Transcript MCH Life Course Models and MCH Needs Assessment

The Maternal and Child Health
Life Course Model:
Introduction and Opportunities for
Public Health Nutrition
Milton Kotelchuck, PhD, MPH
Harvard Medical School
Massachusetts General Hospital
Center for Child and Adolescent Health Policy
October 12, 2010
Goal of Presentation
• Provide an understanding for the current new emphasis on
life course and social determinant models
• Introduce the MCH Life Course paradigm and briefly note
its scientific underpinnings
• Review its theoretical principles
• Present an MCH Life Course strategic framework for the
Title V MCH Bureau
• Provide examples of MCH Life Course related public
health research, program and policy, partnership initiatives
• And explore barriers and opportunities for MCH life course
use by public health nutritionists
Ideas and Slides Freely Adapted
From my Colleagues
Amy Fine
Michael Lu
Cheri Pies
Deborah Allen
Neal Halfon
Richmond & Kotelchuck, 1983
75th Anniversary of Title V of the
Social Security Act
• MCHB will initiate a new strategic planning
effort – using MCH Life Course and Social
Determinants as its guiding framework
• October 20, 2010
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
Why a new strategic approach?
• MCH health status is not improving -- existing MCH
programmatic approaches are not sufficiently effective
• The current balance of clinical & public health practices
relative to social environmental practices and policies
seems out of kilter
• There is substantial new life course research to guide
new initiatives
• Reasserts the Children’s Bureau/Title V MCH leadership
mandates
• New political and programmatic opportunities
• Prior 5 year strategic plan expired and on life supports
MCH Populations Health Status
Not Improving
• Perinatal health is not improving
–
IM stagnant; LBW rising; PTB raising; C-sections increasing
• Child Health Status is not improving
–
Obesity rates sky rocketing
• Maternal Health Status is unknown
–
–
Too much post-partum weight gain, rising rates of diabetes
High rates of parental depression
• Family Health is straining
–
Less family stability
• MCH racial/ethnic disparities remain and may be rising
• US International health status rankings declining
• We have to do something different
Low birth weight
US, 1996-2006
Low birth weight is less than 2500 grams (5 1/2 pounds).
Source: National Center for Health Statistics, final natality data. Retrieved February 22, 2010, from
www.marchofdimes.com/peristats.
Adequate/adeq+ prenatal care
US, 1992-2002
Footnotes available in notes section.
Source: National Center for Health Statistics, final natality data. Kotelchuck M. An
evaluation of the Kessner Adequacy of Prenatal Care Index and a proposed Adequacy of
Prenatal Care Utilization Index. Am J Public Health 1994; 84: 1414-1420. Retrieved
February 21, 2010, from www.marchofdimes.com/peristats.
Failure of Enhanced Prenatal Care
to Reduce Racial Disparities or
Improve Birth Outcomes
• “You can’t cure a life time of ills in nine
months of a pregnancy”
• Failure of late 20th Century movement to
reduce Infant Mortality through increased
access to comprehensive prenatal care (WIC)
• Renewed search for understanding of
disparities
• New scientific knowledge
• Paradigm shift in MCH – to MCH Life Course
Current programmatic approaches
• Pay insufficient attention to social and
environmental/root causes of illnesses
• Focus on increasing access to medical
care, quality of health care services (while
reducing costs), changing individuals’
behavior, building service systems for
treatment of specific chronic conditions
• Utilize life stage not life course
approaches, with limited child to adult to
aging adult continuities
Need for Change
• The old MCH/PH practices are not working
sufficiently
• New 21st Century Science emerging
• New or renewed scientific/causal theory
emerging
MCH Life Course Scientific Basis
• The challenge is to understand how the social
environment gets built into or embodied into our
physical bodies – which manifests itself in our
health and disease status.
• To bridge the world of our intuitive social
understanding of the causes of ill health
(poverty, malnutrition) with our understanding of
its clinical manifestations and treatment
• To better link downstream with upstream health
(or to move downstream further downstream
(root causes))
MOD slide 1
LCHD and Birth Outcomes
White
Reproductive Potential
African
American
Age
Pregnancy
LCHD and Birth Outcomes
White
Reproductive Potential
African
American
Age
Pregnancy
Life Course Perspective
Lu MC, Halfon N. Racial and ethnic disparities in birth outcomes: a life-course perspective.
Matern Child Health J. 2003;7:13-30.
The MCH Life Course Perspective: Moving
from Research and Theory to Practice
• There is a convergence of similar life
course frameworks in related health fields
– Reproductive life course models
– Child development models
– Chronic Illness models
• The knowledge base for the MCH Life
Course Perspective is strong and getting
stronger
Underlying Scientific Basis for Life
Course Models
• Reproductive Health
– Cumulative Stress Impact / Weathering
– Early Programming (Epigenetics / Set Points)
– Intergenerational Reproductive Health Effects
• Child Health and Development
–
–
–
–
Brain Development / Developmental Sciences
Early Childhood Interventions
Chronic Illness / Obesity Onset
Teratogens
• Chronic Disease Models
– Fetal Origins of Adult Diseases
New Science Underlying MCH Life
Course: Reproductive Health
• Cumulative Impact
– Cumulative multiple stresses over time can
have a profound direct impact on health and
development, and an indirect impact through
associated behavioral or health service
seeking change (Weathering)
• Early Programming
– Early experiences can “program” an
individual’s future health and development,
either directly in a disease or condition or in a
vulnerability to a disease in the future
Epigenetics
Prenatal Programming of
Childhood Obesity
Neurons to Neighborhoods
Early 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
Drawing by Tom
Prentiss
In: Cowan MW
1979. The
development of
the brain.
Scientific
American 113;
113-133
Als, H. 1986
Human Brain Development Synapse Formation
Language
Sensing
Pathways
(vision, hearing)
Higher Cognitive
Conception
Function
-6
-3
0
3
6
9
1
Months
4
8
12
16
Years
AGE
C. Nelson, in From Neurons to Neighborhoods, 2000.
2004 National Research Council and
Institute of Medicine Report
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.
WHO Definition of Community
Health
• A healthy city or community is…”one that
is continually creating and improving those
physical and social environments and
expanding those community resources
that enable people to mutually support
each other in performing all the functions
of life and in developing their maximum
potential”
Hancock and Duhl, WHO Healthy Cities Papers No.1, 1988
Life Course Chronic Disease
Epidemiology
Adolescent Origins of Adult Diseases
Childhood Origins of Adult Diseases
Fetal Origins of Adult Diseases
• High blood pressure
•
•
•
•
Diabetes Mellitus
Coronary Heart Disease
Cancer
Obesity
The Barker Hypothesis: Historical Cohort Analysis
Barker Hypothesis
Birth Weight and Insulin Resistance Syndrome
18
Odds ratio adjusted for BMI
16
14
12
10
8
6
4
2
0
<5.5
5.6-6.5
6.6-7.5
7.6-8.5
Birthweight (lbs)
8.6-9.5
>9.5
Barker 1993
Barker Hypothesis
165
160
155
Systolic Pressure (mmHg)
170
Birth Weight and Hypertension
<=5.5
5.6-6.5
6.6-7.5
Birthweight (lbs)
7.6-8.5
>8.5
Law 1993
Barker Hypothesis
Birth Weight and Coronary Heart Disease
1.5
Age Adjusted Relative Risk
1.25
Rich-Edwards 1997
1
0.75
0.5
0.25
0
<5.0
5.0-5.5
5.6-7.0
7.1-8.5
Birthweight (lbs)
8.6-10.0
>10.0
Adverse childhood events and
adult ischemic heart disease
3.5
3
0
1
2
3
4
5,6
7,8
Odds Ratio
2.5
2
1.5
1
0.5
0
Center for Healthier Children,
Families & Communities
Adverse Events
Dong et al, 2004
Adverse childhood events and
adult depression
5
4.5
4
3.5
0
1
2
3
4
5+
3
2.5
2
1.5
1
0.5
0
Adverse Events
Center for Healthier Children,
Families & Communities
Chapman et al, 2004
MCH 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
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
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
Human Rights
….these commitments (human rights)
provide a useful framework for shaping
national laws and policies, provide a
useful tool for ensuring accountability and
point to approaches useful for promoting
public health.
Gruskin and Dickens, 2006,
American Journal of Public Health; 96:1903-1905
Life Course Perspective
Lu MC, Halfon N. Racial and ethnic disparities in birth outcomes: a life-course perspective.
Matern Child Health J. 2003;7:13-30.
MCH Life Course
• Could it be true?
• Could we really transform disparities into
equity?
• The WHO Nutrition Standards
WHO Multicentre Growth Reference Study
Background / 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?)
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
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]
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
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
WHO Multicentre Growth Reference Study
Major Conclusions
1. Inter-cultural variability only 4% of variance
2. All growth retardation reflects environmental
insults
3. Overall (genetic / cultural) longitudinal
continuity for human growth and motor
development under optimal conditions
4. Breastfeeding established as norm for
growth standards
5. Supports social justice orientation
MCH Life Course Paradigm Shift
MCH Life Course Conference
June 2008, Oakland CA
MCH Life Course Model Topics to be Addressed
•
•
•
•
•
Theory
Research
Practice
Policy
Education and Training
Kotelchuck, Lu, Pies, 2008
MCH Life Course Theory
• There is no formal or official MCH Life
Course theory
• Indeed, it is unclear if the correct word is
even theory or perspective or model or
paradigm
• But without theory there is no guide
practice and policy
• Life Course theory must be surmised from
existing literature
HRSA/MCHB Concept Paper
Rethinking MCH: The Life Course Model as
an Organizing Framework
Amy Fine
Milton Kotelchuck
October 2010
Life Course Perspective
A way of looking at life not as
disconnected stages, but as an
integrated continuum
M. Lu, 2010
Life Course Development
Life course development provides a
framework to understand how multiple
determinants of health interact across the
life span and across generations to
produce health outcomes
Halfon, 2007
MCH Life Course Goals
• To optimize health across the lifespan for
all people; and
• To eliminate health disparities across
populations and communities
Draft, Fine and Kotelchuck 2010
Key concepts of the MCH Lifecourse Model
• Today’s experiences and exposures
determine tomorrow’s health
• Health trajectories are particularly affected
during critical or sensitive periods
• The broader environment – biologic,
physical, and social – strongly affects the
capacity to be healthy
• Inequality in health reflects more than
genetics and personal choice.
Amy Fine, Milt Kotelchuck, 2009
Key concepts of the MCH Lifecourse Model
• Timeline conveys movement along a continuum and
cumulative impacts over time.
• Timing reflects the importance of the earliest
experiences and exposures and of critical periods
throughout life.
• Environment recognizes the importance of family and
community in shaping health, including the physical,
social, and economic environment in which people live,
grow and develop.
• Equity refers to the importance of addressing disparities
in health and development across populations.
MCH Life Course core concepts
• MCH life course, social determinants, and social
justice models are complementary and
synergistic
• Move beyond, but include, medical/clinical care;
they are not safety net programs
• Life course not as disconnected stages, but as
an integrated continuum; we are one
• Not deterministic but transformational and
interactive trajectories
• Equitable valuation of life at every age
MCH Life Course
• Our challenge is to transform this new
MCH Life Course theory and research into
new MCH practice and policies
• MCHB Strategic Planning Initiative
MCH Bureau Life Course Initiatives
• Commitment of Dr. Peter Van Dyck to use MCH
life course theory as a strategic planning
framework for the Bureau
• Multiple MCH Bureau-wide and Senior
Leadership meetings and presentations
• State Needs Assessment Conference, and a
State Title V Directors’ workgroup
• Several new MCHB Life Course initiatives
• Amy Fine and Milt Kotelchuck engaged to
develop a Life Course concept paper to help
kick off their new Strategic Planning initiative
Developing an MCHB strategic
agenda for change
• Strengthening the life course knowledge
base
• Developing new program and policy
strategies
• Enhancing political will
Draft, Fine and Kotelchuck, 2010
MCH Life Course Research
• Research growing, but more is needed
• Barriers to longitudinal life course research
–
–
–
–
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
• New MCHB initiatives
MCH Research
MCH Life Course Research
Network
Public Health Nutrition Research Needs
and MCH Life Course
• Basic obesity research
– Intergenerational transmission of obesity/GDM
– Early cellular/genetic transformations
– Micronutrients
• Childhood dietary history and intervention
impacts
– Longitudinal and programmatic research
– Epidemiologic research
• Public Policy and Public Health root cause
analyses
• …..
MCH Life Course
Practice and Policies
• The ultimate challenge – transforming life
course to concrete programs and policies
• The most difficult MCH Life Course task
• Requires more than renaming existing
programs
• The science of MCH practice is the
hardest science
• MCH learning community needed
MCH Life Course Model
Barbara 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
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 ( or programmatic) continuity
– Horizontal (or contextual) continuity
– Holistic continuity
Public Health Nutrition
Discontinuities
• Longitudinal
– Public Health nutrition more thoughtful than other MCH areas (about
upstream causes; longitudinality of impacts)
– Limited downstream intervention effectiveness (TV monitoring itself;
Adolescent diets)
– Poor longitudinal nutrition records
• Vertical or programmatic
– WIC ends, where do the children or mothers go?
– Limited primary care to tertiary care handoffs
• Horizontal
– Limited ties between physicians and schools
– Difficulties of recruiting parents to community nutrition resources
• Holistic
– You are what you eat
– Too many intervention overloads
Public Health Nutrition
Life Course Initiatives
• Within public health/clinical programs
• Across programs
– MCH Life Course organizations
• Policy level
MCH Nutrition Life Course
Interventions (examples)
• Pediatric practice quality care
improvement initiatives (NICHQ)
• Birmingham Sunday Greens
• Numerous multi-pronged communitybased Obesity reduction campaigns
• Michelle Obama’s LetsMove.gov efforts
• Delaware Nemours Obesity Reduction
Initiative (5,2,1,Almost None)
Medical
Care
Childcare
Housing
Jobs
Healthy
Food
Parks
and
Activities
Alameda
County
Building
Blocks
Collaborative
Economic
Justice
Education
Residents
Clean Air
Policy
Makers
Safe
Neighbor
-hoods
Preschool
Transpor
tation
MCH Life Course Policy
• Many needed public health nutrition life
course reforms require policy level
initiatives
• Creating a policy agenda
Policy Implications for the
Government Sector
• Avoid the allure of categorical solutions
• Focus on upstream population needs
• Assure that needed programmatic
collaboration happens
• Partner with all sectors
• Install visionary leadership
• Invest in data for policy decisions
Debbie Allen, 2008
“Policies that seek to remedy deficits
incurred in early years are much more
costly than early investments wisely
made, and do not restore lost capacities
even when large costs are incurred. The
later in life we attempt to repair early
deficits, the costlier the remediation
becomes.”
James J. Heckman, PhD
Nobel Laureate in Economics, 2000
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
MCH Life Course Policy Initiative
• Realigning Health Services and Systems
• Integrating Health and Other Service Systems
for Women, Children and Families
• Building Community Capacity to Support Health
• Creating National and Federal Agenda to
Address Social Determinants of Health
Draft, Kotelchuck and Fine 2010
MCH Life Course
Partnerships
• Generate new political will to implement
the MCH life course models
MCH Partners/Political Will
• MCH Bureau (and HRSA) Staff
• The broader MCH “family”
• Other health and non-health federal
agencies
• Non-traditional stakeholders
• Local community and political
stakeholders
Draft, Fine and Kotelchuck, 2010
MCH Life Course Training and
Education Tasks
• Integrate MCH life course models into
MCH training programs
• Leadership training
• Retool the current MCH workforce
• Enhance MCHB leadership
competencies/long term training to
prepare future MCH leadership
New Needed MCH Life Course
Skills/Capacities
•
•
•
•
•
•
Coalition building and collaboration
Advocacy
Longitudinal data capacity
Community-based participatory research
Enhanced needs assessment capacities
And many other skills
Possible MCH Life Course Barriers
for Public Health Nutritionists
• Difficulty of balancing social determinant with
clinical nutrition models of care (RD vs. PH
Nutritionist)
• Lack of capacity for addressing “non-health”
aspects of population nutrition
• Limited success of primary prevention / upstream
involvement
• Isolation from other health, welfare, education and
community development systems
• Difficulty of balancing new life course opportunities
versus existing programmatic mandates
MCH Life Course Strengths for
Public Health Nutritionists
• There is already strong motivation for social justice
• There is a strong longitudinal and social determinant
orientation for PHN
• Long programmatic history of Public Health Nutrition-MCH
life course initiatives
• There are strong links between basic/epidemiologic
sciences and public health practices
• PHN is a multi-disciplinary field
• The new initiatives may help PHN gain new allies (and
vice versa), new political will to address upstream health
issues, be less isolated and part of broader MCH/Public
health agenda
• The MCH Life Course is not new to you
MCH Bureau Strategic Planning
and Leadership
• MCHB has a critical leadership role in fostering
the MCH life course paradigm shift
• The life course perspective, along with the social
determinants, and social justice models, offers
MCHB the opportunity to reinvigorate its
Children’s Bureau legacy and political mandate
– to address all factors that impact on children’s
health and well-being
• It provides a federal and national leadership
opportunity to broadly improve the health and
well being of mothers, children and families
75th Anniversary of Title V of the
Social Security Act
• MCHB will initiate a new strategic planning
effort – using MCH Life Course and Social
Determinants as its guiding framework
• October 20, 2010
MCH Life Course Resources
• CityMatCH
http://www.citymatch.org/lifecoursetoolbox/
• MCHB
• http://mchb.hrsa.gov/lifecourseresources.htm
• Future MCHB Web site
Richmond & Kotelchuck, 1983