious diseaseGerm TheoryAcute Medical CareInsurance-based financingReducing DeathsThe Third Era(Tomorrow)Increasing focus on chronic diseaseMultiple Risk FactorsChronic Disease Mgmt & PreventionPre-paid benefitsProlonging Disability free LifeIncreasing focus on achieving optimal health statusComplex Causal PathwaysInvesting in population-based preventionProducing Optimal Health for AllEach 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 achieveFight against disease- infectious disease, war on cancer and heart disease was not about waging healthlike 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 functionalityStructure 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 shiftOrderly and planned or chaotic and reactiveDrip 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 transformedThis is happening all over the worldHealth 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 technologiesNew operating system (rather than patching the old system) and new algorithmsCome Back to what I meanHealth System 1.0Health System 2.0Health System 3.0
122004 National Research Council and Institute of Medicine Report
13IOM/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.
14Community Workplace School Family Individual 5 10 15 20 30 40 50 60 70 DayCareCommunityWorkplaceSchoolRelative Magnitude of InfluenceFamilyIndividual5101520304050607080Age (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.
15Health as a Developmental Process Health is developmentalHealth develops across the life courseHealth development can be represented by health trajectoriesCritical/ Sensitive periodsGene - Environment – Interaction have different impacts during different periodsMacro and Micro pathways delineate how toxic environment and risky families get under the skin
16How Risk Reduction and Health Promotion Strategies influence Health Development20Health Development406080Age (Years)HPRRRisk Reduction StrategiesHealth Promotion StrategiesRRRisk FactorsOptimal TrajectoryTrajectory Without RR and HP StrategiesProtective FactorsHPFIGURE 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):
17Fig.From: Lamberts SWJ, van den Beld AW, van der lely A. The endocrinology of aging. Science. 1997;278:
18From: Kuh D, Ben-Shlomo Y From: Kuh D, Ben-Shlomo Y. A life course approach to chronic disease epidemiology. New York: Oxford University Press
19Health Development Trajectories Strategies to ImproveHealth Development TrajectoriesBack toOverall ModelPovertyLack of health servicesFamily DiscordAge6 mo mo mo mo yrs yrsReady to learnPre-school“Healthy” TrajectoryHealth ServicesAppropriate DisciplineReading to child“At Risk” TrajectoryParent educationEmotional HealthLiteracy“Delayed/Disordered ” TrajectoryBirthEarly InfancyLate InfancyEarly ToddlerLate ToddlerEarly PreschoolLate PreschoolGraphic Concept Adapted form Neal Halfon , UCLA
20Risk and protective factors Risk FactorsChildFamilyCommunitySchoolProtective FactorsChildFamilyCommunitySchoolOutcomeNegativevulnerabilityPositiveresilience
21Cumulative, Programming and Pathway Mechanisms Influence LCHD Three basic mechanisms influence LCHDCumulative - additive effect of multiple risks and protective factors, weatheringProgramming - time specific influence of stimulus or insult during a critical or sensitive period on selection, adaptation, compensatory processesPathways-chains of (eco-culturally constructed) linked exposures that create a constrained conduit of gene-environment transactions
22Cumulative SES (birth - 33 yrs) poor health, age 33 % fair/poor healthbestworstLifetime SES scoreSource: Power et al, 1999
23Birthweight and CVD Outcomes Nurses’ Health Study Curhan et al., Rich-Edwards et al.
25Cumulative, Programming and Pathway Mechanisms Influence LCHD Three basic mechanisms influence LCHDCumulative - additive effect of multiple risks and protective factors, weatheringProgramming - time specific influence of stimulus or insult during a critical or sensitive period on selection, adaptation, compensatory processesPathways- chains of (eco-culturally constructed) linked exposures that create a constrained conduit of gene-environment transactions
26Child Social-Emotional Poverty & ECDParentDistressBehaviorInvestmentChildCognitiveDevelopmentPhysicalChild Social-EmotionalFamily Income PovertyFinancialHardshipParent- and Family-Level Predictorsof Income And Hardship Parent Work Status Job Prestige Education Level Parent Marital Status Race-EthnicityNeighborhood- and Community-Level Influences
29Brains are built over time, a significant proportion is constructed during the early years of life, and the capacity for change decreases with age
30LCHD: Childhood Antecedents of later Childhood and Adult Health Early social and material deprivation (financial, educational, environmental)Prior poor health, fetal nutrition, case-mixImmunologic& physiologic moderatorsCurrent poor health/ premature mortalityPrior poor physical activityCurrent poor physical activityPrior adverse behaviorCurrent adverse behaviorSource: 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 deprivationSource: van de Mheen et al, IJE 1998From Starfield 02/03
32Disease Progression 1 = current practice 2 = current capability 1 3 = future capability1SymptomsCost32YearsSource: Snyderman R. AAP presidential address: the AAP and the transformation of medicine. Journal of Clinical Investigation. 2004;114(8): (suppl)
33Risk assessment decision support Risk Assessment for Prospective HealthRisk assessment decision supportSymptomsLate chronicCostEarly chronicLow riskHigh riskYearsPersonal lifestyle planRisk modificationDisease managementPersonalized health planWellness education and Internet and health provider guided planning for allWellness education and Internet and health provider guided planning for allIndividual-focused; integrated provider systems. Focus on quality of life and palliation at appropriate late stagesSource: Snyderman R. AAP presidential address: the AAP and the transformation of medicine. Journal of Clinical Investigation. 2004;114(8): (suppl)
35LCHD and Birth Outcomes WhiteReproductive PotentialAfricanAmericanPregnancyAge
36LCHD and Birth Outcomes WhiteReproductive PotentialAfricanAmericanPregnancyAge
37Life Course Health Development WhitePoor NutritionStressAbuseTobacco, Alcohol, DrugsPovertyLack of Access to Health CareExposure to ToxinsAfricanAmericanPoor Birth OutcomeAge5PubertyPregnancy
38LCHD: AA – White Birth outcomes Primary Carefor ChildrenEarlyInterventionPrenatalCarePrenatalCareInternatalCarePrimary Carefor WomenAfricanAmericanPoor Birth OutcomeAge5PubertyPregnancy
39Children & Youth at Risk 4-6%Severe Disabilities12-16%Special HealthCare Needs30-40%Behavioral, Mental Health Learning Problems50-60%Good EnoughWhat % are thriving ?30% ?40% ?50% ?
40How well is the 2.0 Child Health System Performing?
41The existing child health service system Demand greater than services availableFamilies have complex needs - often beyond capability of any single serviceDifficulty accessing servicesSocio-economic gradient of accessFocus on treatment rather than prevention/early interventionEpisodic contactPoor quality of Well Child Care
43Transforming 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 careIll equipped for this new eraUnder-performingFacing many new challenges
45Trajectory Optimizing Service Linkage Pathway Optimal Health DevelopmentTrajectory Optimizing Service Linkage PathwayTutorFRCPEDSRFRCPEDLower Health Development TrajectoryDevelopmentRORFRCPEDPediatric ContinuityNHVFRCPEDNetwork Connections1357Years
46Optimizing Trajectories: Multisector Multilevel Strategies Health DevelopmentEducationHealthFamilysupportChildFamilyNeighborhood ServicesCommunityPolicySocial Welfare20406080Age (Years)
47Systematic Data Collection For tracking Health Development Trajectories Birth1yr4 ys3 ys2 ysPreschool AssessmentPediatric Early ChildAssessmentBirthCertificateSchool ReadinessPhysical Wellbeing & motor dev’tSocial & emotional dev’tApproaches to learningLanguage dev’tCognition & general knowledge
48LCHD Key Economic Issues Human health is the product of “investments” made across the life spanRate of return on investments in childhood may be particularly advantageousRate 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
49Benefit-Cost Ratios for Longitudinal Studies Perry Pre School$17 to $1Abecedarian Educational Child Care$4 to $1Chicago-Child Parent$7 to $1Elmira Prenatal/Early Infancy Project$5 to $1
50Rates of Return to Human Development Investment Across all Ages 8Pre-school Programs6SchoolReturn Per $ Invested4R2Job TrainingPre-SchoolSchoolPost School618AgePedro Carneiro, James Heckman, Human Capital Policy, 2003
52Historical 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
54Big Idea – Forward looking Integrative Framework What does LCHD New Synthesis Provide to the Discourse on Health System Reform?Big Idea – Forward lookingIntegrative FrameworkConnect up an increasingly balkanized fieldReframe for health system reform goalsPositions child/MCH in Vanguard of New Era in Health and Health Care ReformNew Rational for current and future activities
55LCHD Framework: Think Different! Developmentally - in order to optimize outcomesPopulation and upstream determinants of the outcomes that we want to achieveHow to shift population risk curves and not just work at the individual levelHow to use alignment, connection, networking strategies to join up people, sectors, systems into a more functional approach - open source for a flatter health policy worldHow to change the culture of the system we work inTo frame health in terms of its life long impacts
56ConclusionLCHD 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 outcomesLCHD will become an increasingly important framework for guiding policy analysis, interventions, and solving medical conundrums like infant mortality difference.
57ConclusionLCHD 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 healthLCHD 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.
58UCLA Center for Healthier Children, Families and Communities & National Center for Infancy and Early Childhood Health Policy AIM-MCHB Child and Adolescent Policy Support Centerhttp.//healthychild.ucla.edu
59Applying the Life Course Perspective in a Local MCAH Program Cheri Pies, MSW, DrPHDirector, Family, Maternal and Child Health Programs
67Staff Education Content Theory of the Life Course PerspectiveLife Course GameLife Course Initiative activitiesA 12-Point PlanIntegrating the Life Course Perspective into their workWhat are you currently doing that fits with the Life Course Perspective?How can you integrate the Life Course Perspective into future activities?
68The Contra Costa Experience Conducted a series of interactive educational activities for staffEngaged staff in identifying current and future activitiesCreated opportunities for staff to have their own “A-ha!” moment
69The Contra Costa Experience Established a Life Course Initiative Data TeamConducted educational survey of Family, Maternal and Child Health Programs staffStarted to identify some intermediate outcomes for clients as possible measures of success (vs. long-term perinatal outcomes)
70The Contra Costa Experience Improved sense of well being, empowerment, resilienceIncrease in social supportDecreased stress
71The Contra Costa Experience Increase in financial security and stabilityImproved financial status
72The Contra Costa Experience Launched a financial education pilot project: BEST – Building Economic Security TodayMaking the link between an increase in asset development (wealth) and health
73Building Economic Security Today (BEST) With Life Course Data Team, developed a logic model for an asset development pilot project: BESTHosting Family Economic Success and Security training for 40 home visiting and WIC staff in October 2008Viewing and discussing Unnatural CausesApplying for grant funding for training and project from various sources
74Getting Started What is the story your local data are telling you? What are you already doing that may fall under the Life Course Perspective?
75Getting StartedWhich community partners need to be on board from the start?What could this paradigm shift mean for MCH in your community?
76Getting There Be prepared for skeptics (internal and external) Have a plan – fiscal and programmaticOffer interactive educational sessions to community partners
77Getting There Lay the groundwork with higher-level management Get ready to evaluateArticulate and clarify the value of making this paradigm shift
78Sharing Lessons Learned Share your enthusiasmRecognize and acknowledge what staff are already doing and build on thisUtilize the imagination and experience of staff to chart the course for the future
79Sharing Lessons Learned Engage the community of people whose lives you hope to touchHave a long viewRecognize that change takes time
81National Conference of State Legislatures Communicating about the Life-Course Health Development Model with State LegislatorsforCityMatCH & NACCHOBy theNational Conference of State LegislaturesMartha KingOctober 16, 2008
82NCSL National membership organization: Goals: 7,382 state legislators across the countryThousands of legislative staffOffices in Denver and Washington, D.C.Goals:To improve the quality & effectiveness of state legislaturesTo promote policy innovation and communication among state legislaturesTo ensure states a strong, cohesive voice in the federal systemAt 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.
83Why Focus on State Legislatures? Establish policies & programsControl the state’s purse $tring$Enact requirementsProvide oversightProvide leadership
84Legislators Are Generalists AgricultureCorrectionsEducationHealthHousingHuman ServicesLaborTransportationZoning . . .Dozens of topics:A to ZHundreds of billsCan’t be experts in all
85Health Issues by the Dozens! MedicaidInsurance/mg’d carePharmaceuticalsLong-term CareHealth disparitiesUninsuredHealth professionsHealth FacilitiesEnvironmentalPublic healthSCHIPPrenatal CareEmergency servicesChronic diseasesOral healthInjury preventionMental HealthDisabilitiesSubstance Abuseetc. ...
86Human Services & Education Issues by the Dozens! Child welfareHome visitingChild careAbuse preventionHunger & nutritionPoverty issuesEtc.Early childhoodPreschoolSchool success factorsAfterschool programsSchool retentionNo child left behindEtc.
87Overload!!“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
88Competing For Legislators’ Attention "Your topic"A BLIP ON THEPOLITICAL RADARSCREEN
89For the Life-Course Health Development Model Issues Your Strategic RoleThe “blip enlarger”For the Life-Course Health Development Model IssuesRaise awarenessProvide information resourcesProvide tools to make a difference
90Polling Question Have you ever been involved in communicating “Life-Course" issues to state legislators in your state?
91Getting Their Attention: Barriers Competing needs and demandsBudget issues & competitionNew legislators (20-25% turnover)Lack of awareness/understandingRelative size of the issueLimited time & resourcesComplexity of cross-cutting "life course" concepts
92Life-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 legislatorsMay sound overwhelming--where to start?Translate message to their language and information needs
93Translation 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"
94Some 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
95Where Does "Life Course" Fit In? Identify existing policies & programs where these ideas may fit--especially the "protective factors"Give specific examplesCommunicate conciselyWhat will this cost? (and what are the costs associated with "risk factors"?)Is there return on investment? If so, what? And when?
96Consider 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?
97What policies & programs are related? Identify specific programs that relate to the "life course" concepts and be specificPrenatal careSCHIP & Medicaid opportunitiesEarly childhood programsEducationSocial servicesPreventive & primary carePromote health & well-being