System, policy and environmental change:

1. System, policy and environmental change: Presented by: Laura K. Brennan, PhD, MPH Evidence, Gaps and Implications

2. Overview

3. Our Team • Julie Claus, Chief Operating Officer • Sarah Castro, Project Director • Peter Holtgrave, Project Director • Tammy Behlmann, Project Manager • Laura Runnels, Project Manager • Courtney Jones, Project Coordinator • Allison Kemner, Project Coordinator • Daedra Lohr, Financial Coordinator • Many part-time staff and interns

4. Our Local Collaborators • Elizabeth Baker, Saint Louis University • Cheryl Kelly, Saint Louis University • Ross Brownson, Washington University • Cheryl Carnoske, Washington University • Debra Haire-Joshu, Washington University • Christine Hoehner, Washington University • Peter Hovmand, Washington University • Timothy Hower, Washington University

5. Policy/Practice Partners • Don Bishop • Elaine Borton • Leah Ersoylu • Steve Farrar • Harold Goldstein • Dean Grandin • James Krieger • Jacqueline Martinez • MalisaMcCreedy • Leslie Mikkelsen • Joyal Mulheron • Maya Rockeymoore • Marion Standish • Sarah Strunk • Ian Thomas • Mildred Thompson Our National Advisors • RWJF, NIH & CDC • Rachel Ballard-Barbash • Jamie Bussell • William Dietz • Terry Huang • Laura Kettel-Khan • Laura Leviton • Elizabeth Majestic • Robin McKinnon • Shawna Mercer • Marilyn Metzler • Meredith Reynolds • Tracy Orleans • Thomas Schmid • Celeste Torio • Pattie Tucker • Researcher Partners • Karen Glanz • Frank Chaloupka • Lawrence Green • Shiriki Kumanyika • Marc Manley • Barbara Riley • James Sallis • Eduardo Sanchez • Loel Solomon • Janice Sommers • Mary Story • Antronette Yancey

6. Social Determinants of Health:Learning from Doing

7. Ottawa Charter • International Conference on Health Promotion in 1986 • Health promotion approach: • Building healthy public policy • Creating supportive environments • Strengthening community actions • Developing personal skills • Reorienting health services

8. Ottawa Charter “Health promotion is the process of enabling people to increase control over, and to improve, their health. To reach a state of complete physical, mental and social well-being, an individual or group must be able to identify and to realize aspirations, to satisfy needs, and to change or cope with the environment... People cannot achieve their fullest health potential unless they are able to take control of those things which determine their health. At the heart of this process is [communities taking] ownership and control of their own endeavors and destinies.” Ottawa Charter for Health Promotion (1986)

9. Common Language • Community • Health disparities • Health inequities • Health equity • Social determinants of health (SDOH)

10. Community • A group of people with a shared identity, including: • living in a particular geographic area; • having some level of social interaction; • sharing a sense of belonging; or • having common political or social responsibilities References: Eng, Parker (1994), Fellin (1995), Hunter (1975), Israel, et al (1994), MacQueen, et al (2001), McKnight (1992)

11. Distribution of U.S. Population by Race/Ethnicity, 2007 American Indian/ Native Alaska Native Hawaiians/Pacific 1% Islanders (2.3 million) 0% (0.4 million) Asian Two or more races 4% 1% (13.1 million) (4.2 million) African American 12% (37.0 million) Hispanic White 15% 66% (45.5 million) (199.1 million) Total = 301.6 million NOTES: Data do not include residents of Puerto Rico, American Samoa, Guam, the U.S. Virgin Islands, or the Northern Mariana Islands. Totals may not add to 100% due to rounding. All racial groups and individuals reporting “two or more races” non-Hispanic. SOURCE: Kaiser Family Foundation, based on Table 3: Annual Estimates of the Population by Sex, Race and Hispanic Origin for the United States: April 1, 2000 to July 1, 2007 (NC-EST2007-03). Population Division, U.S. Census Bureau.

12. Share of Population that is a Racial/Ethnic Minority by State, 2005-2006 Less than 14% (11 states) 14% to 21% (13 states) 22% to 36% (14 states) More than 37% (13 states) SOURCE: Urban Institute and Kaiser Commission on Medicaid and the Uninsured analysis of March 2006 and March 2005 Current Population Survey.

13. Distribution of U.S. Population by Race/Ethnicity, 2000 and 2050 Total = 282.1 million Total = 419.9 million NOTES: Data do not include residents of Puerto Rico, Guam, the U.S. Virgin Islands, or the Northern Marina Islands. “Other” category includes American Indian/Alaska Native, Native Hawaiian or Other Pacific Islander, and individuals reporting “Two or more races.” African-American, Asian, and Other categories jointly double-count 1% (2000) and 2% (2050) of the population that is of these races and Hispanic; thus, totals may not add to 100%. SOURCE: Kaiser Family Foundation, based on http://www.census.gov/population/www/projections/popproj.html, U.S. Census Bureau, 2004, US Interim Projections by Age, Sex, Race, and Hispanic Origin.

14. Health Disparities • Differences in the incidence and prevalence of health conditions and health status between groups, based on: • Race/ethnicity • Socioeconomic status • Sexual orientation • Gender • Disability status • Geographic location • Combination of these Reference: Braveman P. (2006)1

15. Cancer Screening Rates by Race/Ethnicity*, 2003 Breast Cancer (Mammography) Cervical Cancer (Pap Test) Colon and Rectum Cancer (Fecal Occult Blood Test) NOTES: * Data for American Indians/Alaska Natives and Native Hawaiians/Pacific Islanders do not meet the criteria for statistical reliability, data quality or confidentiality. Age-adjusted percentages of women 40 and older who reported a mammography within the past 2 years, women 18 and older who reported a pap test within the past 3 years, and adults 50 and older (male and female) who reported a fecal occult blood test within the past 2 years. SOURCE: Kaiser Family Foundation, based on the National Healthcare Disparities Report, 2005, available at: http://www.ahrq.gov/qual/nhdr05/index.html, using data from the Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey.

16. Health Inequities • Systematic and unjust distribution of social, economic, and environmental conditions needed for health • Access to healthcare • Employment • Education • Access to resources (e.g., grocery stores, car seats) • Income • Housing • Transportation • Positive social status • Freedom from discrimination Reference: Whitehead M. et al7

17. Health Insurance Status, by Race/Ethnicity: Children, 2007 Private (Employer and Individual) Medicaid and Other Public Uninsured * * White 44.7 million Hispanic 16.5 million African American 11.6 million American Indian/ Alaska Native 0.5 million Two or More Races 2.1 million Asian/ Pacific Islander 3.3 million Total Child Population 2007 NOTES: “NSD” = Not sufficient data; “Other Public” includes Medicare and military-related coverage. All racial groups non-Hispanic. * = Estimate has a large 95% confidence interval of +/- 5.0 - 7.9 percentage points. SOURCE: Urban Institute and Kaiser Commission on Medicaid and the Uninsured analysis of the March 2008 Current Population Survey.

18. Percent Uninsured, Ages 55-64, by Race/Ethnicity, 2006 33% Two or More Races White, Non-Hispanic Hispanic African American, Non-Hispanic Asian/Pacific Islander American Indian/Alaska Native DATA: March 2007 Current Population Survey SOURCE: Kaiser Commission on Medicaid and the Uninsured estimates.

19. No Doctor Visit in Past Year for Nonelderly Adults by Race/Ethnicity and Insurance Status, 2005-2006 SOURCE: Kaiser Family Foundation and Urban Institute analysis of the National Health Interview Survey, 2005 and 2006, two-year pooled data.

20. No Usual Source of Care for Nonelderly Adults by Race/Ethnicity and Insurance Status, 2005-2006 SOURCE: Kaiser Family Foundation and Urban Institute analysis of National Health Interview Survey, 2005 and 2006, two-year pooled data.

21. Life Expectancy at Age 25 for U.S. Black and White Men with Similar Income Levels * $25,000 or more $10,000-$24,999 $10,000 or less * 1980s income levels SOURCE: NLMS: Lin et al 2003 and Nancy E. Adler, Health Disparities: Measurement, Mechanisms, and Meaning presentation, NIH

22. Infant deaths per 1,000 live births: Infant Mortality Rates for Mothers Age 20+, by Race/Ethnicity and Education, 2001-2003 Less than High School High School College+ SOURCE: Kaiser Family Foundation, based on Health, United States, 2006, Table 20, using data from the National Center for Health Statistics, National Vital Statistics System, National Linked Birth/Infant Death Data.

23. Health Equity • The opportunity for everyone to attain his or her full health potential • No one is disadvantaged from achieving this potential because of his or her social position or other socially determined circumstance • Distinct from health equality Reference: Whitehead M. et al7

24. Social Determinants Life-enhancing resources, such as food supply, housing, economic and social relationships, transportation, education and health care, whose distribution across populations effectively determines length and quality of life. Reference: James S. (2002)6

26. Diseases and Behaviors

27. SDOH and Health

28. Pathways from social determinants to health

30. Active Living by Design • National program, The Robert Wood Johnson Foundation • Purpose: To establish innovative approaches to increase physical activity through community design, public policy, and communications strategies • ALbD Community Action (or “5P”) Model: • Preparation • Promotion • Programs • Policy Influence • Physical Projects www.activelivingbydesign.org

33. ALbD Products • ALbD Best Practices special issue (available: http://www.activelivingbydesign.org/AJPM) • ALbD Evaluation special issue (under development) • Active Living Research evaluation (2 communities) • Progress reporting • Concept mapping • “5P” strategies and integration of approaches • Other reports/products: • Cross-site report • Community partnership summaries

34. Healthy Kids, Healthy Communities • National program, The Robert Wood Johnson Foundation • Purpose: To implement healthy eating and active living policy- and environmental-change initiatives that can support healthier communities for children and families across the United States • HKHC places special emphasis on reaching children who are at highest risk for obesity on the basis of race/ethnicity, income and/or geographic location www.healthykidshealthycommunities.org

35. Healthy Kids, Healthy Communities (50 Grantees) HKHC Leading Site Communities Seattle/King County, WA Portland/Multnomah County, OR Houghton, MI Benton County, OR Fitchburg, MA Rochester, NY Milwaukee, WI Buffalo, NY Somerville, MA Kingston, NY Flint, MI Kane County, IL Philadelphia,PA Chicago, IL Omaha, NE Oakland, CA Hamilton County, OH Washington, DC Denver, CO Watsonville/Parajo Valley, CA Kansas City, MO Charleston, WV Central Valley, CA Columbia, MO Louisville, KY Nash/Edgecombe Counties, NC Cuba, NM Baldwin Park, CA Knoxville, TN Moore/Montgomery Counties, NC Rancho Cucamonga, CA Chattanooga, TN Boone/Newton Counties, AR Greenville, SC San Felipe Pueblo, NM Spartanburg, SC Jefferson County, AL Desoto/Marshall/ Tate Counties, MS Phoenix, AZ Milledgeville, GA Grant County, NM Jackson, MS Cook County, GA El Paso, TX New Orleans, LA San Antonio, TX Duval County, FL Houston, TX Lake Worth/Greenacres/ Palm Springs, FL Caguas, PR Healthy Kids, Healthy Communities

44. Assessment & Evaluation

45. Why Evaluate? • To determine the effectiveness of local policy, environment, and systems approaches to prevent or reduce childhood obesity • Short-, intermediate- & long-term impacts and outcomes related to health behaviors and obesity • Reliable & valid quantitative tools & measures • Study design and execution to ensure confidence in the findings from the evaluation • To identify the approaches with the greatest impact, relevance, feasibility and sustainability • What works, where it works, when it works, how it works & why it works (or why not) • Multi-method quantitative & qualitative measures • Local representation and participation to ensure confidence in the findings from the evaluation • To inform local decision-making, document successes & obtain more funding • Track intended/unintended results, practical considerations (resources, costs), assets & challenges • Simple, quick measures serving multiple purposes (advocacy, marketing, cost/benefit) • Findings translate to the interests of local audiences (decision-makers, business owners) THESE ARE NOT MUTUALLY EXCLUSIVE…

47. Evidence Goals • Tobridge research/evaluation and policy/practice efforts associated with environment and policy nutrition and physical activity intervention strategies for childhood obesity prevention. • To accelerate the translation of replicable, evidence-based environment and policy interventions that will lead to leveling and eventually reducing rates of childhood obesity, especially in lower income and racial/ethnic populations.

48. Evidence Levels How do we define levels of evidence in order to bridge the gap between research/evaluation and policy/practice efforts?

50. Evidence Review How do we create a complementary process to identify, collect and review a range of different evidence resources from research/evaluation and policy/practice efforts?