Tulsa Children’s Project: Addressing the social determinants of health

1. Tulsa Children’s Project: Addressing the social determinants of health Jennifer Hays-Grudo, PhD George Kaiser Family Foundation Chair in Community Medicine School of Community Medicine, OU-Tulsa Principal Investigator,Tulsa Children’s Project

2. Tulsa Children’s Project • Based at Tulsa Educare 1 • OU-Tulsa engaged during first planning year • Multi-faceted intervention • Enhance early childhood curriculum • Adult education, workforce training for parents • Promote physical health for family, staff • Integrate positive mental health in all components • Funded by George Kaiser Family Foundation

3. Tulsa Educare Caren Calhoun, Vicki Wolfe OU-Tulsa School of Community Medicine: Jennifer Hays-Grudo, Jerry Root School of Social Work: Julie Miller-Cribbs, graduate assistants College of Education: Diane Horm Family and Children’s Services Ruth Slocum Educare mental health & family support specialists Harvard University Center on the Developing Child: Jack Shonkoff Graduate School of Education: Catherine Snow, Hiro Yoshikawa Boston Children’s Hospital: William Beardslee U of Texas, Ray Marshall School of Public Policy Chris King, Bob Glover George Kaiser Family Foundation (GKFF) Annie Van Henken and Monica Basu, project officers TCP: Collaborative Partners

4. Intervention Model Low-Income Families Children prepared to succeed in school (foundation for life-long success) Education Children (birth-5) enrolled in Tulsa Educare Medical Home Nutrition Physical activity Health Early Childhood Education Healthy Competent Children in Healthy Competent Families Social- Emotional Health Low-opportunity communities EduCareers: Adult Education Workforce Training Parents actively improving their own & their children’s life circumstances Economic security Reduction in inter-generational poverty Current Situation Short-term outcomes Long-term outcome Intervention

5. Key features of interventions • Curriculum development and training • Mental health (socioemotional literacy) integrated in curriculum (Snow’s VOICES) and in teacher/staff training (Beardslee’s Family Connections) • Interactive process with Tulsa (Educare master teachers, Ruth Slocum) • Health promotion • Integrated with mental health messages (yoga for reflective practice, physical activity and depression) • Parents and staff: self-care and role models • Workforce, adult education (EduCareers) • Integrated with FCS goals, Workforce Tulsa initiatives • Focused on work readiness: job and life skills

6. 3 Components of EduCareers Nursing Cohort Focus on high demand occupation: Nursing (CNA, LPN, RN) Team-based college education (TCC, TTC) Financial incentives Workforce Tulsa/WIA Weekly partner support meetings Transportation support Limited slots: 10 currently enrolled Adult Education GED (Union PS) ESL (Union PSon-site at Educare Civic and Work Readiness Open eligibility Free childcare Biweekly partner support meetings Transportation support Limited seats GED: 10 enrolled ESL: 30 enrolled Individual CareerCoaching One-on-one coaching through Workforce Tulsa Educational/employment focus Enhanced Employment Planning (EEP) process Biweekly partner support meetings Transportation support Limited seats: 4 enrolled

7. Why? Education and income are major drivers of health www.cdc.gov/dhdsp/library/index.htm

9. Socioeconomically determined factors Social circumstances 15% Environmental exposure 5% Behavioral patterns 40% Health care access 5-10% TOTAL 65-70% Determinants of health* *and their contributions to premature mortality; Schroeder, NEJM, 2007

10. Social determinants of health The World Health Organization Commission defined social determinants of health as the conditions in which people are born, grow, live, work and age, including the health system.” “The structural determinants and conditions of daily life constitute the social determinants of health and are responsible for a major part of health inequities between and within countries” (WHO Commission on Social Determinants of Health, Final Report, 2008). WHO Commission on Social Determinants of Health, final report, 2008.

11. WHO Commission on SDH (2008) • Three action areas: • tackle the daily living conditions in which people are born, grow, live, work and age • tackle the structural drivers of those conditions at global, national and local levels • carry out more research to measure the problem, evaluate action and increase awareness

12. What have we been doing? (where did it get us?) What do we see that could be done? What do we sense from the community? What is our deepest purpose? What is possible? What can we begin to do? Let’s start. Apply Theory U to address SDH

13. Interventions to address SDH • Downloading: what do we know? (health outcomes tied to SDH: education and income) • Seeing fresh: what are we not seeing? (programs don’t target root causes, not coordinated) • What do we sense is needed? (partners, communication, trust) • What are we called we do? (build relationships, develop organic programs) • What would it look like? (user friendly, responsive) • Let’s try it.

14. Engaging community partners in new ways attitudes governments Possible Disciplines Clinical medicine Behavioral science Public health Nursing Education Social work Public policy Economics Law Architecture Urban design Marketing Media Nutrition Exercise science insurers churches health care family built environment economic environment Engage community schools Individual physical resources Environment Systems retailers Policy norms workplace Culture school boards values

15. Health disparities and social determinants of health: framing the conversation Public opinion/messaging research, funded by Robert Wood Johnson Foundation • What do you feel and think of when you hear this • Participants: Republican and Democratic Congressional staff Political difference on issue of imbalance: Democrats see it as unnatural, cause for anger Republicans see it as natural, fear effort to redistribute resources But agree on importance of fairness and personal responsibility

16. Shared beliefs • Health starts long before illness, in our homes, schools and jobs. • Your neighborhood or job shouldn’t be hazardous to your health. • All Americans should have the opportunity to make the choices that allow them to live a long, healthy life, regardless of their income, education or ethnic background. http://www.rwjf.org/pr/product.jsp?id=66428

17. Putting health into context The conditions in which we live and work have an enormous impact on our health, long before we ever see a doctor (social determinants of health). It’s time we expand the way we think about health to include how to keep it, not just how to get it back (prevention). The more we see the problem of health this way, the more opportunities we have to improve it, individually and as a society.

18. Resources • Schroeder SA. We can do better--Improving the health of the American people. N Engl J Med 2007;357:1221-8. • WHO Commission report: http://www.who.int/social_determinants/en/ • Adler NE, Marmot M, McEwen BS, Stewart J (eds.) (1999). Socioeconomic Status and Health in Industrial Nations: Social, Psychological, and Biological Pathways. New York: New York Academy of Sciences. • Framing the message: http://www.rwjf.org/files/research/vpmessageguide20100729.pdf • Centers for Disease Control: http://www.cdc.gov/socialdeterminants/ • AMA: http://www.ama-assn.org/ama/pub/physician-resources/public-health/eliminating-health-disparities.shtml