1. 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

2. 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.

3. 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: , Fall 2002.

4. 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

5. 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.

6. What is this public health achievement of the 20th Century?
What is the evaluation method to judge this an achievement?
35%
22%

7. 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

8. 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.

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

10. 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

11. Cost (US$) Per Year of Life Saved
Smoking cessation
Low intensity interventions $
Brief advice, MD $1, ,000
High intensity interventions $6, ,000
Common disease prevention $1, ,000
Secondary or tertiary care $20, ,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.

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

13. Change in Per Capita Cigarette Consumption California & Massachusetts versus Other 48 States, 5 -5
Percent Reduction
-10
-15
-20
-25
Other 48 States
California
Massachusetts

14. 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.

15. 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.

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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
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.

22. 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
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.

23. 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

24. 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

25. 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

26. 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.

27. 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)

28. 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.

29. 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.

30. 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?

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

32. 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

33. 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

34. 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

35. 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

36. 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.

37. 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...