Transcript Improving Community Health Through Policy Next Steps

Improving Community Health Through Policy
Next Steps
John J. Librett, Ph.D., MPH
Centers for Disease Control and Prevention
Division of Nutrition and Physical Activity
Physical Activity and Health Branch
Atlanta, GA
TRANSLATING RESEARCH
INTO POLICY
Physical Activity Policy Framework
Evaluation
Make The Case
Define
The
Problem
Identify
Solutions
Implement
Programs
Policy Definitions
• Organizing structure and guidance
• Legislative or regulatory action
• Formal and informal rules
• Explicit or implicit
• Formal written codes
• Written standards that guide choices
• Unwritten social norms
Policy Research
 Identifying relevant policies
• Determinants of establishing policy
Process of developing and implementing policy
• Outcomes of implementation of policy
Physical Activity Policy
Research Agenda
•
•
•
•
•
•
Schools
Walk to School
Worksite
Active Commute to
Work
Recreation, parks and
trails
Health
•
•
•
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Public spaces
Safety and crime
Economics
Neighborhood
walkability
• Connectivity, land use
and community design
Physical Activity Policy Framework
Policy
Outcomes of Policy
Develop and Implement Policy
Determinants of Policy
Identify Policies
Health
Transportation
Parks/Public Spaces
Worksite
Sector
School
Local
Regional
State
Scale
National
How are Decisions Made in
Public Health Settings?
• Anecdote or “Gut Feeling”
• Press Reports
• Pressure from Policy Makers or Administrators
• History
Barriers to Using
Evidence Based Public Health
• Lack of leadership in setting a clear and focused
agenda for evidence-based approaches
• Lack of a view of the long-term “horizon” for program
implementation and evaluation
• External (including political) pressures drive the
process away from an evidence-based approach
Barriers to using Evidence Based
Public Health (cont)
• Inadequate training in key public health disciplines
• Lack of time to gather information, analyze data,
and review the literature for evidence
• Lack of comprehensive, up-to-date information on
the effectiveness of programs and policies (overall
and in special populations)
Triangle of Key Concepts for Optimal Support
Valid Research & Evaluation
“Enumerate the Problem”
Triad for
Policy Infrastructure
Strong Leadership
Effective Policies
“Enunciate a Solution”
“Create the Team/Facilitate the Process”
Hollander, Librett, Fenton et al., 2004
Preventive Effects of
Physical Activity
•
•
•
•
•
•
Long-standing evidence
Cardiovascular disease
High blood pressure
Diabetes
Obesity
Colon cancer
Osteoporosis
Substantial Evidence
• Depression
• Cholesterol levels
• Fall injuries
• Stroke
• Functional status
(ADLs)
Emerging Evidence:
Gall stones; Sleep; Immune function, Other
cancers; Dementia
Therapeutic Effects of
Physical Activity
Clinical practice guidelines for physical activity:
 High blood pressure
 Diabetes
 Chronic lung disease
 Osteoporosis
 Cholesterol
management
 Arthritis
 Cardiovascular
disease
 Obesity
Community Developments
Suburban
development,
many cul-de-sacs
Well-connected
urban
development with
mixed land uses
Weight and Residential Density: Atlanta
As density of households increases BMI decreases.
(SMARTRAQ N=4430)Frank et al, 2004
26.4
26.2
26
25.8
25.6
BMI
25.4
25.2
25
24.8
0-<2
2-<4
4- <6
6-<8
8+
Estimated Annual Costs Attributable to
Obesity in the U.S.
Overweight and Obesity
Direct health care costs: $93 billion
9% of all health care costs
Obesity- $732 more per person
$1,486 Medicare
$
864 Medicaid
Source : Finkelstein, Fiebelkorn and Wang. Health Affairs, May,
2003.
"U.S. Firms Losing Health Care Battle”
General Motors Chairman Says
Washington Post, Feb.2005
"Failing to address the health care crisis would be the worst kind of
procrastination; the kind that threatens the global competitiveness of our
nation's economy.“
 $5.2 billion to cover retirees, employees & families.
 $1.9 billion in prescription drugs cost .
 $400 million projected increase this year.
Your interest? Corporations are seeking healthy environments for their
employees.
State’s Cost of Obesity
Total
Population
(%)
Millions
($)
Medicare
population
(%)
Millions
($)
Medicaid
Populatio
n
Millions
($)
Utah
5.2
$393
5.8
$62
9
$71
Colorado
5.1
$874
5.1
$139
8.7
$158
Wyoming
4.9
$87
5.9
$15
8.5
$23
Nevada
4.8
$337
5
$74
*
$56
Idaho
5.3
$227
5.6
$40
12
$69
New
Mexico
4.8
$324
4.6
$51
8.5
$84
10.1
Finkelstein, EA, Fiebelkorn, IC, Wang, G. State-Level Estimates of Annual Medical Expenditures Attributable to Obesity.
Obesity Research 2004;12(1):18–24.
Atherosclerosis Among Children?!
• Obesity in children is independently associated with arterial endothelial
dysfunction and wall thickening, key early events in atherogenesis that
precede plaque formation.
“We were surprised that the children had developed vascular abnormalities
at such a young age. The arteries of overweight children act like those of
middle-aged smokers, increasing their risk of an early heart attack or
stroke. But the damage can be reversed with simple lifestyle measures
such as diet and regular exercise, according to a report in today’s rapid
access issue of Circulation.
• At 1 year, there was significantly less thickening of the carotid wall
(P<0.001) as well as persistent improvements in body fat content and
lipid profiles in the group continuing an exercise program. Vascular
function was significantly better in those children continuing exercise
(n=22) compared with children who withdrew from the exercise
program (n=19) (P<0.05).
Woo, et al. Circulation. 2004; Effects of Diet and Exercise on Obesity-Related Vascular Dysfunction in
Children, 109:1981-1986, American Heart Association.
Community Physical Activity Policy
for Cancer Survivorship
"Cancer is not an inescapable fact of life. Things we do, and
social policies, make a huge difference.“
"The pieces that are missing in terms of prevention are effective
ways by which communities and social policies can help people
maintain a healthy body weight and get regular physical
activity, the big thing to tackle is, what are the interventions
that will actually begin to turn it around?“
Michael Thun, MD
Vice President, epidemiology and surveillance research
American Cancer Society
Convinced? Now What?
For cancer Survivors
exercise results in positive
outcomes related to:
 Increase in vigor and
vitality
 Increae in
cardiorespiratory fitness
 Increase in quality of
life
 Reduction in depression
 Reduced in anxiety
 Reduced in fatigue and
tiredness
“Results of the reviewed
studies generally indicate
that it is safe for cancer
survivors to be physically
active, even during bone
marrow transplant
procedures and high-dose
chemotherapy.”
Agency for Healthcare
Research and Quality
Cumulative Mortality by Distance
Walked per Day
Mortality (%)
50%
0 to 0.9
miles/day
1.0 to 2.0
miles/day
2.1 to 8.0
miles/day
40%
30%
20%
10%
0%
0
2
4
6
8
10
Year of Follow-up
Hakim NEJM 1998;338:94-9.
12
Diabetes Risk Reduction
(Diabetes Prevention Program; NEJM, April 2002)
100%
Risk Reduction
Risk Reduction
80%
0.58
60%
40%
0.31
20%
0%
Metformin
Lifestyle
Relative to Control Group (standard intervention)
Community Physical Activity Policy
for Cancer Survivorship
"Cancer is not an inescapable fact of life. Things we do, and
social policies, make a huge difference.“
"The pieces that are missing in terms of prevention are effective
ways by which communities and social policies can help people
maintain a healthy body weight and get regular physical
activity, the big thing to tackle is, what are the interventions
that will actually begin to turn it around?“
Michael Thun, MD
Vice President, epidemiology and surveillance research
American Cancer Society
Cancer Survivors Need Physical Activity
Research Translated to Great
Community Physical Activity Policy
For cancer Survivors
exercise results in positive
outcomes related to:
 Increase in vigor and
vitality
 Increae in
cardiorespiratory fitness
 Increase in quality of
life
 Reduction in depression
 Reduced in anxiety
 Reduced in fatigue and
tiredness
“Results of the reviewed
studies generally indicate
that it is safe for cancer
survivors to be physically
active, even during bone
marrow transplant
procedures and high-dose
chemotherapy.”
Agency for Healthcare
Research and Quality
Triangle of Key Concepts for Optimal Support
Valid Research & Evaluation
“Enumerate the Problem”
Triad for
Policy Infrastructure
Strong Leadership
Hollander, Librett, Fenton et al., 2004
Effective Policies
“Enunciate a Solution”
Some Key Characteristics of Evidence
Based Public Health
1.
Intervention approaches developed based on the best
possible scientific information
2.
Problem solving is multi-disciplinary
3.
Theory and systematic planning approaches are followed
4.
Sound evaluation principles are followed
5.
Results are disseminated to others who need to know and
take action
Evidence Based Policy Domains
• Informational Approaches to Increasing PA
• Behavioral and Social Approaches to Increasing
PA
• Environmental and Policy Approaches to
Increasing PA
Summary: Strongly Recommended
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Modified physical education
Individualized behavioral change
Non-family social support
Create or enhance access
Community-wide campaigns
Summary: Insufficient Evidence
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Mass media
Health education
TV/video game turn off
College health education
Family-based social support
Modified Physical Education
• Modified curricula and policies
• Studies designed to modify the amount of
physical activity during PE
• Lifetime activities and games
School-Based Approached to
Increasing Physical Activity . . .
P.A.P.P.I. (?)
Physical
Activity
Promotion
through
Predator
Introduction
Kids Walk
Primary Aims
• Analyze the scope & impact of
Walk to School programs
• Identify key determinants that
affect active travel to school &
program effectiveness
http://www.cdc.gov/nccdphp/dnpa/kidswalk/index.htm
Community-wide Campaigns
Informational Approaches to Increasing
Physical Activity
•
Large-scale, high intensity, high visibility
•
Use of TV, radio, newspaper, information sites
•
Multi-component, multi-site
•
‘Combined Package’
VERB
http://www.cdc.gov/youthcampaign/index.htm
“Point-of-decision” prompts
• Motivational signs placed by elevators and
escalators
• Encourage stair use for health/weight
control
• Single component
StairWELL to Better Health: A Worksite
Intervention
http://www.cdc.gov/nccdphp/dnpa/stairwell/
Paint — to make your stairwells bright and colorful.
Carpet — easier on the feet than concrete, and more attractive too!
Rubber Stairtreads — necessary for extra safety when taking the stairs.
Framed Artwork — gives people something to look at while they are
walking up and down.
Motivational Signs — both inside and outside the stairwell.
Music — also helps create interest and increase use.
Stairwell Use Tracking system — If you are interested in tracking how
much more employees are taking the stairs.
Budget Worksheet — some general guidelines to developing a budget for
your
Behavioral and social approaches
• Individually-adapted health behavior change
• Other social support
Individually-adapted
Health Behavior Change
• Goal setting and self-monitoring
• Building social support
• Behavioral reinforcement
• Structured problem solving
• Relapse prevention
Physical Activity
Counseling for Exercise
Men in Motion
PACE+: Counseling for Overweight
Women for Diet and Activity
PACE+: Counseling Adolescents for
Exercise and Nutrition
http://www.paceproject.org/homepage.html
Social Support in Community
Contexts
• Creating, strengthening, and maintaining
social networks
• Use of ‘buddy’ systems
• Contracting
• Walking groups
Well-Integrated Screening and Evaluation for
Women Across the Nation
http://www.cdc.gov/wisewoman/index.htm
Environmental and Policy
Approaches
• Create or enhance access
• Urban planning – zoning, land use
Creation and/or enhanced access to places
for physical activity
• Built environment - trails and/or facilities
access
• Reducing barriers - safety, affordability
• Training & incentives
• Site-specific programs
Wheeling Walks
http://www.wheelingwalks.org
Street-scale Urban Design and Land Use
Intervention Characteristics
The interventions use policy instruments and practices
such as:
• Implementation of improved street lighting
• Infrastructure projects to
– Increase ease and safety of street crossing
– Ensure sidewalk continuity
– Introduce or enhance traffic calming
– Enhance aesthetics of the streetscape
Built Environment Changes
Built Environment Changes
Built Environment Changes
Resources: Don’t reinvent the wheel, pick the
wheel that fits your needs, price range, and style. . .
http://www.healthpolicycoach.org/
http://www.centerforhealthimprovement.org/
• American Planning Association
• National Association of City & County
Health Officials
• Expert Symposium
Existing and model approaches for integrating ph and
planning
• National Survey
Current and potential collaborations
• Conference Session Tracks
Cross- pollination at conferences
• Fact Sheets
What public health officers need to know about planning
What planners need to know about public health
• Pilot Grants
Planning and PH working together
Opportunities for public successful & private partnerships
Opportunities for public successful & private partnerships
Active Community
Environments
Senior Wellness
Trails for Health
Promoting Physical Activity Through Recreation i
America’s Great Outdoors
HealthierUS
Based on the premise
that increasing personal
fitness and becoming
healthier is critical to
achieving a better and
longer life.
http://www.cdc.gov/nccdphp/dnpa/ICPAPH
Triangle of Key Concepts for Optimal Support
Valid Research & Evaluation
“Enumerate the Problem”
Triad for
Policy Infrastructure
Strong Leadership
Effective Policies
“Enunciate a Solution”
“Create the Team/Facilitate the Process”
Hollander, Librett, Fenton et al., 2004
Creating the Team
• Who’s in. . . ?