The impact of policies on health determinants and health: the information we need

1
The impact of policies on health determinants
and health the information we need

• Giuseppe Costa
• Dept. Public Health, University of Turin
• Collaborating Centre of the Italian CDC
• for Health in All Policies and Equity in
  Prevention

8th IUHPE, Turin, September 12, 2008
2
Critical issues for HiAP the information we need

• Health in All Policies in Europe and Italy
• The chain of causation policy-health
  determinants-health
• Transport a benchmark for evidence
• Inequalities modelling interaction
• Closing the information gap

3
Critical issues for HiAP the information we need

• Health in All Policies in Europe and Italy
• The chain of causation policy-health
  determinants-health
• Transport a benchmark for evidence
• Inequalities modelling interaction
• Closing the information gap

4
HiAP rationale and definition

• Rationale
• Health determinants influenced by measures
  managed by non health sectors
• Health in the society adds productive life
  years
• Health criteria need to be involved in early
  stages of policy making of other sectors at all
  levels for both the interest of public health and
  the contribution to economy
• what is called healthy policies

5
HiAP what is new?

• Promoted under different labels for decades
• From Health for All
• Through Healthy Public Policies and Supportive
  Environments, and Gaining Health
• To Health in All Policies (HiAP)
• What is new? To systematically take into account
  the health impacts of other policies

6
HiAP in Europe

• Integrating the development goals of the Lisbona
  Agenda with health protection in all communities
  policies and activities (Art 152 of The Amsterdam
  Treaty) however not yet part of the hard core of
  the EU priorities
• The main issue of the EU Presidency of Finland
  2006 (Stahl et al, 2006) and of the EU-WHO Europe
  Conference in Rome 2007, asking European
  countries to adopt the HiAP strategy
• Confirmed as a priority in the EU Health Strategy
  White Paper, 2007

7
HiAP in Italy

• The 1978 Health Reform (the Italian NHS) strong
  support to the responsibility of other policies
  in health promotion
• A critical incident in April 1993 Referendum
  suppressing competences of the health sector in
  the domain of environmental risks
• a negletted issue during the phase of 90s NHS
  reforms toward efficiency
• An Italian Strategy for Gaining Health (2007)
  initial agreements btw twelve National Depts and
  22 national public and private agencies and
  institutions, to create supportive environments
  for the adoption of healthier lifestyles (mainly
  diet, physical activity and smoking)
• A few Regional and Local initiatives of health
  planning in the local community not only
  lifestyles but also social determinants
• However the evidence on the health impact of
  policies was too poor and sparse (despite its
  importance to raise the health impact in the
  agenda of decision makers)

8
Critical issues for HiAP the information we need

• Health in All Policies in Europe and Italy
• The chain of causation policy-health
  determinants-health
• Transport a benchmark for evidence
• Inequalities modelling interaction
• Closing the information gap

9
In few cases clearly understood relationship
between health and policy
price of fuel and death of older people
!
Policy
Health

• This makes HiAP an easier exercise in some
  sectors
• - such as water supply, waste disposal
  (estimating relative
• importance of their impact compared to the
  others)
• - such as transport (but limited to deaths and
  injuries due to
• accidents and pollution) ( neglected dimensions
  of health
• impact physical exercise, transport for
  disabled)
• same for housing (traditional heath based
  regulation
• of sanitation and safe cooking) (neglected areas
  
• adaptation for elderly and disabled, lighstreet
  and crime)

10
In most cases
lack of a pure epidemiologic outcome, need for
better evidence on the link with health
determinants, often delay between intervention
and health outcome
Policy
Health
?
HiAP more difficult in most of the sectors
such as pensions, education, labour, poverty,
agricolture
11
Scientific paradigms to which evidence in HiAP
should refer
Policy
Health
Determinants
Chain of causation
12
Scientific paradigms to which evidence in HiAP
should refer
Risk assessment and Burden of disease
Policy
Health
Determinants
public health
13
The World Health Report WHO, 2002
DALYs x1000 ATTRIBUTABLE TO HEALTH DETERMINANTS


EUROPE

WORLD

Risk related to diet and physical exercise

56.223

183.876


Risk related to substance abuse

36.206

128.622



Occupational risks
2.483

22.553


Environmental risks
2.402

119.005


Malnutrition
1.909
227.530


Unsafe sex and reproduction
1.168

100.683


Other risk factors


981

18.696


14
Scientific paradigms to which evidence in HiAP
should refer
Economic, SocialAssessment
Policy
Health
Determinants
Other sectors of policy
15
Two difficulties different validity of sources
of evidence
Validity
Evidence
RCT Cohort Case control Controlled
ITS ITS Controlled BA BA Case analysis Expert
opinion
max min
16
Two difficulties the need of an integrated list
of determinants
Policy
Health
Determinants
Other sectors of policy
public health
by experts of
a classification of determinants manageble
17
A taxonomy of determinants by needs categories

• Freedom in lifestyles
• Being acknowledged (self-efficacy)
• Exposure to developmental opportunity (cognitive,
  emotional)
• Adequacy of work conditions
• Adequacy of housing
• Adequacy of environment
• Mobility
• Protection from vulnerability/susceptibility/crit
  ical events

18
A taxonomy of determinants by needs categories

• Freedom in lifestyles
• Being acknowledged (self-efficacy)
• Exposure to developmental opportunity (cognitive,
  emotional)
• Adequacy of work conditions
• Adequacy of housing
• Adequacy of environment
• Mobility
• Protection from vulnerability/susceptibility/crit
  ical events

• Addictions
• smoking
• alcohol
• substances
• gambling
• Nutrition
• Calories
• Nutrients
• Physical exercises
• Unsafe sexual promiscuity

19
A taxonomy of determinants by needs categories

• Education
• Work
• Prestige
• Income
• Equality/ no discrimination

• Freedom in lifestyles
• Being acknowledged (self-efficacy)
• Exposure to developmental opportunity (cognitive,
  emotional)
• Adequacy of work conditions
• Adequacy of housing
• Adequacy of environment
• Mobility
• Protection from vulnerability/susceptibility/crit
  ical events

20
A taxonomy of determinants by needs categories

• Freedom in lifestyles
• Being acknowledged (self-efficacy)
• Exposure to developmental opportunity (cognitive,
  emotional)
• Adequacy of work conditions
• Adequacy of housing
• Adequacy of environment
• Mobility
• Protection from vulnerability/susceptibility/crit
  ical events

• Education and training
• Leisure time
• Arts
• Empowerment

21
A taxonomy of determinants by needs categories

• Freedom in lifestyles
• Being acknowledged (self-efficacy)
• Exposure to developmental opportunity (cognitive,
  emotional)
• Adequacy of work conditions
• Adequacy of housing
• Adequacy of environment
• Mobility
• Protection from vulnerability/susceptibility/crit
  ical events

• Safety
• Hygiene
• Psychosocial wellbeing
• Ergonomics
• Reconciling time for work and care

22
A taxonomy of determinants by needs categories

• Freedom in lifestyles
• Being acknowledged (self-efficacy)
• Exposure to developmental opportunity (cognitive,
  emotional)
• Adequacy of work conditions
• Adequacy of housing
• Adequacy of environment
• Mobility
• Protection from vulnerability/susceptibility/crit
  ical events

• Availability
• Hygiene
• Safety
• Crowding

23
A taxonomy of determinants by needs categories

• Freedom in lifestyles
• Being acknowledged (self-efficacy)
• Exposure to developmental opportunity (cognitive,
  emotional)
• Adequacy of work conditions
• Adequacy of housing
• Adequacy of environment
• Mobility
• Protection from vulnerability/susceptibility/crit
  ical events

• Security/criminality
• Adequacy of productive settlements
• Adequacy of technical infrastructures water,
  sewerage, waste disposals, energy, communications
  
• Social cohesion/ segregation
• Offer of services
• Morphology

24
A taxonomy of determinants by needs categories

• Freedom in lifestyles
• Being acknowledged (self-efficacy)
• Exposure to developmental opportunity (cognitive,
  emotional)
• Adequacy of work conditions
• Adequacy of housing
• Adequacy of environment
• Mobility
• Protection from vulnerability/susceptibility/crit
  ical events

• Accessibility/ proximity of transportations
• Road safety

25
A taxonomy of determinants by needs categories

• Freedom in lifestyles
• Being acknowledged (self-efficacy)
• Exposure to developmental opportunity (cognitive,
  emotional)
• Adequacy of work conditions
• Adequacy of housing
• Adequacy of environment
• Mobility
• Protection from vulnerability/susceptibility/crit
  ical events

• Family support
• Network support
• Access to services
• Sustainable
• Pro-active
• Effective and safe

26
Two difficulties the need of an integrated list
of determinants
Policy
Health
Determinants
Other sectors of policy
public health
by experts of
a classification of determinants manageble
27
Economic development and health in Europe 1960-99
Health impact of a welfare universalistic and
generous? A necessary and sufficient cause? No!
A contributory cause? May be Need to
disentangle the causal chain
Modified from Diderichsen et al, in Equipop 2008
28
distribution
determinants (pathways)
context
influencing distribution
exposure
reducing exposure
risk factors
vulnerability
reducing vulnerability
health
consequences
preventing consequences
retroactive effects
impact
policies
Modified from Diderichsen 2001
29
Critical issues for HiAP the information we need

• Health in All Policies in Europe and Italy
• The chain of causation policy-health
  determinants-health
• Transport a benchmark for evidence
• Inequalities modelling interaction
• Closing the information gap

30
context
The context of transport
Need of mobility enabling access to services,
goods, people, leisure

• Demand side
• fixed share of income on transport
• price failing to reflected cost

• Changes in
• Barriers (globalisation)
• Logistic (just in time)
• Spatial sprawl (separate live work leisure)
• Infrastructures (community severance, land use)

road rail / water annual trend 1.8
passanger 2.8 freight (2.3 GDP)
THE PEP Assessment Report (UNECE / WHO,2008)
31
context

• Health promoting determinants
• General economic development
• Employment
• Access to services
• Access to exercise/cycling

?
?
?
THE PEP Assessment Report (UNECE / WHO,2008)
32
context
?
THE PEP Assessment Report (UNECE / WHO,2008)
33
context

• Tecnological requirements
• content of fuels
• emission of vehicles

Greenhouse gas emission Climate change and
variability 2 per year

• Temperature - related illnesses mortality
• Vector home diseases, water / food contamination
  dis.
• Mental health, stress, quality of lile
• ?

?
THE PEP Assessment Report (UNECE / WHO,2008)
34
context

• Driving attitudes
• Spead
• Alcohol

• Road casualties due to
• Speeding 50
• Alcohol ?

Injuries, premature death - 1 year LE
?
THE PEP Assessment Report (UNECE / WHO,2008)
35
context

• Land use and noise
• Spatial planning
• Noise barriers
• Technological measures
• (by sensitive areas and time)

• Noise
• 30 gt 55 d B
• trend

Communication, hearing Sleep quality,
Performance Hypertension (CHD?) Behavioural
/social/ cognitive responses (vulnerability,
children) ?
?
THE PEP Assessment Report (UNECE / WHO,2008)
36
context

• Land use and community severance
• Access to green spaces
• Social support network
• Less land for housing, employment, recreation
• Isolation of sensitive areas (biodiversity,
  landscape)

Stress Biodiversity ?

• Psychosocial and social impact
• Mental health
• Fear of crashes
• Post traumatic disorders
• ?

?
THE PEP Assessment Report (UNECE / WHO,2008)
37
context

• Opportunities for
• walking
• cycling

Physical activity ?

• obesity 22
• CHD, diabetes, some cancers 10-16
• mortality 5 10

?
THE PEP Assessment Report (UNECE / WHO,2008)
38
context
Urban congestion
Psychosocial ?
Mental health, Stress, quality of life ?
Conseguences on mobility
THE PEP Assessment Report (UNECE / WHO,2008)
39
Opportunity for Walking cycling
Community severace
Context
Tecnological requirements
Attitudes
Land use
Urban congestion
stress
Speed / alcool
Transport
Air quality
Greenhouse
noise
Physical activity
networks
IMPACT (GDP) 10 -2 -2
-2 -0,5? ? ?
?
POLICIES
Policies Amsterdam Treaty 1997 THE PEP 1997 TERM
1998 EIA HIA SEA 2007 White Paper 2001 new
strategy 2007

• New need/ principle
• Substainablily
• Health
• Resources
• Energy
• Land
• Externality
• Acceptability
• Safety

THE PEP Assessment Report (UNECE / WHO,2008)
40
Opportunity for Walking cycling
Community severace
Driving press
Tecnological requirements
Attitudes
Land use
Urban congestion
stress
Speed / alcool
Air quality
Greenhouse
Noise planning
Physical activity
networks
Externalized costs
lead
sulphur
emissions
IMPACT 10 -2 -2 -2
-0,5? ? ? ?
POLICIES

• Internalizing costs
• subsidies
• user-pays
• fuel prices

ban limits standard
limits and demerit point
standard, control actions
ignored / under estimated
not only domain of sport
ignored / under estimated
abatment
THE PEP Assessment Report (UNECE / WHO,2008)
41
Critical issues for HiAP the information we need

• Health in All Policies in Europe and Italy
• The chain of causation policy-health
  determinants-health
• Transport a benchmark for evidence
• Inequalities modelling interaction
• Closing the information gap

42
Mackenbach et al, NEJM, 2008
43
control over distribution of resources and
opportunities (material, status, support)i.e.
unemployment, income, immigration, lone
matherhood
Social stratification
exposure
Exposure to psychosocial lifestyle external
access to care PARP high? high?
low? high?
vulnerability
Inequalities in health
consequences
Social consequences social mobility PARP low
Impact 1.4-9.5 GDP (Mackenbach et al, 2007)
Address distribution of power and money Improve
conditions of every day life Measure/evaluate/rese
arch/training/ public awareness
WHO Commission SDH, 2008, Lancet 2008
Modified from Diderichsen, 2005
44
Economic development and health in Europe 1960-99

• And Health in all Politics?
• Politics and health a neglected area of research
  (V. Navarro)
• Politics and health policy design and
  implementation are even more neglected than
  political values? (K. Judge)
• (Eur J Public Health, 18, 4, August 2008)

Modificato da Diderichsen, in Equipop 2008
45
Critical issues for HiAP the information we need

• Health in All Policies in Europe and Italy
• The chain of causation policy-health
  determinants-health
• Transport a benchmark for evidence
• Inequalities modelling interaction
• Closing the information gap

46
Closing the gap of information
Policy
Health
Determinants
other sectors of policy
public health
with experts of
A systematic collection of evidence with academic
experts about the chain of causation to identify
knowledge gaps for research and evaluation
47
Closing the gap of information
Policy
Health
Determinants
A validation of such evidence with
professionals, decision makers and stakeholders
in the field to start up processes of healthy
policy planning (at the regional and local level)
48
HiAP in the field
Health gradient
Turin mortality distribution by neighbourhood is
characterized by a geographical gradient, mainly
due to compositional differences in individual
socioeconomic conditions
Policies and interventions
Municipal policies aim at reducing disparities in
development and living conditions and at
promoting economic and social cohesion among
geographical areas in Turin
But health is not a criteria for such polices
49
Mortality by neighbourhood in Turin 1991-98
Health gradient
Turin mortality distribution by neighbourhood is
characterized by a geographical gradient, mainly
due to compositional differences in individual
socioeconomic conditions
Toward a City Master Plan for Health, Wellbeing
and Social Quality An Health in All Policy
approach, the Health Impact Assessment in the
main decisions, and an adequate longitudinal
health information system
Deprivation by neighbourhood in Turin 1991-98
Policies and interventions
Municipal policies aim at reducing disparities in
development and living conditions and at
promoting economic and social cohesion among
geographical areas in Turin
Urban regeneration by neighbourhood in Turin
during 90s
But health is not a criteria for such polices
50
Turin Longitudinal Study
Individual health biographies
51
Inequalities in mortality according to different
indicators of socioeconomic status. Turin,
2000-2004
I more advantaged IV more disadvantaged
Piedmont Region. Health Report 2006