The Emerging Case for the Effectiveness of Health Promotion David V. McQueen Associate Director for Global Health Promotion World Bank, September 14, 2004.

The Emerging Case for the The Emerging Case for the Effectiveness of Health Effectiveness of Health

PromotionPromotion

David V. McQueenDavid V. McQueenAssociate Director for Global Associate Director for Global

Health PromotionHealth PromotionWorld Bank, September 14, 2004World Bank, September 14, 2004

The accepted triangular relationship

Policies & ProgramsPolicies & Programs(Health or Non-health)(Health or Non-health)

DeterminantsDeterminantsof Healthof Health

Health ImpactHealth Impact(Outcomes)(Outcomes)

An old-old (tedious) storyAn old-old (tedious) story

The health of populations is affected The health of populations is affected by and is a product of the social by and is a product of the social determinants in the populationdeterminants in the population

Early Insights orEarly Insights orwe knew it thenwe knew it then

Graunt (London, 1662)Graunt (London, 1662)• Analysis of social distribution of Analysis of social distribution of

mortality rates mortality rates Virchow and Engels (mid-19Virchow and Engels (mid-19thth

century) century) • Effects of social class and work Effects of social class and work

conditions on illness ratesconditions on illness rates Durkheim (Paris, 1897)Durkheim (Paris, 1897)

• Social integration and suicideSocial integration and suicide

History and Theory of Public Health:History and Theory of Public Health:

Slowly Changing ParadigmsSlowly Changing Paradigms Sanitary Era (when we knew it)Sanitary Era (when we knew it)

Germ TheoryGerm Theory

Infectious & Chronic Disease Infectious & Chronic Disease Epidemiology Epidemiology (individual risk factor (individual risk factor epidemiology--“social” Epidemiology)epidemiology--“social” Epidemiology)

* * Health Promotion (finding it again)Health Promotion (finding it again)

Health Promotion Perspective: Health Promotion Perspective: The Components of The Components of ContextContext

LIFELIFESTYLESTYLE: Collective pattern of life conduct: Collective pattern of life conduct LIFE LIFE CONDUCTCONDUCT: Pattern of behavior of an : Pattern of behavior of an

individual in their day-to-day livesindividual in their day-to-day lives LIFE LIFE CONDITIONSCONDITIONS: Patterns of resources of an : Patterns of resources of an

individual or group (including health status)individual or group (including health status) LIFE LIFE SITUATIONSITUATION: Collective pattern of life : Collective pattern of life

conditions conditions LIFE LIFE CHANCESCHANCES: Structural-based probability of : Structural-based probability of

correspondence of lifestyle and life situationcorrespondence of lifestyle and life situation

Adapted from Rutten, A. (1995). The implementation of health Adapted from Rutten, A. (1995). The implementation of health promotion: a new structural perspective. promotion: a new structural perspective. Social Science & MedicineSocial Science & Medicine, , 41(2), 1627-1637.41(2), 1627-1637.

SOCIOCULTURAL ENVIRONMENT FRAMEWORK

Determinants

SOCIALRESOURCES

Standard of livingCulture and historySocial institutionsBuilt environmentsPolitical structuresEconomic systems Technology

Neighborhood Living Conditions

Community Development and Employment Opportunities

Opportunities for Learning and

Developing Capacity

Community Customs, Norms and Processes

Civic Engagement & Participation

in Decision-Making

Intermediate Outcomes

Health Outcome

Health Promotion, Prevention

and Care Opportunities

PHYSICALENVIRONMENT

Natural Resources

EQUITY ANDSOCIALJUSTICE

.

HEALTHIER COMMUNITIES

“The process of enabling people to increase control over, and to improve, their health” WHO, 1984, 1986 and Epp, 1986

“Any activity or program designed to improve social and environmental living conditions such that people’s experience of well-being is increased” Labonté & Little, 1992

HP definitionsHP definitions(there are many)(there are many)

The Historical Development of Health The Historical Development of Health Promotion in the 20Promotion in the 20thth Century: Two Traditions, Century: Two Traditions,

Two OriginsTwo Origins

The continentThe continent North AmericaNorth America

Framed by concernswith the social,economic and political roots of health

Focus on the sociopolitical

Framed by the enlargementof the traditional scope ofhealth education

Focus on the individual

The Historical Development of Epidemiology The Historical Development of Epidemiology in the 20in the 20thth Century: Two Traditions, One Old, Century: Two Traditions, One Old,

One RecentOne Recent

EpidemiologyEpidemiology Social EpidemiologySocial Epidemiology

Framed by concerns with etiology, traditional bio-medical model and a developed disciplinary base in scientific method

Framed by the enlargementof the traditional scope ofepidemiology

Focus on the individual plusfocus on the sociopolitical

Dominant Patterns of WorkDominant Patterns of Work

MethodsMethods ActionAction TheoryTheory Concerned Concerned

with CAUSEwith CAUSE

ActionAction Concepts and Concepts and

PrinciplesPrinciples MethodsMethods Concerned Concerned

with with CHANGECHANGE

Epidemiology Health Promotion

Health Promotion and EffectivenessHealth Promotion and Effectiveness

Effectiveness is a broad, loosely defined Effectiveness is a broad, loosely defined term, generally linked to the notion of term, generally linked to the notion of “outcomes”“outcomes”

Notion that effective health promotion Notion that effective health promotion leads to changes in the determinants of leads to changes in the determinants of health is a little differenthealth is a little different

Underlying epistemology of “outcomes” Underlying epistemology of “outcomes” remains complicatedremains complicated

Complexity and Methodology areComplexity and Methodology areIntertwined in Health PromotionIntertwined in Health Promotion

Most community-based health promotion Most community-based health promotion interventions include a complex mixture of interventions include a complex mixture of many disciplines, many variables of varying many disciplines, many variables of varying degrees of measurement difficulty, and degrees of measurement difficulty, and dynamic changing settingsdynamic changing settings

Understanding multi variate fields of action Understanding multi variate fields of action may require a mixture of complex may require a mixture of complex methodologies and considerable time to methodologies and considerable time to unravel causal relationshipsunravel causal relationships

Identifying appropriate change processes

HighCertainty about what works

Low

High

Low

Agreement about how to do it

Standards Guidance

Political compromise

Experiment

Innovation

Creativity

“Zone of Complexity”

Trial & Error

• Focus on areas with high certainty and high agreement• Understand and utilze effective change processes

StrategyStrategyHealth DisparitiesHealth Disparities

Focus on the closing the gap in Focus on the closing the gap in both the rates and risks for poor both the rates and risks for poor

healthhealth

Tackle DeterminantsTackle Determinants

The root causes of socioeconomic The root causes of socioeconomic inequitiesinequities

Social Resources Social Resources Mediate Exposure to Health RisksMediate Exposure to Health Risks

Social ResourcesStandard of livingCulture and historySocial institutionsBuilt environmentsPolitical structuresEconomic systems Technology

PhysicalEnvironment

COMMUNITYHEALTH

Part IIPart II

EFFECTIVE INTERVENTIONS IN THE SOCIAL ENVIRONMENT TO IMPROVE COMMUNITY HEALTH

Efforts of the CPSTF**Community Preventive Services Task Force – an HHS task force

Priority Interventions for Health Priority Interventions for Health Enhancing Social EnvironmentsEnhancing Social Environments

RANKED BY POTENTIAL IMPACT ON IMPROVING COMMUNITY HEALTHRANKED BY POTENTIAL IMPACT ON IMPROVING COMMUNITY HEALTH

11 Child development programs (Head Start, etc.).Child development programs (Head Start, etc.).

22 Adequate public investment in education.Adequate public investment in education.

33 ““Living wages” to move working families above poverty.Living wages” to move working families above poverty.

44 Access to quality health care for all ages.Access to quality health care for all ages.

55 Mixed income housing to decrease segregation by Mixed income housing to decrease segregation by socioeconomic status.socioeconomic status.

66 Programs to reintegrate stigmatized populations.Programs to reintegrate stigmatized populations.

77 Parenting classes in settings: schools, churches, etc.Parenting classes in settings: schools, churches, etc.

88 Neighborhood schools as a setting forprograms.Neighborhood schools as a setting forprograms.

99 Family-focused, 1-stop health and human services centers.Family-focused, 1-stop health and human services centers.

1010 Adequate health benefits with employment.Adequate health benefits with employment.

Completed Systematic ReviewsTT

OO

PP

II

CC

NeighborhoodNeighborhood

LivingLiving

ConditionsConditions

Opportunities for Opportunities for Learning and Learning and Developing Developing

CapacityCapacity

Health Promotion Health Promotion Prevention and Prevention and

Care OpportunitiesCare Opportunities

II

NN

TT

EE

RR

VV

EE

NN

TT

II

OO

NN

Mixed-income Mixed-income housing housing developments.developments.

Rental voucher Rental voucher subsidies which subsidies which allow families allow families choice in choice in residential residential location.location.

Publicly funded, Publicly funded, center-based, center-based, comprehensive comprehensive early childhood early childhood development development programs for low-programs for low-income children, income children,

3-5 years of age.3-5 years of age.

Culturally competent Culturally competent health care systems:health care systems:

-interpreters and-interpreters and

bilingual staffbilingual staff

-cultural diversity -cultural diversity

training for training for providersproviders

-linguistically and-linguistically and

culturally culturally appropriateappropriate

health informationhealth information

-ethnic specific -ethnic specific servicesservices

Center-Based Early Childhood Center-Based Early Childhood Development ProgramsDevelopment Programs

•Publicly funded for low-income children ages 3-5

•Comprehensive focus (e.g. Head Start)

cognitive development

social development

health and dental services

home environment

Search for EvidenceSearch for Evidence

English language research literatureEnglish language research literature

1965 to the present1965 to the present

educational, health and social science educational, health and social science databasesdatabases

2,000 citations were screened2,000 citations were screened

57 studies were the subject of detailed 57 studies were the subject of detailed abstractionabstraction

15 studies constituted the best evidence 15 studies constituted the best evidence based on study design and qualitybased on study design and quality

Key Findings:Key Findings:Preventing Cognitive Preventing Cognitive Developmental DelayDevelopmental Delay

Effect measureEffect measure MedianMedian

Placement in special Placement in special education classeseducation classes

(12 studies)(12 studies)

12% decrease12% decrease

Retained (“held-back”) Retained (“held-back”) in grade levelin grade level


21% decrease21% decrease

The spatial concentration of poverty has been shown to have an adverse effect on a range life experiences, from isolating families from employment opportunities to limiting youth to inferior education, dangerous neighborhood conditions, and harmful environmental conditions.

HOUSING AND HEALTH

Family Housing InterventionsFamily Housing Interventions

Provide affordable housing Provide affordable housing

Decrease residential segregation by Decrease residential segregation by socioeconomic statussocioeconomic status

deconcentration interventions: deconcentration interventions:

mixed-income housing mixed-income housing developmentsdevelopments

dispersion interventions: dispersion interventions:

tenant-based rental voucherstenant-based rental vouchers

Tenant-based Rental VouchersTenant-based Rental Vouchers

Intervention Description

•Rental assistance to low-income families so no more that 30% of household income is required for housing

•Allow families choice in residential location in the private rental market in neighborhoods with adequate goods and services


English language research literatureEnglish language research literature


governmental, architectural, economic, governmental, architectural, economic, health and social science databaseshealth and social science databases

510 citations were screened510 citations were screened



Key Findings:Key Findings:Intentional injuries, victimization, and Intentional injuries, victimization, and

neighborhood safetyneighborhood safety

Effect measureEffect measure MedianMedian

Household member Household member victimized by crime against victimized by crime against

person or property person or property


6% 6% decreasedecrease

Neighborhood social disorderNeighborhood social disorder

(6 studies)(6 studies)16% 16%

decreasedecrease

Culturally Competent Health Care Culturally Competent Health Care SystemsSystems

•Recruit, retain, and promote staff to reflect the cultural diversity of the community served

•Diversity training for staff

•Access to bilingual staff or interpreter services

•Culturally and linguistically appropriate health education materials

•Ethnic-specific healthcare settings (e.g. neighborhood clinic for recent immigrant group)


English language literatureEnglish language literature


health, social and behavioral science health, social and behavioral science databasesdatabases

980 citations were screened980 citations were screened



Recruit and retain diverse staffRecruit and retain diverse staff

0 study0 studyInsufficient EvidenceInsufficient Evidence

Cultural sensitivity trainingCultural sensitivity training


Bilingual providers & interpretersBilingual providers & interpreters


Culturally appropriate Culturally appropriate educational materialseducational materials

4 studies4 studies

Insufficient EvidenceInsufficient Evidence

Ethnic specific care settingsEthnic specific care settings


Summary of Evidence

So what can we conclude? So what can we conclude?

We have initial evidence that health We have initial evidence that health promotion interventions on the promotion interventions on the social determinants of health worksocial determinants of health work

However, comprehensive and/or However, comprehensive and/or systematic reviews have only been systematic reviews have only been conducted on a few interventions conducted on a few interventions and almost entirely on western and almost entirely on western literatureliterature

What we need What we need

Many more health promotion Many more health promotion interventions based on the best interventions based on the best theory of practicetheory of practice

Comprehensive and/or systematic Comprehensive and/or systematic reviews that account for efforts in reviews that account for efforts in less developed countriesless developed countries

Conclusion Conclusion Thank youThank you More More

information:[email protected]:[email protected]

Context and HealthContext and Health

Contextual approach uses ecologic Contextual approach uses ecologic and multilevel principles and data to and multilevel principles and data to understand determinants of health understand determinants of health and disease and disease

(Social) environment has (Social) environment has independent and/or modifying independent and/or modifying impact on healthimpact on health

Contextual FactorsContextual FactorsExample: Income InequalityExample: Income Inequality

Reflects distribution of Reflects distribution of income/wealth in a populationincome/wealth in a population

Measures: Gini Coefficient, Robin Measures: Gini Coefficient, Robin Hood IndexHood Index

Policy implicationsPolicy implications: g: growth vs. rowth vs. redistributionredistribution

Income Inequality – Income Inequality – Potential Pathways of EffectPotential Pathways of Effect

Underinvestment in human capitalUnderinvestment in human capital

Erosion of social cohesion / capitalErosion of social cohesion / capital

Direct psychological pathwaysDirect psychological pathways

Deconstructing Social Deconstructing Social CapitalCapital (Morenoff, Sampson, Earls)(Morenoff, Sampson, Earls)

Neighborhood resources (parks, local Neighborhood resources (parks, local media, community groups)media, community groups)

Participation in neighborhood Participation in neighborhood voluntary associationsvoluntary associations

Social cohesion (“close-knit”, “trust”)Social cohesion (“close-knit”, “trust”) Social control (action vs. resource)Social control (action vs. resource) Social exchange (action vs. Social exchange (action vs.

resource)resource)

The Emerging Case for the Effectiveness of Health Promotion David V. McQueen Associate Director for Global Health Promotion World Bank, September 14, 2004.

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