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Urban Health: Public Health Lessons from Los Angeles. Wharton School of Business October 18, 2007. Jonathan E. Fielding, M.D., M.P.H., M.B.A Director of Public Health and Health Officer L.A. County Department of Public Health. Los Angeles County – Background. 4,300 square miles

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urban health public health lessons from los angeles

Urban Health:Public Health Lessons from Los Angeles

Wharton School of Business

October 18, 2007

Jonathan E. Fielding, M.D., M.P.H., M.B.A

Director of Public Health and Health Officer

L.A. County Department of Public Health

los angeles county background
Los Angeles County – Background
  • 4,300 square miles
  • 89 incorporated cities and 2 islands
  • 9.9 million residents (more than 42 States)
  • 46% Latino, 32% White, 13% Asian/Pacific Islander, 10% African American, 0.3% American Indian
  • Over 100 different languages spoken by significant size populations
  • 15% living in poverty (14% of families & 24% <18)
  • 22% of adults & 8% of children have no health insurance
why should we care about urban health
Why Should We Care About Urban Health?
  • Urbanization represents a major demographic shift in human history
    • At beginning of 19th century 5% of people lived in urban areas
    • At end of 19th century 45% of people were living in urban areas
    • Today almost 400 cities have pops. > 1 million
  • Studying urban health requires us to investigate the relation between the urban context and the distribution of health and disease within an urban population

Source: Galea & Vlahov. “Urban Health: Evidence, Challenges, and Directions.” Annual Review of PH, 2005 (26).

determinants of health in urban areas
Determinants of Health in Urban Areas
  • Characteristics of the urban environment that affect population health
    • Access to health and social services
    • Physical environment
      • Land use and community design
      • Pollution
      • Housing
      • Water
    • Social environment
      • Poverty
      • Social cohesion
      • Education opportunities

Source: Galea & Vlahov. “Urban Health: Evidence, Challenges, and Directions.” Annual Review of PH, 2005 (26).

what is urban health
South Los Angeles:

Poor residents

Crowded but much lower density than mid-West and each coast cities

Fewer community resources (such as greenspace, food outlets, ERs/trauma centers)

Los Angeles suburbs:

Higher income residents

Housing density lower than inner city

More community resources (parks, grocery stores & restaurants, hospitals)

What Is Urban Health?

Urban area is often characterized by dense inner city surrounded by less dense suburbs

slide7

Leading Causes of Premature Death

(Before age 75) - Los Angeles County, 2004

how we can approach disease
How We Can Approach Disease
  • Level 1 – Treating disease condition
    • e.g. enhancing disease management for diabetes
  • Level 2 – Reducing risk factors for disease
    • e.g. improve nutrition and increase physical activity to prevent diabetes
  • Level 3 – Focus on underlying determinants of disease
    • e.g. ensure opportunities for people to achieve optimal health by
      • Supporting anti-poverty programs so people can afford to eat healthfully
      • Supporting the development of greenspaces and parks so people can be physically active
how we can reduce the overall disease and injury burden
How We Can Reduce the Overall Disease and Injury Burden
  • Level 1 – Treating disease conditions
    • Pros:
      • No substitute for non-preventable conditions
      • Applying good disease management can reduce burden of many diseases
      • New medical advances can further reduce burden
    • Cons:
      • Usually costly and less cost-effective than working on other levels
      • For people without regular access to care, the benefits of medical advances are minimized
effectiveness of chronic disease self management programs
Effectiveness of Chronic Disease Self-Management Programs
  • Of 780 studies screened, 53 studies contributed data to the random-effects meta-analysis
  • Data on diabetes, osteoarthritis and hypertension:

Self-management interventions led to a statistically and clinically significant pooled effect size of:

1) -0.36 (95% CI, -0.52 to -0.21) for hemoglobin A1c, equivalent to a reduction in HgbA1c level of about 0.81%.

2) Decreased systolic blood pressure by 5 mm Hg (effect size, -0.39 [CI, -0.51 to -0.28]).

3) Decreased diastolic blood pressure by 4.3 mm Hg (effect size, -0.51 [CI, -0.73 to -0.30]).

4) Data on osteoarthritis statistically significant but clinically trivial for pain and function outcomes.

Chodosh et al. Meta-analysis: chronic disease self-management programs for older adults. Ann Intern Med. 2005;143:427-438.

roi from changes in employee health risks on a company s health care costs
ROI From Changes in Employee Health Risks on A Company’s Health Care Costs
  • Estimate of the impact of corporate health-management and risk-reduction programs for The Dow Chemical Company using a prospective return-on-investment (ROI) model
  • Methods: risk and expenditure estimates derived from multiple regression analyses
  • Results: “Break-even” scenario would require company o reduce each of 10 population health risks by 0.17% points per year over course of 10 years
  • Conclusion: results support continued investments in health improvement programs to achieve risk reduction and cost savings

Goetzel et al. Estimating the Return-on-Investment from changes in employee health risks on the

Dow Chemical Company’s Health Care Costs. J Occup Environ Med. 2005;47:759-768.

level 1 treating the disease healthcare spending
Level 1 – Treating the Disease:Healthcare Spending
  • Financial outlay:
    • 16% (~$2 trillion) of U.S. GDP spent on health care in 20051
    • Projected to increase to 20% by 20152
    • U.S. has highest health care spending per capita ($6,700 in 2005), more than twice as high as the median OECD country3
  • ROI:
    • U.S. healthcare system performance ranked #37 in world (out of 191 countries)4
    • U.S. ranked #38th in world in life expectancy5

1 (Catlin et al. 2007, Health Affairs); 2 (Borger et al. 2006, Health Affairs); 3 (Anderson et al. 2007, Health Affairs), (OECD) Organization for Economic Cooperation and Development; 4 (World Health Report 2000); 5 (United Nations: World Population Prospects: 2006 revision)

level 1 treating the disease u s healthcare expenditures 1970 2004
Level 1 – Treating the Disease:U.S. Healthcare Expenditures, 1970-2004

Source: Smith, et.al., Health Affairs, 2006

level 1 treating the disease efficacy of disease management
Level 1 – Treating the Disease:Efficacy of Disease Management
  • 23% of adults in LAC report being diagnosed with hypertension (2005)
    • percent of adults taking medication to lower blood pressure has increased from 65% in 1999 to 73% in 2005
  • 24% of adults in LAC report being diagnosed with high cholesterol (2005)
    • only 52% taking medication to lower cholesterol
pfp report high impact low cost clinical preventive services
PFP Report – High Impact, Low Cost Clinical Preventive Services

Source: Dr. Eduardo Sanchez, PFP (2007)

pfp report high impact low cost clinical preventive services20
PFP Report – High Impact, Low Cost Clinical Preventive Services

Source: Dr. Eduardo Sanchez, PFP (2007)

actual causes of death in the united states in 2000
Actual Causes of Death in the United States in 2000

Deaths

Estimated Percentage of

Cause No. Total Deaths

Tobacco 435,000 18

Diet/activity patterns 365,000 15

Alcohol 85,000 4

Microbial agents 75,000 3

Toxic agents 55,000 2

Motor vehicles 43,000 2

Firearms 29,000 1

Sexual behavior 20,000 1

Illicit use of drugs 17,000 <1

Total 1,124,000 47

Sources: Mokdad, Marks, Stroup & Gerberding, JAMA 2004

Mokdad, Marks, Stroup & Gerberding, JAMA 2005

how we can approach disease22
How We Can Approach Disease
  • Level 2 – Addressing the behavioral risk factors for diseases
    • Pros:
      • Relatively few risk factors heavily impact incidence of various diseases
      • Each risk factor affects multiple diseases
      • Preventing disease often has much better ROI than treating and managing disease
    • Cons:
      • Must address both prevention (to reduce incidence) and risk-reduction (to reduce prevalence)
      • Variable evidence of effectiveness of interventions by behavior
      • Very large disparities still exist between various demographic groups even after effective intervetions
level 2 addressing risk factors effect of smoking reduction efforts
Level 2 – Addressing Risk Factors:Effect of Smoking Reduction Efforts
  • About 50% of decline in heart disease mortality due to medical treatments, other 50% due to reductions in risk factors1
  • NY state ban on smoking at worksites associated with 8% drop in hospital admissions for heart attacks2
    • Similar declines seen in cities that have implemented smoking bans (e.g. Bowling Green, OH, Pueblo, CO, Helena, MO)
  • One study estimates about 40% of the decline in male death rate from lung CA between 1991-2003 due to reductions in tobacco smoking3

1 (Ford et al, 2007 NEJM)

2 (Juster et al, 2007 AJPH)

3 (Thun and Jemal, 2006, Tobacco Control)

percent of adults who smoke cigarettes by race la county 1997 2005
Percent of Adults who Smoke Cigarettes by Race - LA County, 1997-2005

Large disparities still exist!

level 2 addressing risk factors benefits of regular physical activity
Level 2 – Addressing Risk Factors:Benefits of Regular Physical Activity
  • Life span increase: 2 years
  • Risk of Cardiovascular Disease: 40% less
  • Rates of High Blood Pressure and Diabetes: Reduced
  • Risk of breast & colon cancer: Reduced
  • Mood and mental health status: Improved
  • Body Mass Index (BMI): Reduced
  • Health care costs: $300-$400 less per year for adults
  • Cost: low to moderate; major cost can be individual opportunity cost but cost varies greatly

Source: Surgeon General’s Report, 1996

what are the combined effects of treatment risk factor reduction
What Are the Combined Effects Of Treatment & Risk Factor Reduction?
  • The best news you never heard
  • Gradual improvements are not newsworthy
  • Not high tech
  • No single intervention to feature
  • No quick fix
trends in the leading causes of death los angeles county 1993 2004
Trends in the Leading Causes of Death,Los Angeles County, 1993-2004

* age-adjusted to year 2000 U.S. standard population

behavioral causes of death 2000
Behavioral Causes of Death - 2000

Source: Schroeder, NEJM, 9/20/07

life expectancy at birth by sex race ethnicity la county 2000
Life Expectancy at Birth by Sex & Race/Ethnicity - LA County, 2000

Life expectancy in LA County increased by approx 2.6 years from 1991 to 2000

Source: 1991 PEPS and Census 2000 Summary File 1

movements in wrong direction
Movements in Wrong Direction
  • Alzheimers – As population continues to live longer, disease will become more common
  • Diabetes – Increase allType 2 and directly correlated with increase in overweight and obesity
  • While not on list, dental disease is very common, often inadequately treated—and mostly preventable
estimated number of new alzheimer cases in thousands
Estimated Number Of NewAlzheimer Cases (In Thousands)

Source: Hebert et al. (2001). Alzheimer’s Disease and Associated Disorders, 15(4), 169-173.

trends in the leading causes of death los angeles county 1993 200435
Trends in the Leading Causes of Death,Los Angeles County, 1993-2004

* age-adjusted to year 2000 U.S. standard population

impact of alzheimer s disease
Impact of Alzheimer’s Disease
  • Healthcare costs – medical care; hospitalizations; skilled nursing; home care; long term care costs often lead to depletion of patient’s personal savings and assets
  • Personal costs – disease progression with memory loss, wandering, behavioral problems, injuries, depression
  • Caregiving – caregiver stress, caregiver illness, paid and unpaid costs of caregiving
  • Costs to businesses – absenteeism due to caregiving, etc.
health disparities persist
Health Disparities Persist
  • Caveats
    • Not just about health insurance/access
      • Latino health paradox
    • Major difference among Asian American groups
  • Possible causes
    • Does culture play a role?
    • What about environment?
      • Noxious environment theory
    • What about income inequities and wealth distribution?
      • Example of US vs other OECD countries on health indicators
slide40

Comparison of Economic Equality Within Nations

Note: Data presented by PBS based on OECD Reports: Income Distribution in 13 OECD Countries (2000).

slide42
Cost-Related Access Problems, by Income, 2004 (Percent reporting any of 3 access problems because of costs^)

*

*

*

*

*

^ Access problems include: Had a medical problem but did not visit a doctor; skipped a medical test, treatment, or follow-up recommended by a doctor; or did not fill a prescription because of cost.

* Significant difference between below and above average income groups within country at p<.05.

Data: 2004 Commonwealth Fund International Health Policy Survey of Adults’ Experiences with Primary Care

(Schoen et al. 2004; Huynh et al. 2006).

health status by income 2004
Health Status by Income, 2004

^ Chronic illnesses include: hypertension, heart disease, diabetes, arthritis, lung problems, and depression.

* Significant difference between below and above average income groups within country at p<.05.

Data: 2004 Commonwealth Fund International Health Policy Survey of Adults’ Experiences with Primary Care (Schoen et al. 2004; Huynh et al. 2006).

how we can approach disease44
How We Can Approach Disease
  • Level 3 – Focus on the underlying determinants of disease and injury
    • Pros:
      • Addressing the underlying determinants of disease can affect positive change for wide variety of diseases
    • Cons:
      • Difficult to understand the complex relationships of the underlying determinants and interrelated factors that affect health
      • Traditional sources of public health funding will not cover cost of these efforts
      • Requires working on issues that require knowledge and actions in non-health and non-public health sectors
the underlying determinants of health and their contribution to premature death
The Underlying Determinants of Health and Their Contribution to Premature Death

Source: Schroeder, NEJM, 9/20/07

level 3 addressing the underlying determinants figuring out what to do
Level 3 – Addressing the Underlying Determinants:Figuring Out What To Do
  • LAC DPH decided to create 2 new strategic initiatives to address factors that affect health in the:
    • Physical Environment
    • Social Environment
underlying determinants of health in the physical environment
Underlying Determinants of Health in the Physical Environment
  • Air quality
    • New research showing that small particle pollution contributes to excess mortality
    • LA area studies showing that proximity to roads increases asthma incidence and symptoms
    • National and international ramifications as pollution in Midwest affects New England and some of pollution in California originates in China
  • Water quality
    • Issues of quantity and conservation
  • Climate
    • Global warming impacts public health
    • Catastrophic events (e.g. hurricanes, heatwaves) have had devastating effects on urban areas
underlying determinants of health in the physical environment49
Underlying Determinants of Health in the Physical Environment
  • Urban Planning/Land Use
    • Walkability
    • Places for physical activity
    • Access to mass transit (impacts access to work and health care services)
    • Zoning requirements
  • Neighborhood safety
    • Can impact likelihood of residents being physically active
  • Housing
    • Crowded conditions influence communicable diseases
    • Availability of affordable housing and housing stock
the rising cost of housing
The Rising Cost of Housing

Percentage of households spending at least 50%

of their income on housing in 2006

US average in 2006 = 14%

US average in 2000 = 10%

Source: US Census data

slide51

traffic safety

â

air pollution

á

water quality & quantity

â

obesity & chronic disease

á

physical activity

â

crime & violence

á

social capital

â

elder health & mobility

â

mental health

â

health disparities

á

Multiple Possible Adverse Health Impacts From Poor Community Design

health and sprawl
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

commuting
Commuting
  • Los Angeles has the nation's worst Travel Time Index (TTI), 1.75 -- driving times during peak traffic hours are 75% longer than during off-peak times. (SCAG)
  • According to national statistics, Los Angeles is among the top 10 U.S. cities with the most long-distance commuters. (LA Times, September 2006)
  • Commuters spend 93 hours in rush-hour commuter traffic. (Texas Transportation Institute)
let s play spot the pedestrian
Let’s Play “Spot the Pedestrian”

Source: Dr. Howard Frumkin

summary of health effects of air pollution
Summary of Health Effects of Air Pollution
  • More pre-term babies and birth defects
  • Increases in:
    • abnormal lung development in children1
    • asthma symptoms and other respiratory diseases in children and adults2
    • deaths from heart disease and lung cancer3

1 (Gauderman et al. 2007, Lancet)

2 (McConnel et al. 2006, Env Health Perspectives; Meng et al. 2006, UCLA CHPR Research Brief)

3 (Pope et al. 2002, JAMA)

summary of health effects of air pollution56
Summary of Health Effects of Air Pollution
  • Amount of goods transported through California projected to nearly quadruple between 2000 and 20201
  • Will have significant impact on air quality and health2
  • Diesel particulate matter (PM)
    • concentrated around ports, railyards, and heavily trafficked roads3
      • premature deaths
      • cancer
      • respiratory disease
      • lost workdays
      • global warming (2nd to CO2)

Annual Health Impacts in CA from PM and Ozone4

1 (Cal EPA, 2005); 2 (Pacific Institute, 2006)

3 (CA/EPA Air Resources Board); 4 (CA/EPA Air Resources Board, 2004)

air pollution and infant death

Oil refinery, Wilmington, LA, CA

Air Pollution and Infant Death

Air pollution implicated in infant deaths from respiratory causes and sudden infant death syndrome

Ritz et al, “Air Pollution and Infant Death in Southern CA, 1989-2000,” Pediatrics 2006; 118;493-502

potential effects of climate change
Potential Effects of Climate Change

Source: Dr. Howard Frumkin

slide63

Overweight Prevalence Among School Children in LA County, 1999-2006

Projected prevalence (LAUSD) approaches 30% by 2010

Projected prevalence (LA County) approaches 26% by 2010

Healthy People 2010 Goal: 5%

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

slide64

Prevalence† of Diabetes Among Adultsin LA County, 1997-2005

† age-adjusted to 2000 US population

changes in future life expectancies related to obesity and diabetes
Changes in Future Life Expectancies Related to Obesity and Diabetes
  • Life expectancy has steadily increased over the past two centuries.
  • Current rates of obesity projected to reduce life expectancy by .33 to .75 years over the next century.
  • If rates of obesity and diabetes continue to increase at current rates, reductions in life expectancy may be to 2 to 5 years, or more

(Olshansky et al NEJM March 17, 2005)

determining effective interventions
Determining Effective Interventions
  • Where is the research base?
  • Relatively few studies
  • Many studies not in “health” or “public health” literature
  • Not amenable to design and methods used in most clinical trials
the guide to community preventive services one example
The Guide to CommunityPreventive Services: One Example
  • Expert task force, staffed by CDC, assisted by other Federal/ state agencies
  • Study methods well defined

Source: Briss, et. al., Annual Review of Public Health, 2004

the guide to community preventive services one example68
The Guide to CommunityPreventive Services: One Example
  • Consistent set criteria for findings and related recommendations
  • Expert consultation panels for each topic e.g. physical activity
physical activity reviews
Physical Activity Reviews
  • The Task Force reviewed various ways to promote physical activity
    • Informational approaches
      • “point-of-decision” prompts, e.g. to use stairs (recommended)
    • Behavioral and social approaches
      • School based physical education (recommended)
    • Environmental and policy approaches
      • Creating and/or enhancing access to places for physical activity (recommended)
      • Community-scale & street-scale urban design and land use policies and practices (recommended)
  • The Task Force reviewed various ways to promote physical activity
    • Informational approaches
      • “point-of-decision” prompts, e.g. to use stairs (recommended)
    • Behavioral and social approaches
      • School based physical education (recommended)
    • Environmental and policy approaches
      • Creating and/or enhancing access to places for physical activity (recommended)
      • Community-scale & street-scale urban design and land use policies and practices (recommended)
community guide promoting pa summary of findings
Recommended:

Community-wide info campaigns

“Point-of-decision” prompts

Individually-adapted health behavior change

School-based physical education

Social support interventions in community settings

Increasing access to places for PA with info outreach activities

Urban planning approaches (zoning and land use)

Insufficient Evidence:

Classroom-based health education focused on info provision

Mass media campaigns

Health education with TV/video game turnoff component

College-age physical education/health education

Family-based social support

Transportation policy & infrastructure changes to promote non-motorized transit

Community Guide – Promoting PA: Summary of Findings
environmental and policy approaches to increase physical activity
Environmental and Policy Approaches to Increase Physical Activity
  • The Task Force recommended: Creating or improving access to places for physical activity
  • Background on interventions:
    • Involve worksites, coalitions, agencies, communities to change the local environment
    • Examples of changes: creating walking trails, building exercise facilities, providing access to existing facilities nearby
  • Findings:
    • In all 10 studies, improving access to places for physical activity was effective in getting people to exercise more
      • Median estimates = 25% increase in percent of people exercising at least 3 times a week
    • These interventions were effective among both men and women and in various settings, including industrial plants, universities, federal agencies, and low-income communities.
environmental and policy approaches to increase physical activity72
Environmental and Policy Approaches to Increase Physical Activity
  • The Task Force recommended: Community-scale urban design and land use policies and practices to promote physical activity
  • Background on interventions:
    • Defined as urban design and land use policies and practices that support physical activity in geographic areas, generally several square kilometers in area or more.
    • Involve urban planners, architects, engineers, developers, and public health professionals
    • Design elements include the proximity of residential areas to stores, jobs, schools and recreation areas: the continuity and connectivity of sidewalks and streets; and the aesthetic quality and safety aspects of the physical environment
  • Findings:
    • Studies generally compared behavior of residents in auto-oriented (suburban) communities with those in urban communities
    • In 12 studies, overall median improvement in some aspect of physical activity (e.g., # of walkers) was 161%
environmental and policy approaches to increase physical activity73
Environmental and Policy Approaches to Increase Physical Activity
  • The Task Force recommended: Street-scale urban design and land use policies and practices to promote physical activity
  • Background on interventions:
    • Defined as street-scale urban design and land use policies that support physical activity in small geographic areas, generally limited to a few blocks
    • Involve urban planners, architects, engineers, developers, and public health professionals
    • Design components include improved street lighting, infrastructure projects to increase safety of street crossing, use of traffic calming approaches, & enhancing the street landscape
  • Findings:
    • Studies assessed effectiveness in providing a more inviting and safer outdoor environment for physical activity
    • In 6 studies, the overall median improvement in some aspect of physical activity (e.g., # of walkers) was 35%
dangers of poor food environment
Dangers of Poor Food Environment
  • More Americans eating food prepared outside the home, typically higher in fat and calories and lower in nutrients1
  • Percentage of total energy intake from restaurant and fast foods consumption 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
  • Estimated to be 4x as many fast food restaurants and convenience stores as supermarkets and produce vendors in LAC4

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)

proximity of fast food restaurants to public schools in los angeles county
Proximity of Fast Food Restaurants toPublic Schools in Los Angeles County

* Based on the median household income of the census tract in which the school is located

strategies for improving the physical environment for nutrition
Strategies for Improving the Physical Environment for Nutrition

Source: Public Health Institute

underlying determinants of health in the social environment
Underlying Determinants of Health in the Social Environment
  • Education
    • LAUSD has over 25% dropout rate
    • Key determinant of health because it affects employment, which affects poverty/ health insurance/ gang membership/ criminal activity/ drug use etc.
  • Employment
    • Middle class is disappearing in Los Angeles
  • Poverty status
  • Health Insurance
  • Social support and connectedness
  • Substance Abuse
    • Drug overdose was the 7th leading cause of premature death in Los Angeles County in 2004 (17,591 years of life lost)
annual age adjusted mortality rate by median household income la county 2003 2005
Annual Age-adjusted Mortality Rate by Median Household Income - LA County, 2003-2005*

*provisional data used for 2005

dph strategies regarding the social environment
How it affects health

Poverty – poor access to healthy food, housing, clean air, medical care

Safety – violence, no opportunity for physical activity

Social Networks – isolation, lack of social support

Education—high drop out rates; poor school readiness

What DPH can do

Advocate for evidence-based social programs such as center-based early childhood development programs or rental assistance programs

Assess and explain how educational/ tax/ social policies affect health and disparities

DPH Strategies Regarding theSocial Environment
key new tool health impact assessment hia
Key New Tool –Health Impact Assessment (HIA)
  • HIA is tool for systematically evaluating, synthesizing, and communicating information about potential health impacts for more informed decision-making, especially in other sectors.
  • An HIA might ask:
    • What are the health consequences of high rates of students dropping out from high schools?
    • What elements of school site design are most cost-effective in encouraging physical activity?
  • Why use an HIA?
    • It influences decision makers using a broad understanding of health and a wide range of evidence – it places public health on the agenda
    • It highlights potentially significant health impacts that are unknown, under-recognized, or unexpected
    • It facilitates inter-sectoral working and public participation in decision making
living wage hia
Living Wage HIA
  • Employees working on city contracts must be
    • Paid at least $7.99/hr
    • Provided health insurance, or an additional $1.25/hr
  • Covers approximately 10,000 workers
  • Health insurance coverage is more cost-effective in reducing excess mortality than an equivalent amount in the form of wages
  • Any changes to the ordinance should consider increasing health insurance coverage
  • Applicability: many living wage ordinances throughout the U.S.

Source: PFP/UCLA HIA – Living Wage in LA

key new tool health forecasting
Key New Tool - Health Forecasting
  • Currently we spend time examining health status, health risks, and health improvement opportunities for today
    • But optimal planning requires us to understand how our current activities will influence future health status
  • Health forecasting = a modeling project that helps us to estimate what health status will be in the future
  • HF allows us to:
    • Model future health status based on health behavior patterns, population trends, and other variables
    • Compare policy options to determine which are the most cost-effective for improving health
    • Demonstrate the health impact of non-health oriented policies
    • Model effect of multiple interventions
  • Have benefited from expert advisory group, including Prof. Scott Armstrong
physical activity obesity are not independent

15

20

25

30

35

40

45

50

20

30

40

50

60

70

80

90

Physical Activity & Obesity Are Not Independent

People with healthy BMI have higher levels of Physical Activity:

People with low levels of Physical Activity (<8 METhrs/wk) are more likely to be overweight:

Inactive

Active

Percent Overweight

Median METhrs/week

BMI

Age

Source: CA-BRFS 1984-2000

identifying strategies to reduce disparities
Identifying Strategies to Reduce Disparities

Charts show the forecasted percent change in age-adjusted mortality:

+2 METs

Hours per

week

Up to Best

further increases in bmi additional 12 b in personal medical expenditures in ca annually by 2025
Further Increases in BMI = Additional $12 B. in Personal Medical Expenditures in CA Annually by 2025

Total direct personal medical expenditures*, age 18+ (2003 $000,000)

Direct personal medical expenditures for the non-institutionalized population make up about 50-55% of total medical expenditures as defined by the National Health Accounts

All dollars used below are 2003 actual dollars, NOT adjusted for inflation of medical costs.

127,499

115,672

108,350

* personal direct expenditures for the non-institutionalized population as defined by MEPS

opportunities
Opportunities
  • Inter-sectoral cooperation
    • E.g. Working with Chambers of Commerce, other employer groups
    • E.g Faith based organizations—
    • E.g. Regional planning---
    • E.g. Social services (public and private)---
    • E.g. Transportation
    • E.g. Education
  • Develop shared vision of future and admit interdependency (e.g. need skilled and healthy workforce)
opportunities90
Opportunities
  • Involve elected and appointed decision makers at all levels of government
    • Show why health consequences should be considered in deliberations on issues as diverse as:
      • Farm subsidies
      • Tax policy affecting wealth distribution
      • Nutritional labelling in fast food restaurants
      • Zoning/ developer incentives
      • Bonds to increase mass transit
    • Education about sources of best evidence
opportunities91
Opportunities
  • Maintain a balanced civic health improvement portfolio
    • Physical/social environment vs. risk reduction vs. improved treatment/disease management
    • Short, intermediate and long term benefits
    • Regulation vs. voluntary with and without economic incentives
    • Attention to entire population vs. disparities
  • Monitor key indicators of population health status and determinants and feed back into civic health improvement process
examples of some la county public health successes
Examples of Some LA CountyPublic Health Successes
  • Improved the nutritional quality of food in schools-vending machines and food service
  • Called attention to sources of air pollution that adversely affect health, including greatest impact from LA/ Long Beach Ports
  • Argued for R rating for films with tobacco use because they contribute to teen-age smoking
  • Reduced smoking to 14% of adults
  • Strongly advocated for nutritional labeling of fast food (including on order board)
  • Reduced serious food-borne illness due to restaurant grading system
  • Established LA County Health Survey
tactics to overcome challenges
Tactics to Overcome Challenges
  • Work with a wider variety of partners, including physicians, other providers, schools, faith-based orgs., voluntary orgs., and business partners
    • Increase awareness of the need for emergency planning and preparedness
    • Working with partners to engage them in health promotion activities (e.g., public transportation benefits for employees, healthy food policies)
  • Work on some of the factors outside of the medical world that affect health that are not typically considered “Public Health issues”
    • Social environment issues
    • Physical environment issues
the ultimate public health challenge
The Ultimate Public Health Challenge
  • Population growth
    • 75 million annual increase in population—1/4 U.S. population
    • Strain on basic resources in most urban areas in U.S.---water, fuel
    • Accelerates global warming with serious health consequences
    • Little public discourse