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

 Health Promotion, Health Protection,
and Disease Prevention
Social Culture, lifestyle, Health
structure, attitudes &
policies about risk Promotion
conditions

Risk behaviors & Primary Prevention &

Environmental exposures Health Protection

Adverse
health events Secondary Prevention
Self-care
Sequelae, Outcomes Tertiary Prevention

Lesson 1. Social determinants operate as background & as distal

determinants on most of the proximal determinants of health.
 Determinants of Health*
More Distal More Proximal
Income & social status Personal health practices
Gender & coping skills
Education Healthy child

Employment &
development
working conditions Health & social services

Physical environment Culture

Biology & genetic Social support networks

endowment Social environment

*Tonmyr et al., The population health perspective Chronic Diseases

in Canada 23:123-129, Fall 2002.
 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
 Achieving Health for All*
ACHIEVING HEALTH
AIM FOR ALL

HEALTH REDUCING INCREASING ENHANCING

CHALLENGES INEQUITIES PREVENTION COPING

HEALTH
SELF-CARE MUTUAL AID HEALTHY
PROMOTION ENVIRONMENTS
MECHANISMS

IMPLEMENTATION FOSTERING STRENGTHENING COORDINATING

PUBLIC COMMUNITY HEALTHY PUBLIC
STRATEGIES
PARTICIPATION HEALTH SERVICES POLICY

*Epp, Jake. Achieving health for all: a framework for health promotion.
Ottawa: Minister of Supply and Services, 1986.
 What is this public health achievement of the 20th Century?
What is the evaluation method to judge this an achievement?

5,000

4,000
35%
Number of Cigarettes

3,000

2,000 22%

1,000

0
1900 1910 1920 1930 1940 1950 1960 1970 1980 1990
 Adult Per Capita Cigarette Consumption and
Major Historical EventsUnited States, 1900-2000
Broadcast
1st World Conference Ad Ban
on Smoking and Health
5,000 1st Great American Smokeout
1st Surgeon Nicotine
Generals Report Medications
Available Over
4,000 the Counter
End of WW II Master
Number of Cigarettes

Settlement
Agreement
3,000 Fairness Doctrine
Messages on TV
and Radio
1st Smoking-
2,000 Cancer Concern Surgeon Generals
Report on
Nonsmokers Environmental
Rights Tobacco Smoke
1,000
Movement Federal
Begins Cigarette
Great Depression
Tax Doubles
0
1900 1910 1920 1930 1940 1950 1960 1970 1980 1990

Source: USDA; 1986 Surgeon General's Report

 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.
Lesson 4:
Evaluation of
ecological
approaches to
prevention on
community-wide or
province-wide scale
should not attempt
to isolate the
components.
 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
 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.
Estimated Efficacy (6-month quit rates),
Reach (number using), and Impact of
Main Cessation Strategies
Intervention Ef Reach # Impact Impact
% us ing US U.S. B .C.
None (un aided) 3 22,800,000 684,000 7,600
R x NR T 14 2,500,000 280,000 3,111
O TC NR T 14 6,300,000 560,000 6,222
Behavioral 24 395,000 94,800 1,053
Inpatient Rx 32 500 160 2

Lesson 7: Cost-benefit and cost-effectiveness depend as

much on the reach as on the efficacy of interventions.
Change in Per Capita Cigarette Consumption
California & Massachusetts versus Other 48 States, 1984-1996
5

0
Percent Reduction

-5

-10

-15

-20

-25
Other 48 States California Massachusetts

1984-1988 1990-1992 1992-1996

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
 Components of Comprehensive
Tobacco Control Programs

Community Programs Counter-Marketing

Statewide Programs Cessation Programs

Chronic
Disease Surveillance and
Programs Evaluation
School Programs Administration and
Enforcement Management
 Lesson 8: The Ecological
Imperative
Need to address the problem at all levels
Individual
Organizational, institutional
Community
State, regional
National, international
Needto make these levels of intervention
mutually supportive and complementary
 Percent Reductions in Per Capita Cigarette
Consumption Attributable to Non-Price Public
Health Interventions
Reduction in State Consumption

80%
70%
60%
55%
40%

20% 20%

$ $ $ $ $
0 2 4 6 8 10
Dollars Per Capita Annual Spending on
Programs
 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
 Per Capita Spending on Tobacco
Prevention and Control--FY1997

CDC
CDC/ RWJF
NCI
NCI/ RWJF
Oregon
Arizona
California
Massachusetts

$0 $2 $4 $6 $8 $10 $12
Dollars Per Capita
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
 100-Percent Smokefree Ordinances, by Year of Passage

Number of 18
Ordinances Workplace
16 Restaurant
Restaurant and Workplace
14

12

10

1985 1986 1987 1988 1989 1990 1991 1992*

* Through September 1992. Year
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.
 Tobacco Vending Machine Ordinances

Number of
Ordinances 180
(Cumulative) Total Ban
160
Partial Ban
140

120

100

80

60

40

20

1985 1986 1987 1988 1989 1990 1991 1992*

* Through September 1992. Year
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.
 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
 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
Breaking the Intervention-Based
Research and Planning Habit
1. Select off-the-shelf
Intervention or
Service to be Studied

4. Evaluate Response to the 2. Assess Response

Intervention or Service to the Intervention or
Service
3. Increase Dose
or Increase Demand
Strengthening Population-based,
Diagnostic Planning Approaches*
1. Assess Needs & Capacities
of Population

Reassess causes
4. Evaluate 2. Assess Causes,
Program Set Priorities &
Objectives
Redesign
3. Design &
Implement
Program
*Procedural models, such as PRECEDE, PATCH, Intervention Mapping. See
Green & Kreuter, Health Promotion Planning, 3rd ed., Mayfield, 1999.
 Uses of Evidence in Population-
Based Planning Models

A. Evidence 1. Assess Needs & Capacities

from community of Population B. Evidence from
or population Research

4. Evaluate Reconsider X 2. Assess Causes (X)

Program & Resources

D2 C. Evidence
from R&D
3. Design & and Exptal.
Implement Studies
D. Program Evidence
Program
From previous evaluations (D1)
 Surveillance, Planning and Evaluating for Policy and
Action: PRECEDE-PROCEED MODEL*
Phase 5 Phase 4 Phase 3 Phase 2 Phase 1
Administrative & Educational & Behavioral & Epidemiological Social
policy assessment ecological environmental assessment assessment
assessment assessment
Formative evaluation & baselines
Health Predisposing
Program for outcome evaluation
Intervention Health
Mapping education
Behavior
& Reinforcing
Health Quality of
Tailoring Policy life
regulation
organization Environment
Enabling

Phase 6 Phase 7 Phase 8 Phase 9

Implementation Process evaluation Impact evaluation Outcome evaluation
Monitoring & Continuous Quality Improvement
Input Process Output Short-term Longer-term Short-term Long-term
impact health outcome social impact social impact

*Green & Kreuter, Health Promotion Planning, 3rd ed., 1999.

 Towards an Integrated Model*

FRAMING FOCUSING EVALUATING

Population Health
Social
Ecology
Models of Change

Life Analysis
Community
Course Best Practices and
Partnering
Interpretation
Dissemination
Health Promotion
Planning
Policy

*A.Best, D.Stokels, L.Green, et al., AJHP, in press.

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?
 CIHR Knowledge Translation
KT Research Cycle
Research
Priorities
Research Evaluation
of Uptake Research
Open
Competition

Use Communication
Marketing Knowledge
Training Priority Setting

Knowledge Knowledge
Distribution
& Application Synthesis
Expertise Expertise
Research Research
 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
 Evidence-Advocacy-Policy-Practice
Extramural
Cycle* External
Research Advocacy
Agenda
Setting Commitment to
Develop Policy
Assessment of Need Advocacy and Action
Evidence
Inequalities
Refine programs Best Practices
Consultation
Diffusion research To frame policy
Dissemination and action plan
To build support

Surveillance Uptake & Outcomes

and Endorsement
Government All agencies with
Evaluation Professionals capacity to act or
Communities Contribute (coalition)
 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
Understanding Differences Among Publics
Perception of Needs, the Health Sectors
Assessments, and the Political Assessments

Publics Actual
perceived needs, C needs
priorities
A
A
D

E B

Resources,
feasibilities,
policy

LW Green, Inst of Health Promotion Research, Univ. British Columbia, Vancouver, BC V6T 1Z3
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.
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