Lawrence W. Green

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 Primary Prevention & Health Protection Risk behaviors & Environmental exposures 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. 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 Determinants of Health*More Distal More Proximal *Tonmyr et al., The population health perspective… Chronic Diseases in Canada 23:123-129, 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 AIM FOR ALL HEALTHCHALLENGES REDUCING INCREASING ENHANCING INEQUITIES PREVENTION COPING HEALTHPROMOTIONMECHANISMS SELF-CARE MUTUAL AID HEALTHY ENVIRONMENTS FOSTERING STRENGTHENING COORDINATING IMPLEMENTATIONSTRATEGIES PUBLIC COMMUNITY HEALTHY PUBLIC PARTICIPATION HEALTH SERVICES 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 Master Settlement Agreement End of WW II 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 $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.

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 ConsumptionCalifornia & Massachusetts versus Other 48 States, 1984-1996 5 0 -5 Percent Reduction -10 -15 -20 -25 Other 48 States California Massachusetts 1984-1988 1990-1992 1992-1996

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

15. Community Programs Statewide Programs Chronic Disease Programs School Programs Enforcement Counter-Marketing Cessation Programs Surveillance and Evaluation Administration and Management Components of Comprehensive Tobacco Control Programs

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 0 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 TobaccoPrevention 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 Number of Ordinances 18 Workplace Restaurant Restaurant and Workplace 16 14 12 10 8 6 4 2 0 1985 1986 1987 1988 1989 1990 1991 1992* 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.

22. Tobacco Vending Machine Ordinances Number of Ordinances (Cumulative) 180 Total Ban Partial Ban 160 140 120 100 80 60 40 20 0 1985 1986 1987 1988 1989 1990 1991 1992* 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.

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 A. Evidence from community or population B. Evidence from Research 2. Assess Causes (X) & Resources Reconsider X 4. Evaluate Program C. Evidence from R&D and Exp’tal. Studies D2 3. Design & Implement Program D. Program Evidence From previous evaluations (D1)

28. Surveillance, Planning and Evaluating for Policy and Action: PRECEDE-PROCEED MODEL* Phase 5 Administrative & policy assessment Phase 4 Educational & ecological assessment Phase 2 Epidemiological assessment Phase 1 Social assessment Phase 3 Behavioral & environmental assessment Predisposing Health Program Health education Behavior Reinforcing Quality of life Health Policy regulation organization Environment Enabling 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 Short-term social impact Output Short-term impact Longer-term health outcome Long-term social impact *Green & Kreuter, Health Promotion Planning, 3rd ed., 1999.

29. FRAMING FOCUSING EVALUATING Population Health SocialEcology Models of Change AnalysisandInterpretation LifeCourse CommunityPartnering Best Practices Dissemination Health PromotionPlanning Policy Towards an Integrated Model* *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. Research Priorities Evaluation of Uptake Research Research Open Competition Communication MarketingTraining Use Knowledge Priority Setting Knowledge Knowledge Distribution Synthesis & Application Expertise Expertise Research Research CIHR Knowledge Translation KT Research Cycle

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