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Symposium on the Social Determinants of Health
Dr. Tina Cheng Dr. Robert Blum Dean David Andrews
1
Influence of Early Life
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May 2012 2
Social Determinants of Health: Influence of Early Life
Tina L. Cheng, MD, MPH
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Institute of Medicine Report
• 2003 Evidence-based review by panel of experts
• Offered broad range of recommendations
• Only 5 out of 103 studies addressed child health
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Child Health Disparities
• Invitational conference 2008 developed a research action agenda
• Need for research on biologic, environmental and psychosocial factors
• Need for a life course perspective
Pediatrics. Nov 2009;124:S161-331
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A Model of Children’s Health & Influences
National Research Council/IOM Committee on Evaluation of Children’s Health. Children’s Health, the Nation’s Wealth. DC: National Academies Press, 2004.
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Adverse Childhood Experiences (ACE) Study
7
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Childhood Experiences Underlie Chronic Depression
0 10 20 30 40 50 60 70 80
0 1 2 3 >=4
% W
ith a
Life
time
His
tory
of
Dep
ress
ion
ACE Score
Women Men
http://www.cdc.gov/ace/about.htm
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Significant Adversity
Supportive Relationships, Stimulating Experiences, Health-Promoting Environments
Healthy Developmental Trajectory
Impaired Health & Development
Trajectories: Conceptual Framework Guiding Early Childhood Policy & Practice
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Rethinking MCH: The Life Course Model as an Organizing Framework
• “whole-person, whole-family, whole-community systems approach”
• “greater emphasis on early (“upstream”) determinants of health” and critical or sensitive periods
• “developing integrated, multi-sector service systems that become lifelong “pipelines” for healthy development.”
Nov 2010, http://mchb.hrsa.gov/lifecourse/rethinkingmchlifecourse.pdf
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Life Course Theory Translation Opportunities and Models
• Whole Person, Whole Family, Whole Community : CONTEXT
• Address Upstream Determinants with Earlier Detection of Risks: LONGITUDINAL
• Integrated Multi-sector Service Systems: INTEGRATION
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• 95% Health insurance • 82% Housing
vouchers • 82% Dental care • 72% Job training
Quality child care, education & opportunities for their children Safe homes & neighborhoods
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Harriet Lane Clinic A Comprehensive Community Clinic
Developmental Assessment &
Services
Legal Advocacy Services
Reach Out and Read , Adolescent
Literacy Programs
Specialty Communication
and Case Management
Transition Readiness
Screening & Planning
Parent Support & Leadership Institute
Co-located Medical, Dental, Mental
Health, Nutrition Services
Youth Fitness Circle
Preventive Care
Developmental Services
Chronic Care
Acute Care
Social Work & Child Life
Services
Educational Support with Tutoring Program
Family-Centered Pediatric Primary
Care
Education
Safety Resource Center
Family Needs Screening & Health
Leads Family Resource Desk
Healthy Futures Career
Counseling
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New Protective Interventions
Protective Interventions
Significant Adversity
Healthy Developmental Trajectory
Supportive Relationships, Stimulating Experiences, and Health-Promoting Environments
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Life Course Theory Translation Opportunities and Models
• Whole Person, Whole Family, Whole Community : CONTEXT
• Address Upstream Determinants with Earlier Detection of Risks: LONGITUDINAL
• Integrated Multi-sector Service Systems: INTEGRATION
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History of Medical Progress
Adapted from E. Zerhouni, A Vision for Transforming Medicine in the 21st Century, 9/13/06, http://www.nih.gov/about/director/slides/vision.pdf
19th Century
20th Century 21st Century
Treat symptoms
Treat diseases
Predictive Preemptive Participatory Personalized
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The Future Paradigm: 4 P’s
Tole
rabl
e In
tole
rabl
e Pr
eclin
ical
Time
Cost
Molecular preemption
Curative treatment
Symptom management
Dis
ease
Bur
den
Cost Savings
Zerhouni, EA. Annual Mtg of NIH Roadmap Multidisciplinary Clinical Research Career Dev Program, 2007
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History of Medical Progress: 8 P’s
19th Century
20th Century 21st Century
Treat symptoms
Treat diseases
Predictive Preemptive Participatory Personalized Pediatrics, Prenatal Population Health Policy
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• Aim: To examine the effects of the environment, as broadly defined to include factors such as air, water, diet, sound, family dynamics, community and cultural influences, and genetics on the growth, development, and health of children across the United States, following them from before birth until 21 years of age.
• Largest long-term study of children’s health and development ever to be conducted in the U.S.
• Longitudinal study of 100,000 children, their families, and their environment
National Children’s Study
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Life Course Theory Translation Opportunities and Models
• Whole Person, Whole Family, Whole Community : CONTEXT
• Address Upstream Determinants with Earlier Detection of Risks: LONGITUDINAL
• Integrated Multi-sector Service Systems: INTEGRATION
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Perrin JM et al. Arch Pediatr Adolesc Med 2007;161:933-936
Community-Based System of Services for Children and Youth
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Halfon N. www.nihcm.org/pdf/ExpertVoices_Halfon_FINAL.pdf, 2009
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Neal Halfon, adapted from Nordio S. Riviste Italiana di Pediatrica 1978;4:3-20
Health Settings Across the Life Course
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The Social Determinants of Adolescent Health
Social Determinants of Health Conference Johns Hopkins University
9 May 2012
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The Shifting Realities A generation ago AIDS was unknown; today it is
the second leading cause of mortality in the second decade
More than a generation ago infectious diseases were the major killers of youth; today, except for HIV, social, behavioral and environmental factors predominate;
A generation ago many more young people lived in rural areas, fewer went to school, and most married earlier than today.
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Demographic Trends Today, 27% of the world’s population is
between the ages of 10-24 years; 86% of all youth live in developing
countries; In many developing countries young people
make up 25-30% of the population– double that of many industrialized countries.
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10 Leading Causes of Death10 to 24 year olds
Rank % total1 Road traffic accidents 10.02 Self-inflicted injuries 6.33 Violence 6.04 Lower respiratory infections 5.95 Tuberculosis 5.56 HIV/AIDS 5.57 Drownings 4.18 Fires 2.69 Meningitis 2.010 War 1.8
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How do Disparities Arise?
Differences in life opportunities, exposures, and stresses that result in differences in underlying health status
Differences in access to and/or quality of services
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Social Determinants of Adolescent Health
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Macro National Wealth
Income Inequality
Racism/Discrimination
War/Conflict
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Community Racism/Discrimination
Minority Status Education Opportunities
Employment Opportunities Poverty
Social Disruption Violence/Incarceration
Urban/Rural Built/ Environment
Residential Instability Social Cohesion
Macro
National Wealth
Income Inequality
Racism/Discrimination
War/Conflict
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Family Behaviors
Conflict/Violence Monitoring
Communications Financial & Social Capital
Family Mobility Birth Spacing Expectations
Community Racism/Discrimination
Minority Status Education Opportunities
Employment Opportunities Poverty Social Disruption Violence/Incarceration
Urban/Rural Built/ Environment
Residential Instability
Social Cohesion
Macro
National Wealth
Income Inequality
Racism/Discrimination
War/Conflict
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ADOLESCENT HEALTH RISK OUTCOMES AND PARENT/FAMILY CONNECTEDNESS
(parameter estimates, p < .001)
Younger teen (7th-8th grade)
Older teen (9th-12th grade)
Emotional distress - .37 - .33
Suicidality - .17 - .24
Violence - .21 - .13
Cigarette use - .19 - .13
Alcohol use - .24 - .14
Marihuana use - .18 - .19
Sexual Intercourse RR = 0.85 -
Resnick, Bearman, Blum et. al., 1997
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Positive Family Relations: Brazil
Males Females
n % P N % p
Smoking 79 9.8 .001 127 12.8 .001
Drug use 64 7.9 .001 44 4.4 .001
Age at 1st sex <15 yr 300 38.4 .01 110 11.2 .001
Pregnancy 13 1.9 .05 27 3.0 .01
Suicidal 164 20.3 .001 270 20.3 .001
Suicide attempt 54 6.6 .01 75 7.5 .001
(Anteghini, Blum et al 2001)
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Community Racism/Discrimination
Minority Status Education Opportunities
Employment Opportunities Poverty Social Disruption Violence/Incarceration
Urban/Rural Built/ Environment
Residential Instability
Social Cohesion
Macro
National Wealth
Income Inequality
Racism/Discrimination
War/Conflict
School / Peers Teachers supports or
expectations
Academic Performance
Pro-social peer network
Family Behaviors
Conflict/Violence Monitoring
Communications
Financial & Social Capital
Family Mobility Birth Spacing
Expectations
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The Protective Role of School Connectedness Among Caribbean Youth
Risk Behavior Males Females
Low* High* Low* High*
Sexual debut 79.0 49.2 84.8 19.6
Violence 68.1 39.9 71.9 11.6
Regular alcohol use 62.1 8.6 78.7 2.1
Smoke cigarettes 51.3 9.1 66.6 9.8
Blum, Ireland, 2004
* Net of any other protective factors and holding risk factors constant
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School Connectedness and Pregnancy
12
14
16
18
20
22
24
Not at All Very Little Somewhat Quite a Bit A Lot
Students who feel connected to school are less likely to become pregnant
Levels of connectedness
Per
cent
eve
r Pre
gnan
t
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Community Racism/Discrimination
Minority Status Education Opportunities
Employment Opportunities Poverty Social Disruption Violence/Incarceration
Urban/Rural Built/ Environment
Residential Instability
Social Cohesion
Macro
National Wealth
Income Inequality
Racism/Discrimination
War/Conflict
Family Behaviors
Conflict/Violence Monitoring
Communications
Financial & Social Capital
Family Mobility Birth Spacing
Expectations
School / Peers
Teachers supports or expectations
Academic Performance
Pro-social peer network
Individual
Macro
Community
Family
School/Peers
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How do the Social Determinants of Health
Get Under the Skin
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Epigenetics is the missing link between environment and the development of diseases. Genetics explain only a small fraction of human disease at any age.
Epigenetics
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Epigenetic Control of Gene Expression
DNA methylation
small RNAs
histone methylation and acetylation
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Folate and B12 have transgenerational effect on decreased expression of the gene that controls skin color and weight
Obesity Diabetes Cancer
Waterland and J irtle . Mol Cell Bio l 2003; 23:5293
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Contexts Matter in the lives of Young People
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Community Matters– geography is destiny
Growing up in low resource communities is associated with every negative youth outcome– independent of national resources
Consequences of behaviors are often environmentally influenced
Poor communities are associated with: more social disorganization, less communal efficacy, more discrimination, less social and financial capital.
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Positive Communities create…
♦ Safety and structure; ♦ Belonging and group membership; ♦ Personal empowerment; ♦ Control over one’s life; ♦ Competence; ♦ Closeness with peers and nurturing
adults. Kirby & Coyle
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Positive Parenting Matters
Globally, family has been shown to be the most protective factor in the lives of young people
Elements of positive parenting: connectedness, emotional availability and responsiveness, high behavioral and educational expectations, behavioral monitoring.
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School Matters
Feeling part of the school Experiencing school as safe:
emotionally, physically and academically
Perceiving teachers as supportive and caring
Experiencing high expectations Believing rules and discipline are fair
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P
P C A
A Adolescent
People: An adult who cares, who is connected; a network of adults who are involved in the life of the adolescent
Contributions: The opportunities to contribute to family, neighborhood, community, youth involvement
Activities: School and community activities that develop a sense of connection/belonging and skills
Place: A place for youth to congregate, to recreate with adult supervision, to develop friendships.
PCAP: A Model for Promoting Youth Health and Development
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David W. Andrews
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Generalizations on Developmental Trajectories
Those who start behind fall further behind. Those who fall behind early need more,
but get less.
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Trajectories and Outcome Gaps (Those who start behind fall further behind)
Infancy Early Childhood Adolescence Adulthood
Hayden Keyshawn
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Understanding Complexity (webs of social determination)
Poverty shapes multiple social determinants as factors beget factors Multiple influences are cumulative at
best, often multiplicative
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Webs of Complexity Interrelated Disparities in the Web - More Exposure - Violence - Drugs, Alcohol, Tobacco - Environmental Risks - Deviant Peers - Dysfunctional Adults - Less Access - Housing - Nutrition - Education - Health Care - Pro-social Peers - Supportive Adults
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Implications for Prevention and Intervention
START EARLY! Plan and implement holistically across developmental
domains Social-emotional Cognitive Health
Multi-systemic Family School Community