Life Course Health Development:
A Framework to Guide Research,
Practice and Health Reform
Neal Halfon, MD, MPH
UCLA Schools of Public Health, Medicine, Public Affairs
UCLA Center for Healthier Children, Families and Communities
MCHB-AIM Child & Adolescent Policy Support Center
Center for Healthier Children,
Families & Communities
Goals of this Presentation

To review the evidence, importance and
potential impact of the developmental origins
of health and disease

To consider the strategic role that the emerging
Life Course Health Development approach can
play in
Advancing a progressive Health Policy Agenda
 Enabling significant Health System Reform in the
US

Center for Healthier Children,
Families & Communities
Presentation



Introduce Life Course Health Development
Framework (LCHD)
Distinguish LCHD from Lifespan and Life-course
approaches
Describe implications and applications of the LCHD
model for
Health interventions
 Organization and delivery of health services
 Financing health services


Discuss relevance to child health policy development
Center for Healthier Children,
Families & Communities
Why Do We Need a New Framework?





Now more than ever there is a need to prioritize public
expenditures and invest strategically
Many current policies are based on outdated norms,
data, and approaches
Need to be able to communicate to policy makers why
investments at key points in the life span are important; and
why more integrated approaches are necessary
Supports innovation in design, delivery and measuring
outcomes that matter
Supports collaboration, cooperation, and
communication
Center for Healthier Children,
Families & Communities
From Lifespan to LCHD




Lifespan models – connect the dots- linking
early life to later life
Life stage models – periods of psychological
development
Life-course models – are concerned with
patterns and pathways that connect the dots
between early and later life
Life Course Health Development modelsConnect the dots
 Describe the pathways or heath trajectories
 Address the mechanisms that determine or
influence health trajectories

Center for Healthier Children,
Families & Communities
Center for Healthier Children,
Families & Communities
LCHD
Where We Have Been
Center for Healthier Children,
Families & Communities
Figure 22. Life expectancy at birth and at 65 years
of age by sex: United States, 1901-2001
100
NOTE: See Data Table for data points
graphed and additional notes.
Life expectancy in years
Females
80
Life Expectancy at birth
Males
60
40
20
Females
Life expectancy at 65 years
Males
0
1901
1910
1920
1930
1940
1950
Year
Center for Healthier Children,
Families & Communities
1960
1970
1980
1990
2001
Source: Centers for Disease
Control and Prevention, National
Center for Health Statistics.
Health, United States, 2004
Life Span
Health Span
Performance Span
0 years
Center for Healthier Children,
Families & Communities
20 years
80 years
Social/Nutritional/Epidemiological/
Developmental Shift

Social Conditions dramatically changes over this time
period





Nature, Array, and Prevalence of Risk, Protective and Health
Promoting factors
Nutritional Conditions change- high sugar, high fat
diets
Type, prevalence, distribution of acute and chronic
disease changes dramatically
Developmental expectancies change
Capacity of Medical Care to intervene, modify risk and
treat disease changes
Center for Healthier Children,
Families & Communities
The Evolving Health Care System
The First Era
(Yesterday)
 Focused on acute
and infectious
disease
 Germ Theory
 Acute Medical
Care
 Insurance-based
financing
 Reducing Deaths
Health System
1.0
Center for Healthier Children,
Families & Communities
The Second Era
(Today)
 Increasing focus on
chronic disease
The Third Era
(Tomorrow)
 Multiple Risk
Factors
 Increasing focus on
achieving optimal
health status
 Chronic Disease
Mgmt & Prevention
 Complex Causal
Pathways
 Pre-paid benefits
 Investing in
population-based
prevention
 Prolonging
Disability free Life
Health System
2.0
 Producing Optimal
Health for All
Health System
3.0
2004 National Research Council and Institute
of Medicine Report
Center for Healthier Children,
Families & Communities
IOM/NRC Definition of Children’s
Health (2004)
“Children’s health is the extent to which individual
children or groups of children are able or enabled to
(a) develop and realize their potential, (b) satisfy their
needs, and (c) develop the capacities that allow them to
interact successfully with their biological, physical, and
social environments.”
From Children’s Health, the Nation’s Wealth,
National Academies Press, 2004.
Center for Healthier Children,
Families & Communities
Day
Care
Community
Workplace
School
Relative
Magnitude
of Influence
Family
Individual
5
10
15
20
30
40
Age (years)
50
60
70
80
FIGURE 2: INFLUENCE OF HEALTH STATUS ACROSS THE LIFE COURSE. Across the life course, the health status of individuals is a
function of endogenous factors (genetic, physiological, psychological), family influences, and a range of influences from the immediate
community (school and workplace), and the larger community (neighborhood, city, and nation). As illustrated in figure 2, the relative influence of
these factors changes as a function of age. Adapted from Nordio S. 1978. Needs in Child and Maternal Care. Rational Utilization and SocialMedical Resources. Rivists Italiana di Pediatria 4:3-20.
Center for Healthier Children,
Families & Communities
Health as a Developmental Process

Health is developmental
Health develops across the life course
 Health development can be represented by health
trajectories
 Critical/ Sensitive periods
 Gene - Environment – Interaction have different
impacts during different periods
 Macro and Micro pathways delineate how toxic
environment and risky families get under the skin

Center for Healthier Children,
Families & Communities
How Risk Reduction and Health Promotion Strategies
influence Health Development
Risk Factors
RR
Risk Reduction Strategies
HP
Health Promotion Strategies
Trajectory Without RR and HP
Strategies
Optimal Trajectory
RR
RR
RR
HP
HP
HP
Protective Factors
0
20
40
Age (Years)
60
80
FIGURE 4: This figure illustrates how risk reduction strategies can mitigate the influence of risk factors on the developmental trajectory, and how health promotion strategies can
simultaneously support and optimize the developmental trajectory. In the absence of effective risk reduction and health promotion, the developmental trajectory will be sub-optimal (dotted
curve). From: Halfon, N., M. Inkelas, and M. Hochstein. 2000. The Health Development Organization: An Organizational Approach to Achieving Child Health Development. The Milbank
Quarterly 78(3):447-497.
Fig.
From: Lamberts SWJ, van den Beld AW, van der lely A. The endocrinology of aging. Science. 1997;278:419-424.
From: Kuh D, Ben-Shlomo Y. A life course approach to chronic disease epidemiology. New York: Oxford University Press. 1997.
Strategies to Improve
Health Development Trajectories
Back to
Overall Model
Family Discord
Lack of health services
“Healthy” Trajectory
Ready to learn
Poverty
“At Risk” Trajectory
Pre-school
Health Services
“Delayed/Disordered ” Trajectory
Appropriate Discipline
Reading to child
Parent education
Emotional Health
Literacy
Late Infancy
Birth
6 mo
12 mo
Early Infancy
Center for Healthier Children,
Late Preschool
Late Toddler
18 mo
Early Toddler
Families
& Communities
Graphic Concept
Adapted
form Neal Halfon , UCLA
24 mo
3 yrs
Early Preschool
5 yrs
Age
Risk and protective factors
Risk Factors
Child
Family
Community
School
Negative
vulnerability
Center for Healthier Children,
Families & Communities
Protective Factors
Child
Family
Community
School
Outcome
Positive
resilience
Cumulative, Programming and Pathway
Mechanisms Influence LCHD

Three basic mechanisms influence LCHD



Cumulative - additive effect of multiple risks and protective
factors, weathering
Programming - time specific influence of stimulus or insult
during a critical or sensitive period on selection, adaptation,
compensatory processes
Pathways-chains of (eco-culturally constructed) linked
exposures that create a constrained conduit of geneenvironment transactions
Center for Healthier Children,
Families & Communities
Cumulative SES (birth - 33 yrs) poor health, age
33
% fair/poor health
25
20
15
Men
Women
10
5
0
4 5 6
best
Center for Healthier Children,
Families & Communities
7
8 9 10 11 12 13 14 15 16
Lifetime SES score
worst
Source: Power et al, 1999
Birthweight and CVD Outcomes
Nurses’ Health Study
Relative risk
2.5
CHD
Stroke
Hypertension
Type 2 Diabetes
2
1.5
1
0.5
0
<5.0
5.0-5.5
5.6-7.0
7.1-8.5
Birthweight (lb)
Curhan
et al., Rich-Edwards et al.
Center for Healthier Children,
Families & Communities
8.6-10.0
>10.0
Center for Healthier Children,
Families & Communities
Cumulative, Programming and Pathway
Mechanisms Influence LCHD

Three basic mechanisms influence LCHD



Cumulative - additive effect of multiple risks and protective
factors, weathering
Programming - time specific influence of stimulus or insult
during a critical or sensitive period on selection, adaptation,
compensatory processes
Pathways- chains of (eco-culturally constructed) linked
exposures that create a constrained conduit of geneenvironment transactions
Center for Healthier Children,
Families & Communities
Poverty & ECD
Parent- and FamilyLevel Predictors
of Income And
Hardship
 Parent Work Status
 Job Prestige
 Education Level
 Parent Marital Status
 Race-Ethnicity
Family
Income
Poverty
Financia
l
Hardshi
p
Parent
Investment
Child
Physical
Developmen
t
Parent
Behavior
Child
Cognitive
Developmen
t
Parent
Distress
Neighborhood- and Community-Level Influences
Center for Healthier Children,
Families & Communities
Child SocialEmotional
Developmen
t
Center for Healthier Children,
Families & Communities
Center for Healthier Children,
Families & Communities
Center for Healthier Children,
Families & Communities
LCHD: Childhood Antecedents of
later Childhood and Adult Health
Early social
and material
deprivation
(financial,
educational,
environmental)
Prior poor health,
fetal nutrition,
case-mix
Immunologic
& physiologic
moderators
Prior poor
physical
activity
Current poor
physical
activity
Prior adverse
behavior
Current
adverse
behavior
Source: van de Mheen et al, IJE 1998
Center for Healthier Children,
Families & Communities
Current social
and material
deprivation
Current poor health/
premature mortality
From Starfield
02/03
LCHD: New
Approaches to Old
Problems
Center for Healthier Children,
Families & Communities
Disease Progression
1 = current practice
1
2 = current capability
Cost
Symptoms
3 = future capability
3
2
Years
Source: Snyderman R. AAP presidential address: the AAP and the transformation of medicine. Journal of
Clinical Investigation. 2004;114(8):1169-1173 (suppl)
Center for Healthier Children,
Families & Communities
Risk Assessment for Prospective Health
Late chronic
Low risk
Cost
Symptoms
Risk assessment decision support
Early chronic
High risk
Years
Personalized health plan
Personal lifestyle plan
Risk modification
Wellness education and Wellness education and
Internet and health
Internet and health
provider guided
provider guided
planning for all
planning for all
Disease management
Individual-focused; integrated provider
systems. Focus on quality of life and palliation
at appropriate late stages
Source: Snyderman R. AAP presidential address: the AAP and the transformation of medicine. Journal of
Clinical Investigation. 2004;114(8):1169-1173 (suppl)
Center for Healthier Children,
Families & Communities
Center for Healthier Children,
Families & Communities
LCHD and Birth Outcomes
White
Reproductive Potential
African
American
Age
Center for Healthier Children,
Families & Communities
Pregnancy
LCHD and Birth Outcomes
White
Reproductive Potential
African
American
Age
Center for Healthier Children,
Families & Communities
Pregnancy
Life Course Health Development
White
Poor Nutrition
Stress
Abuse
Tobacco, Alcohol, Drugs
Poverty
Lack of Access to Health Care
Exposure to Toxins
Poor Birth Outcome
Age
0
5
Center for Healthier Children,
Families & Communities
Puberty
Pregnancy
African
American
LCHD: AA – White Birth outcomes
White
Primary Care
for Children
Early
Intervention
Prenatal
Care
Primary Care
for Women
Prenatal
Care
Internatal African
Care American
Poor Birth Outcome
Age
0
5
Center for Healthier Children,
Families & Communities
Puberty
Pregnancy
Children & Youth at Risk
4-6%
Severe
Disabilities
12-16%
Special Health
Care Needs
30-40%
Behavioral,
Mental Health
Learning
Problems
50-60%
Good Enough
Center for Healthier Children,
Families & Communities
What % are
thriving ?
30% ?
40% ?
50% ?
How well is the 2.0 Child
Health System
Performing?
Center for Healthier Children,
Families & Communities
The existing child health service system







Demand greater than services available
Families have complex needs - often beyond
capability of any single service
Difficulty accessing services
Socio-economic gradient of access
Focus on treatment rather than prevention/early
intervention
Episodic contact
Poor quality of Well Child Care
Center for Healthier Children,
Families & Communities
Center for Healthier Children,
Families & Communities
Transforming the Child Health System: New
Paradigm vs. Old System





Child health system was designed for the first
era of health care ( acute, infectious disease
model)
It was upgraded a bit for the 2nd era, with more
regionalization, chronic disease care
Ill equipped for this new era
Under-performing
Facing many new challenges
Center for Healthier Children,
Families & Communities
Center for Healthier Children,
Families & Communities
Optimal Health
Development
Trajectory Optimizing Service
Linkage Pathway
PED
Tutor FRC
PED
Lower Health
Development
Trajectory
Development
SR FRC
PED
ROR FRC
Pediatric
Continuity
Network
Connections
PED
NHV FRC
0
1
Center for Healthier Children,
Families & Communities
3
5
7
Years
Optimizing Trajectories: Multisector Multilevel Strategies
Education
Health
Family
support
Child
Family
Neighborhood Services
Community
Policy
Social Welfare
0
20
Center for Healthier Children,
Families & Communities
40
Age (Years)
60
80
Systematic Data Collection
For tracking Health Development Trajectories
Preschool Assessment
Pediatric Early Child
Assessment
Birth
Certificate
School Readiness
• Physical Wellbeing & motor dev’t
• Social & emotional dev’t
• Approaches to learning
• Language dev’t
• Cognition & general knowledge
Birth
1yr
Center for Healthier Children,
Families & Communities
2 ys
3 ys
4 ys
5 ys
LCHD Key Economic Issues



Human health is the product of “investments”
made across the life span
Rate of return on investments in childhood may be
particularly advantageous
Rate of return can be thought of as a function of
neural plasticity, and the efficiency with which
environments and interventions can program
development more broadly
Center for Healthier Children,
Families & Communities
Benefit-Cost Ratios for Longitudinal Studies

Perry Pre School


Abecedarian Educational Child Care


$4 to $1
Chicago-Child Parent


$17 to $1
$7 to $1
Elmira Prenatal/Early Infancy Project

$5 to $1
Center for Healthier Children,
Families & Communities
Rates of Return to Human Development
Investment Across all Ages
8
Pre-school Programs
6
Return
Per $
School
4
Invested
R
Job Training
2
PreSchool
0
School
6
Post School
18
Age
Pedro Carneiro, James Heckman, Human Capital Policy, 2003
Center for Healthier Children,
Families & Communities
Center for Healthier Children,
Families & Communities
Historical and Projected Components of
Federal Spending, 1962 – 2050
45.0
2.5 Percent Excess Cost Growth
(Simulation 1)
Actual
Predicted
40.0
Long-term Revenue 18.4%
35.0
25.0
20.0
15.0
Social Security,
Medicare, Medicaid
10.0
Interest
Other Federal
Spending
5.0
Defense
0.0
19
62
19
65
19
68
19
71
19
74
19
77
19
80
19
83
19
86
19
89
19
92
19
95
19
98
20
01
20
04
20
07
20
10
20
13
20
16
20
19
20
22
20
25
20
28
20
31
20
34
20
37
20
40
20
43
20
46
20
49
Percent of GDP
30.0
Source: Congressional Budget Office
Center for Healthier Children,
Families & Communities
Year
Figure 6: Demonstrates how risk factors negatively affect developments in health.
Normal Development
Health Development
Risk Factors
0 years
Center for Healthier Children,
Families & Communities
20 years
80 years
What does LCHD New Synthesis Provide to
the Discourse on Health System Reform?


Big Idea – Forward looking
Integrative Framework




Connect up an increasingly balkanized field
Reframe for health system reform goals
Positions child/MCH in Vanguard of New Era
in Health and Health Care Reform
New Rational for current and future activities
Center for Healthier Children,
Families & Communities
LCHD Framework: Think Different!






Developmentally - in order to optimize
outcomes
Population and upstream determinants of the
outcomes that we want to achieve
How to shift population risk curves and not just
work at the individual level
How to use alignment, connection, networking
strategies to join up people, sectors, systems
into a more functional approach - open source
for a flatter health policy world
How to change the culture of the system we
work in
To frame health in terms of its life long impacts
Center for Healthier Children,
Families & Communities
Conclusion

LCHD framework has an important role to play
in understanding how multiple determinants of
health interact across the life span and across
generations to produce health outcomes

LCHD will become an increasingly important
framework for guiding policy analysis,
interventions, and solving medical conundrums
like infant mortality difference.
Center for Healthier Children,
Families & Communities
Conclusion

LCHD will increasing be used to understand how
multiple levels of gene environment transactions unfold
in the process of human development to create risks,
diseases, and different levels of health

LCHD will be used to guide new research efforts like
the millennium cohort study in the US.

LCHD will be used to transform our notions of how to
invest in the health capital of individuals and the
nation.
Center for Healthier Children,
Families & Communities
UCLA Center for Healthier Children, Families
and Communities
&
National Center for Infancy and Early
Childhood Health Policy
AIM-MCHB Child and Adolescent Policy
Support Center
http.//healthychild.ucla.edu
Center for Healthier Children,
Families & Communities
Applying the Life Course
Perspective in a Local
MCAH Program
Cheri Pies, MSW, DrPH
Director, Family, Maternal
and Child Health Programs
Overview
• Background
• Experience of one local MCAH
program
• Suggestions and tips for getting
started and getting there
• Sharing lessons learned
The Life Course Initiative
• A 15-year initiative
• Launched in 2005
• Based on the Life
Course Perspective
and a 12-Point Plan
to close the BlackWhite gap in birth
outcomes
Life Course Initiative
Goals
• Reduce health disparities overall
• Optimize reproductive potential
• Create a paradigm shift in MCH
Life Course Initiative
Goals
• To change the health of a
generation
Our Road Map: A 12-Point
Plan
• Improving Health
Care Services
• Strengthening
Families and
Communities
• Addressing Social
and Economic
Inequities
Where is
Contra Costa
County?
Staff Education Content
• Theory of the Life
Course
Perspective
• Life Course
Game
• Life Course
Initiative activities
• A 12-Point Plan
• Integrating the
Life Course
Perspective into
their work
 What are you
currently doing
that fits with the
Life Course
Perspective?
 How can you
integrate the Life
Course
Perspective into
future activities?
The Contra Costa
Experience
• Conducted a series of interactive
educational activities for staff
• Engaged staff in identifying
current and future activities
• Created opportunities for staff to
have their own “A-ha!” moment
The Contra Costa
Experience
• Established a Life Course
Initiative Data Team
• Conducted educational survey of
Family, Maternal and Child Health
Programs staff
• Started to identify some
intermediate outcomes for clients
as possible measures of success
(vs. long-term perinatal outcomes)
The Contra Costa
Experience
• Improved sense of well being,
empowerment, resilience
• Increase in social support
• Decreased stress
The Contra Costa
Experience
• Increase in financial security and
stability
• Improved financial status
The Contra Costa
Experience
• Launched a financial education
pilot project: BEST – Building
Economic Security Today
• Making the link between an
increase in asset development
(wealth) and health
Building Economic
Security Today (BEST)
• With Life Course Data Team, developed
a logic model for an asset development
pilot project: BEST
• Hosting Family Economic Success and
Security training for 40 home visiting
and WIC staff in October 2008
• Viewing and discussing Unnatural
Causes
• Applying for grant funding for training
and project from various sources
Getting Started
• What is the story your local data
are telling you?
• What are you already doing that
may fall under the Life Course
Perspective?
Getting Started
• Which community partners need
to be on board from the start?
• What could this paradigm shift
mean for MCH in your
community?
Getting There
• Be prepared for skeptics
(internal and external)
• Have a plan – fiscal and
programmatic
• Offer interactive educational
sessions to community partners
Getting There
• Lay the groundwork with higherlevel management
• Get ready to evaluate
• Articulate and clarify the value of
making this paradigm shift
Sharing Lessons Learned
• Share your enthusiasm
• Recognize and acknowledge
what staff are already doing and
build on this
• Utilize the imagination and
experience of staff to chart the
course for the future
Sharing Lessons Learned
• Engage the community of people
whose lives you hope to touch
• Have a long view
• Recognize that change takes
time
The sky’s the limit!
Communicating about the LifeCourse Health Development
Model with State Legislators
for
CityMatCH & NACCHO
By the
National Conference of State Legislatures
Martha King
October 16, 2008
Martha.king@ncsl.org
303-856-1448
NCSL
National membership organization:



7,382 state legislators across the country
Thousands of legislative staff
Offices in Denver and Washington, D.C.
Goals:



To improve the quality & effectiveness of state
legislatures
To promote policy innovation and communication
among state legislatures
To ensure states a strong, cohesive voice in the
federal system
Why Focus on State Legislatures?

Establish policies & programs

Control the state’s purse $tring$

Enact requirements

Provide oversight

Provide leadership
Legislators Are Generalists

Dozens of topics:
A to Z





Hundreds of bills




Can’t be experts
in all


Agriculture
Corrections
Education
Health
Housing
Human Services
Labor
Transportation
Zoning . . .
Health Issues by the Dozens!










Medicaid
Insurance/mg’d care
Pharmaceuticals
Long-term Care
Health disparities
Uninsured
Health professions
Health Facilities
Environmental
Public health










SCHIP
Prenatal Care
Emergency services
Chronic diseases
Oral health
Injury prevention
Mental Health
Disabilities
Substance Abuse
etc. ...
Human Services & Education Issues by
the Dozens!







Child welfare
Home visiting
Child care
Abuse prevention
Hunger & nutrition
Poverty issues
Etc.

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




Early childhood
Preschool
School success factors
Afterschool programs
School retention
No child left behind
Etc.
Overload!!
“Going through all this information we
have here is kind of like trying to drink
from a fire hydrant.” Colo. Rep. Mark Paschall
“My seatmate told me this was a bad bill.
I was going to vote no on it until I
realized it was my own bill.” Colo. Sen. Ray
Powers
Competing For Legislators’ Attention
"Your topic"
A BLIP ON THE
POLITICAL RADAR
SCREEN
Your Strategic Role
The “blip enlarger”
For the Life-Course Health
Development Model Issues



Raise awareness
Provide information resources
Provide tools to make a difference
Polling Question
Have you ever been involved in communicating
“Life-Course" issues to state legislators in your state?
Getting Their Attention: Barriers
Competing needs and demands
 Budget issues & competition
 New legislators (20-25% turnover)
 Lack of awareness/understanding
 Relative size of the issue
 Limited time & resources
 Complexity of cross-cutting "life course"
concepts
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Life-Course: Where to Start
Consider Legislative Terminology:
“Life-Course Health Development Model”
“Health development trajectories”
“Interplay of biological, behavioral, psychological,
and social protective and risk factors …”
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Unlikely to resonate with state legislators
May sound overwhelming--where to start?
Translate message to their language and information
needs
Translation Example
From this:
"Maternal and child health programs that address
preconceptional and interconceptional issues and
needs are an important epidemiological approach
to improving birth outcomes."
To this:
"Promoting healthy pregnancies will save both lives
and money. Here are some examples: xxx"
Some Ideas
“Life-Course Health Development Model”
A way to address health needs in a more comprehensive and
coordinated way
“Health development trajectories”
People's health needs and status should be considered over
time
“Interplay of biological, behavioral, psychological,
and social protective and risk factors …”
Both negative and positive factors affect people's health--if
we reduce the negative and increase the positive, health
status will improve
Where Does "Life Course" Fit In?
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Identify existing policies & programs where
these ideas may fit--especially the
"protective factors"
Give specific examples
Communicate concisely
What will this cost? (and what are the costs
associated with "risk factors"?)
Is there return on investment? If so, what?
And when?
Consider the State Budget
Process & Cycles
Need to revise the following message:
“Public policy should include greater
investments in children, women’s health,
community health, and improvement of
social conditions for families.”
What, specifically, can a state legislature do
about this?
What policies & programs are
related?
Identify specific programs that relate to the
"life course" concepts and be specific
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Prenatal care
SCHIP & Medicaid opportunities
Early childhood programs
Education
Social services
Preventive & primary care
Promote health & well-being
Questions and Answers
Thank you!