Presentation is loading. Please wait.

Presentation is loading. Please wait.

Life Course Health Development: A Framework to Guide Research, Practice and Health Reform Neal Halfon, MD, MPH UCLA Schools of Public Health, Medicine,

Similar presentations

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:

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than ever there is a need to prioritize public expenditures and invest strategically Many current policies are based on outdated norms, data, and approaches Need to be able to communicate to policy makers why investments at key points in the life span are important; and why more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 Ages
8 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.//

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

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!

Download ppt "Life Course Health Development: A Framework to Guide Research, Practice and Health Reform Neal Halfon, MD, MPH UCLA Schools of Public Health, Medicine,"

Similar presentations

Ads by Google