determinants of health and policy approaches to improve ... · 5/31/2012 · los angeles county...

1

Determinants of Health and

Policy Approaches to Improve Population Health

UCLA Luskin School of Public Affairs Senior Fellow Briefing - May 31, 2012

Jonathan E. Fielding, MD, MPH Director and Health Officer

Los Angeles County Department of Public Health Distinguished Professor of Health Services and Pediatrics

Schools of Public Health and Medicine, UCLA

2

Public Health in the 21st Century •  Epidemic of overweight: diabetes, heart disease

–  Diabetes affects 25.8 million

people = 8.3% of U.S. Population1

–  26.9% of U.S. residents

over 65 years had diabetes in 2010

–  More than 1 in 3 (81 million) U.S. adults currently live with cardiovascular disease2

1) National Diabetes Fact Sheet, 2011, CDC; 2) Heart Disease and Stroke Prevention, Addressing the Nation’s Leading Killers: At a Glance 2010, CDC

Public Health in the 21st Century •  Impacts of population density/growth

–  Infectious diseases

– Mental health problems

– Environmental exposures

• E.g. air pollution, toxic exposures

•  Macro-environment: climate, conflict

•  Emergency preparedness

Public Health in the 21st Century •  Increased burden and costs of care for aging

populations –  In 2009, over 55 million

U.S. residents were age 60 or older = 18% of the population

–  Projected to grow to 92.2 million in 2030 and 112 million by 2050

4

US Census Bureau, Population Division, Annual Estimates of the Resident Population by Sex and Five-Year Age Groups for the United States: April 1, 2000 to July 1, 2009

Public Health in the 21st Century •  Increasing Disparities

–  Strongly associated with social environment (education, job opportunities, etc)

–  In Los Angeles County, life expectancy for an African American

male at birth (69.4 yrs) is nearly 18 years shorter than that of an Asian/Pacific Islander female (86.9yrs)

5 Los Angeles County Department of Public Health. Life Expectancy in Los Angeles County: How Long Do We Live and Why? July 2010.

6

Changing Causes of Death: Crude Death Rate for Infectious Diseases, U.S.,

1900 - 2000

MMWR, CDC, 1999

* Rate is per 100,000

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Leading Causes of Death & Premature Death, Los Angeles County, 2009

Leading Causes of Death Leading Causes of Premature** Death Rank

Cause of Death

No. of Deaths

Premature Death Rank

Rank

Cause of Death

Years of Life Lost

Death Rank

1. Coronary heart disease

12,725 1. 1. Coronary heart disease

59,440 1.

2. Stroke 3,301 8. 2. Homicide 31,270 16.

3. Lung cancer 2,958 7. 3. Motor vehicle crash 22,017 19.

4. Emphysema/COPD 2,904 13. 4. Liver disease 21,515 9.

5. Alzheimer's disease 2,125 48. 5. Suicide 20,835 14.

6. Pneumonia/influenza 2,022 15. 6. Drug overdose 20,484 18.

7. Diabetes 1,964 9. 7. Lung cancer 17,295 3.

8. Colorectal cancer 1,388 11. 8. Stoke 15,554 2.

9. Liver disease 1,246 4. 9. Diabetes 14,697 7.

10. Breast cancer 1,173 10. 10. Breast cancer 13,466 10.

Mortality in Los Angeles County: Los Angeles County Department of Public Health, Office of Health Assessment & Epidemiology 57,602 total deaths and 455,513 years of life lost, excluding infants less than 1 year of age and persons of unknown age. **Death before age 75 years.

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Cause of Death 2000 2009 Percent Change

Coronary heart disease 220 129 -42%

Stroke 57 34 -41%

Lung cancer 41 31 -23%

COPD 35 30 -13%

Alzheimer’s disease 11 21 94%

Pneumonia/influenza 32 21 -34%

Diabetes 24 20 -17%

Colorectal cancer 18 14 -19%

Liver disease 14 11 -10%

Breast cancer (females) 24 21 -9%

HIV/AIDS 6 3 -50%

Homicide 10 7 -33%

Rate (per 100,000) Age-adjusted to year 2000 U.S. standard population

The Best News You Never Heard: Trends in the Leading Causes of Death,

Los Angeles County, 2000-2009

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Comparison of the Leading Causes of Premature Death by Race/Ethnicity,

Los Angeles County 2009

Race/ethnicity

#1 cause

#2 cause

#3 cause

#4 cause

#5 cause

White Coronary heart disease

Drug Overdose Suicide

Lung cancer Liver disease

Hispanic Homicide Coronary heart disease

Motor Vehicle Crash

Liver disease Drug Overdose

Black

Coronary heart disease

Homicide Diabetes Lung cancer HIV

Asian/Pacific Islander


Lung cancer Suicide Stroke Colorectal cancer

Los Angeles County Total


Homicide Motor Vehicle Crash

Liver disease Suicide

Mortality in Los Angeles County: Los Angeles County Department of Public Health, Office of Health Assessment & Epidemiology

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Homicide Rate by Age Group, Los Angeles County, 1997-2006

0

5

10

15

20

25

30

35

40

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Years

Rat

e pe

r 100

,000 0-14

15-24

25-44

45-64

65+

Source: Linked DSMF for Los Angeles County residents, 1997-2006 PEPS, 1997-2006; ICD 9 (1997-1998): E960-E969; ICD 10 (1999-2006): X85-Y09, Y87.1

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What produces health? •  Genetics

•  Behaviors –  Health related –  Risk taking –  Health care seeking –  Complying with medical advice

•  Health care system

•  Environment –  Physical –  Social –  Economic

One Model of Population Health

12 County Health Rankings Model. Copyright 2010 UWPHI

Medical 20%

Underlying Determinants

of Health 50%

Health Behaviors

30%

13

Common Health Improvement Approaches

•  Shaping health behaviors –  Individual – Group

•  Medical care

– Preventive services – Access for underserved

Bottom photo credit: Adithya Sambamurthy The Bay Citizen June 28, 2011.

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Modern Public Health •  Adapting more ecologic

models of health

•  Recognizing that environments in which we live, work, play and age strongly influence health outcomes

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•  Behavioral outcomes •  Specific risk factors, diseases& conditions •  Injuries •  Well-being & health-related Quality of Life •  Health equity

•  Policies •  Programs •  Information

Assessment, Monitoring, Evaluation & Dissemination

Interventions Outcomes

Ecologic Model of Health

Action Model to Achieve Healthy People 2020 Overarching Goals

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Leading Causes of Disability-Adjusted Life Years (DALYs) in Los Angeles County, 2005

28,766

30,642

30,691

39,931

40,069

47,698

52,463

53,364

65,198

79,281

0 10,000 20,000 30,000 40,000 50,000 60,000 70,000 80,000 90,000

Emphysema

Stroke

Motor Vehicle Crash Injuries

Osteoarthritis

Homicide/Other Violence

Depression

Alzheimer's/Other Dementia

Diabetes Mellitus

Alcohol Dependence

Coronary Heart Disease

DALYs

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Alcohol’s Costly Toll •  Alcohol-related illness accounted for 1,370 deaths and over

27,000 hospitalizations

•  Alcohol is implicated in DUIs, falls, suicide, poisonings, & occupational injuries ≈700 deaths and 27,530 injuries per year

•  Annual economic cost of alcohol use in LAC $5.4 billion in illness $2.0 billion in traffic and DUI $1.0 billion in other injury + $2.4 billion in crime $10.8 billion dollars

17 Los Angeles County Department of Public Health. Facts and Figures: Alcohol in Los Angeles County. October 2010

Alcohol’s Costly Toll (cont.) •  Communities with high density

alcohol outlets are: –  9 to 10x more likely to have

increased rates of violent crimei,ii

–  3x more likely to have increased rates of alcohol-involved crashesi

–  5x more likely to have increase rates of alcohol-related deathsii

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Off-Premises Alcohol Outlet Density among LA County Cities and Communities, 2009

Los Angeles County Department of Public Health. Reducing Alcohol-Related Harms in Los Angeles County: A Cities and Communities Report. March 2011. i – on-premise outlets (alcohol consumed on site); ii – off-premise outlets (alcohol consumed off site)

19

Percent of adults who reported binge drinking in the past month, by gender, in LA County, 2007

9.4%

23.3%

0%

10%

20%

30%

40%

LA County

Men Women

Binge drinking for males is drinking 5 or more drinks on one occasion at least one time in the past month. Binge drinking for females is drinking 4 or more drinks on one occasion at least one time in the past month.

20

The Guide to Community Preventive Services (“The Community Guide”)

•  Congressionally mandated expanding resource for recommendations on evidence-based interventions to improve public health

•  Directed by the 15 member independent volunteer Task Force on Community Preventive Services

•  Liaisons with key organizations support the science and dissemination

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Community Guide (cont.) •  Systematic reviews of

available evidence lead to recommendations based on standardized methods –  Effectiveness of population-

and health system-based interventions

•  Recommendations for policy and practice (programs and services)

•  Identification of research

gaps

www.thecommunityguide.org

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The CG Seeks to Answer Key Questions about Interventions

•  Do they work? •  How well? •  For whom? •  Under what circumstances

are they appropriate? •  What do they cost? •  Do they provide value? •  What there barriers to their use? •  Are there any harms? •  Are there any unanticipated outcomes?

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Community Guide Topics

•  Adolescent Health •  Alcohol •  Asthma •  Birth Defects •  Cancer •  Cardiovascular Disease •  Diabetes •  Health Communication •  Health Equity •  HIV/AIDS, STIs, &

Pregnancy

•  Nutrition •  Obesity

•  Mental Health •  Motor Vehicle •  Nutrition •  Obesity •  Oral Health •  Physical Activity •  Social Environment •  Tobacco Use •  Vaccines •  Violence •  Worksite

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Tobacco’s Costly Toll •  Tobacco use is single most preventable cause of death,

with 10 million annual deaths estimated by the 2030. •  50,000 annual deaths in the US due to secondhand smoke

exposure alone. –  In LAC, an estimated 336,000 children are exposed to secondhand

smoke at home

•  A million+ smokers in LAC. •  Prevalence is at 14.3%; cities range from 5.3% -21.9% •  1 out of every 7 deaths in LAC is caused by tobacco use (≈

9,000 deaths)

•  In LAC, tobacco use is linked to: –  15% coronary heart disease deaths –  9% stroke deaths –  77% lung cancer deaths –  15% pneumonia deaths –  85% emphysema deaths

•  Smoking costs to LAC per year $2.3 billion in direct medical costs + $2.0 billion in lost productivity $4.3 billion dollars

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Tobacco’s Costly Toll (cont.)

27

18.6 17.1

18.7

10.4 10.8 10.1

0

10

20

30

2002 2005 2007

Men Women

Percent of Adults who Smoke Cigarettes by Gender - LA County, 2002-2007

Los Angeles County Health Survey

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•  Working to create a climate where tobacco use is less acceptable.

•  Goal to reduce smoking prevalence and exposure to secondhand smoke, especially among vulnerable populations.

Project TRUST - Tobacco Control & Prevention Program

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Select Tobacco Policy Objectives •  Reducing secondhand smoke

exposure –  Smoke-free Multi-unit Housing –  Outdoor Areas (dining areas,

plazas, malls, events, service lines, transit stops, doorways, etc.)

•  Reducing demand by raising the minimum price

•  Strengthening California’s current Some-Free Workplace law

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Tobacco Control Policies Adopted in LAC, 2004-2011

Policy Type Totals

Tobacco Retail License 33

Smoke-Free Multi-Unit Housing 8

Smoke-Free Parks 35

Smoke-Free Outdoor Dining 6

Smoke-Free Beaches 13

Comprehensive Smoke-free Outdoor Areas

13

Other 7

TOTAL 115

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Trends in Lung Cancer Mortality, US, CA, LA County, 1979-2004

0

10

20

30

40

50

60

70

1979

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

2001

2003

Age

-adj

uste

d ra

te/1

00,0

00

US California Los Angeles Co.

Source: CDC, National Center for Health Statistics. Compressed Mortality File 1979-1998. CDC, National Center for Health Statistics. Compressed Mortality File 1999-2004.

32

0

50

100

150

200

250

300

350

2001 2002 2003 2004 2005 2006 2007 2008 2009

White Hispanic Black Asian/Pacific Islander

Coronary Heart Disease Mortality by Race/Ethnicity, LA County, 2001-2009

Age

– A

djus

ted

rate

per

100

,000

Los Angeles County Public Health, Office of Health Assessment & Epidemiology

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Benefits of Physical Activity •  Increased life span and improved function •  Reduced hypertension, heart disease, and

stroke •  Prevention of diabetes and related

complications •  Decreased risk of colon cancer •  Improved mental health •  Body weight maintenance and obesity

control •  Increased bone mass •  Improved immune function •  Reduced health care costs

Surgeon General’s Report, 1996

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Self Reported Levels of Physical Activity among Adults in LA County, 2007

53%

11%

36%

0%

10%

20%

30%

40%

50%

60%

Active (meets guidelines) Some Activity (does not meet guidelines)

Minimal to No Activity (sedentary)

LA County


Physical Activity Guidelines for Americans (PAGA) Study

•  2011 study assessed self-reported vs. objectively measured physical activity among U.S. adults (n=4,773) using accelerometer data

Percentage of adults meeting the PAGA:

Self reported: 62% Objectively measured: 9.6%

35 Tucker, J, et al. Physical Activity in U.S. Adutlts: Compliance with the Physical Activity Guidelines for Americans. AM J Prev Med 2011; 40(4): 454-461

36

14.3% 16.7%

18.9% 20.9%

22.2%

0%

5%

10%

15%

20%

25%

1997 1999 2002 2005 2007

Prevalence of Adult Obesity Los Angeles County, 1997-2007


The county’s adult population gained 51 million lbs from 1997-2007

37

Prevalence of Obesity Among 5th, 7th, and 9th Graders in Los Angeles County Public Schools,

California Physical Fitness Testing, 1999-2009

18.9% 20.4% 20.9% 21.9% 22.2% 23.3%

23.0% 22.9% 23.0% 22.6%

0%

5%

10%

15%

20%

25%

30%

35%

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Obe

sity

Pre

vale

nce

Prevalence of obesity

Projected obesity prevalence assuming linear trend Healthy People 2010 Goal (<5%)

Source: California Physical Fitness Testing Program, California Department of Education. Includes 5th, 7th, and 9th graders enrolled in LA County public schools.

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Obesity Prevalence Among 3 and 4 Year Olds in the WIC Program, Los Angeles County, 2003-2010

17.3% 19.0% 20.0% 21.0% 21.3% 22.1% 22.5% 21.7%

16.4% 17.4% 18.3% 19.5% 19.7%

21.1% 21.1% 19.8%

0%

10%

20%

30%

2003 2004 2005 2006 2007 2008 2009 2010

Prev

alen

ce (%

)

Year

4-year-olds 3-year-olds

Source: PHFE WIC Program, LA County

39

0

10

20

30

40

50

60

2001 2002 2003 2004 2005 2006 2007 2008 2009

White Hispanic Black Asian/Pacific Islander

Diabetes Mortality by Race/Ethnicity, Los Angeles County, 2001-2009 A

ge –

Adj

uste

d ra

te p

er 1

00,0

00

Los Angeles County Public Health, Office of Health Assessment & Epidemiology

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Dangers of Poor Food Environment •  More Americans eating food prepared outside the home,

typically higher in fat and calories and lower in nutrients1

•  % of total energy intake from restaurant and fast food increased by nearly 300% among adolescents from 1977 to 19962

•  Portion sizes have increased

•  Less access to healthy and affordable food options in lower income neighborhoods3

•  LA County is estimated to have 4x as many fast food restaurants and convenience stores as supermarkets and produce vendors4

1) Guthrie et al. 2002 J Nutr Educ Behav; 2) Nielsen, et al., 2002 Obesity Research; 3) Baker et al. 2006 Prev Chronic Disease; Powell et al. 2006 Preventive Medicine; 4) ‘Searching for Healthy Food: The Food Landscape in California Cities and Counties’, 2007 CCPHA brief

42

Access to Fresh, Quality Food •  Availability of high quality

fresh fruits & vegetables where people shop varies by income:

•  Only 29% of adults living below poverty in Los Angeles reported having access to high quality fresh fruits & vegetables

•  vs 44% of adults living at or above 300% FPL

2007 Los Angeles County Health Survey

Does Healthy Food Cost More? •  Healthy foods are no more costly than

unhealthy foods, when compared by weight and portion size:

–  Potato chips are nearly twice as expensive as carrots

–  Carrots, onions, pinto beans, mashed potatoes, bananas and orange juice are less expensive per portion than soft drinks, ice cream, chocolate candy, French fries, and sweet rolls

43 Carlson, Andrea, and Elizabeth Frazão. Are Healthy Foods Really More Expensive? It depends on How You Measure the Price, EIB-96, U.S. Department of Agriculture, Economic Research Service, May 2012. Accessed at: http://www.ers.usda.gov/Publications/EIB96/EIB96.pdf

45 45 45

Cities/Communities with Lowest and Highest Childhood Obesity Prevalence, 2008

*Table excludes cities/communities where number of students with BMI data < 500. Source: California Physical Fitness Testing Program, California Department of Education. Includes 5th, 7th, and 9th graders enrolled in LA County public schools; 2000 Census

Top 10*

City/Community Name Obesity

Prevalence (%)

Rank of Economic Hardship (1 - 128)

Manhattan Beach 3.4 2

Calabasas 5.0 8

Hermosa Beach 5.1 1

Agoura Hills 5.3 10

Beverly Hills 5.4 19

Malibu 5.9 4

Palos Verdes Estates 7.3 5

San Marino 7.8 15

Rolling Hills Estate 8.4 9

La Canada Flintridge 8.5 18

Average 10 lowest 6.2%

Ave Median Household Income $99,555

Bottom 10*

City/Community Name Obesity

Prevalence (%)

Rank of Economic Hardship (1 - 128)

West Athens 30.6 94

South Gate 30.7 110

Florence-Graham 31.0 128

West Whittier-Los Nietos 31.1 81

West Carson 31.4 56

Vincent 32.2 69

East Los Angeles 32.9 117

Hawaiian Gardens 33.4 107

South El Monte 34.5 111

Walnut Park 38.7 113

Average 10 highest 32.7%

Ave Median Household Income $37,747

46

Economic Hardship & Childhood Obesity

47

RENEW Los Angeles County Renew Environments for Nutrition, Exercise, and Wellness

•  Seeks to implement policy, systems and environmental changes to improve nutrition, increase physical activity and reduce obesity

•  Particularly in disadvantaged communities

Community Market Conversion Pilot

•  RENEW partnered with the City of LA Community Redevelopment Agency, California Endowment and Los Angeles Neighborhood Initiative on pilot program to transform 4 corner stores in South Los Angeles

48 Photo of Gus Harris, Jr., pilot participant. Credit: http://communitymarketconversion.org

Vision of the pilot:

•  Increased access to healthy food •  Improved public health through community education •  Improved food retail environment (physical design of stores to promote healthy options) •  Affordability •  Community driven process

Healthy Food Procurement Policies •  RENEW works with cities and organizations to

improve procurement and vending policies –  Healthy food and beverage policies have been adopted

in ten cities –  All events requiring food and beverages provided at

city facilities meet specific nutrition standards, limiting fat, sugar and sodium levels, and restricting sugar sweetened beverages

•  RENEW also works on food procurement and food promotion policies for the County of Los Angeles

–  RENEW assists County agencies to improve their food environments

–  Namely, menu labeling, sodium reduction plans, portion size limits on sugar-sweetened beverages and healthy entrees, side options and snacks that meet DPH nutrition standards

49

50

DPH Campaign: Rethink Your Drink •  Sugar sweetened beverages (SSB)

are the largest single source of added sugar and calories in the American diet.

•  On average, nearly 39% of adults in LA County drink at least one SSB per day.

•  > 43% of children 17 or younger consume at least one SSB on an average day. –  A child’s risk for obesity increases an

average of 60% with every additional daily serving of soda.

Our Environments Matter

52

traffic safety

air pollution

water quality & quantity

obesity & chronic disease

physical activity

crime & violence

social capital

elder health & mobility

mental health

health disparities

Adverse Health Impacts From Poor Community Design

53

Health and Sprawl People living in counties marked by

sprawling development:

•  Walk less in their leisure time

•  Are more likely to have high blood pressure

•  Have higher body mass indexes

•  Are more likely to be overweight (average 6 pound difference)

Ewing R, et al: American Journal of Health Promotion 18(1) Sept/Oct 2003 Photo from: http://blog.travelpod.com/travel-photo/arsucasas/1/1267654070/2_rty.jpg/tpod.html

Land Use Decisions and Public Health •  The public’s health is greatly influenced by the

physical environment

•  Exposure to traffic emissions has been linked to many adverse health effects¹

•  Many residents live along major transportation corridors, where pollution levels are highest²

•  Reaching ambient air quality standards will not adequately protect populations living close to local sources of pollution

1) Ciccone et al. 1998; CDC report: Diesel Epidemiology Expert Panel 1999: Lipsett & Campleman, “Environmental Triggers of Asthma Case Study”, US Dept. of Health & Human Services; AAPCEH 1993; Ostro et al. 2001; Tolbert et al. 2000; 2) 2: Kunzli, N, et al “Ambient Air Pollution and the Progression of Atherosclerosis in Adults”, 2010

55

PLACE Program Policies for Livable Active Communities and Environments

•  Created to foster policy and environmental change to support safe, healthy and active communities

•  Key strategies for infusing PH into land use and community design:

•  Grants to cities & non-profits to create safe routes to school plans, bicycle/ pedestrian master plans, complete streets etc.

•  Provide technical assistance to cities with high rates of childhood obesity for policy change through the “Healthy Policies Initiative”

•  Influence regional transportation policies to support PH goals

:

56

PLACE Grants: 2008 – 2011 •  City-level policy change to facilitate

physical activity –  Aligned with physical project

•  Grantees formed “city-CBO”

partnerships

•  5 grantees funded for 3 years –  New Healthy Eating, Active Living RFP

to be issued this spring

•  Technical assistance to cities via consultants –  e.g. active transportation planners and

landscape architects

:

57

Healthy Policies Initiative •  Providing technical assistance on:

–  Safe Routes to School Plans

•  Huntington Park and South Gate

–  Bike and Pedestrian Master Plans

•  Lynwood and Pomona

–  Provide workshops for city staff and community

partners on bike/ped planning, complete streets, bike

friendly business districts, etc.

58

•  Behavioral outcomes •  Specific risk factors, diseases& conditions •  Injuries •  Well-being & health-related Quality of Life •  Health equity

•  Policies •  Programs •  Information

Assessment, Monitoring, Evaluation & Dissemination

Interventions Outcomes

Social Determinants of Health

Action Model to Achieve Healthy People 2020 Overarching Goals

59

Definition: Societal Determinants of Health

“Conditions in the social, physical, and economic environment in which people are born, live, work, and age. They consist of policies, programs, and institutions and other aspects of the social structure, including the government and private sectors, as well as community factors.”

Healthy People 2020: An Opportunity to Address Societal Determinants of Health in the U.S., Objectives for 2020, July 11, 2010. Top photo credit: New York Times, Beatrice de Gea, Oct 19, 2008.

60

Healthy People 2020 •  An overarching goal of Healthy People 2020 is to

‘create social and physical environments that promote good health for all.’

•  HP 2020 recognizes that social determinants influence

population heath and limit the ability of many to achieve health equity.

Koh, H., Pitrowski J., Kumanyika S., Fielding J. Healthy People: A 2020 Vision for the Social Determinants Approach. Health Education & Behavior, Dec 2011, 38(6) 551-557.

Some Examples of Social Determinants:

•  Availability of resources to meet daily needs –  Eg. safe housing

•  Access to educational, economic and job opportunities

•  Access to health care services •  Quality of education and job

training •  Social support

61

•  Exposure to crime, violence and social disorder

•  Social norms and attitudes –  Eg. discrimination, racism

•  Socioeconomic conditions –  Eg. concentrated poverty

•  Language/Literacy •  Availability of jobs that pay

living wage

Healthy People 2020 Overview - Social Determinants of Health Accessed at: healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=39

A Closer Look: Social Determinants

in LA County

62

Poverty US, CA, LA County: All Ages

63

15.3

15.8

17.6

10

11

12

13

14

15

16

17

18

% o

f Pop

ulat

ion

in P

over

ty

U.S. CA LA County

U.S. Census Bureau, Small Area Income and Poverty Estimates Program, November 2011 Accessed at: http://www.census.gov/did/www/saipe/data/interactive/

Poverty US, CA, LA County: Under Age 18

64

21.6

22

24.5

12

14

16

18

20

22

24

26

28

% o

f Pop

ulat

ion

in P

over

ty

U.S. CA LA County

U.S. Census Bureau, Small Area Income and Poverty Estimates Program, November 2011 Accessed at: http://www.census.gov/did/www/saipe/data/interactive/

65

Life Expectancy by Median Household Income of Census Tract, Los Angeles County (2005)

77.5

79.0

79.6

80.6

82.9

74 76 78 80 82 84

0-$24,999

$25,000-$34,999

$35,000-$44,999

$45,000-$59,999

$60,000+

Life Expectancy at Birth in Years

Med

ian

Hou

seho

ld In

com

e

Note: Median income of LA County census tracts are for the year 1999 and are obtained from: Census 2000 Summary File 3 - United States prepared by the U.S. Census Bureau, 2002

Family Economic Self-Sufficiency Standard

•  How much income is needed for a family to adequately meet its minimal basic needs without public or private assistance?

•  Self-sufficiency standard is

based on the costs families face on a daily basis

–  Housing, food, child care, out-of-pocket medical expenses, transportation, and other necessary spending.

66 Insight Center for Community Economic Development. Accessed at http://www.insightcced.org/communities/cfess/ca-sssold/SSS-Los-Angeles-12.html

Percent of Persons Living Below the Federal Poverty Level, by Race/Ethnicity, LAC

67 U.S. Census Bureau, 2005-2009. 5-Year American Community Survey, Table C17002

<100% FPL = Percent of persons less than 100% of Federal Poverty Level *<200%FPL not available by race/ethnicity

15%

8%

21% 20%

11%

15%

0%

5%

10%

15%

20%

25%

Total White, Non-Hispanic Hispanic Black Asian Pacific Islander

Potential Solutions to Keep People Out of Poverty

•  Educational programs •  Vocational training •  Job training •  Child care supports •  Literacy programs •  English as Second

Language (ESL) •  Earned Income Tax Credit •  Housing subsidies •  Supplemental food assistance programs (CalFresh, WIC, school nutrition)

68 County Health Rankings 2011; Robert Wood Johnson Foundation. How Social Factors Shape Health: Income, Wealth and Health. Issue Brief Series: Exploring the Social Determinants of Health. April 2011 Photo credit: Ruby Washington, New York Times

Recent Example: AB 6 (Fuentes) Removing Fingerprint Imaging

•  Signed by Gov. Brown in October 2011

•  Into effect on January 1, 2012

•  Amended Welfare and Institutions Code Section 10830 by repealing the requirement that CalFresh applicants be fingerprinted and photo imaged as a condition of benefit issuance.

69

70

Improved Educational Outcomes

Improved Health Outcomes

71

Education Matters: More Formal Education = Longer Life Expectancy

47.9

53.4 50.6

56.4 52.2

57.4 54.7 58.5

0

10

20

30

40

50

60

70

Men Women

Life expectancy at age 25

0‐11 yrs

12 years

13‐15 years

16 or more years

Years of School Completed

Robert Wood Johnson Foundation. Overcoming Obstacles to Health: Report from the Robert Wood Johnson Foundation to the Commission to Build a Healthier America. February 2008.

72

And It Matters to the Next Generation: Mother’s Education Related to Infant Mortality

0

1

2

3

4

5

6

7

8

9 In

fant

Mor

talit

y R

ates

(pe

r 1,0

00 li

ve b

irths

)

0‐11 years

12 years

12‐15 years

16 or more years

Years of School Completed by

Mother, All Ages

Robert Wood Johnson Foundation. Overcoming Obstacles to Health: Report from the Robert Wood Johnson Foundation to the Commission to Build a Healthier America. February 2008.

Education’s Influence on Health

73 Robert Wood Johnson Foundation. Education Matters for Health. Issue Brief Series: Exploring the Social Determinants of Health . April 2011

74

Education Status of Adults (18+ years old), Los Angeles County, 2007

22.1% 18.6%

24.4%

34.9%

0%

10%

20%

30%

40%

50%

Less than high school

High school Some college or trade school

College or post graduate degree

2007 Los Angeles County Health Survey

Percent of Adults with Less than a High School Diploma, by Race/Ethnicity, LA County

75

Note: African American, Asian, Pacific Islander, and American Indian Alaska Native categories include persons reporting both Hispanic and non-Hispanic Origin, therefore categories are not mutually exclusive

7%

46%

14% 13% 16%

0%

10%

20%

30%

40%

50%

White, Non-Hispanic Hispanic Black Asian Pacific Islander

U.S. Census Bureau, 2005-2009. 5-Year American Community Survey, Table B15002 &C15002

Education and Working Conditions Workers with less education are: •  more likely to hold lower-paying jobs which

may put them at higher risk of injury, fatality –  More occupational hazards, including environmental

and chemical exposures (e.g. pesticide, asbestos)

–  Poor working conditions (e.g. shift work, potentially harmful tools)

•  less likely to have health-related benefits including paid sick and personal leave, workplace wellness programs, child and elder care resources, retirement benefits or employer-sponsored health insurance

76

Robert Wood Johnson Foundation. Education Matters for Health. Issue Brief Series: Exploring the Social Determinants of Health. April 2011

Potential Actions to Improve Educational Attainment •  Increase Nurse Family Partnership •  Expand early childhood development programs

–  E.g., HeadStart, SmartStart, universal pre-kindergarten

•  Comprehensive K-12 school reform to improve achievement

•  Career Academies –  Small learning communities within large high schools in

low-income, urban areas that usually focus on a specific field and provide preparatory, technical, and occupational courses to connect coursework to job opportunities.

•  Mentorship-model programs to improve high school graduation rates

•  Programs to help dropouts attain GED certificates •  Targeted programs to improve college enrollment

77 County Health Rankings 2011; Recommendations from the Robert Wood Johnson Foundation Commission to Build a Healthier America April 2009.

78

Policy as a Means to Improve Our Environments and Health

•  Historically, policy changes have yielded significant improvements in public health – Tobacco: smoking bans –  Injury prevention: helmet laws, seat belt regulation – Disease prevention: sanitation improvements,

immunization requirements •  The biggest opportunities to address large

disease/illness burdens are often via policy

79

Policies Can Work on Multiple Levels

•  Level 1: burden of disease –  e.g. Siting schools away from freeways to reduce asthma burden

•  Level 2: risk factors for disease –  e.g. Smoking bans and tobacco retail licensing to reduce

smoking opportunities

•  Level 3: health physical, social and economic environments –  e.g. Create a healthier built environment by incorporating health

into land use decisions

Health in All Policies Approach “An innovative strategy that introduces improved population health outcomes and closing the health gap as goals to be shared across all parts of government. Health in All Policies seeks to address complex health challenges through an integrated policy response across sectors.”

Kickbusch I. Adelaide Revisited: From Healthy Public Policy to Health in All Policies. Health Promotion International 2008 23(1):1-4

81 81 81

Examples of Sector-based Policy •  Agriculture

–  Direct agricultural subsidies toward more nutritious food (corn/corn syrup fresh fruits and vegetables)

•  Tax –  Use tax policy to reduce percentage in poverty –  Increase proportion of eligible residents claiming earned income tax credit

•  Transportation –  Increase development and utilization of mass transit less driving,

more walking better air and weight loss –  Complete streets initiatives

•  Environment –  Support environmental policies that improve air quality

(e.g., higher CAFE standards, cleaner energy sources)

82 82

Health Impact Assessment (HIA) A systematic process that uses an array of data sources and analytic methods and considers input from stakeholders to determine the potential effects of a proposed policy, plan, program, or project on the health of a population and the distribution of those effects within the population. HIA provides recommendations on monitoring and managing those effects.

82 - National Research Council, Improving Health in the United States: The Role of Health Impact Assessment, 2011.

83

How HIA Can Affect Policy-making

•  Tip the scales Adding evidence in favor or against a certain course of action

•  Put new issues on the table Raising awareness of un-/under-recognized health effects

•  Change the terms of debate Encouraging open, transparent decision-making and consideration of best available evidence

84

How HIA Can Affect Policy-making •  Tweak plans

Suggesting measures to modify implementation in ways that minimize potential harm and maximize potential benefits

•  Bring new parties to the table Giving voice to concerns of affected stakeholders who have difficulty making their concerns known

•  Change institutional missions and responsibilities Encouraging formulation of policies that anticipate potential health effects

85

Two HIA Flavors

1.  Project Oriented Primarily physical environment (eg. access to parks and green spaces)

2.  Policy Oriented

Physical and social environment (eg. living wage and paid leave)

86

Another Tool: Health Forecasting

Using Health Forecasting to Model Scenarios of Interest

•  “What-if” scenarios: situations that are not necessarily policy-specific, but spell out alternative future scenarios –  e.g. how does climate change affect air quality in the future (compared

to baseline/no change)? •  Target scenarios: hypothetical action-related scenario

–  e.g. how does a targeted reduction in PM2.5 and Ozone affect future outcomes?

•  Intervention scenarios: modeling specific policy intervention –  e.g. how does a specific policy intervention targeted at improving air

quality affect outcomes?

Source: UCLA Health Forecasting Project

Health Impact Assessment and Health Forecasting Compared

Health Forecasting

HIA

Long Term (10+ Years)

Examine impact of a particular policy or program

on exposures and subsequent health outcomes

in static population

Examine impact of exposures on outcomes in dynamic population (over time)

Short-Medium Term (2-5 Years)

Policy and Program Alternatives

Population Health Outcomes

Behaviors and Exposures

Conclusion •  Partnerships are critical to address

underlying determinants of health •  Policies have significant influence on the

environments in which we live •  Public Health has a responsibility to

improve health outcomes and aims to achieve that by: –  Informing decision makers of linkages between

health and the underlying determinants –  Evaluating effectiveness of actions and policies

on population health –  Adding to the scientific literature about what

works and what does not 89

90

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