System, policy and environmental change: Evidence, Gaps and Implications Presented by: Laura K. Brennan, PhD, MPH.

System, policy and environmental change:

Evidence, Gaps and Implications

Presented by:

Laura K. Brennan, PhD, MPH

Overview

Projects Brief Description

1. Social determinants of health(2003-2010)

Funding: Centers for Disease Control & PreventionProcess: Forum, Presentation, ApplicationProducts: Workbook, Training, Train-the-trainer

2. Evaluation of Active Living by Design (2006-2010)

Funding: Robert Wood Johnson FoundationProcess: Interviews/Site visitsProducts: Journal Supplement, Case Reports

3. Review of environment & policy interventions for childhood obesity prevention (2008-2011)

Funding: Robert Wood Johnson FoundationProcess: Advisors, Resource reviewProducts: Intervention strategy summaries, Gaps

4. Evaluation of Healthy Kids, Healthy Communities (2009-2014)

Funding: Robert Wood Johnson FoundationProcess: Technical assistance, Interviews/Site visitsProducts: Articles, Policy Briefs, Resources, Tools

5. System dynamics modeling to inform overweight and obesity-relevant policy (2009-2011)

Funding: National Institutes of HealthProcess: Group model buildingProducts: System dynamics models

Our Team

Julie Claus, Chief Operating Officer

Sarah Castro, Project Director

Peter Holtgrave, Project Director

Tammy Behlmann, Project Manager

Laura Runnels, Project Manager

Courtney Jones, Project Coordinator

Allison Kemner, Project Coordinator

Daedra Lohr, Financial Coordinator

Many part-time staff and interns

Our Local Collaborators

Elizabeth Baker, Saint Louis University

Cheryl Kelly, Saint Louis University

Ross Brownson, Washington University

Cheryl Carnoske, Washington University

Debra Haire-Joshu, Washington University

Christine Hoehner, Washington University

Peter Hovmand, Washington University

Timothy Hower, Washington University

Our National Advisors

Researcher Partners Karen Glanz Frank Chaloupka Lawrence Green Shiriki Kumanyika Marc Manley Barbara Riley James Sallis Eduardo Sanchez Loel Solomon Janice Sommers Mary Story Antronette Yancey

RWJF, NIH & CDC Rachel Ballard-Barbash Jamie Bussell William Dietz Terry Huang Laura Kettel-Khan Laura Leviton Elizabeth Majestic Robin McKinnon Shawna Mercer Marilyn Metzler Meredith Reynolds Tracy Orleans Thomas Schmid Celeste Torio Pattie Tucker

Policy/Practice Partners Don Bishop Elaine Borton Leah Ersoylu Steve Farrar Harold Goldstein Dean Grandin James Krieger Jacqueline Martinez Malisa McCreedy Leslie Mikkelsen Joyal Mulheron Maya Rockeymoore Marion Standish Sarah Strunk Ian Thomas Mildred Thompson

Social Determinants of Health:Learning from Doing

Ottawa Charter

International Conference on Health Promotion in 1986

Health promotion approach:– Building healthy public policy– Creating supportive environments– Strengthening community actions– Developing personal skills– Reorienting health services

Ottawa Charter

“Health promotion is the process of enabling people to increase control over, and to improve, their health. To reach a state of complete physical, mental and social well-being, an individual or group must be able to identify and to realize aspirations, to satisfy needs, and to change or cope with the environment... People cannot achieve their fullest health potential unless they are able to take control of those things which determine their health. At the heart of this process is [communities taking] ownership and control of their own endeavors and destinies.”

Ottawa Charter for Health Promotion (1986)

Common Language

Community

Health disparities

Health inequities

Health equity

Social determinants of health (SDOH)

Community

A group of people with a shared identity, including:

living in a particular geographic area; having some level of social interaction; sharing a sense of belonging; or having common political or social responsibilities

References: Eng, Parker (1994), Fellin (1995), Hunter (1975), Israel, et al (1994), MacQueen, et al (2001), McKnight (1992)

Two or more races1%

American Indian/ Alaska Native

1%

African American12%

Hispanic15%

Native Hawaiians/Pacific

Islanders0%

White

66%

Asian4%

Distribution of U.S. Population by Race/Ethnicity, 2007

NOTES: Data do not include residents of Puerto Rico, American Samoa, Guam, the U.S. Virgin Islands, or the Northern Mariana Islands. Totals may not add to 100% due to rounding. All racial groups and individuals reporting “two or more races” non-Hispanic.SOURCE: Kaiser Family Foundation, based on Table 3: Annual Estimates of the Population by Sex, Race and Hispanic Origin for the United States: April 1, 2000 to July 1, 2007 (NC-EST2007-03). Population Division, U.S. Census Bureau.

Total = 301.6 million

(199.1 million)

(4.2 million)

(45.5 million)

(37.0 million)

(13.1 million)

(2.3 million)

(0.4 million)

Share of Population that is a Racial/Ethnic Minority by State, 2005-2006

SOURCE: Urban Institute and Kaiser Commission on Medicaid and the Uninsured analysis of March 2006 and March 2005 Current Population Survey.

Less than 14% (11 states)

14% to 21% (13 states)

22% to 36% (14 states)

More than 37% (13 states)

Distribution of U.S. Population by Race/Ethnicity, 2000 and 2050

NOTES: Data do not include residents of Puerto Rico, Guam, the U.S. Virgin Islands, or the Northern Marina Islands. “Other” category includes American Indian/Alaska Native, Native Hawaiian or Other Pacific Islander, and individuals reporting “Two or more races.” African-American, Asian, and Other categories jointly double-count 1% (2000) and 2% (2050) of the population that is of these races and Hispanic; thus, totals may not add to 100%.SOURCE: Kaiser Family Foundation, based on http://www.census.gov/population/www/projections/popproj.html, U.S. Census Bureau, 2004, US Interim Projections by Age, Sex, Race, and Hispanic Origin.

8.0%12.7%14.6%

12.6%

24.4%

69.4%

50.1%

2.5% 5.3%3.8%

2000 2050

White, Non-Hispanic

Hispanic

African American

Asian

Other



http://www.census.gov/population/www/projections/popproj.html

Health Disparities

Differences in the incidence and prevalence of health conditions and health status between groups, based on:

Race/ethnicitySocioeconomic statusSexual orientationGenderDisability statusGeographic locationCombination of these

Reference: Braveman P. (2006)1

Cancer Screening Rates by Race/Ethnicity*, 2003

18.3%

67.8%

58.2%

22.3%

82.6%

70.0%

15.4%

74.6%

65.1%

22.7%

80.2%

70.4% White, Non-Hispanic

Hispanic

African-American, Non-Hispanic

Asian

NOTES: * Data for American Indians/Alaska Natives and Native Hawaiians/Pacific Islanders do not meet the criteria for statistical reliability, data quality or confidentiality. Age-adjusted percentages of women 40 and older who reported a mammography within the past 2 years, women 18 and older who reported a pap test within the past 3 years, and adults 50 and older (male and female) who reported a fecal occult blood test within the past 2 years. SOURCE: Kaiser Family Foundation, based on the National Healthcare Disparities Report, 2005, available at: http://www.ahrq.gov/qual/nhdr05/index.html, using data from the Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey.

Breast Cancer (Mammograph

y)

Cervical Cancer

(Pap Test)

Colon and Rectum Cancer

(Fecal Occult Blood Test)

http://www.ahrq.gov/qual/nhdr05/index.html

Health Inequities

Systematic and unjust distribution of social, economic, and environmental conditions needed for health

Access to healthcare Employment Education Access to resources (e.g., grocery stores, car seats) Income Housing Transportation Positive social status Freedom from discrimination

Reference: Whitehead M. et al7

Health Insurance Status, by Race/Ethnicity: Children, 2007

36% 43%

68%

31%

58%

43%45%

19% 34%

8%21%

13% 12% 19%

73%

20%

NSD

8%

White

44.7 million

AfricanAmerican

11.6 million

Hispanic

16.5 million

Asian/Pacific

Islander

3.3 million

American Indian/Alaska Native

0.5 million

NOTES: “NSD” = Not sufficient data; “Other Public” includes Medicare and military-related coverage. All racial groups non-Hispanic.* = Estimate has a large 95% confidence interval of +/- 5.0 - 7.9 percentage points.SOURCE: Urban Institute and Kaiser Commission on Medicaid and the Uninsured analysis of the March 2008 Current Population Survey.

Total Child

Population 2007

Two or More Races

2.1 million

Private (Employer and Individual) Medicaid and Other Public Uninsured

*

*

9.5%

18.7%16.5%

23.0%

12.7%

Percent Uninsured, Ages 55-64, by Race/Ethnicity, 2006

DATA: March 2007 Current Population SurveySOURCE: Kaiser Commission on Medicaid and the Uninsured estimates.

33%

White, Non-Hispanic

Hispanic African American, Non-Hispanic

Asian/Pacific Islander

American Indian/Alaska Native

Two or More Races

No Doctor Visit in Past Year for Nonelderly Adults by Race/Ethnicity and Insurance

Status, 2005-2006

14%

21%

13% 13%

20%

14%

39%

53%

40%

31%

48%45%

White, Non-Hispanic

Hispanic AfricanAmerican

AmericanIndian/ Alaska

Native

Asian andNHPI

Two or MoreRaces

Insured Uninsured

SOURCE: Kaiser Family Foundation and Urban Institute analysis of the National Health Interview Survey, 2005 and 2006, two-year pooled data.

No Usual Source of Care for Nonelderly Adults by Race/Ethnicity and Insurance

Status, 2005-2006

9%13%

8% 7%11% 11%

45%

62%

45%

35%

48%41%

White, Non-Hispanic

Hispanic AfricanAmerican

AmericanIndian/ Alaska

Native

Asian and NHPI Two or MoreRaces

Insured Uninsured

SOURCE: Kaiser Family Foundation and Urban Institute analysis of National Health Interview Survey, 2005 and 2006, two-year pooled data.

Life Expectancy at Age 25 for U.S. Black and White Men with Similar

Income Levels

52.950.2

45.050.2

47.441.6

0

10

20

30

40

50

60

White Men

Black Men

* 1980s income levelsSOURCE: NLMS: Lin et al 2003 and Nancy E. Adler, Health Disparities: Measurement, Mechanisms, and Meaning presentation, NIH

$25,000 or more $10,000 or less$10,000-$24,999

*

Infant Mortality Rates for Mothers Age 20+, by Race/Ethnicity and Education,

2001-2003

4.6

5.3

5.2

3.9

5.6

5.0

4.2

6.5

9.2

7.0

9.2

10.7

11.5

13.4

15.1 African American,Non-Hispanic

AmericanIndian/ Alaska Native

White, Non-Hispanic

Asian/ PacificIslander

Hispanic

SOURCE: Kaiser Family Foundation, based on Health, United States, 2006, Table 20, using data from the National Center for Health Statistics, National Vital Statistics System, National Linked Birth/Infant Death Data.

Less than

High School

High School

College+

Infant deaths per 1,000 live births:

Health Equity

The opportunity for everyone to attain his or her full health potential

No one is disadvantaged from achieving this potential because of his or her social position or other socially determined circumstance

Distinct from health equality

Reference: Whitehead M. et al7

Social Determinants

Life-enhancing resources, such as food supply, housing, economic and social relationships, transportation, education and health care, whose distribution across populations effectively determines length and quality of life.

Reference: James S. (2002)6

Diseases and Behaviors

Tobacco Use

Poor Nutrition

Physical Activity

Physician Visits

Arthritis/Lupus ✓ ✓ ✓

Asthma ✓ ✓ ✓

Breast Cancer ✓ ✓ ✓

Colorectal Cancer ✓ ✓ ✓

COPD (Lung Disease) ✓ ✓

Diabetes ✓ ✓ ✓ ✓

Heart Disease and Stroke ✓ ✓ ✓ ✓

Hepatitis B ✓

Immunizations (for adults) ✓

Infant Health Problems ✓ ✓ ✓ ✓

Injury from falls ✓ ✓

Lung Cancer ✓ ✓ ✓

Oral Health ✓ ✓ ✓

Pneumonia and Influenza ✓ ✓

SDOH and Health

Pathways from social determinantsto health

Active Living by Design

National program, The Robert Wood Johnson Foundation

Purpose: To establish innovative approaches to increase physical activity through community design, public policy, and communications strategies

ALbD Community Action (or “5P”) Model: – Preparation– Promotion– Programs– Policy Influence– Physical Projects

www.activelivingbydesign.org

http://www.activelivingbydesign.org/

ALbD Products

ALbD Best Practices special issue (available: http://www.activelivingbydesign.org/AJPM)

ALbD Evaluation special issue (under development)– Active Living Research evaluation (2 communities)– Progress reporting– Concept mapping– “5P” strategies and integration of approaches

Other reports/products: – Cross-site report– Community partnership summaries

http://www.activelivingbydesign.org/AJPM

Healthy Kids, Healthy Communities

National program, The Robert Wood Johnson Foundation

Purpose: To implement healthy eating and active living policy- and environmental-change initiatives that can support healthier communities for children and families across the United States

HKHC places special emphasis on reaching children who are at highest risk for obesity on the basis of race/ethnicity, income and/or geographic location

www.healthykidshealthycommunities.org

http://www.healthykidshealthycommunities.org/

HKHC Leading Site Communities

Healthy Kids,Healthy Communities

Seattle/King County, WA

Oakland, CA

Central Valley, CA

Baldwin Park, CA

Columbia, MO

Chicago, IL

Louisville, KY

Washington, DC

Somerville, MA

Benton County, OR

Watsonville/Parajo Valley, CA

Rancho Cucamonga, CA

Phoenix, AZ

Cuba, NM

San Felipe Pueblo, NM

Grant County, NM

El Paso, TX

San Antonio, TX Houston, TXNew Orleans, LA

Jackson, MS

Desoto/Marshall/ Tate Counties, MS Jefferson County, AL

Boone/Newton Counties, AR

Kansas City, MO

Omaha, NE

Denver, CO

Kane County, IL

Milwaukee, WI

Houghton, MI

Flint, MI

Hamilton County, OH

Knoxville, TNChattanooga, TN

Moore/Montgomery Counties, NC

Greenville, SCSpartanburg, SC

Milledgeville, GA

Cook County, GA

Duval County, FL

Lake Worth/Greenacres/ Palm Springs, FL

Caguas, PR

Charleston, WV

Philadelphia, PA

Kingston, NYBuffalo, NY

Fitchburg, MARochester, NY

Healthy Kids, Healthy Communities (50 Grantees)

Nash/Edgecombe Counties, NC

Portland/Multnomah County, OR

Assessment & Evaluation

To determine the effectiveness of local policy, environment, and systems approaches to prevent or reduce childhood obesity Short-, intermediate- & long-term impacts and outcomes related to health behaviors and obesity Reliable & valid quantitative tools & measures Study design and execution to ensure confidence in the findings from the evaluation

To identify the approaches with the greatest impact, relevance, feasibility and sustainability What works, where it works, when it works, how it works & why it works (or why not) Multi-method quantitative & qualitative measures Local representation and participation to ensure confidence in the findings from the evaluation

To inform local decision-making, document successes & obtain more funding Track intended/unintended results, practical considerations (resources, costs), assets & challenges Simple, quick measures serving multiple purposes (advocacy, marketing, cost/benefit) Findings translate to the interests of local audiences (decision-makers, business owners)

THESE ARE NOT MUTUALLY EXCLUSIVE…

Why Evaluate?

Evidence Goals

1) To bridge research/evaluation and policy/practice efforts associated with environment and policy nutrition and physical activity intervention strategies for childhood obesity prevention.

2) To accelerate the translation of replicable, evidence-based environment and policy interventions that will lead to leveling and eventually reducing rates of childhood obesity, especially in lower income and racial/ethnic populations.

Evidence Levels

How do we define levels of evidence in order to

bridge the gap between

research/evaluation and

policy/practice efforts?

How do we create a complementary process

to identify, collect and review

a range of different evidence resources from research/evaluation

and

policy/practice efforts?

Evidence Review

PROMISING STRATEGIES

INPUT Identification and collection of resources (inclusion/exclusion criteria)

EFFECTIVE (1st TIER) STRATEGIES

EMERGING STRATEGIES

Remove OUTPUTImplementation

guides

OUTPUTEvaluation, feasibility &

impact studies

OUTPUTPilot studies

EFFECTIVE (2nd TIER) STRATEGIES

OUTPUTSystematic review

Evidence gaps

Review Cycle

Inventory & Abstraction

Articles Inventoried– Approx. 850 to be considered for effective (1st & 2nd tier)– Approx. 350 to be considered for promising and emerging– 227 federal bills

Articles Abstracted– 44 from effective (1st tier) reviews– Approx. 390 effective (2nd tier) or promising

• 128 Nutrition• 259 Physical Activity

Intervention Strategy Summary

Summary & synthesis of findings for each intervention strategy

Includes:– Strategy overview (e.g., description, evidence

rating)– Evidence summary (e.g., key ingredients,

research/evaluation gaps, policy/practice implications)

– Evidence tables for each study

Applying the Evidence TypologyE

FF

EC

TIV

E

Design/ Execution/Effectiveness Reach/Adoption/Implementation/Maintenance

Experimental, quasi-experimental, prospective cross-sectional or natural experimental study design

High quality study execution (sampling/recruitment, statistical power, measures of exposure, internal validity)

Effectiveness of intervention at changing obesity, physical activity or nutrition outcomes; demonstrating policy, environmental or economic impact

Potential to directly or indirectly reach children and families; racial/ethnic and lower income populations

Description of resources needed; anticipated support and opposition influencing adoption

Use of theory or logic model; implementation fidelity or quality assurance assessment; sufficient description of intervention for replication

Description of practicability for ongoing funding and support; plans for enforcement and maintenance

Applying the Evidence TypologyP

RO

MIS

ING


Quantitative or qualitative study design

High quality study execution (sampling/recruitment, statistical power, measures of exposure, internal validity)

Plausible effectiveness of intervention at changing obesity, physical activity or nutrition outcomes; demonstrating policy, environmental or economic impact





Applying the Evidence TypologyE

ME

RG

ING


Plausible effectiveness of intervention at changing obesity, physical activity or nutrition outcomes; demonstrating policy, environmental or economic impact





Intervention Strategy Summaries

Healthy EatingSchool food & beverage policies

School wellness policies

National school lunch & breakfast program

Provision of free or subscription F&V at school

Provision of free drinking water at school

Menu Labeling

Childcare food & beverage policies

Food pricing (schools & community)

Neighborhood availability of restaurants

Neighborhood availability of food stores

Neighborhood availability of food stores & restaurants

School & Community Gardens

Government Nutrition Assistance Programs

TOTAL number of Interventions to-date= 128

Active LivingSchool physical activity policies

School physical activity environments

Childcare physical activity policies

Safe Routes to School

Neighborhood availability of parks, playgrounds, trails and recreation centers

Neighborhood safety

Point of decision prompts for physical activity

Community design

Street design

Transportation policies

Screen time

TOTAL number of interventions to-date= 259

Inputs & Outputs

RESOURCEINVENTORY ABSTRACTION

StrategicPartners

&SystematicMethods

StrategicPartners

&SystematicMethods

Inputs

SystematicReviews

Peer-Reviewed Studies

Evaluation Reports

Community Demonstration

Projects

Pilot or Case Studies

Policy Briefs

Standards of Practice

Outputs

Research & Evaluation Findings

Gaps in Existing

Evidence

Policy & Environment

Changes

Other Key Ingredients

Local Context

Tools, Guides & Models

Transtria LLC/Washington University Institute for Public Health

Build connections to related efforts

Review of Environment &

Policy Interventions

Food and Nutrition Board

Institute of Medicine

Center of Excellence for Training and Research

Translation

University of North Carolina, Chapel Hill

Task Force on Community Preventive

Services

Centers forDisease Controland Prevention

Physical Activity Policy

Research Network

StateHealthDepts

CDC/RWJF Measurement (COCOMO)

CDC/RWJF Early Assessment Initiative

The Robert WoodJohnson Foundation

Leadership for Healthy Communities

Center for Childhood Obesity Prevention

National Institutesof Health

Healthy Kids, Healthy Communities

Bridging the Gap

Active Living Research

Healthy EatingResearch

Salud America!

Communities Creating Healthy Environments

Discussion Activity

County Health Rankings (115 Missouri Counties Ranked)

Health Outcomes (Morbidity & Mortality)

Robert Wood Johnson Foundation & University of Wisconsin Population Health Institute

County Outcomes Morbidity Mortality

St. Louis City 106 106 107

St. Louis County 18 32 11

St. Charles County 2 6 1

Discussion Activity

County Health Rankings (115 Missouri Counties Ranked)

Health Factors (Behaviors, Clinical Care, Social and Economic, and Environmental)

Robert Wood Johnson Foundation & University of Wisconsin Population Health Institute

County Factors Behavior Clinical Social & Economic Environment

St. Louis City 115 113 4 115 115

St. Louis County 6 3 2 15 114

St. Charles County

1 1 5 2 111

Community

Who does your community include? Who does it not include?

Does your community have definite geographic boundaries?

Are there social or cultural ties that link your community members to one another?

Does your community have multiple communities within it? How would you describe these communities?

What are other characteristics of your community?

Health Equity

o What are the health concerns of individuals in your community (e.g., asthma, diabetes)?

o What are the conditions that affect your whole community (e.g., air pollution, high concentration of fast food restaurants)?

o Are the health concerns and conditions affecting health differently for various groups in your community?

Social Determinants of Health

How are resources (e.g., food, housing, local businesses, transportation, health care services) distributed within your community?

How do resources in your community compare to those in surrounding communities?

How can social determinants impact health behaviors?

Laura K. Brennan, PhD, MPH

President and [email protected]

mailto:[email protected]

System, policy and environmental change: Evidence, Gaps and Implications Presented by: Laura K. Brennan, PhD, MPH.

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