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

Make The CaseDefine

The Problem

IdentifySolutions

ImplementPrograms

Physical Activity Policy Framework

Evaluation

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

• Public spaces• Safety and crime• Economics• Neighborhood

walkability• Connectivity, land use

and community design

 

 

Physical Activity Policy Framework

 

Outcomes of Policy

Develop and Implement Policy

Determinants of Policy

Identify Policies

LocalRegional

StateNational

Policy

Sector Scale

TransportationParks/Public Spaces

WorksiteSchool

Health

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 BasedPublic 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 Triangle of Key Concepts for Optimal SupportSupport

Strong LeadershipStrong Leadership

Valid Research & EvaluationValid Research & Evaluation

Effective PoliciesEffective Policies

Triad for Policy Infrastructure

Triad for Policy Infrastructure

Hollander, Librett, Fenton et al., 2004Hollander, Librett, Fenton et al., 2004

““Enumerate the Problem”Enumerate the Problem”

““Enunciate a SolutionEnunciate a Solution””““Create the Team/Facilitate the Create the Team/Facilitate the Process”Process”

Preventive Effects ofPhysical Activity

Long-standing evidence• Cardiovascular disease• High blood pressure• Diabetes• Obesity• Colon cancer• Osteoporosis

Emerging Evidence:Gall stones; Sleep; Immune function, Other cancers; Dementia

Substantial Evidence• Depression• Cholesterol levels• Fall injuries• Stroke• Functional status (ADLs)

Therapeutic Effects ofPhysical Activity

Clinical practice guidelines for physical activity:

High blood pressure

Chronic lung disease

Cholesterol management

Cardiovascular disease

Diabetes

Osteoporosis

Arthritis

Obesity

Community Developments

Suburban development, many cul-de-sacs

Well-connected urban development with mixed land uses

Weight and Residential Density: AtlantaAs density of households increases BMI decreases.

(SMARTRAQ N=4430)Frank et al, 2004

24.8

25

25.2

25.4

25.6

25.8

26

26.2

26.4

0-<2 2-<4 4- <6 6-<8 8+

BMI

Estimated Annual Costs Attributable to Obesity in the U.S.

Overweight and ObesityDirect 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.

 

Total Population

(%)Millions

($)

Medicare population

(%)Millions

($)

Medicaid Populatio

nMillions

($)

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 10.1* $56

Idaho 5.3 $227 5.6 $40 12 $69

New Mexico

4.8 $324 4.6 $51 8.5 $84

Finkelstein, EA, Fiebelkorn, IC, Wang, G. State-Level Estimates of Annual Medical Expenditures Attributable to Obesity. Obesity Research 2004;12(1):18–24.

State’s Cost of Obesity

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 Policyfor 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, MDVice President, epidemiology and surveillance researchAmerican 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

0%

10%

20%

30%

40%

50%

0 2 4 6 8 10 12Year of Follow-up

Mo

rta

lity

(%

)

0 to 0.9miles/day

1.0 to 2.0miles/day

2.1 to 8.0miles/day

Hakim NEJM 1998;338:94-9.

Diabetes Risk Reduction(Diabetes Prevention Program; NEJM, April 2002)

0.31

0.58

0%

20%

40%

60%

80%

100%

Metformin Lifestyle

Relative to Control Group (standard intervention)

Ris

k R

educ

tion

Risk Reduction

Community Physical Activity Policyfor 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, MDVice President, epidemiology and surveillance researchAmerican 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 Triangle of Key Concepts for Optimal SupportSupport

Strong LeadershipStrong Leadership

Valid Research & EvaluationValid Research & Evaluation

Effective PoliciesEffective Policies

Hollander, Librett, Fenton et al., 2004Hollander, Librett, Fenton et al., 2004

““Enumerate the Problem”Enumerate the Problem”

““Enunciate a SolutionEnunciate a Solution””

Triad for Policy Infrastructure

Triad for Policy Infrastructure

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• Modified physical education• Individualized behavioral change• Non-family social support• Create or enhance access• Community-wide campaigns

Summary: Insufficient Evidence• 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 WalkPrimary 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 CampaignsInformational Approaches to Increasing

Physical Activity

• Large-scale, high intensity, high visibility

• Use of TV, radio, newspaper, information sites

• Multi-component, multi-site

• ‘Combined Package’

http://www.cdc.gov/youthcampaign/index.htm

VERB

“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-adaptedHealth Behavior Change

• Goal setting and self-monitoring

• Building social support

• Behavioral reinforcement

• Structured problem solving

• Relapse prevention

Men in Motion

PACE+: Counseling Adolescents for Exercise and Nutrition

PACE+: Counseling for Overweight Women for Diet and Activity

http://www.paceproject.org/homepage.html

Physical Activity Counseling for Exercise

Social Support in Community Contexts

• Creating, strengthening, and maintaining

social networks

• Use of ‘buddy’ systems

• Contracting

• Walking groups

http://www.cdc.gov/wisewoman/index.htm

Well-Integrated Screening and Evaluation for Women Across the Nation

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 practicessuch 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 ChangesBuilt Environment Changes

Built Environment ChangesBuilt Environment Changes

Built Environment ChangesBuilt 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/

• 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

• American Planning Association• National Association of City & County

Health Officials

Opportunities for public successful & private partnerships

Active Community Environments

Trails for Health

Senior Wellness

Opportunities for public successful & private partnerships

Promoting Physical Activity Through Recreation in America’s Great Outdoors

HealthierUSBased 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 Triangle of Key Concepts for Optimal SupportSupport

Strong LeadershipStrong Leadership

Valid Research & EvaluationValid Research & Evaluation

Effective PoliciesEffective Policies

Hollander, Librett, Fenton et al., 2004Hollander, Librett, Fenton et al., 2004

““Enumerate the Problem”Enumerate the Problem”

““Enunciate a SolutionEnunciate a Solution””““Create the Team/Facilitate the Create the Team/Facilitate the Process”Process”

Triad for Policy Infrastructure

Triad for Policy Infrastructure

Creating the Team

• Who’s in. . . ?

http://www.dilbert.com/