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PBH 805: Week 2 Slides
- 1. | http://online.mcphs.edu Week 2 Life Course Theory and the Pyramids Instructor: Gina Crosley-Corcoran, MPH PBH 805 – Maternal & Child Health
- 2. | http://online.mcphs.edu Chapter 2 A Life Course Perspective on Maternal and Child Health and Health Inequities
- 3. | http://online.mcphs.edu Chapter 2 Introduction Historically, focus on contemporaneous/temporally proximate risk factors have been the approach to MCH research, policy, and practice. Increased understanding of complexity, the impact of the social context, and importance of individual in relationship to others called for a more comprehensive research and programmatic approach to MCH. Life course perspective on MCH provides a new direction for the field.
- 4. | http://online.mcphs.edu The Five Defining Principles of Life Course Theory • suggests that health and well-being are lifelong processes and can only be fully understood within the context of experiences across one’s entire lifespan Principle of Life Span Development • highlights central roles of personal control and behavior in health and illness Principle of Human Agency • suggests that our health is shaped not only by what happens to us but also by when it happens, duration and sequencing Principle of Timing • explains notion of interdependent lives Principle of Linked Lives • highlights the ways in which period, cohort, and contextual factors influence the life course Principle of Historical Time and Place
- 5. | http://online.mcphs.edu Three Key Concepts in Life Course Theory Trajectories •Dynamic descriptors of health and well being that describe substantial period of the life span Transitions •Embedded within trajectories, usually take place within a relatively brief time frame (e.g., childbirth or turning 18) Turning Points •A redirection of life course through changes in situation, meaning, and/or behavior (e.g., marriage or retirement) (Elder, 2006
- 6. | http://online.mcphs.edu Influences and Actions along the Life Course
- 7. | http://online.mcphs.edu Fundamental Concepts in Life Course Epidemiology The body records all our life experiences and tells a story of one’s past and that of the preceding generation. Transitions, turning points, and durations have implications for health trajectories. Risk and protective factors may accumulate or interact with each other to impact current, future, and intergenerational health.
- 8. | http://online.mcphs.edu Three Life Course Models of Health Republished with permission of Annual Review of Public Health, from Social epidemiology: Social determinants of health in the United States: Are we losing ground?, Berkman, L. F. ,30, 27-41 (2009),permission conveyed through Copyright Clearance Center, Inc <insert Figure 3-2 here>
- 9. | http://online.mcphs.edu Historical Applications to MCH Over 150 years ago, health reformers realized that “… if infant mortality was to be reduced, the health of all urban slum residents had to be improved.” Nearly a century ago, the principle of life span development was implicit in MCH discourse. Potential applicability to racial disparities in birth outcomes was recognized long before the 1990s.
- 10. Copyright © 2020 by Jones and Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com. Background texture © Bunphot/Getty Images. Contemporary Applications to MCH
- 11. | http://online.mcphs.edu Preconception Health and Well-Being Pregnancy now viewed as part of an integrated continuum or trajectory of health rather than a detached stage of development Birth outcomes may be affected by maternal development across the life span prior to pregnancy. The weathering hypothesis posits a cumulative negative impact of social environmental stressors on reproductive health and birth outcomes, as well as a disproportionate burden of these accumulated stressors on African-American women due to systemic and historic racism.
- 12. | http://online.mcphs.edu Impact of Adverse Childhood Experiences Adverse Childhood Experiences (ACE) study found associations between adverse childhood experiences and a variety of negative adult health outcomes. Evidence of dose-response relationship from ACE study and National Comorbidity Survey Replication indicating that the greater the number of ACEs, the greater the risk of long term consequences to health and well-being Many principles and concepts of life course theory are implicit in literature on childhood experiences.
- 13. | http://online.mcphs.edu Fetal Origins of Adult Disease Fetal origin hypothesis suggests that adult disease cannot be fully understood without considering early life exposures at critical or sensitive periods. Suggests that fetal undernutrition in mid- to late gestation is consequential for adult disease risk How to measure fetal exposures remains a major challenge “Developmental origins of health and disease” (DOHaD) include the role of epigenetic regulation and exposures within the DNA of sperm and egg prior to conception. This work is helpful in understanding intergenerational trauma at a cellular level.
- 14. Copyright © 2020 by Jones and Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com. Background texture © Bunphot/Getty Images. Implications for Policy and Practice
- 15. | http://online.mcphs.edu Policy Strategies to Improve MCH Outcomes Adopting a life course perspective on MCH research would lead to (or require) changes to policy and practice. Need to expand strategies for improving perinatal health to a focus on the overall health of women, regardless of childbearing history or plans Focusing on early life health and development regardless of gender is essential While investment early in the life course is imperative, a person’s life trajectory can always be shifted with supports and resources.
- 16. | http://online.mcphs.edu Types/Targets of Policy Strategies Life course approach suggests intervention at multiple time points and in multiple domains (i.e., both upstream and downstream phenomena) that contribute to MCH problems Life course approach requires expansion of definition of health policy to include social policy that can influence population-wide exposures Need for comprehensive health care services for women and their families over the entire life span Integration with community-based programs may be necessary to reach women without access to the health care system who are often at highest risk Intensive services should be focused on specific lifespan points/periods
- 17. | http://online.mcphs.edu Barriers to Policy and Practice Changes Requires collaboration between multiple entities involved in forming health and social policy Requires longer timeframe to evaluate the policy benefits U.S. health policy continues to demonstrate a primary focus on health care rather than prevention (e.g., the passage of the ACA of 2010).
- 18. | http://online.mcphs.edu Chapter 2 Conclusions The Life Course Theory is defined by five principles (life span development, human agency, timing, linked lives, and historical time and place) and three temporal concepts (trajectories, transitions, and turning points). Investment in cohort studies is key, as they provide the most appropriate data for evaluating life course hypotheses. Life course theory–driven interventions require expanding the definition of health policy to include social policy and starting at the earliest stages of life to address upstream factors.
- 19. | http://online.mcphs.edu MCH Pyramid of Services From the Title V MCH Services Block Grant
- 20. | http://online.mcphs.edu Title V MCH Block Grant Since 1935, the Social Security Act has provided funding for the Title V MCH Block Grant. HRSA administers the grants to states. Funds from the Title V MCH Block Grant help: Assure access to quality maternal and child health care services to mothers and children, especially those with low incomes or limited availability of care Reduce infant mortality Provide access to prenatal, delivery, and postnatal care to women, especially pregnant women who are low income and at-risk Increase regular screenings and follow-up diagnostic and treatment services for children who are low income Provide access to preventive and primary care services for children who are low income and rehabilitative services for children with special health needs Implement family-centered, community-based, systems of coordinated care for children with special health care needs Set up toll-free hotlines and assistance with applying for services to pregnant women with infants and children eligible for Medicaid
- 21. | http://online.mcphs.edu What is the MCH Pyramid of Services? The MCH Pyramid depicts the working framework for the MCH Block Grant Aligns with the 10 MCH Essential Services and consists of three levels.
- 22. | http://online.mcphs.edu Smallest Tier: Direct Services Direct services are preventive, primary, or specialty clinical services to pregnant women, infants and children, including children with special health care needs, where MCH Services Block Grant funds are used to reimburse or fund providers for these services through a formal process similar to paying a medical billing claim or managed care contracts Examples include, but are not limited to: preventive, primary or specialty care visits emergency department visits, inpatient services outpatient and inpatient mental and behavioral health services prescription drugs occupational and physical therapy, speech therapy durable medical equipment and medical supplies medical foods, dental care, and vision care
- 23. | http://online.mcphs.edu Middle Tier: Enabling Services Enabling services are non-clinical services (i.e., not included as direct or public health services) that enable individuals to access health care and improve health outcomes where MCH Services Block Grant funds are used to finance these services. Enabling services include, but are not limited to case management, care coordination, referrals translation/interpretation transportation eligibility assistance health education for individuals or families environmental health risk reduction health literacy and outreach
- 24. | http://online.mcphs.edu Largest Tier: Public Health Services and Systems Public health services and systems are activities and infrastructure to carry out the core public health functions of assessment, assurance, and policy development, and the 10 essential public health services. Examples include the development of standards and guidelines needs assessment, program planning, implementation, and evaluation policy development, quality assurance and improvement workforce development population-based disease prevention and health promotion campaigns for services such as: • newborn screening, immunization, injury prevention, safe-sleep education and anti-smoking
- 25. | http://online.mcphs.edu Health Impact Pyramid Developed by Thomas Friedan Director of Centers for Disease Control
- 26. | http://online.mcphs.edu Health Impact Pyramid The Health Impact Pyramid seems similar to the MCH pyramid at first, but there are important differences we will highlight. As you can see this model has five tiers: 1. Counseling and education 2. Clinical interventions 3. Long-lasting protective interventions 4. Changing the context 5. Socioeconomic factors This model was developed by Thomas Frieden, the Director of the CDC in response to previous models, including the MCH Pyramid of Services, which largely focus on various aspects of clinical health services and their delivery. He argues that public health involves much more than healthcare; and that the social determinants of health are often overlooked in frameworks that describe health system structures.
- 27. | http://online.mcphs.edu 1. Socioeconomic Factors Often referred to as social determinants of health Includes income, household resources, education, occupation Exact pathways between socioeconomic status (SES) and health outcomes not always well understood In general, lower SES is related to worse health outcomes
- 28. | http://online.mcphs.edu 2. Changing the Context to Encourage Healthy Decisions Interventions that change the social and environmental context to make healthy options the default, regardless of SES. Particularly, interventions that the public accesses without expending any effort (e.g. fluoridated water, elimination of trans fats in foods)
- 29. | http://online.mcphs.edu 3. Long-Lasting Protective Interventions May have less impact than interventions at bottom 2 tiers E.g. immunizations, newborn screening Represents 1-time or infrequent protective interventions that do not require ongoing care
- 30. | http://online.mcphs.edu 4. Clinical Interventions Ongoing clinical interventions that are evidence-based can reduce disability and prolong life. However, aggregate impact of these is limited by lack of access to care, erratic and unpredictable adherence and imperfect effectiveness. Example, interventions to prevent CVD interventions have the greatest potential impact. Numerous drugs are used to treat and control hypertension. If one does not go to the doctor, then s/he can’t be diagnosed in the first place. Even after diagnosis, the drugs may be too expensive, or the individual may not remember to take them regularly. Also, not all anti-hypertensive drugs are effective for all people with hypertension. These are some of the barriers and challenges to clinical interventions.
- 31. | http://online.mcphs.edu 5. Counseling and Educational Interventions PROVIDED DURING CLINICAL ENCOUNTERS AS WELL AS EDUCATION IN OTHER SETTINGS GENERALLY LEAST EFFECTIVE (ACCORDING TO FRIEDEN) RESULT OF “FAILURE TO ESTABLISH CONTEXTS IN WHICH HEALTHY CHOICES ARE DEFAULT ACTIONS”
- 32. | http://online.mcphs.edu Pyramids Summary MCH Pyramid of Health Services – 3 tiers that guide Title V programs and funding Health Impact Pyramid – 5 tiers, some overlap with MCH Pyramid of Health Services HIA emphasizes SES and changing the context Both frameworks can be used for program and policy design.
- 33. | http://online.mcphs.edu Week #2 Assignments Discussion Board Quiz on Chapter 2
Editor's Notes
- This image is a graphic and text representation of the Life Course Theory in general. This graph was put together by the Fair Society, Healthy Lives program, an initiative out of England that highlights the need to address health inequalities. There are different stages in the life course. The black band in the middle reviews the various stages: prenatal, infancy, childhood, adolescence, adulthood, and old age. Above that in the blue graphics are different influences on individuals as well as how much these factors influence individuals in the life course. As an example, the developmental environment has the greatest impact of all the influences and during the earliest time period in the life course. Under the black band, there are a series of green bands that include different actions of communities to support individuals throughout the life course. For example parental support of early education in prenatal and infancy stages and education, employment, and professional development in childhood and beyond.
- The Health Impact Pyramid seems similar to the MCH pyramid at first, but there are important differences we will highlight. As you can see this model has five tiers: Counseling and education Clinical interventions Long-lasting protective interventions Changing the context Socioeconomic factors This model was developed by Thomas Frieden, the Director of the CDC in response to previous models, including the MCH Pyramid of Services, which largely focus on various aspects of clinical health services and their delivery. He argues that public health involves much more than healthcare; and that the social determinants of health are often overlooked in frameworks that describe health system structures.
- Socioeconomic factors form the base of the pyramid that impacts everything around the health of individuals as well as public health. It is often referred to as social determinants of health as opposed to the biological determinants of health. Socioeconomic factors include income, household resources, education, occupation. The exact pathway between socioeconomic status (SES) and health outcomes are not always well understood. We know that in general, lower SES is related to worse health outcomes and is highly correlated. Some sources argue SES is the greatest predictor of health outcomes in the U.S.
- The second level is ‘changing the context to make individuals’ default decisions healthy.’ So let’s break this down. This includes making or creating interventions that change the social and environmental context to make healthy options the default, regardless of SES. Particularly, interventions that the public can access without expending much or any effort. A couple examples include fluoridated water and elimination of trans fats in restaurants. Fluoridated water is difficult to avoid when it is from the public water supply. NYC has passed legislation that prohibits restaurants from using trans-fats. Currently, cardiovascular disease (CVD) is addressed at the individual level through screening and medication. But, it can be addressed by changing the social context through tactics such as passing smoke-free laws, taxing soda and other sugary beverages, creating infrastructure to encourage bicycling and walking, and designing buildings to promote stair use.
- The third level of the health impact Pyramid is long-lasting protective interventions. These services represent one-time or infrequent protective interventions that do not require ongoing care. These services may have less impact than interventions at the bottom two tiers because they must reach people as individuals, rather than collectively. So examples are immunizations and newborn screening. Even though these services are provided and available at a population level, they still must be provided to one person at a single point in time, rather than provided to a collective group.
- The fourth level is clinical interventions. Ongoing clinical interventions that are evidence-based can reduce disability and prolong life. However, aggregate impact of these is limited by lack of access to care, erratic and unpredictable adherence and imperfect effectiveness. So for example, interventions to prevent CVD interventions have the greatest potential impact. Numerous drugs are used to treat and control hypertension. If one does not go to the doctor, then s/he can’t be diagnosed in the first place. Even after diagnosis, the drugs may be too expensive or the individual may not remember to take them regularly. Also, not all anti-hypertensive drugs are effective for all people with hypertension. These are some of the barriers and challenges to clinical interventions.
- Finally, the top tier is Counseling and Educational Interventions provided during clinical encounters as well as education in other settings. Frieden argues that these are generally the least effective method and are perceived by some as the essence of public health action. But, they are only needed because there is a symptomatic failure to establish contexts in which healthy choices are the default actions. For example, obesity programs that counsel individuals to eat well and exercise may have little impact unless the environmental context supports those behavioral choices. In neighborhoods where health food stores and safe areas to exercise exist, healthy choices would more likely be the default action. However, if one lives in a neighborhood where they can’t get access to healthy fruits and vegetables and there is limited safe space to exercise, then counseling and education has limited impact. Another example, is smoking cessation education. Historically, smoking cessation education has had little impact. State laws prohibiting smoking have had the greatest impact on decreasing smoking rates. Frieden does concede that educational interventions are often the only ones available for certain issues, and can be successful when applied consistently and repeatedly. He gives the example of peer counselors who advise MSM about reducing HIV risk. This was an effective intervention in the MSM community in the 1990s.
- Some key takeaway messages from module B include: The MCH Pyramid of Health Services is a 4-tier model that guides Title V programs and funding The Health Impact Pyramid is a 5-tier model and has some overlap with the MCH Pyramid of Health Services - HIA emphasizes SES and changing the context for health behaviors Both frameworks can be used for program and policy design.