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 Risk behaviors & Environmental exposures Primary Prevention & Health Protection Adverse health events are “initial” events, including… first diagnosis of disease or major risk for disease first major event (e.g., AMI) an injury episode immediate death Sequelae are the range of health and economic consequences following the initial event. Adverse health events Secondary Prevention Tertiary Prevention Self-care 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 More Proximal Income & social status Gender Education Employment & working conditions Physical environment Biology & genetic endowment 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 HEALTH CHALLENGES HEALTH PROMOTION MECHANISMS IMPLEMENTATION STRATEGIES REDUCING INEQUITIES INCREASING PREVENTION ENHANCING COPING SELF-CARE MUTUAL AID HEALTHY ENVIRONMENTS FOSTERING PUBLIC PARTICIPATION STRENGTHENING COMMUNITY HEALTH SERVICES COORDINATING HEALTHY PUBLIC POLICY ACHIEVING HEALTH FOR ALL *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? 35% 22%

Adult Per Capita Cigarette Consumption and Major Historical Events—United States, 1900-2000 Broadcast Ad Ban 1st World Conference on Smoking and Health 1st Great American Smokeout 1st Surgeon General’s Report Nicotine Medications Available Over the Counter End of WW II Master Settlement Agreement Fairness Doctrine Messages on TV and Radio 1st Smoking- Cancer Concern Surgeon General’s Report on Environmental Tobacco Smoke Nonsmokers’ Rights Movement Begins Federal Cigarette Tax Doubles Great Depression 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 $100 - 500 Brief advice, MD $1,000 - 3,000 High intensity interventions $6,000 - 15,000 Common disease prevention $1,500 - 15,000 Secondary or tertiary care $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.

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 -5 Percent Reduction -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 Decades of research in tobacco control has refined our approach so that we are finding what is most effective use of resources in reducing and preventing tobacco use. CA and MA were the first states to have adequate resources to conduct evaluation of their comprehensive excise tax funded programs, and have served as models for the nation. We now have information from evaluations of OR’s tax funded program, and Florida’s settlement funded program.

Components of Comprehensive Tobacco Control Programs Community Programs Statewide Programs Chronic Disease Programs School Programs Enforcement Counter-Marketing Cessation Programs Surveillance and Evaluation Administration and Management CDC provides a manual of Best Practices for Comprehensive Tobacco Control Programs which describes in great detail the elements listed here. While it looks more complicated than the matrix, they overlap each other. This model provides guidelines for resource allocation for a comprehensive, sustainable, and accountable program. Their development drew upon “best practices’ determined by evidence-based analyses of comprehensive State programs such as CA and MA. Two types of evidence supports these recommendations. 1) Published, evidence-based practices support community programs to reduce the burden of tobacco-related diseases, school programs, cessation, enforcement, and counter-marketing. 2) Evidence of the efficacy of the large-scale and sustained efforts of CA, MA supports the recommendations for the other program elements. Based upon this evidence, CDC has developed specific funding ranges and program recommendations. Will vary within States depending on State characteristics, demographics, prevalence, other factors. However, evidence supports implementation of some level of activity within each element.

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

Percent Reductions in Per Capita Cigarette Consumption Attributable to Non-Price Public Health Interventions 80% 70% 60% 55% 40% Reduction in State Consumption 20% 20% $2 $4 $6 $8 $ 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 $10 $12 Dollars Per Capita

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 1985 1986 1987 1988 1989 1990 1991 1992* 2 4 6 8 10 12 14 16 18 Workplace Restaurant Restaurant and Workplace Number of Ordinances Year * 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. The early 1990s saw enormous increases in the relative coverage of clean air laws for workplaces, restaurants, and even by the late-1990s some bars and lounges.

Tobacco Vending Machine Ordinances 1985 1986 1987 1988 1989 1990 1991 1992* 20 40 60 80 100 120 140 160 180 Total Ban Partial Ban Number of Ordinances (Cumulative) Year * 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. Cigarette vending machines also saw remarkable increases in coverage during this period. In short, public health was turning from individual behavior and smoking cessation to the social and physical environment that could provide protections for the nonsmoker.

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 Reassess causes 2. Assess Causes, Set Priorities & Objectives 4. Evaluate Program 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 Population-Based Planning Models 1. Assess Needs & Capacities of Population Evidence from community or population B. Evidence from Research 4. Evaluate Program Reconsider X 2. Assess Causes (X) & Resources When we speak of evidence-based practice in health education and hp, unlike the evidence that might be sufficient in medical practice, we need to be clear about what best practices means. It does not mean that if you insert magic bullet A into your community program guns you can count on outcome B for a whole population. For medicine, the biological organism is very uniform across the human species. We are dealing with human behavior…whole populations…culture, social forces, norms, traditions, values…We have to bring several types of evidence to bear, and at each of several levels of analysis…But not all the evidence is positive--->[next slide] D2 C. Evidence from R&D and Exp’tal. Studies 3. Design & Implement Program D. Program Evidence From previous evaluations (D1)

Surveillance, Planning and Evaluating for Policy and Action: PRECEDE-PROCEED MODEL* Health education Policy regulation organization Program Phase 5 Administrative & policy assessment Predisposing Reinforcing Enabling Phase 4 Educational & ecological assessment Behavior Environment Phase 3 Behavioral & environmental assessment Health Phase 2 Epidemiological assessment Quality of life Phase 1 Social assessment Formative evaluation & baselines for outcome evaluation Intervention Mapping & Tailoring Phase 6 Implementation Phase 7 Process evaluation Phase 8 Impact evaluation Phase 9 Outcome evaluation Monitoring & Continuous Quality Improvement Input Process Output Short-term impact Longer-term health outcome Short-term social impact Long-term social impact *Green & Kreuter, Health Promotion Planning, 3rd ed., 1999.

Towards an Integrated Model* FRAMING FOCUSING EVALUATING Population Health Models of Change Best Practices Dissemination Policy Analysis and Interpretation Social Ecology Health Promotion Planning Community Partnering Life Course *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 Precede-Proceed Model - How do we plan & promote change? Community Partnering - How do we work together?

CIHR Knowledge Translation KT Research Cycle Research Open Competition Knowledge Priority Setting Use Evaluation of Uptake Priorities Synthesis Expertise Distribution & Application Communication Marketing Training

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* Extramural Research External Advocacy Agenda Setting Commitment to Develop Policy and Action Assessment of Need Inequalities Refine programs Advocacy Evidence “Best Practices” Diffusion research Dissemination Consultation To frame policy and action plan To build support Surveillance and Evaluation Uptake & Outcomes Government Professionals Communities Endorsement All agencies with capacity to act or Contribute (coalition) *Adapted from Australia Commonwealth Dept of Health, 2001

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 Public’s Perception of Needs, the Health Sector’s Assessments, and the Political Assessments Public’s perceived needs, priorities “Actual needs” C A A D E B 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 Our definition, then, involved three essential elements: Systematic investigation Learning or enlightenment Action More effective learning, planning and action would flow from the first of these... Empowerment would flow from the last two of these...