Behavior, Lifestyle, and Social Determinants of Heart Health: From Research to Policy, Planning, Programs & Services

Lawrence W. Green
Office of Extramural Prevention Research Public Health Practice Program Office Centers for Disease Control and Prevention U.S. Department of Health & Human Services
York University Forum, Toronto, Feb. 20, 2003

Health Promotion, Health Protection, and Disease Prevention

Social
structure, conditions
Culture, lifestyle, attitudes & policies about risk

Health Promotion
Primary Prevention & Health Protection

Risk behaviors & Environmental exposures

Adverse health events

Secondary Prevention
Self-care Tertiary Prevention

Sequelae, Outcomes

Lesson 1. Social determinants operate as background & as distal determinants on most of the proximal determinants of health.

Determinants of Health*
More Distal
Income & social status Gender Education Employment & working conditions Physical environment Biology & genetic endowment

More Proximal
Personal health practices & coping skills Healthy child development Health & social services Culture Social support networks Social environment

*Tonmyr et al., The population health perspective Chronic Diseases in Canada 23:123-129, Fall 2002.

Lesson 2: The Social Determinants Imperative and Opportunity

From

tobacco control experience, we know that some work with other sectors and work within the health sector on more distal determinants is essential to long-term success Many, if not most, social determinants are:
More proximal, and/or Amenable to health sector intervention, and/or Amenable to collaboration with other sectors

Achieving Health for All*

AIM
ACHIEVING HEALTH FOR ALL

HEALTH CHALLENGES

REDUCING INEQUITIES

INCREASING PREVENTION

ENHANCING COPING

HEALTH PROMOTION MECHANISMS

SELF-CARE

MUTUAL AID

HEALTHY ENVIRONMENTS

IMPLEMENTATION STRATEGIES

FOSTERING PUBLIC PARTICIPATION

STRENGTHENING COMMUNITY HEALTH SERVICES

COORDINATING HEALTHY PUBLIC POLICY

*Epp, Jake. Achieving health for all: a framework for health promotion. Ottawa: Minister of Supply and Services, 1986.

What is this public health achievement of the 20th Century? What is the evaluation method to judge this an achievement?
5,000

4,000

Number of Cigarettes

35%

3,000

2,000

22%

1,000

0 1900

1910

1920

1930

1940

1950

1960

1970

1980

1990

Adult Per Capita Cigarette Consumption and Major Historical EventsUnited States, 1900-2000
1st World Conference on Smoking and Health
5,000

Broadcast Ad Ban

1st Surgeon Generals Report End of WW II

4,000

Number of Cigarettes

3,000

2,000

1,000

1st Great American Smokeout Nicotine Medications Available Over the Counter Master Settlement Agreement Fairness Doctrine Messages on TV and Radio 1st SmokingCancer Concern Surgeon Generals Report on Environmental Nonsmokers Tobacco Smoke Rights

Great Depression
0 1900 1910 1920 1930 1940 1950

Movement Begins
1960 1970

Federal Cigarette Tax Doubles

1990

1980

Source: USDA; 1986 Surgeon General's Report

Lesson 3: Surveillance--Making Better Use of Natural Experiments

Key

to establishing baselines & trend lines that can be projected to warn against neglect Key to putting an issue on the public policy agenda Key to showing change in relation to other trends, policy and program interventions Key to comparing progress in relation to objectives and programs, over time and between jurisdictions.

Lesson 4: Evaluation of ecological approaches to prevention on community-wide or province-wide scale should not attempt to isolate the components.

Lesson 5: Comprehensiveness
In

trying to isolate the essential components of tobacco control programs that made them effective, none could be shown to stand alone Any combination of methods was more effective than the individual methods The more components, the more effective The more components, the better coverage

Cost (US$) Per Year of Life Saved

Smoking cessation Low intensity interventions Brief advice, MD High intensity interventions Common disease prevention Secondary or tertiary care $100 - 500 $1,000 - 3,000 $6,000 - 15,000 $1,500 - 15,000 $20,000 - 100,000

Source: Warner KE. Smoking cessation: Alternative strategies: Financial implications. Tobacco Control , Autumn 1995.

Lesson 6: Effectiveness and benefit may increase with intensity, but cost-utility and cost-effectiveness often decline. Intensity limits reach. -->Issue of inequalities.

Estimated Efficacy (6-month quit rates), Reach (number using), and Impact of Main Cessation Strategies
Intervention Ef Reach # Impact Impact % us ing US U.S. B .C. None (un aided) 3 22,800,000 684,000 7,600 R x NR T O TC NR T Behavioral Inpatient Rx 14 14 24 32 2,500,000 280,000 3,111 6,300,000 560,000 6,222 395,000 500 94,800 1,053 160 2

Lesson 7: Cost-benefit and cost-effectiveness depend as much on the reach as on the efficacy of interventions.

Change in Per Capita Cigarette Consumption

California & Massachusetts versus Other 48 States, 1984-1996
5
Percent Reduction

0 -5 -10 -15 -20 -25

Other 48 States California Massachusetts

1984-1988

1990-1992

1992-1996

What Worked? Making Better Use of Natural Experiments

Comprehensive

program and tax increases in CA and MA resulted in:

2 - 3 times faster decline in adult smoking prevalence Slowed rate of youth smoking prevalence compared to the rest of the nation Accelerated passage of local ordinances

Similar,

though later, experience in OR & AZ, and in population segments of FL

Components of Comprehensive Tobacco Control Programs

Community Statewide

Programs

Counter-Marketing Cessation

Programs

Programs

Chronic

Disease Programs
Programs

Surveillance

and
and

Evaluation
Administration

School

Enforcement

Management

Lesson 8: The Ecological Imperative

Need

to address the problem at all levels

Individual Organizational, institutional Community State, regional National, international

Need

to make these levels of intervention mutually supportive and complementary

Reduction in State Consumption

Percent Reductions in Per Capita Cigarette Consumption Attributable to Non-Price Public Health Interventions
80%

70%
60% 55% 40% 20% $ 2 $ 4 $ 6 $ 8 20% $ 10

Dollars Per Capita Annual Spending on Programs

Lesson 9: Threshold Spending

A

critical mass of personal exposure is needed for individuals to be influenced A critical mass of population exposure is necessary to effect detectable community response A critical distribution of exposure is necessary to reach segments of the population who are less motivated

Per Capita Spending on Tobacco Prevention and Control--FY1997

CDC CDC/ RWJF NCI NCI/ RWJF Oregon

Arizona
California Massachusetts $0 $2 $4 $6 $8 Dollars Per Capita $10 $12

Lesson 10: The Environmental Imperative

Environments

provide opportunities Environments provide cues Environments enable choices Social environments reinforce positive behavior and punish negative behavior Legal penalties and financial incentives can be built into environments

100-Percent Smokefree Ordinances, by Year of Passage

Number of Ordinances
18 16 14 12
Workplace Restaurant Restaurant and Workplace

10
8 6 4 2 0 1985 1986 1987 1988 1989 1990 1991 1992*

* Through September 1992. Source: National Institutes of Health, National Cancer Institute (1993). Smoking and Tobacco Control - Monograph 3. Major Local Tobacco Control Ordinates in the U.S.

Year

US Dept. of Health and Human Service. Public Health Service, National Institutes of Health. NIH Publ. No. 93-3532.

Tobacco Vending Machine Ordinances

Number of 180 Ordinances (Cumulative) 160 140 120 100 80 60 40 20 0 1985 1986 1987 1988 1989 1990 1991 1992*

Total Ban Partial Ban

* Through September 1992. Source: National Institutes of Health, National Cancer Institute (1993). Smoking and Tobacco Control - Monograph 3. Major Local Tobacco Control Ordinates in the U.S.
US Dept. of Health and Human Service. Public Health Service, National Institutes of Health. NIH Publ. No. 93-3532.

Year

Lesson 11: The Educational Imperative

Public

awareness of risks and benefits Public interest in lifestyle options Public understanding of behavioral steps Public attitudes toward the options & steps Public outrage at the conditions that have put them at risk or in danger Personal and political actions

Lesson 12: The Evidence-Based Imperative: The Need to Bridge...

best

practices indicated by research to their application in practice in underserved areas best practices from research to the most appropriate adaptations for special populations The success of individual behavior changes of the affluent to the system changes needed to reach the less affluent, less educated University-based, investigator-driven research to practitioner- & community-centered research

Breaking the Intervention-Based Research and Planning Habit

1. Select off-the-shelf Intervention or Service to be Studied 4. Evaluate Response to the Intervention or Service 2. Assess Response to the Intervention or Service

3. Increase Dose or Increase Demand

Strengthening Population-based, Diagnostic Planning Approaches*

1. Assess Needs & Capacities of Population

4. Evaluate Program

Reassess causes

2. Assess Causes, Set Priorities & Objectives Redesign

3. Design & Implement Program

*Procedural models, such as PRECEDE, PATCH, Intervention Mapping. See

Green & Kreuter, Health Promotion Planning, 3rd ed., Mayfield, 1999.

Uses of Evidence in PopulationBased Planning Models

A. Evidence
from community or population

1. Assess Needs & Capacities of Population B. Evidence from

Research

4. Evaluate Program D2 D. Program Evidence

Reconsider X

2. Assess Causes (X) & Resources

C. Evidence from R&D and Exptal. Studies

3. Design & Implement Program

From previous evaluations (D1)

Surveillance, Planning and Evaluating for Policy and Action: PRECEDE-PROCEED MODEL*
Phase 5 Administrative & policy assessment Phase 4 Educational & ecological assessment
Predisposing

Phase 3 Behavioral & environmental assessment

Phase 2 Phase 1 Epidemiological Social assessment assessment

Health Program

Formative evaluation & baselines for outcome evaluation

Behavior Health Quality of life

Intervention Mapping & Tailoring

Health education Reinforcing Policy regulation organization Enabling

Environment

Phase 6 Implementation
Input Process

Phase 7 Process evaluation

Output

Phase 8 Impact evaluation

Longer-term health outcome

Phase 9 Outcome evaluation

Short-term social impact Long-term social impact

Monitoring & Continuous Quality Improvement

Short-term impact

*Green & Kreuter, Health Promotion Planning, 3rd ed., 1999.

Towards an Integrated Model*

FRAMING
Social Ecology
Life Course Community Partnering

FOCUSING
Population Health Models of Change Best Practices Dissemination Policy

EVALUATING

Analysis and Interpretation

Health Promotion Planning

*A.Best, D.Stokels, L.Green, et al., AJHP, in press.

Components of an Integrated Model

Social Ecology - How do we see the problem? Life Course Health Development - How do people and their health needs change? Health Promotion Planning & the PrecedeProceed Model - How do we plan & promote change? Community Partnering - How do we work together?

CIHR Knowledge Translation

KT Research Cycle
Research
Research Priorities Open Competition

Evaluation of Uptake

Research

Use

Communication Marketing Training

Knowledge Priority Setting

Knowledge Distribution & Application

Knowledge Synthesis
Expertise Research

Expertise Research

Dissemination Model
Tends

to linear, one-way communication Presumes centrally defined needs Limited, inconsistent impact Incomplete monitoring and evaluation capacity Disciplines and literatures isolated Lack of systems thinking

Evidence-Advocacy-Policy-Practice Cycle* External Extramural

Research Agenda Setting Advocacy Assessment of Need Evidence Inequalities Refine programs Best Practices Commitment to Develop Policy and Action Advocacy
Consultation
To frame policy and action plan To build support

Diffusion research Dissemination

Surveillance and Evaluation

Uptake & Outcomes Government Professionals Communities

All agencies with capacity to act or Contribute (coalition)

Endorsement

The Lenses of Health Professionals and Lay People

Subjective Indicators of Health Professional Layperson

Objective Indicators of Health

Adapted from Yukon Bureau of Statistics, Whitehorse, 1995 LW Green, Inst of Health Promotion Research, Univ. British Columbia, Vancouver, BC V6T 1Z3

Understanding Differences Among Publics Perception of Needs, the Health Sectors Assessments, and the Political Assessments
Publics perceived needs, C priorities
E

Actual needs
D B

A A

Resources, feasibilities, policy

LW Green, Inst of Health Promotion Research, Univ. British Columbia, Vancouver, BC V6T 1Z3

Strategies to Reconcile Perceived & Actual Needs, & Resources

Participatory Research
A A

Health Education
(advocacy)

Community mobilization & organizational development

LW Green & MW Kreuter, Health Promotion Planning: An Educational and Ecological Approach , 1999.

Definition of Participatory Research (www.ihpr.ubc.ca/guidelines.html)

--Systematic investigation...
--Actively involving people in a learning process... --For the purpose of social action (new services, resource allocation, regulation or policy) conducive to [their/their constituents] health or quality of life. --What Participatory Research is not... --not just involving people more intensively as subjects of research