System, policy and environmental change:
Evidence, Gaps and Implications
Presented by:
Laura K. Brennan, PhD, MPH
Overview
Projects
Brief Description
1. Social determinants of health
(2003-2010)
Funding: Centers for Disease Control & Prevention
Process: Forum, Presentation, Application
Products: Workbook, Training, Train-the-trainer
2. Evaluation of Active Living by
Design (2006-2010)
Funding: Robert Wood Johnson Foundation
Process: Interviews/Site visits
Products: Journal Supplement, Case Reports
3. Review of environment & policy
interventions for childhood obesity
prevention (2008-2011)
Funding: Robert Wood Johnson Foundation
Process: Advisors, Resource review
Products: Intervention strategy summaries, Gaps
4. Evaluation of Healthy Kids, Healthy
Communities (2009-2014)
Funding: Robert Wood Johnson Foundation
Process: Technical assistance, Interviews/Site visits
Products: Articles, Policy Briefs, Resources, Tools
5. System dynamics modeling to
inform overweight and obesityrelevant policy (2009-2011)
Funding: National Institutes of Health
Process: Group model building
Products: System dynamics models
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
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
Our National Advisors
Policy/Practice Partners
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
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Don Bishop
Elaine Borton
Leah Ersoylu
Steve Farrar
Harold Goldstein
Dean Grandin
James Krieger
Jacqueline Martinez
Malisa McCreedy
Leslie Mikkelsen
Joyal Mulheron
Maya Rockeymoore
Marion Standish
Sarah Strunk
Ian Thomas
Mildred Thompson
Social Determinants of Health:
Learning from Doing
Ottawa Charter
International Conference on Health Promotion in 1986
Health promotion approach:
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Building healthy public policy
Creating supportive environments
Strengthening community actions
Developing personal skills
Reorienting health services
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)
Common Language
Community
Health disparities
Health inequities
Health equity
Social determinants of health (SDOH)
Community

A group of people with a shared identity, including:


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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)
Distribution of U.S. Population by
Race/Ethnicity, 2007
Native
Hawaiians/Pacific
Islanders
0%
Asian
4%
American Indian/
Alaska Native
1%
(2.3 million)
(0.4 million)
Two or more races
1%
(13.1 million)
(4.2 million)
African American
12%
(37.0 million)
Hispanic
15%
(45.5 million)
White
66%
(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.
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.
Distribution of U.S. Population by
Race/Ethnicity, 2000 and 2050
50.1%
White, Non-Hispanic
69.4%
Hispanic
African American
24.4%
12.6%
3.8%
2.5%
12.7%
2000
Total = 282.1 million
Asian
Other
14.6%
8.0%
5.3%
2050
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.
Health Disparities
Differences in the incidence and prevalence of health
conditions and health status between groups, based on:
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Race/ethnicity
Socioeconomic status
Sexual orientation
Gender
Disability status
Geographic location
Combination of these
Reference: Braveman P. (2006)1
Cancer Screening Rates by
Race/Ethnicity*, 2003
70.4%
65.1%
70.0%
58.2%
Breast Cancer
(Mammography)
White, NonHispanic
Hispanic
80.2%
74.6%
82.6%
67.8%
Cervical
Cancer
(Pap Test)
Colon and
Rectum Cancer
(Fecal Occult
Blood Test)
22.7%
15.4%
22.3%
18.3%
AfricanAmerican, NonHispanic
Asian
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.
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
Health Insurance Status, by Race/Ethnicity:
Children, 2007
Private (Employer and Individual)
8%
21%
13%
20%
12%
19%*
19%
43%
8%
34%
NSD
68%
36%
Uninsured
45%
73%
Total Child
Population
2007
Medicaid and Other Public
43%
58%
31%*
White
Hispanic
African
American
Asian/
Pacific
Islander
American
Indian/
Alaska Native
Two or
More Races
44.7 million
16.5 million
11.6 million
3.3 million
0.5 million
2.1 million
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.
Percent Uninsured, Ages 55-64, by
Race/Ethnicity, 2006
33%
23.0%
18.7%
16.5%
12.7%
9.5%
White,
Non-Hispanic
Hispanic
African American,
Asian/
American Indian/
Non-Hispanic
Pacific Islander Alaska Native
DATA: March 2007 Current Population Survey
SOURCE: Kaiser Commission on Medicaid and the Uninsured estimates.
Two or
More Races
No Doctor Visit in Past Year for Nonelderly
Adults by Race/Ethnicity and Insurance
Status, 2005-2006
Insured
Uninsured
53%
48%
40%
39%
45%
31%
21%
14%
White, NonHispanic
20%
13%
Hispanic
African
American
14%
13%
American
Indian/Alaska
Native
Asian and
NHPI
SOURCE: Kaiser Family Foundation and Urban Institute analysis of the National Health Interview Survey, 2005 and
2006, two-year pooled data.
Two or More
Races
No Usual Source of Care for Nonelderly
Adults by Race/Ethnicity and Insurance
Status, 2005-2006
Insured
Uninsured
62%
45%
48%
45%
41%
35%
9%
White, NonHispanic
13%
Hispanic
8%
African
American
7%
11%
American
Asian and NHPI
Indian/Alaska
Native
SOURCE: Kaiser Family Foundation and Urban Institute analysis of National Health Interview Survey, 2005 and 2006, twoyear pooled data.
11%
Two or More
Races
Life Expectancy at Age 25 for U.S.
Black and White Men with Similar
Income Levels*
60
50
52.9
50.2
50.2
47.4
45.0
41.6
40
White Men
30
Black Men
20
10
0
$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
Infant Mortality Rates for Mothers Age
20+, by Race/Ethnicity and Education,
2001-2003
Infant deaths per 1,000 live births:
Less than
High
School
15.1
10.7
9.2
5.0
5.2
African American,
Non-Hispanic
American
Indian/Alaska Native
13.4
High
School
9.2
White, Non-Hispanic
6.5
5.6
5.3
11.5
College
+
7.0
4.2
3.9
4.6
Asian/Pacific
Islander
Hispanic
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.
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
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
Diseases and Behaviors
Tobacco
Use
Poor
Nutrition
Physical
Activity
Physician
Visits
Arthritis/Lupus
✓
✓
✓
Asthma
✓
✓
✓
Breast Cancer
✓
✓
✓
Colorectal Cancer
✓
✓
✓
COPD (Lung Disease)
✓
Diabetes
✓
✓
✓
✓
Heart Disease and Stroke
✓
✓
✓
✓
✓
Hepatitis B
✓
Immunizations (for adults)
✓
Infant Health Problems
✓
Injury from falls
✓
✓
✓
✓
✓
Lung Cancer
✓
✓
✓
Oral Health
✓
✓
✓
Pneumonia and Influenza
✓
✓
SDOH and Health
Pathways from
social determinants
to health
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
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
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
Healthy Kids, Healthy Communities
(50 Grantees)
HKHC Leading
Site Communities
Seattle/King County, WA
Portland/Multnomah County, OR
Houghton, MI
Benton County, OR
Rochester, NY
Milwaukee, WI
Buffalo, NY
Somerville, MA
Kingston, NY
Flint, MI
Kane County, IL
Omaha, NE
Oakland, CA
Watsonville/Parajo Valley, CA
Denver, CO
Hamilton County, OH
Washington, DC
Charleston, WV
Columbia, MO
Baldwin Park, CA
Rancho Cucamonga, CA
Cuba, NM
San Felipe Pueblo, NM
Boone/Newton Counties, AR
Louisville, KY
Knoxville, TN
Chattanooga, TN
Desoto/Marshall/ Tate Counties, MS
Phoenix, AZ
Nash/Edgecombe Counties, NC
Moore/Montgomery Counties, NC
Greenville, SC
Jefferson County, AL Spartanburg, SC
Milledgeville, GA
Grant County, NM
Jackson, MS
El Paso, TX
San Antonio, TX
Philadelphia,PA
Chicago, IL
Kansas City, MO
Central Valley, CA
Fitchburg, MA
Houston, TX
New Orleans, LA
Cook County, GA
Duval County, FL
Lake Worth/Greenacres/ Palm Springs, FL
Caguas, PR
Healthy Kids,
Healthy Communities
Assessment & Evaluation
Assessment
Planning &
Implementation
Evaluation
• Identify assets, needs &
previous or
complementary work
(inform planning and
implementation)
• Identify goals/objectives &
prioritize efforts (use
assessment findings)
• Measure new or modified
systems, policies &
environments (what
changed)
• Measure current systems,
policies & environments
(baseline evaluation)
• Track activities, impacts,
outcomes, strengths &
challenges (determine
evaluation priorities)
• Contextualize the
changes through analysis
of processes, strengths &
challenges (what worked)
Why Evaluate?
To determine the effectiveness of local policy, environment, and systems
approaches to prevent or reduce childhood obesity
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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
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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
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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…
Evidence Goals
1) To bridge research/evaluation and policy/practice
efforts associated with environment and policy
nutrition and physical activity intervention strategies
for childhood obesity prevention.
2) To accelerate the translation of replicable, evidencebased environment and policy interventions that will
lead to leveling and eventually reducing rates of
childhood obesity, especially in lower income and
racial/ethnic populations.
Evidence Levels
How do we define levels of
evidence in order to
bridge the gap between
research/evaluation and
policy/practice efforts?
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?
Review Cycle
INPUT
Identification and collection of resources (inclusion/exclusion criteria)
Remove
Building the Evidence for
Environment & Policy Change
OUTPUT
Implementation
guides
EFFECTIVE (1st TIER) STRATEGIES
OUTPUT
Systematic review
Evidence gaps
EFFECTIVE (2nd TIER) STRATEGIES
PROMISING STRATEGIES
OUTPUT
Evaluation,
feasibility &
impact studies
OUTPUT
Pilot studies
EMERGING STRATEGIES
Inventory & Abstraction
Articles Inventoried
– Approx. 850 to be considered for effective (1st & 2nd tier)
– Approx. 350 to be considered for promising and
emerging
– 227 federal bills
Articles Abstracted
– 44 from effective (1st tier) reviews
– Approx. 390 effective (2nd tier) or promising
• 128 Nutrition
• 259 Physical Activity
Intervention Strategy Summary
Summary & synthesis of findings for each
intervention strategy
Includes:
– Strategy overview (e.g., description, evidence
rating)
– Evidence summary (e.g., key ingredients,
research/evaluation gaps, policy/practice
implications)
– Evidence tables for each study
EFFECTIVE
Applying the Evidence Typology
Design/ Execution/Effectiveness
Reach/Adoption/Implementation/Maintenance
 Experimental, quasi-
 Potential to directly or indirectly reach
experimental, prospective crosssectional or natural experimental
study design
children and families; racial/ethnic and lower
income populations
 High quality study execution
(sampling/recruitment, statistical
power, measures of exposure,
internal validity)
 Effectiveness of intervention at
changing obesity, physical activity
or nutrition outcomes;
demonstrating policy, environmental
or economic impact
 Description of resources needed; anticipated
support and opposition influencing adoption
 Use of theory or logic model; implementation
fidelity or quality assurance assessment;
sufficient description of intervention for replication
 Description of practicability for ongoing funding
and support; plans for enforcement and
maintenance
PROMISING
Applying the Evidence Typology
Design/ Execution/Effectiveness
Reach/Adoption/Implementation/Maintenance
 Quantitative or qualitative study
 Potential to directly or indirectly reach
design
children and families; racial/ethnic and lower
income populations
 High quality study execution
(sampling/recruitment, statistical
power, measures of exposure,
internal validity)
 Plausible effectiveness of
intervention at changing obesity,
physical activity or nutrition
outcomes; demonstrating policy,
environmental or economic impact
 Description of resources needed; anticipated
support and opposition influencing adoption
 Use of theory or logic model; implementation
fidelity or quality assurance assessment;
sufficient description of intervention for replication
 Description of practicability for ongoing funding
and support; plans for enforcement and
maintenance
EMERGING
Applying the Evidence Typology
Design/ Execution/Effectiveness
Reach/Adoption/Implementation/Maintenance

 Potential to directly or indirectly reach
Plausible effectiveness of
intervention at changing obesity,
physical activity or nutrition
outcomes; demonstrating policy,
environmental or economic impact
children and families; racial/ethnic and lower
income populations
 Description of resources needed; anticipated
support and opposition influencing adoption
 Use of theory or logic model; implementation
fidelity or quality assurance assessment;
sufficient description of intervention for replication
 Description of practicability for ongoing funding
and support; plans for enforcement and
maintenance
Intervention Strategy Summaries
Healthy Eating
School food & beverage policies
School wellness policies
National school lunch & breakfast
program
Provision of free or subscription F&V at
school
Provision of free drinking water at school
Menu Labeling
Childcare food & beverage policies
Food pricing (schools & community)
Neighborhood availability of restaurants
Neighborhood availability of food stores
Neighborhood availability of food stores
& restaurants
School & Community Gardens
Government Nutrition Assistance
Programs
TOTAL number of Interventions to-date= 128
Active Living
School physical activity policies
School physical activity environments
Childcare physical activity policies
Safe Routes to School
Neighborhood availability of parks,
playgrounds, trails and recreation centers
Neighborhood safety
Point of decision prompts for physical
activity
Community design
Street design
Transportation policies
Screen time
TOTAL number of interventions to-date= 259
Inputs
Inputs & Outputs
Systematic
Reviews
Outputs
Research &
Evaluation
Findings
PeerReviewed
Studies
Evaluation
Reports
Community
Demonstration
Projects
Strategic
Partners
&
Systematic
Methods
RESOURCE
INVENTORY
ABSTRACTION
Transtria LLC/Washington University Institute for Public Health
Pilot or Case
Studies
Strategic
Partners
&
Systematic
Methods
Gaps in
Existing
Evidence
Policy &
Environment
Changes
Other Key
Ingredients
Local Context
Policy Briefs
Standards of
Practice
Tools, Guides
& Models
Build connections to related efforts
Task Force on
Community Preventive
Services
CDC/RWJF
Measurement
(COCOMO)
CDC/RWJF Early
Assessment Initiative
Centers for
Disease Control
and Prevention
Center of Excellence for
Training and Research
Translation
University of North
Carolina, Chapel Hill
Food and
Nutrition
Board
Institute of
Medicine
Active Living Research
National
Institutes
of Health
Healthy Eating
Research
Healthy Kids, Healthy
Communities
Review of
Environment &
Policy
Interventions
Leadership for Healthy
Communities
Center for Childhood
Obesity Prevention
Communities Creating
Healthy Environments
Salud America!
Physical
Activity Policy
Research
Network
State
Health
Depts
Bridging the Gap
The Robert Wood
Johnson Foundation
Discussion Activity
 County Health Rankings (115 Missouri Counties Ranked)

Health Outcomes (Morbidity & Mortality)
County
Outcomes
Morbidity
Mortality
St. Louis City
106
106
107
St. Louis County
18
32
11
St. Charles County
2
6
1
Robert Wood Johnson Foundation & University of Wisconsin Population Health Institute
Discussion Activity
 County Health Rankings (115 Missouri Counties Ranked)

Health Factors (Behaviors, Clinical Care, Social and Economic,
and Environmental)
County
Factors
Behavior
Clinical
Social & Economic
Environment
115
113
4
115
115
St. Louis County
6
3
2
15
114
St. Charles
County
1
1
5
2
111
St. Louis City
Robert Wood Johnson Foundation & University of Wisconsin Population Health Institute
Community
 Who does your community include? Who does it not
include?
 Does your community have definite geographic
boundaries?
 Are there social or cultural ties that link your community
members to one another?
 Does your community have multiple communities within
it? How would you describe these communities?
 What are other characteristics of your community?
Health Equity
o What are the health concerns of individuals in your
community (e.g., asthma, diabetes)?
o What are the conditions that affect your whole
community (e.g., air pollution, high concentration of fast
food restaurants)?
o Are the health concerns and conditions affecting health
differently for various groups in your community?
Social Determinants of Health
 How are resources (e.g., food, housing, local
businesses, transportation, health care services)
distributed within your community?
 How do resources in your community compare to those
in surrounding communities?
 How can social determinants impact health behaviors?
Laura K. Brennan, PhD, MPH
President and CEO
laura@transtria.com