A Framework for Public Health Action: The Health Impact Pyramid

Interventions focusing on lower levels of the pyramid tend to be more effective because they reach broader segments of society and necessitate less person attempt. Implementing interventions at each of the levels can achieve the maximal possible sustained public health benefit. A 5-tier pyramid best describes the shock of different types of public health interventions and provides a framework to improve health. At the base of this pyramid, indicating interventions with the greatest likely impact, are efforts to address socioeconomic determinants of health. In ascending order are interventions that change the context to make individuals ‘ nonpayment decisions healthy, clinical interventions that require limited contact but confer long-run protection, ongoing target clinical caution, and health education and rede. All of these models, however, focus most of their attention on assorted aspects of clinical health services and their delivery and, to a lesser extent, health system infrastructure. Although these are of critical importance, public health involves far more than health caution. The fundamental typography, organization, and operation of society form the underpinnings of the determinants of health, yet they are often overlooked in the exploitation frameworks to describe health system structures. As a result, existing frameworks accurately describe neither the part elements nor the character of public health. The traditional depiction of the potential impact of health wish interventions is a four-tier pyramid, with the penetrate level representing population-wide interventions that have the greatest impact and ascend levels with decreasing impact that represent primary, secondary, and tertiary concern. 6 other frameworks more specific to public health have been proposed. Grizzell ‘s 6-tier intervention pyramid stress policy change, environmental enhancement, and community and neighborhood collaboration. 7 Hamilton and Bhatti ‘s three-dimensional population health and health promotion cube incorporates 9 health determinants ( for example, healthy child development, biota and genetics, physical environments, working conditions, and social support networks ) and evidence-based actions to address them ( for example, reorienting health services, creating supportive environments, enacting goodly public policy, and strengthening community military action ). 8 The parental and child health pyramid of health services, developed by the US Health Resources and Services Administration, consists of 4 levels of services used by states to allocate resources for mothers and children. 6 infrastructure build ( for example, monitor, train, systems of care, and information systems ) is at the bottom of the pyramid, followed by population-based services ( for example, newborn screen, immunization, and lead screen ) and enabling services ( for example, department of transportation, translation, case management, and coordination with Medicaid ), with direct health care services at the peak.

LIFE EXPECTANCY IN DEVEL oped countries has increased from less than 50 years in 1900 to closely 80 years today. 1 The greatest improvement occurred in the first gear half of the twentieth hundred, when life anticipation in the United States and many parts of Europe increased by an median of 20 years, 2 largely because of cosmopolitan handiness of clean water and rapid declines in infectious disease, 3 arsenic well as broad economic growth, rising life standards, and improved nutritional condition. 4 Smaller gains in the latter half of the twentieth century resulted chiefly from advances in discussion of cardiovascular disease and control of its risk factors ( i.e., smoke, high blood pressure, and high cholesterol ). 5


An alternative conceptual model for populace health action is a 5-tier health impact pyramid ( ). In this pyramid, efforts to address socioeconomic determinants are at the base, followed by populace health interventions that change the context for health ( for example, clean and jerk water, safe roads ), protective interventions with long-run benefits ( for example, immunizations ), conduct clinical care, and, at the crown, guidance and department of education. In general, populace natural process and interventions represented by the establish of the pyramid want less individual attempt and have the greatest population impingement. however, because these actions may address sociable and economic structures of society, they can be more controversial, particularly if the public does not see such interventions as falling within the government ‘s allow sphere of natural process. Interventions at the top tiers are designed to help individuals rather than entire populations, but they could theoretically have a boastfully population impact if universally and efficaciously applied. In practice, however, even the best programs at the pyramid ‘s higher levels achieve limited public health affect, largely because of their dependence on long-run individual behavior change. 9 As Rose writes ,

personal life style is socially conditioned…. Individuals are improbable to eat very differently from the rest of their families and social circle…. It makes little sense to expect individuals to behave differently than their peers ; it is more allow to seek a general change in behavioral norms and in the circumstances which facilitate their borrowing. 10 ( p135 )

Socioeconomic Factors

The bottom tier of the health impact pyramid represents changes in socioeconomic factors ( for example, poverty reduction, improved education ), frequently referred to as social determinants of health, that help form the basic foundation of a society. 11, 12 Socioeconomic status is a strong determinant of health, both within and across countries. 13 Although the exact mechanisms by which socioeconomic status exerts its effects are not always apparent, poverty, low educational attainment, relative loss, and lack of access to sanitation increase exposure to environmental hazards. 14 educational condition is besides tightly correlated with cardiovascular gamble factors, including smoking. 15, 16 Although poverty increases ill health within a club, economic development can besides increase illness and death from noncommunicable disease. As living standards and life anticipation improve, risk for cardiovascular disease and some cancers increases. 17 much of this increase results from modifiable risk factors related to overconsumption of tobacco, insalubrious food, and alcohol, with a coincident decrease in physical activity. Greater wealth can besides lead to more roads and an increase in motive vehicle use, which can result in increase outdoor tune pollution and more injury and death from traffic crashes. A third base of the populace ‘s urban population lives in slums. 18 solid health improvements in high-poverty areas will require better economic opportunities and infrastructure, including reliable electric power, sanitation, transportation, and other basic services. 19 clean water system and improved sanitation introduced in the United States in the former 19th and early twentieth centuries may have been chiefly responsible for reducing mortality rates by about half and child deathrate rates by closely two thirds in major cities. 20 calm, more than 900 million people worldwide have no access to clean drinking urine and about 2.5 billion have no entree to adequate sanitation. 21 As the World Health Organization ‘s Commission on Social Determinants of Health reported, “ Social injustice is killing people on a expansive scale. ” 11 ( p26 )

Changing the Context to Encourage Healthy Decisions

The second tier of the pyramid represents interventions that change the environmental context to make healthy options the default option, regardless of education, income, service provision, or other social factors. The defining feature of this tier of intervention is that individuals would have to expend significant campaign not to benefit from them. For exercise, fluoridated water—which is unmanageable to avoid when it is the public supply—not only improves individual health by reducing tooth decay, 22 but besides provides economic benefits by reducing health spending and productivity losses. In countries without either adequate natural or add fluoridation, health authorities are limited to counseling interventions, such as encouraging toothbrushing. other contextual changes that create healthier defaults include clean water, air, and food ; improvements in road and fomite invention ; elimination of lead and asbestos exposures ; and iodization of salt. 22 The potential social impact of decreasing cardiovascular risk factors by changing from saturated to unsaturated cook oils was demonstrated in Mauritius 23 ; eliminating artificial trans fat in food is another way to prevent cardiovascular disease. 24 Strategies to create healthier environmental context besides include designing communities to promote increase physical action ; enacting policies that encourage populace passage, bicycling, and walking rather of driving ; designing buildings to promote step manipulation ; passing smoke-free laws ; and taxing tobacco, alcohol, and insalubrious foods such as sodium carbonate and other sugar-sweetened beverages. cardiovascular disease risk factors ( for example, high blood pressure ) are presently addressed at the individual level through riddle and medication. But even assuming perfective treatment, this approach fails to prevent about half of the disease effect caused by elevated blood pressure ; cardiovascular risk increases with systolic blood pressure above 115 millimeter Hg, a degree at which checkup treatment is not recommended presently. 25, 26 Changing the environmental context so that individuals can well take heart-healthy actions in the normal course of their lives can have a greater population shock than clinical interventions that treat individuals. For exercise, modern diets contain many times the minimum casual requirement of sodium—mostly from packaged foods and restaurant meals—making it unmanageable for individuals to control their consumption. 27 Reducing dietary sodium can reduce high blood pressure at the population tied. 28, 29 A healthier food environment can be created by decreasing salt in packaged foods. This is happening in the United Kingdom, which introduced four-year sodium reduction targets, 30 and in Finland, where dietary sodium intake decreased approximately 25 % in the past 30 years. 31

Long-Lasting Protective Interventions

The one-third grade of the pyramid represents 1-time or infrequent protective interventions that do not require ongoing clinical care ; these generally have less shock than interventions represented by the bottom 2 tiers because they necessitate reaching people as individuals quite than jointly. historic examples include immunization, which prevents 2.5 million deaths per class among children globally. 32 Another example is colonoscopy, which can significantly reduce colon cancer and is alone needed every 5 to 10 years for most people. Smoking cessation programs increase depart rates ; life anticipation among men who quit at age 35 is about 7 years longer than for those who continue to smoke. 33 male circumcision, a child outpatient surgical procedure, can decrease female-to-male HIV transmittance by american samoa a lot as 60 %. 34 Scale-up could potentially prevent millions of HIV infections in sub-saharan Africa. 35, 36 A single venereal disease of azithromycin or ivermectin can reduce the preponderance of onchocerciasis, a major cause of blindness. 37

Clinical Interventions

The fourthly level of the pyramid represents ongoing clinical interventions, of which interventions to prevent cardiovascular disease have the greatest potential health impact. Although evidence-based clinical care can reduce disability and prolong life, the aggregate impingement of these interventions is limited by lack of access, erratic and unpredictable attachment, and fallible potency. Access can be limited even in systems that guarantee health coverage for all 38 and is a a lot greater problem in the United States and early countries without universal joint health wish coverage. 39, 40 Nonadherence is particularly debatable for chronic conditions that are normally asymptomatic, such as high blood pressure, lipemia, and diabetes. At least a third of patients do not take medications as advised, and nonadherence can not be predicted from socioeconomic or demographic characteristics. 41, 42 rigorous accountability, incentives for meaningful outcomes ( for example, lineage imperativeness and cholesterol see ), and systems to enable improved performance are all substantive to improve health care system performance. Electronic health records have the potential—if and alone if they are implemented with prevention and accountability as guiding principles—to facilitate greatly improved preventive and chronic care. 43 This goal is more likely to be attained if electronic commemorate keeping is implemented along with changes in both fiscal incentives and doctor practices to proactively support preventive care and control of chronic diseases. 44

Counseling and Educational Interventions

The pyramid ‘s one-fifth tier represents health education ( department of education provided during clinical encounters vitamin a well as education in other settings ), which is perceived by some as the perfume of public health action but is by and large the least effective type of intervention. 9 The need to urge behavioral change is diagnostic of failure to establish context in which healthy choices are nonpayment actions. For exercise, counterbalances to our obesogenic environment include exhortations to increase physical bodily process and improve diet, which have little or no effect. More than one third of US adults, or 72 million people, were corpulent in 2006, a dramatic addition over 1980. 45 Two thirds of these individuals were counseled by a health care supplier to lose weight, 46 however daily calorie and adipose tissue intake continues to rise. Counseling, either within or outside the clinical context, is broadly less effective than other interventions ; successfully inducing individual behavioral transfer is the exception preferably than the rule. For exemplar, although clear, impregnable, and personalized smoking cessation advice, even in the absence of pharmacological treatment, doubles quit rates among smokers who want to stop and should be the norm in medical manage, it still fails to help 90 % of those who are motivated to quit. 47, 48 however, educational interventions are much the only ones available, and when applied systematically and repeatedly may have considerable affect. An model of a successful evidence-based educational intervention is trained peer counselors advising men who have sex with men about reducing HIV risk. 49

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