The Determinants of Health: Getting to the Root Causes
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1 The Determinants of Health: Getting to the Root Causes University of California, Los AngelesOctober 2, 2013Jonathan E. Fielding, MD, MPH, MBADirector and Health Officer, Los Angeles County Department of Public HealthDistinguished Professor of Health Services and PediatricsSchools of Public Health and Medicine, UCLA
2 Warm-Up Exercise Your health is determined by many factors. In the next 5 minutes allocate a total of 100 points to the factors you believe influence health.Example: X points – your diet/nutrition
4 Los Angeles County Most populous county in the nation Larger population than 43 states26% of Californians live in LA CountyOver 4,000 square miles88 incorporated cities75 miles of coastline≈140 unincorporated areas2 islandsSources: US Census Bureau, State and County QuickFacts - LA County (last rev ); California Department of Transportation: LA County Profile (last rev )
5 Los Angeles County Residents 9.9 million residents24% under 18 years old12% over 65 years old16% below poverty level36% foreign bornOver 140 cultures and 200 languages57% speak a language other than English at home≈1.7 million students in elementary and high schoolThousands attend 27 community colleges and universities≈ 73,000 residents are homelessSources: 1) US Census Bureau, State and County QuickFacts - LA County (last rev );2) Residents, County of Los Angeles,
6 Los Angeles County Residents, by Race/ Ethnicity, 2012Source: US Census Bureau State & County QuickFacts: Los Angeles County, California Accessed September 16, 2013
7 Leading Causes of Death & Premature Death, LA County, 2010 Leading Causes of Premature** DeathRankCause of DeathNo. of DeathsPremature Death RankYears of Life LostDeath Rank1.Coronary heart disease12,635157,6072.Stroke3,2788Homicide28,442173.Lung cancer2,9417Suicide22,390144.Emphysema/COPD2,62215Motor vehicle crash19,750185.Alzheimer's disease2,24245Liver disease19,42596.Pneumonia/influenza1,96421Drug overdose18,652197.Diabetes1,8941018,10038.Colorectal cancer1,28511Stoke14,70929.1,1715Breast cancer12,99910.1,11612,221Los Angeles County Department of Public Health, Office of Health Assessment & Epidemiology. 56,538 total deaths and 430,926 years of life lost, excluding infants less than 1 year of age and persons of unknown age. **Death before age 75 years.
8 Leading Causes of Death by Race/Ethnicity, LA County, 2010 Race/ethnicity Number of deaths Age-adjusted death rate#1 cause#2 cause#3 cause#4 cause#5 causeWhite 28,738667 per 100,000Coronary heart disease 6, per 100,000Emphysema/COPD 1, per 100,000Lung cancer 1, per 100,000Stroke 1, per 100,000Alzheimer’s disease 1, per 100,000Hispanic 13,751529 per 100,000Coronary heart disease 2, per 100,000Stroke per 100,000Diabetes per 100,000Liver disease per 100,000Lung cancer per 100,000Black 7, per 100,000Coronary heart disease 1, per 100,000Stroke per 100,000Lung cancer per 100,000Diabetes per 100,000Emphysema/ COPD per 100,000Asian/Pacific Islander 6, per 100,000Coronary heart disease 1, per 100,000Stroke per 100,000Lung cancer per 100,000Pneumonia/ Influenza per 100,000Diabetes23716 per 100,000Los Angeles County Total* 56,538615 per 100,000Coronary heart disease 12, per 100,000Stroke 3, per 100,000Lung cancer 2, per 100,000Emphysema/COPD 2, per 100,000Alzheimer’s disease 2, per 100,000Los Angeles County Department of Public Health, Office of Health Assessment & Epidemiology; August *Total includes persons of other or unknown race/ethnicity.
9 Leading Causes of Premature Death by Race/Ethnicity, LA County, 2010 WhiteCoronary heart diseaseSuicideDrug OverdoseLung cancerLiver diseaseHispanicHomicideMotor vehicle crashBlackStrokeAsian/Pacific IslanderBreast cancerLos Angeles County Total*Los Angeles County Department of Public Health, Office of Health Assessment & Epidemiology; August *Total includes persons of other or unknown race/ethnicity.
10 Crude Death Rate for Infectious Diseases, US, 1900 - 2000 * Rate is per 100,000MMWR, CDC, 1999MMWR, CDC, 1999
11 Number of Tuberculosis Cases, LA County, 2000-2010
12 AIDS Cases, AIDS Deaths and Persons Living with AIDS, LA County, 1991-2011 1. Number of new cases diagnosed each year.2. Number of deaths occurred each year among persons reported with AIDS.3. Number of persons living with AIDS at the end of each calendar year.*Data are provisional forHIV Epidemiology, Division of HIV and STD Programs, Los Angeles County Department of Public Health Annual HIV Surveillance Report, February 2012: 1-36.
13 59,500 living with HIV (including AIDS) in LAC 2012 Estimated Number of Persons Living with HIV and AIDS in Los Angeles County12,8001,2001,60043,900Estimated59,500 living with HIV (including AIDS) in LAC(1) Estimate that 21.5% of HIV+ in LA County are unaware of their infection; modified from CDC estimate.(2) Of 4,853 notifications pending investigation, estimate half of 2,400 whohave detectable VL or confirmatory test to be unduplicated cases.(3) Out of the 3,200 cases reported as code, half are thought to represent unduplicated cases.Source: LAC Division of HIV and STD Programs, reported as of 12/31/2011.13
14 Chronic Diseases are the Leading Cause of Death in the US Chronic diseases are responsible for 7 out of every 10 deathsTop 5 Causes of Death in U.S. (1980, 2009)198020091Heart disease2Cancer3Cerebrovascular diseases (Stroke, hypertension)Chronic lower respiratory diseases4Unintentional injury5Chronic obstructive pulmonary diseaseFour of the top five causes of death are chronic diseases141) Centers for Disease Control and Prevention. Health, United States, Available at nchs/data/hus/hus07.pdf#summary, and Chronic Disease Overview: 2) Centers for Disease Control and Prevention. Deaths: Final Data for National Vital Statistics Reports, Vol 58, Number 1914
15 Projected Rise in Cases of Seven of the Most Common Chronic Diseases, 2003-2023 *This study evaluated the burden of seven of the most common chronic diseases/conditions (cancer, diabetes, heart disease, hypertension, mental disorders, pulmonary conditions, and stroke).15Source: DeVol, R, Bedroussian, A, et al. An Unhealthy America: The Economic Burden of Chronic Disease. The Milken Institute. October Full report available at:15
16 The Centers for Disease Control and Prevention (CDC) estimates up to… …could be prevented, if Americans were to do 3 things:Stop smokingStart eating healthyGet in shape40% of cancer80% of heart disease and stroke80% of type 2 diabetes16Mensah G. Global and Domestic Health Priorities: Spotlight on Chronic Disease. National Business Group on Health Webinar. May 23, Available at:16
17 Healthy People 2020 Ecologic Model of Health Determinants of Health InterventionsOutcomesBehavioraloutcomesSpecific risk factors,diseases, &conditionsInjuriesWell-being & health-related Quality of LifeHealth equityPoliciesProgramsInformationAssessment, Monitoring, Evaluation & Dissemination
18 Trends in Leading Causes of Death, LA County, 1995-2009 Cause of Death19952009Percent ChangeCoronary heart disease258129-50%Stroke6034-43%Lung cancer4731-34%COPD3330-9%Alzheimer’s disease521+320%Pneumonia/influenza44-52%Diabetes2220Colorectal cancer14-30%Liver disease1312-8%Breast cancer (females)29-28%HIV/AIDS263-89%Homicide177-59%Rate (per 100,000)Age-adjusted to year 2000 U.S. standard population Source: OHAE, LAC DPH18
19 Life Expectancy at Birth by Sex and Race/Ethnicity, LA County, 2011 Sources: 2010 Linked Death Files, Los Angeles County Department of Public Health, Data Collection and Analysis (DCA) Unit.2009 to 2010 Linked Birth Files, Los Angeles County Department of Public Health, Data Collection and Analysis (DCA) Unit. July 1, 2010 Population Estimates, prepared for County of Los Angeles, Internal Services Department, Social Services Systems Division, released 1/26/2013.
20 Coronary Heart Disease Mortality by Race/Ethnicity, LA County, 2001-2009 Age – Adjusted rate per 100,000Los Angeles County Public Health, Office of Health Assessment & Epidemiology
21 Behavior as a Determinant of Health Healthy People 2020 Ecologic Model of Health
22 Trends in Adult Cigarette Consumption, US, 1900–2005 Annual adult per capita cigarette consumption and major smoking and health eventsMasterSettlementAgreement; California first state to enact ban on smoking in barsFirst SurgeonGeneral’s ReportBroadcastad banEnd of WW IIEarly in the 20th century, several events coincided that contributed to increases in annual per-capita cigarette consumption, including the introduction of blends and curing processes that allowed the inhalation of tobacco, the invention of the safety match, improvements in mass production, transportation that permitted widespread distribution of cigarettes, and the use of mass media advertising to promote cigarettes (USDHHS, 1995).Cigarette smoking among women began to increase in the 1920s, when targeted industry marketing and social changes reflecting the liberalization of women's roles and behavior led to the increasing acceptability of smoking among women (USDHHS,1980; Waldron, 1991).Annual per-capita cigarette consumption by adults (i.e., 18 years or older) increased dramatically from 54 cigarettes in 1900 to a peak of 4,345 cigarettes in 1963 (CDC, 1994). For the year 2005, per-capita consumption was estimated at 1,716 cigarettes per person, a 3% drop from 1,791 in 2004 (USDA, 2006).Some decreases correlate with events such as the first research suggesting a link between smoking and cancer in the 1950s, the 1964 Surgeon General’s Report, and increased tobacco taxation and industry price increases during the 1980s. In 1998, the year of the Master Settlement Agreement, California was the first state to enact a ban on smoking in bars. By the end of 2006, more than 20 states had a tax of at least $1.00 per pack on cigarettes.Centers for Disease Control and Prevention (CDC). (1994). Surveillance for selected tobacco-use behaviors—United States, 1900–1994. MMWR 43 (no. SS-3).U.S. Department of Agriculture (USDA), Economic Research Service. (2006, April 28). Tobacco Outlook. Report TBS-260. Retrieved December 31, 2006, fromU.S. Department of Health and Human Services (USDHHS). (1995). For a Healthy Nation: Returns on Investment in Public Health. Atlanta, GA: Public Health Service, Office of Disease Prevention and Health Promotion and CDC.U.S. Department of Health and Human Services. (1980). The Health Consequences of Smoking for Women. A Report of the Surgeon General. Washington, DC: Public Health Service, Office on Smoking and Health.Waldron I. (1991). Patterns and causes of gender differences in smoking. Soc Sci Med 32:989–1005.Number of cigarettesNonsmokers’rights movementbeginsCigarette price dropFederal cigarettetax doubles20 states have > $1 pack taxGreat DepressionYearCenters for Disease Control and Prevention. (1999). MMWR 48:986–993.Per-capita updates from U.S. Department of Agriculture, provided by the American Cancer Society.22
23 Costly Toll Of TobaccoTobacco use is single most preventable cause of death, with 10 million annual deaths estimated by 2030.50,000 annual deaths in the US due to secondhand smoke exposure alone.In LAC, an estimated 336,000 children are exposed to secondhand smoke at homeOne million+ smokers in LAC.Adult smoking prevalence was at 13.1% in 20111 out of every 7 deaths in LAC is caused by tobacco use (≈ 9,000 deaths)Despite impressive declines in the number of people in Los Angeles County who smoke (now at 14.3%), certain vulnerable populations have not benefitted from tobacco control efforts, continue to smoke at alarmingly high rates, and are suffering grievous consequences.Tobacco use remains the single most preventable cause of death, responsible for more than 440,000 deaths per year in the United States.By the year 2030, an estimated 10 million annual deaths will occur worldwide due to tobacco.There are 50,000 deaths every year in the United States due to second hand smoke exposure alone.2323
24 Percent of Adults Who Smoke Cigarettes by Gender, LAC, 2002-2011 Los Angeles County Health Survey
25 Prevalence of Cigarette Smoking by Age, LA County, 2011 PercentAge GroupLos Angeles County Health Survey
26 The Toll of Alcohol2,500 people in LA County die from alcohol-related causes each yearRoughly 78,000 years of potential life lostAlcohol is associated with digestive diseases, neuropsychiatric conditions, cardiovascular disease, malignant neoplasms, pregnancy-related conditions, fetal alcohol syndrome, and high risk sexAlcohol has been implicated in DUIs, falls, suicide, poisonings and occupational injuriesExcessive alcohol consumption costs LA County an estimated $10.8 billion annuallyLos Angeles County Department of Public Health. Facts & Figures: Alcohol in LA County, Oct and Reducing Alcohol-Related Harms in LA County: A Cities & Community Health Report, March 2011.
27 Percent of Adults who Reported Binge Drinking in the Past Month in LA County, 2002-2011 Binge drinking for males is drinking 5 or more drinks on one occasion at least one time in the past month. Binge drinking for females is drinking 4 or more drinks on one occasion at least one time in the past month.Source: LA County Health Survey27
28 Percent of Adults who Reported Binge Drinking in the past month, by Gender in LA County, 2011 Binge drinking for males is drinking 5 or more drinks on one occasion at least one time in the past month. Binge drinking for females is drinking 4 or more drinks on one occasion at least one time in the past month.Source: LA County Health Survey28
29 Drug Abuse in Los Angeles County Over 60,000 residents were admitted to publicly funded treatment programs fromMost frequently reported drugs for which treatment was received were:marijuana/hashish (27%)alcohol (26%)methamphetamine (18%)cocaine/crack (13%)Los Angeles County, Department of Public Health, Substance Abuse Prevention and Control. Fact Sheet: Drug Use and Misuse in Los Angeles County Sept 2010.
30 Drug Use Among LA County High School Students*, Grades 9-12 Have ever used marijuana37.6%Currently∙ use marijuana19.3%Have ever used cocaine9.7%Currently∙ use cocaine3.6%Have ever used inhalants16.9%Have ever used ecstasy11%Have ever used heroine3.8%Have ever used methamphetamines7.1%*Youth Risk Behavior Surveillance 2009, Centers for Disease Control & Prevention“Current use” is that which occurred in the 30 days prior to the surveyLos Angeles County, Department of Public Health, Substance Abuse Prevention and Control. Fact Sheet: Drug Use and Misuse in Los Angeles County Sept 2010.
31 Opioid Prescriptions Filled by Fiscal Year, LA County, 2007-2012 Source: Department of Justice, California Prescription Monitoring Program/ Controlled Substance Utilization Review and Evaluation System (CURES) data.
32 Hospitalizations and Emergency Department (ED) Visits for Opioid Dependence/Abuse, LA County,Source: Office of Statewide Health Planning and Development, Hospital Discharge and Emergency Department Visit Data. Prepared by LA County Department of Public Health, Injury and Violence Prevention Program.
33 Benefits of Physical Activity Increased life span and improved functionReduced hypertension, heart disease, and strokePrevention of diabetes and related complicationsDecreased risk of colon cancerImproved mental healthBody weight maintenance and obesity controlIncreased bone massImproved immune functionReduced health care costsThe benefits of being physically active on a regular basis are documented in thousands of studies. Physical activity can increase the life span while improving quality of life and can help prevent leading physical and psychological disorders. With health care costs continuing steep increases, the lower health care costs of active people is attracting more attention from policy makers.33Surgeon General’s Report, 199633
34 Physical Activity Guidelines for Americans (PAGA) Study 2011 study assessed self-reported vs. objectively measured physical activity among U.S. adults (n=4,773) using accelerometer dataPercentage of adults meeting the PAGA:Self reported: 62%Objectively measured: 9.6%Tucker, J, et al. Physical Activity in U.S. Adults: Compliance with the Physical Activity Guidelines for Americans. AM J Prev Med 2011; 40(4):
35 Makes you wonder how many of these… Self Reported Levels of Physical Activity Among Adults in LA County, 2011Makes you wonder how many of these…are actually these?To meet Physical Activity Guidelines at least one of the following at least one of the following criteria must be fulfilled: 1) Vigorous Activity - hard physical activity causing heavy sweating, large increases in breathing and heart rate - for 20+ minutes, > 3 days/wk, 2) Moderate Activity - cause light sweating, slight increases in breathing and heart rate - for 30+ minutes, > 5 days/wk, 3) A combination of Vigorous and Moderate Activity meeting the time criteria for > 5 days/wk. [Los Angeles County Health Survey35
36 Prevalence of Adult Obesity, LA County, 1997-2011 Los Angeles County Health Survey Department of Public Health363636363636
37 Prevalence of Obesity & Diabetes Among Adults in LA County, 1997-2011 Los Angeles County Health Survey Department of Public Health
38 Prevalence of Obesity Among 5th, 7th, and 9th Graders in LA County Public Schools, CA Physical Fitness Testing,Healthy People 2010 Goal (<5%)Prevalence of ObesityProjected obesity prevalence assuming linear trendSource: California Physical Fitness Testing Program, California Department of Education. Includes 5th, 7th, and 9th graders enrolled in LA County public schools.
39 Obesity Prevalence Among 3 and 4 Year Olds in the WIC Program, LA County, 2003-2010 Source: PHFE WIC Program, LA County
40 Cities/Communities with Lowest and Highest Childhood Obesity Prevalence, 2008 Top 10*City/Community NameObesity Prevalence (%)Rank of Economic Hardship ( )Manhattan Beach3.42Calabasas5.08Hermosa Beach5.11Agoura Hills5.310Beverly Hills5.419Malibu5.94Palos Verdes Estates7.35San Marino7.815Rolling Hills Estate8.49La Canada Flintridge8.518Average 10 lowest6.2%Ave Median Household Income$99,555Bottom 10*City/Community NameObesity Prevalence (%)Rank of Economic Hardship( )West Athens30.694South Gate30.7110Florence-Graham31.0128West Whittier-Los Nietos31.181West Carson31.456Vincent32.269East Los Angeles32.9117Hawaiian Gardens33.4107South El Monte34.5111Walnut Park38.7113Average 10 highest32.7%Ave Median Household Income$37,747*Table excludes cities/communities where number of students with BMI data < 500.Source: California Physical Fitness Testing Program, California Department of Education. Includes 5th, 7th, and 9th graders enrolled in LA County public schools; 2000 Census404040
42 Cost of Overweight, Obesity & Physical Inactivity - California, 2006 BillionsHealth Care $20.7Lost Productivity $20.4Total $41.2*Projected Cost for 2011: $52.7 BILLIONWhy should we care?Obesity is not just a matter of personal health – it is a costly public health concern that affects economic productivity, state budgets, and personal and family well-being.Cost represents loss of productivity at work and direct and indirect health care costs. Also included are workers’ comp costs. This is for the year 2000.There are a wide number of health consequences associated with being overweight or obese and to not participating in any physical activity:Heart DiseaseDiabetesHypertensionHigh CholesterolArthritisAsthmaKidney DiseaseMany CancersDepressionPoor quality of life*Figures may not add to total due to roundingThe Economic Costs of Overweight, Obesity, and Physical Inactivity Among California Adults – 2006 (July 2009). The California Center for Public Health Advocacy.
43 Changes in Future Life Expectancies Related to Obesity and Diabetes Life expectancy has steadily increased over the past two centuries.Current rates of obesity projected to reduce life expectancy by .33 to .75 years over the next century.If rates of obesity and diabetes continue to increase at current rates, reductions in life expectancy may be to 2 to 5 years, or more43Olshansky et al NEJM March 17, 2005
44 Portion Control Campaign "Choose Less, Weigh Less" With bigger food portions come more calories, and consuming extra calories can lead to obesity, diabetes, heart disease and some cancers.Campaign includes advertising on transit shelters, buses, rail cars, billboards, television, radio and online.Videos of portion size PSAs can be found at:
45 Rethink Your Drink Campaign Sugar sweetened beverages (SSB) are the largest single source of added sugar and calories in the American diet.On average, nearly 39% of adults in LA County drink at least one SSB per day.> 43% of children 17 or younger consume at least one SSB on an average day.A child’s risk for obesity increases an average of 60% with every additional daily serving of soda.
47 Different Approaches to Addressing Overweight/Obesity: Personal Eating Behavior Share mealsPartially fill beverage containersAvoid ‘supersizing’Ask for reduced portion optionsCompare nutritional values of your choices on labeled menus
48 Different Approaches to Addressing Overweight/Obesity: Eating Outside the Home Promote healthy eating in workplaces and schoolsRemove sweetened beverages and junk food from vending machines (schools, public agencies, businesses)Create incentives for restaurants and cafeterias that offer healthy food itemsSchools can promote participation in the School Breakfast Program and reduce high calorie snack opportunities in the classroom (e.g. birthday treats)More Americans eating food prepared outside the home, typically higher in fat and calories and lower in nutrients1% of total energy intake from restaurant and fast food increased by nearly 300% among adolescents fromLA County is estimated to have 4x as many fast food restaurants and convenience stores as supermarkets and produce vendors3Guthrie et al J Nutr Educ Behav;2) Nielsen, et al., 2002 Obesity Research;3) ‘Searching for Healthy Food: The Food Landscape in California Cities and Counties’, 2007 CCPHA brief
49 Strategies for Improving the Physical Environment for Nutrition CurrentEnvironmental ChangeIncreased marketing of junk food, tobacco, and alcoholPlace limits on marketing of junk food to children (around schools, parks…)Decreased access to fresh, nutritious, affordable foodPromote local public marketsProvide incentives for businesses that provide healthy foodProliferation of fast food restaurantsUse zoning tools to limit the location and density of fast food restaurantsSource: Public Health Institute
50 Physical and Social Environments as Determinants of Health Healthy People 2020 Ecologic Model of Health
53 What is a Healthy Community? Meets basic needs of allProvides quality and sustainable environmentMaintains adequate levels of economic and social developmentPromotes healthFosters social relationships that are supportive and respectfulWe often talk about communities being healthier, but what does that really mean? Health communities are those that meet the basic needs of all, have a quality and sustainable environment, have adequate levels of economic and social development, promote health and social equity, and promote social relationships that are supportive and respectful.Adapted from Health in All Policies Task Force Report to the Strategic Growth Council, Dec and presentations by CDPH, Linda Rudolph, MD, MPH.
54 Healthy Communities: Meet Basic Needs of All Safe, sustainable, accessible, & affordable transportation optionsAffordable, accessible, and nutritious foodsAffordable, high quality, socially integrated and location-efficient housingAffordable, high quality health careComplete and livable communities including high quality schools, parks and recreation facilities, child care, libraries, financial services and daily needsHealthy communities should need the basic needs of its residents.PLACE Program : In 2007, using these funds, LACDPH launched the PLACE grant project — an over $2 millioninitiative that offered multi-year grants to city/community partnerships to increase physical activity by advancingcity policies and implementing changes to the built environment.The five PLACE grantees are: the cities of El Monte, Culver City, and Long Beach; and the non-profit organizations Pacoima Beautiful and the Los Angeles County Bicycle Coalition.PLACE grants began July 2008 and include:• Developing and implementing a bicycle and pedestrian master plan• Developing a health element for a city’s general plan• Creating a greenway vision plan for a tributary of the Los Angeles River• Creating a bike and pedestrian friendly route that connects to a light rail line under development• Creating a circuit walking loop with signage to local destinations• Developing bicycle boulevards that prioritize biking over carsThe PLACE program has also worked with local jurisdictions to promote and provide guidance on the development of bike paths, conducting walkability assessments in neighborhoods, and promoting safe routes to school…Many of our community liaison staff, with guidance from PLACE, have been working to incorporate health language into cities’ general plans. There is also work being done regarding the revitalization of Compton Creek.Many of our communities lack accessible and nutritious foods and have an abundance of foods that have low nutritional value at low cost. . . HEAC has been working with…..RENEWAdapted from Health in All Policies Task Force Report to the Strategic Growth Council, Dec and presentations by CDPH, Linda Rudolph, MD, MPH.
55 Healthy Communities: Provide Quality and Sustainable Environments Clean air, soil, and water, and environments free of excessive noiseTobacco and smoke freePreserved natural and open spaces, including agricultural landsMinimize waste, toxic chemicals, & harmful emissionsA clean environment is a healthy environment. We know that contaminated soil, toxic chemicals, and waste have a negative impact on health. Clean environments are an integral component of a health community.The Tobacco Control and Prevention Program has been working to support smoke-free policies in Los Angeles County. Most recently, they supported a smoke-free housing ordinance in Santa Monica that prohibits smoking on balconies and any common areas in multi-family housing. They are now working on a smoke-free ordinance for the city of West Hollywood that would ban smoking in outdoor patios and open air public spaces such as restaurants.Adapted from Health in All Policies Task Force Report to the Strategic Growth Council, Dec and presentations by CDPH, Linda Rudolph, MD, MPH.
56 Healthy Communities: Maintain Adequate Levels of Economic and Social Development Adequate, safe, and healthy job opportunities for allSupport for healthy development of children and adolescentsOpportunities for high quality and accessible educationThe South LA Building Health Communities initiative is an effort that DPH has been involved in that words to create healthy environments where children can learn, play and grow.We have been doing a lot of research on the impact educational attainment has on health and are interested in finding ways to work with the LA County Office of Education and the school districts in its jurisdiction.Adapted from Health in All Policies Task Force Report to the Strategic Growth Council, Dec and presentations by CDPH, Linda Rudolph, MD, MPH.
57 Healthy Communities: Promote Health Access to coordinated, quality health care servicesAccess to preventive care to minimize development of chronic diseaseThe SPA 5/6 Area Health Office has been using media to foster discussion about health inequities in their communities. The documentary “Unnatural Causes” has been shown at 3 community based agencies with the hopes of expanding this effort to schools and other places were people come together.The Area Health Office is working with organizations such as Community Health Councils, LAANE, Esperanza CHC, St. John’s to engage communities on topics such as access to health care, safe and healthy housing, and community involvement. These organizations are vital in implementing policy change …Adapted from Health in All Policies Task Force Report to the Strategic Growth Council, Dec and presentations by CDPH, Linda Rudolph, MD, MPH.
58 Healthy Communities: Foster Supportive and Respectful Social Relationships Robust social and civic engagementSocially cohesive and supportive relationships, families, homes, and neighborhoodsSafe communities free of crime and violenceAdapted from Health in All Policies Task Force Report to the Strategic Growth Council, Dec and presentations by CDPH, Linda Rudolph, MD, MPH.
60 Adverse Health Impacts From Poor Community Designâtraffic safetyáair pollutionwater quality & quantityobesity & chronic diseasephysical activitycrime & violencesocial capitalelder health & mobilitymental healthhealth disparitiesIn recent years, more and more public health professionals have started to team up with urban and regional planners to discuss the ways in which urban design can promote or damage a population’s health. Our department is actively searching for opportunities to become more heavily involved in issues like local urban and transportation planning.In the future, DPH will take a more active role in:- Forging partnerships with local planning and transportation officials in order to bring health to the planning table- Using data to arm and inform stakeholders and decision-makers- Expanding the role of pubic health in commenting on development plans & conduct health impact assessments60
61 Health and SprawlPeople living in counties marked by sprawling development:Walk less in their leisure timeAre more likely to have high blood pressureHave higher body mass indexesAre more likely to be overweight (average 6 pound difference)These are some of the ways that the built environment here in Los Angeles affects our health.Ewing R, et al: American Journal of Health Promotion 18(1) Sept/Oct 200361
62 CommutingLos Angeles has the nation's worst Travel Time Index1107 minutes is average total travel time per typical weekday when commuting at peak timesAccording to national statistics, Los Angeles is among the top 10 U.S. cities with the most long-distance commuters.As Los Angeles’ population grows and the economy expands, congestion is predicted to worsen in the next few years, therefore creating vehicle emissions.Air Quality Management Plan 1997621) Texas Transportation Institute: 2011 Urban Mobility Report, September ) LA Times, September 200662
63 The more we drive and the more our built environment favors driving the less fit we are and the hotter our climate becomes.Adapted from Dr. Richard Jackson
64 Let’s Play “Spot the Pedestrian” Here’s an example of how urban planning can affect public health. Notice how the lack of safe crosswalk endangers the pedestrians on this street.Source: Dr. Howard Frumkin
65 Economic Benefits of Open Spaces and Walkable Community Design Open spaces and recreation areas can positively affect property valuesbenefits homeownershigher property tax revenue for local governmentsCompact, walkable developments = economic benefits to developershigher home sale pricesenhanced marketabilityfaster sales or leasesOther direct and indirect benefitsreducing air pollutionflood controlimproved water qualityfacilitating healthy lifestyles65
66 Summary of Health Effects of Air Pollution Amount of goods transported through CA projected to nearly quadruple between 2000 and 20201Will have significant impact on air quality and health2Diesel particulate matter (PM)concentrated around ports, rail yards, & heavily trafficked roads3premature deathscancerrespiratory diseaselost workdaysglobal warming (2nd to CO2)Annual Health Impacts in CA from PM and Ozone41 Business, Transportation, and Housing Agency, and California Environmental ProtectionAgency (Cal EPA). Goods Movement Action Plan Phase 1: Foundations. September20052 (Palaniappian et al Report from the Pacific Institute)3 (CA/EPA Air Resources Board. Health Effects of Diesel Exhaust.4 (CA/EPA Air Resources Board. ‘Health Effects of Particulate Matter and Ozone Air Pollution’, January 2004)1 (Cal EPA, 2005); 2 (Pacific Institute, 2006)3 (CA/EPA Air Resources Board); 4 (CA/EPA Air Resources Board, 2004)
67 Some Examples of Societal Determinants: Availability of resources to meet daily needsEg. safe housingAccess to educational, economic and job opportunitiesAccess to health care servicesQuality of education and job trainingSocial supportExposure to crime, violence and social disorderSocial norms and attitudesEg. discrimination, racismSocioeconomic conditionsEg. concentrated povertyLanguage/LiteracyAvailability of jobs that pay living wageHealthy People 2020 Overview - Social Determinants of Health Accessed at: healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=39
68 Poverty US, CA, LA County: All Ages U.S. Census Bureau, Small Area Income and Poverty Estimates Program, November 2011 Accessed at:
69 Poverty US, CA, LAC: Under Age 18 U.S. Census Bureau, Small Area Income and Poverty Estimates Program, November 2011 Accessed at:
70 Life Expectancy by Median Household Income of Census Tract, LA County, 2005 Note: Median income of LA County census tracts are for the year 1999 and are obtained from: Census 2000 Summary File 3 - United States prepared by the U.S. Census Bureau, 2002
71 *<200%FPL not available by race/ethnicity Percent of Persons Living Below the Federal Poverty Level, by Race/Ethnicity, LA County<100% FPL = Percent of persons less than 100% of Federal Poverty Level*<200%FPL not available by race/ethnicityU.S. Census Bureau, Year American Community Survey, Table C17002
72 Family Poverty Rates* and Education Level, California, 2010 In California, in 2010:, the poverty rate among families without any adult high school graduates was 31.3%.At the other extreme, in families headed by at least one college degree holder, the poverty rate was only 5.2%.For families in which the highest level of education is a high school diploma, the poverty rate was 19.2%.Public Policy Institute of California, Just the Facts: Poverty in California. December Accessed March 14, * Below the Federal Poverty Level of Income (about $22,000 for a family of four)
73 Potential Solutions to Keep People Out of Poverty Educational programsVocational trainingJob trainingChild care supportsLiteracy programsEnglish as Second Language (ESL)Earned Income Tax CreditHousing subsidiesSupplemental food assistance programs (CalFresh, WIC, school nutrition)County Health Rankings 2011; Robert Wood Johnson Foundation. How Social Factors Shape Health: Income, Wealth and Health. Issue Brief Series: Exploring the Social Determinants of Health. April 2011 Photo credit: Ruby Washington, New York Times
74 Improved Educational Outcomes Improved Health Outcomes 74
75 Education Matters: More Formal Education = Longer Life Expectancy Years of School CompletedRobert Wood Johnson Foundation. Overcoming Obstacles to Health: Report from the Robert Wood Johnson Foundation to the Commission to Build a Healthier America. February 2008.75
76 Years of School Completed by Mother, All Ages And It Matters to the Next Generation: Mother’s Education Related to Infant MortalityYears of School Completed by Mother, All AgesRobert Wood Johnson Foundation. Overcoming Obstacles to Health: Report from the Robert Wood Johnson Foundation to the Commission to Build a Healthier America. February 2008.76
77 Percent of Adults with Less than a High School Diploma, by Race/Ethnicity, LA County Note: African American, Asian, Pacific Islander, and American Indian Alaska Native categories include persons reporting both Hispanic and non-Hispanic Origin, therefore categories are not mutually exclusiveU.S. Census Bureau, Year American Community Survey, Table B15002 &C15002
78 Workers with less education are more likely to: Education and Working ConditionsWorkers with less education are more likely to:have occupational hazards (e.g. pesticide, asbestos exposures)have poor working conditions (e.g. shift work)hold lower paying jobsRobert Wood Johnson Foundation. Education Matters for Health. Issue Brief Series: Exploring the Social Determinants of Health. April 2011
79 Education and Working Conditions Workers with less education are less likely to:have paid sick & personal leavereceive retirement benefitshave child or elder care resourcesRobert Wood Johnson Foundation. Education Matters for Health. Issue Brief Series: Exploring the Social Determinants of Health. April 2011
80 Potential Actions to Improve Educational Attainment Increase Nurse Family PartnershipExpand early childhood development programsE.g., HeadStart, SmartStart, universal pre-KComprehensive K-12 school reform to improve achievementMentorship-model programs to improve high school graduation ratesPrograms to help dropouts attain GED certificatesTargeted programs to improve college enrollmentCounty Health Rankings 2011; Recommendations from the Robert Wood Johnson Foundation Commission to Build a Healthier America April 2009.
81 What is Public Health? “…public health is what we, as a society, do collectively to assure the conditions for peopleto be healthy.”- The Future of Public HealthIOM 1988- The Future of the Public’s Health in the 21st CenturyIOM 200381
82 Public Health is…Science of protecting and improving community health by:Using preventive medicine to reduce the community risk for various diseasesEducating the public about things they can do to improve their health (e.g., diet, exercise, safer sex)Controlling the spread of diseaseMonitoring environmental hazardsPromoting policies that improve healthFocused on population and communities, not just individuals82
83 Defining Public Health: 3 Core Functions AssessmentConduct surveillance to measure the health of the population and determinants; investigate health problems and identify causesPolicy DevelopmentInform leaders and the public about health; develop policy solutions and mobilize supportAssuranceEnsure population health by having a competent workforce to enforce laws; medical care available to all; evaluate progress as part of a quality improvement cycle83Institute of Medicine. (1988). The Future of Public Health.
84 Public Health’s Top 10 Accomplishments During the 20th Century Today, Americans live about 30 years longer than in mostly due to Public Health effortsDeveloping vaccinationsEnsuring safer workplacesControlling infectious diseasesDecreasing deaths from heart disease/strokeEnsuring safer and healthier foodsIncreasing family planning optionsRecognizing tobacco use is harmfulDeveloping motor-vehicle safety policiesImproving health for mothers and babiesSource: Centers for Disease Control and Prevention84
85 Los Angeles County Department of Public Health Vision: Healthy People in Healthy CommunitiesMission: To protect health, prevent disease, and promote health and well-beingDepartmental Stats:Annual budget over $850 millionNearly 4,000 employees85
86 Some of Our Staff Public Health Nurses Health Educators EpidemiologistsPhysiciansCommunity WorkersPublic Health InvestigatorsEnvironmental Health SpecialistsMicrobiologistsNutritionistsResearchersVeterinarians86
87 Major Public Health Responsibilities Preventing and Controlling DiseasePromoting Good HealthProtecting Health with Safe and Healthy Environments87
88 Public Health & Health Protection Early warning, emergency preparedness planning & response24/7 disease surveillanceState-of-the-art laboratoryOne-of-a-kind partnershipsBiological, radiological terrorismAction-oriented response to emerging infectionsAssuring conditions to protect healthHousing and food facility inspectionsChildhood lead poisoning preventionLicensure of hospitals/long term care facilities
89 Greater Attention to Public Health Risks & Threats, and Preparedness Overall Naturally emerging disease threats such as pandemic flu, E. coli, West Nile Virus, SARSDiseases used as weapons – anthrax, plague, smallpoxSeptember 11th generated greater emphasis on preparednessPreparedness is not really new to us in CA “earthquake country”The public’s health has been enhanced by substantial investments from CDC, State, and local funds.
90 How We Can Reduce Overall Disease & Injury Burden Level 1 – Treating disease conditionse.g. enhancing disease management for diabetesLevel 2 – Reducing disease risk factors & promoting protective factorse.g. improve nutrition and increase physical activity to prevent obesityLevel 3 – Focus on underlying determinants of diseasee.g. ensure opportunities for people to achieve optimal health bySupporting anti-poverty programs so people can afford to eat healthfullySupporting the development of greenspaces and parks so people can be active
91 Framework for Action: General Model of Health & Improvement Strategies Jobs, urban design, transportation, agriculture, criminal justice, and economic policySocietySocial & Physical EnvironmentEducationWorksite ProgramsClinical Care & Social ServicesSchool HealthIntervention LevelHospital SystemsDisease ManagementAssisted LivingClinical Preventive ServicesHospiceIndividualPRIMARY CARETERTIARY CAREWellDeadHealth StateFielding J, Teutsch S. An Opportunity Map for Societal Investment in Health. JAMA, 2011, Vol 305, No 20,
92 Framework for Action: Applied to Type 2 Diabetes Walkable and Bikeable CommunitiesSocietyMenu LabelingSocial & Physical EnvironmentAffordable ProduceEnhancing School-Based Physical EducationSocial Support Interventions in Community SettingsClinical Care & Social ServicesBehavioral Interventions to Reduce Screen TimeSelf-Management Education (Home & Community)Intervention LevelWorksite Programs for Overweight & ObesityCase Management & Disease ManagementScreen Individuals with Hypertension for DiabetesControl Blood Pressure, Lipid Levels, & SmokingScreen Adults for Obesity and Offer Intensive InterventionsDialysisMajority of health $ investmentsIndividualPRIMARY CARETERTIARY CAREWellPrediabetesDiabetesDeadHealth StateFielding J, Teutsch S. An Opportunity Map for Societal Investment in Health. JAMA, 2011, Vol 305, No 20,
93 How Do We Know What Works? Recommendations for policy and practice, programs and servicesIntervention results and effectiveness
94 The Guides Are Complementary Shawna L. MercerThe Guides Are ComplementaryIndividual levelClinical settingsDelivered by healthcare providersScreening, Counseling, etc.Clinical Guide(USPSTF Recommendations)Group levelHealth system changesInsurance/benefits coverageAccess to/provision of servicesCommunity, population-basedInformational (Group Education, Media)Behavioral, Social, Environmental & Policy ChangeCommunity Guide(TFCPS Recommendations)94
95 The Guides: Selecting Interventions for Systematic Review Over 1,000 single and multi-component interventions to evaluateThose evaluated to date selected on their potential to:burden of disease and injuryhealthy behaviors and reduce unhealthy behaviorsimplementation of effective interventions that are not widely usedlevel of interest among providers and decision makers consistent with resource constraints
96 Why Evidence is Essential Aids in efficiency – doing what we know works firstIncreases accountability by supporting more efficient use of public and private resourcesProvides a higher likelihood of successful programs and policies being implemented (opportunity cost of using non-evidence based strategies can be very high)Brownson RC, et al. Evidence-based public health: a fundamental concept for public health practice. Annu Rev Public Health 2009;30:8-4-0896
97 To Learn More Visit Us at: publichealth.lacounty.gov Annual Report | Data and Statistics | LAC DPH Program Websitestwitter.com/lapublichealth | youtube.com/lapublichealth