Milton Kotelchuck, PhD, MPH

1. Rethinking MCH: The Life Course Theory and Its Implications for Practice: Moving to Action – Knowledge Base, Social Strategy and Political Will Milton Kotelchuck, PhD, MPH MGH Center for Child and Adolescent Health Policy, and Harvard Medical School California MCAH Action May 19, 2011

2. Goal of Presentation Build on the introduction to the MCH Life Course paradigm Introduce the Richmond-Kotelchuck health policy framework as a strategic framework for MCH Life Course implementation Provide examples of MCH Life Course research, practice and policies End on a call to collaborative action

3. Ideas and Slides Freely Adapted From my Colleagues Amy Fine Michael Lu Cheri Pies Deborah Allen Neal Halfon

4. Richmond & Kotelchuck, 1983

5. MCH History and MCH Life Course Title V/MCHB itself has a programmatic life course; it is at a critical transformative moment MCH life course reflects new, and renewed, ideas about how to move us forward to improve MCH population health and reduce disparities

6. Life Course is not new to MCH “MCH does not raise children, it raises adults. All of tomorrow's productive, mature citizens are located someplace along the MCH continuum. They are at some point in their creation either being conceived or born or nurtured for the years to come. There is very little genuine perception that mature people come from small beginnings, that they've had a perilous passage every moment of the way. All the population, everybody of every age were all at one time children. And they bring to their maturity and old age the strength and scars of an entire lifetime.” Pauline Stitt, MCHB 1960

7. Incorporating Life Course, Social Determinants, and Health Equity into California’s MCAH Programs Shabbir Ahmad, DVM, MS, PhD Maternal, Child and Adolescent Health Program Center for Family Health California Department of Public Health February 25, 2010 HRSA / MCHB

8. Social Determinants The social determinants of health are those factors which are outside of the individual; they are beyond genetic endowment and beyond individual behaviors. They are the context in which individual behaviors arise and in which individual behaviors convey risk. The social determinants of health include individual resources, neighborhood (place-based) or community (group-based) resources, hazards and toxic exposures, and opportunity structures. Camara Jones, 2010

9. Health Equity Where systematic differences in health are judged to be avoidable by reasonable action they are, quite simply, unfair. It is this that we label health inequity. Putting right these inequities – the huge and remediable differences in health between and within countries – is a matter of social justice. World Health Organization Commission on Social Determinants of Health

10. Life Course Model Posits a new scientific paradigm for the MCH field Addresses enduring health issues with new perspectives (e.g., disparities) Requires new longitudinal and holistic approaches to MCH programs, policy and research Provides an integrated framework for facilitating the MCH policy agenda Links the MCH community to adult and elderly health and social service policy development

11. Key concepts of the MCH Life- course Model Today’s experiences and exposures determine tomorrow’s health (timeline) Health trajectories are particularly affected during critical or sensitive periods (timing) The broader environment – biologic, physical, and social – strongly affects the capacity to be healthy (environment) Inequality in health reflects more than genetics and personal choice (health equity) Amy Fine, Milt Kotelchuck, 2009

12. Life Course Perspective All four key concepts need to be addressed

13. MCH Life Course Goals To optimize health across the lifespan for all people; and To eliminate health disparities across populations and communities Fine and Kotelchuck, 2010

14. MCH Life Course Could it be true? Could we really transform disparities into equity? The WHO Nutrition Standards

16. WHO Multicentre Growth Reference StudyBackground / Context Current growth curves developed from 1930’s Fels longitudinal studies (White middle class sample) Should there be separate norms for each cultural / racial group? Fierce debate among MCH Epidemiologists, especially given major LBW racial disparities in U.S. Issue arose in Guatemalan INCAP study of the effects of malnutrition on mental development (since Guatemalans were shorter, why use U.S. norms?)

17. WHO Multicentre Growth Reference Study Purpose of Study Goal: to assess optimal child growth (and motor development) and create standards usable throughout the world Distinction between standards and norms Ideal vs.. actual growth curves

18. WHO Multicentre Growth Reference Study Methods I Sample selected for optimal growth All upper middle class families All infants exclusively breastfed for four + months All full-term births, with no birth defects Longitudinal (0 – 24 months) and cross-sectional samples (18 – 71 months) N=1743 longitudinal, N=6697 cross-sectional (N=8440) Six sites chosen around the world U.S. (Palo Alto), Ghana (Accra), Oman (Muscat), India (South New Delhi), Brazil (Pelatos), Norway (Oslo), [China dropped out]

19. WHO Multicentre Growth Reference Study Methods II Standardized measurement protocols, very well trained and supervised staff Physical measurement recorded Length / height, weight, weight for height, BMI Monthly thru12 months, bi-monthly thru 24 months, then 4 times thru age 5 Motor development milestones Sitting with support; hands and knees crawling; standing with assistance; standing alone; walking with assistance; walking alone Measured at same age as above thru 24 months, plus utilized mother’s reports All measurements were home-based

20. WHO Multicentre Growth Reference Study Detailed Results Physical Growth (standards) Essential similar everywhere (data combined) Only 3.4% inter-site variations; 70% intra-site variability; 26% error Motor Development No sex differences 5/6 of motor developments sequential No relationship between infant size and motor development Birth Characteristics Modest variations 3,300 mean birth weight (3.1-3.6 Kg range) 3.2% LBW (vs.. national estimates (up to 30% in India)), shows powerful impact on SES on birth outcomes

21. WHO Multicentre Growth Reference Study Major Conclusions Inter-cultural variability only 4% of variance All growth retardation reflects environmental insults Overall (genetic / cultural) longitudinal continuity for human growth and motor development under optimal conditions Breastfeeding established as norm for growth standards Supports social justice orientation

22. The New 21st Century Scientific Basis for the MCH Life Course Provides an understanding of how the social environment gets built into or embodied into our physical bodies Bridges our intuitive understanding of the social causes of ill health (poverty, malnutrition, stress) with our understanding of its clinical manifestations and treatment Incorporates our growing scientific understanding of the biology of human development into our health trajectories Focuses on root causes of illness and disparities

24. Neurons to NeighborhoodsEarly Environments Matter and Nurturing Relationships are Essential Parents and other regular caregivers in children’s lives are “active ingredients” of environmental influence during early childhood Children’s early development depends on health and well being of parents Early experiences affect the brain (the focus on the 0-3 period begins too late and ends too soon) A wide range of environmental hazards threaten the developing central nervous system The capacity exists to increase the odds of favorable development outcomes through planned interventions

25. 2004 National Research Council and Institute of Medicine Report

26. IOM/NRC Definition of Children’s Health (2004) “Children’s health is the extent to which individual children or groups of children are able or enabled to (a) develop and realize their potential, (b) satisfy their needs, and (c) develop the capacities that allow them to interact successfully with their biological, physical, and social environments.” From Children’s Health, the Nation’s Wealth, National Academies Press, 2004.

27. Developmental Life Course Model Harvard Center For the Developing Child, Jack Shonkoff 2008

29. Life Course Perspective Lu and Halfon, 1998

30. Theory Research Practice Policy Education and Training MCH Life Course Paradigm ShiftMCH Life Course Conference June 2008, Oakland CAMCH Life Course Model Topics to be Addressed Kotelchuck, Lu, Pies, 2008

31. HRSA/MCHB Concept Paper Rethinking MCH: The Life Course Model as an Organizing Framework Prepared under contract by Amy Fine and Milton Kotelchuck October 2010

32. Richmond & Kotelchuck, 1983

33. Starting points for advancing the MCH Life Course • Strengthen the MCH life course knowledge base • Develop new programs and policy strategies • Engage and enhance MCH partnerships

34. Strengthening the Knowledge Base:Life Course Research Network

35. A Life-course Approach to MCH Epidemiology: MCH Data Needs and Applications The current MCH EPI field is not yet well equipped to support a life course approach Limited longitudinal analytic capacity Scattered longitudinal data bases Disciplinary and institutional silos Virtually no measures of life-course trajectories, cumulative risks, cumulative experiences Confidentiality legal infrastructure not in place Few longitudinal data/life course training opportunities Opportunities exist, and need to be nurtured

36. Evolution of LCHD Chronic Disease Epidemiology, Health Demography, Life Course • Social context on individual • Age, cohort, historical effects • Cumulative mechanisms Health Prism MCH LCRN MCH – Life Course Health Development • Linked Lives • Pathways • Transitions • Trajectories • Developmental Pathways • Sensitive, critical period • Plasticity, resilience • Transitions, turning points • Cumulative, Pathway, and Programming mechanisms • Emergent Health Trajectories Life Span Dev. • Development Individual Differences • Adaptivity, Plasticity, Resilience DOAHD Neurodevelopment Intervention Research

37. Life Course Perspective on Basic Mechanisms of Disease Causation Life Course Chronic Disease Epidemiology D O A D Neruo-development Economic Modeling Intervention Studies LCHD Theory Life Course Health Development • New synthesis – MCAH Reframe/positioning • Transdisciplinary Translation: MCAH Practice Health is developmental Complex pathways & Emergent Trajectories Sensitive & Critical Periods Programming, Cumulative , Pathway Mechanisms

38. LCCDE DOAD Neuro-dev Early Inter Econ Analyses & Synthesis LCHD Sensitive periods pathways Theory Development Transitions Bio embedding Trajectories ??? Translational Analysis Translational Research MCH Programs, Policy spreading Clinical T-1 Cc Program PCc T-4 T-2 Community Cc scaling T-3 Cc Systems

40. Research Strategy: Advancing and Applying LCHD Research Policies Service system Interventions Child = • Provide better data • Create new measures • Develop better measurement systems • Develop innovative methods ResearchMethods • Create multidisciplinarytraining pipeline • Increase analytic capacity at multiple sites • Increase $$ & funding opps. Capacity Building • Inform key targetaudiences: academics,service providers,policy makers,parents, & communities Policy Analysis Communication What We Want to Know about LCHD Basic Mechanisms Research: Influences on health, development, behavior, and education trajectories Intervention Research: That improves health, dev, beh, edu trajectories Service & System Research: organization, delivery, & payment of services systems Policy Research: Policies that promote, optimize, improve health, dev, beh, edu of children and youth HowWeWantToDoIt Develop better understanding of risk, protective, & promoting factors and how to improve health, dev, beh, and edu trajectories Increase number of evidence-based interventions for deployment in services and service systems Inform service system design, organization, improvement, and financing Influence public policy at state, local, & national levels Why We Want to Know It

41. Knowledge Base • What’s Needed: There is general agreement among those working on MCH life course strategies that the knowledge base around both concept and practice needs to be further strengthened. Among the key areas to be addressed: • Building and disseminating the scientific evidence supporting the need for a life course approach; • Documenting and disseminating information on the type of programs, practices, and policies to improve life course trajectories; • Developing new standards and measures that capture key life course concepts (i.e., timeline, timing, environment and equity); • Developing new methodological approaches for ongoing monitoring of longitudinal impact; and • Incorporating Life Course Theory concepts into training and continuing education programs to move the MCH field forward. Fine and Kotelchuck, 2010

42. Program and Policy Strategies • What’s Needed: A thoughtful, integrated set of MCH and MCHB programs and policy strategies could provide an opportunity to improve health and well-being across the life course and across the population. • Translating life course theory into concrete programs and policies is perhaps the most difficult of the life course challenges. • Multiple interventions and policies at a variety of levels across multiple time periods are needed. • While many individual MCH programs and policies can and do improve the health of individuals served, more needs to be done to address alarming new trends in chronic diseases and disorders, and to reverse longstanding disparities in health and well-being.

43. Program and Policy Strategies • Life course theory implies the need to go beyond individual programs and policies, aimed at individual diseases and disorders, in order to promote and optimize health across generations and communities. • LCT suggests the need to consciously build a program and policy “pipeline for healthy development” – a continuum of services and supports that promote optimal health and development from birth throughout the lifespan, from the birth of one generation to the next. • What is needed is the integration of services and supports that are longitudinal (over time), vertical (within the health sector) and horizontal (across health and other sectors). • Also needed are programs and policies that address root causes of disparities in health by helping to reshape the conditions in which people live, work, play and develop.

44. MCH Life Course into Practice Our field’s challenge is to transform this new MCH Life Course theory and research into new MCH practice and policies Lots of MCH life course experimentation is now occurring Here are some initial ideas to get us thinking how MCH life course could influence our practice and policy

45. MCH Life Course ModelBarbara Ferrar’s Overview of its Meaning for Practice Multiple time points for intervention Expanded settings for intervention Policy is important at local, state and national levels Ferrar, 2007

46. MCH Life Course Practice The MCH Life Course Theory suggests a greater attention to four key continuities or discontinuities in health and health care that impact on achieving optimal health Longitudinal continuity Vertical continuity Horizontal continuity Holistic continuity Kotelchuck et al 2008

47. New MCH Life-course programmatic integration and discontinuity themes Longitudinal Integration Continuity of care/services- school to workforce Maintenance of longitudinal records (a la Europe) Prevention, upstream approaches Vertical Integration (within health service programs) Good intra-health program hand offs (when WIC ends where do the mothers, children go) Primary to tertiary handoffs; Strong follow-up capacity Horizontal Integration (cross-program, cross-sector collaboration) Cross program linkages; (markers: common funded activities and protocols; regular meetings) Systems matrix (M. Drummond) Good inter-program hand offs and collaboration Addressing broad risk factors Holistic Integration Not discrete safety net programs Mental health/behavioral health and physical heath programs are joined, are one Community involvement Are the programs “individual” or “family “ focused, rather than program focused Programmatic flexibility (e.g. too many home visitors)

48. Housing Childcare Medical Care Jobs Healthy Food Alameda County Building Blocks Collaborative Clean Air Parks and Activities Policy Makers Education Economic Justice Preschool Safe Neighbor-hoods Residents Transportation

49. Barriers to life course practice • Addressing immediate needs versus future theoretical life course gains • Categorical mandates • There is no menu of life course interventions • Attributable risk benefits of proposed interventions not well demonstrated • BUT, while doing good now, we will not prevent current MCH problems from simply re-occuring in the future.

50. Policy concepts deriving from the MCH Life-course Model Refocus the organization and delivery of MCH clinical and population health services Enhance linkages between health services and other child and family services and supports sectors (e.g., educational, social services) Rebuild and redirect social, economic and physical environments to support and promote the health of the population (e.g. building community capacity to support health) Fine, Kotelchuck et al, 2009