Data Sources For Prioritizing Health Problems At Each Level Of The Public Health Pyramid?

Am J Public Health. 2010 April; 100(4): 590–595.

A Framework for Public Health Activity: The Health Affect Pyramid

Accustomed December 8, 2009.

Abstract

A 5-tier pyramid best describes the bear upon of dissimilar types of public health interventions and provides a framework to meliorate health. At the base of operations of this pyramid, indicating interventions with the greatest potential impact, are efforts to address socioeconomic determinants of health. In ascending order are interventions that change the context to brand individuals' default decisions healthy, clinical interventions that require limited contact but confer long-term protection, ongoing direct clinical care, and health education and counseling.

Interventions focusing on lower levels of the pyramid tend to be more effective considering they accomplish broader segments of social club and require less individual effort. Implementing interventions at each of the levels can achieve the maximum possible sustained public health benefit.

LIFE EXPECTANCY IN DEVELoped countries has increased from less than 50 years in 1900 to virtually eighty years today.¹ The greatest improvement occurred in the outset one-half of the 20th century, when life expectancy in the United States and many parts of Europe increased by an average of 20 years,² largely because of universal availability of make clean water and rapid declines in infectious disease,³ as well every bit wide economical growth, rising living standards, and improved nutritional status.⁴ Smaller gains in the latter one-half of the 20th century resulted primarily from advances in treatment of cardiovascular disease and control of its risk factors (i.due east., smoking, high claret pressure level, and loftier cholesterol).⁵

The traditional delineation of the potential impact of health care interventions is a four-tier pyramid, with the lesser level representing population-wide interventions that have the greatest impact and ascending levels with decreasing touch that represent primary, secondary, and tertiary care.^vi Other frameworks more specific to public health accept been proposed. Grizzell's half dozen-tier intervention pyramid emphasizes policy modify, environmental enhancement, and community and neighborhood collaboration.⁷ Hamilton and Bhatti's 3-dimensional population wellness and health promotion cube incorporates 9 wellness determinants (east.g., healthy child evolution, biology and genetics, physical environments, working atmospheric condition, and social support networks) and bear witness-based actions to address them (e.thou., reorienting health services, creating supportive environments, enacting healthy public policy, and strengthening community action).⁸ The maternal and kid health pyramid of health services, adult by the U.s.a. Wellness Resource and Services Administration, consists of iv levels of services used by states to allocate resource for mothers and children.⁶ Infrastructure building (eastward.one thousand., monitoring, preparation, systems of care, and data systems) is at the lesser of the pyramid, followed by population-based services (east.1000., newborn screening, immunization, and lead screening) and enabling services (e.g., transportation, translation, example management, and coordination with Medicaid), with direct health intendance services at the top.

All of these models, however, focus most of their attention on various 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 care. The fundamental composition, organization, and operation of club class the underpinnings of the determinants of health, yet they are ofttimes overlooked in the development frameworks to describe health system structures. As a result, existing frameworks accurately describe neither the elective elements nor the role of public health.

A V-TIER PYRAMID

An alternative conceptual framework for public wellness action is a 5-tier health impact pyramid (Figure 1). In this pyramid, efforts to address socioeconomic determinants are at the base, followed by public health interventions that modify the context for wellness (due east.grand., clean water, safe roads), protective interventions with long-term benefits (e.thousand., immunizations), straight clinical care, and, at the top, counseling and education. In general, public action and interventions represented past the base of the pyramid require less individual try and have the greatest population touch on. However, because these actions may address social and economic structures of society, they tin be more than controversial, particularly if the public does non run across such interventions equally falling within the government's appropriate sphere of action.

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The wellness affect pyramid.

Interventions at the top tiers are designed to aid individuals rather than entire populations, but they could theoretically have a big population touch on if universally and effectively practical. In practise, however, even the best programs at the pyramid's college levels reach limited public health impact, largely because of their dependence on long-term individual beliefs change.^nine Every bit Rose writes,

Personal life-style is socially conditioned… . Individuals are unlikely to eat very differently from the residuum of their families and social circle… . It makes picayune sense to look individuals to acquit differently than their peers; it is more appropriate to seek a general change in behavioural norms and in the circumstances which facilitate their adoption.^ten(p135)

Socioeconomic Factors

The bottom tier of the health bear on pyramid represents changes in socioeconomic factors (e.g., poverty reduction, improved education), often referred to as social determinants of health, that aid form the basic foundation of a order.^11,12 Socioeconomic status is a potent determinant of health, both within and across countries.^thirteen Although the exact mechanisms by which socioeconomic status exerts its effects are not always apparent, poverty, low educational attainment, relative deprivation, and lack of access to sanitation increase exposure to environmental hazards.¹⁴ Educational condition is besides tightly correlated with cardiovascular risk factors, including smoking.^xv,16

Although poverty increases ill wellness within a club, economical development can also increase illness and death from noncommunicable affliction. As living standards and life expectancy improve, risk for cardiovascular illness and some cancers increases.¹⁷ Much of this increase results from modifiable take a chance factors related to overconsumption of tobacco, unhealthy food, and alcohol, with a concurrent decrease in physical activity. Greater wealth can also lead to more than roads and an increase in motor vehicle use, which can result in increased outdoor air pollution and more injury and death from traffic crashes.

A third of the world's urban population lives in slums.¹⁸ Substantial health improvements in loftier-poverty areas will require improved economic opportunities and infrastructure, including reliable electric power, sanitation, transport, and other bones services.¹⁹ Clean water and improved sanitation introduced in the Usa in the late 19th and early 20th centuries may have been primarily responsible for reducing mortality rates past about half and child mortality rates past almost two thirds in major cities.^twenty Notwithstanding, more than than 900 million people worldwide have no access to make clean drinking water and well-nigh 2.5 billion have no access to adequate sanitation.²¹ As the World Health System'south Committee on Social Determinants of Health reported, "Social injustice is killing people on a g calibration."^11(p26)

Changing the Context to Encourage Healthy Decisions

The 2nd tier of the pyramid represents interventions that change the environmental context to make salubrious options the default option, regardless of instruction, income, service provision, or other societal factors. The defining feature of this tier of intervention is that individuals would take to expend pregnant effort not to benefit from them. For example, fluoridated water—which is hard to avoid when it is the public supply—not but improves private wellness by reducing tooth decay,²² but also provides economic benefits past reducing health spending and productivity losses. In countries without either adequate natural or added fluoridation, wellness authorities are limited to counseling interventions, such as encouraging toothbrushing.

Other contextual changes that create healthier defaults include clean h2o, air, and food; improvements in road and vehicle pattern; elimination of lead and asbestos exposures; and iodization of salt.²² The potential societal impact of decreasing cardiovascular run a risk factors by irresolute from saturated to unsaturated cooking oils was demonstrated in Mauritius²³; eliminating artificial trans fatty in nutrient is another way to foreclose cardiovascular disease.²⁴ Strategies to create healthier environmental contexts besides include designing communities to promote increased physical action; enacting policies that encourage public transit, bicycling, and walking instead of driving; designing buildings to promote stair use; passing smoke-complimentary laws; and taxing tobacco, booze, and unhealthy foods such as soda and other saccharide-sweetened beverages.

Cardiovascular disease adventure factors (east.g., hypertension) are currently addressed at the individual level through screening and medication. Just fifty-fifty assuming perfect treatment, this approach fails to forestall virtually half of the disease burden caused past elevated blood pressure; cardiovascular risk increases with systolic blood force per unit area above 115 mm Hg, a level at which medical treatment is not recommended currently.^25,26 Changing the ecology context and then that individuals tin can easily take heart-healthy deportment in the normal course of their lives tin can have a greater population impact than clinical interventions that treat individuals.

For instance, modern diets incorporate many times the minimum daily requirement of sodium—mostly from packaged foods and restaurant meals—making information technology difficult for individuals to control their intake.²⁷ Reducing dietary sodium can reduce hypertension at the population level.^28,29 A healthier food environment can be created by decreasing table salt in packaged foods. This is happening in the Uk, which introduced four-yr sodium reduction targets,³⁰ and in Republic of finland, where dietary sodium intake decreased approximately 25% in the past 30 years.³¹

Long-Lasting Protective Interventions

The third level of the pyramid represents 1-time or infrequent protective interventions that practise non require ongoing clinical care; these generally have less impact than interventions represented by the bottom 2 tiers considering they necessitate reaching people equally individuals rather than collectively. Historic examples include immunization, which prevents ii.v million deaths per yr among children globally.³² Another instance is colonoscopy, which can significantly reduce colon cancer and is but needed every 5 to 10 years for most people. Smoking cessation programs increase quit rates; life expectancy among men who quit at age 35 is nigh 7 years longer than for those who continue to smoke.³³

Male person circumcision, a pocket-sized outpatient surgical process, can decrease female person-to-male HIV manual by every bit much as sixty%.³⁴ Scale-upwards could potentially prevent millions of HIV infections in sub-Saharan Africa.^35,36 A unmarried dose of azithromycin or ivermectin tin reduce the prevalence of onchocerciasis, a major cause of blindness.³⁷

Clinical Interventions

The fourth level of the pyramid represents ongoing clinical interventions, of which interventions to prevent cardiovascular disease accept the greatest potential wellness bear upon. Although evidence-based clinical care can reduce disability and prolong life, the aggregate affect of these interventions is express by lack of admission, erratic and unpredictable adherence, and imperfect effectiveness. Access can be limited fifty-fifty in systems that guarantee health coverage for all³⁸ and is a much greater problem in the United States and other countries without universal health care coverage.^39,40 Nonadherence is particularly problematic for chronic conditions that are usually asymptomatic, such as hypertension, hyperlipidemia, and diabetes. At least a third of patients practise not accept medications as brash, and nonadherence cannot exist predicted from socioeconomic or demographic characteristics.^41,42

Rigorous accountability, incentives for meaningful outcomes (east.chiliad., blood pressure level and cholesterol control), and systems to enable improved operation are all essential to ameliorate wellness care organization performance. Electronic health records accept the potential—if and only if they are implemented with prevention and accountability every bit guiding principles—to facilitate greatly improved preventive and chronic care.⁴³ This goal is more likely to be attained if electronic record keeping is implemented along with changes in both financial incentives and physician practices to proactively support preventive care and control of chronic diseases.⁴⁴

Counseling and Educational Interventions

The pyramid's 5th tier represents health education (pedagogy provided during clinical encounters as well as education in other settings), which is perceived by some every bit the essence of public health activity but is generally the least effective type of intervention.⁹ The need to urge behavioral change is symptomatic of failure to found contexts in which healthy choices are default actions. For example, counterbalances to our obesogenic environment include exhortations to increase physical activeness and improve diet, which have little or no effect. More one tertiary of US adults, or 72 million people, were obese in 2006, a dramatic increment over 1980.⁴⁵ Two thirds of these individuals were counseled by a health care provider to lose weight,⁴⁶ all the same daily calorie and fat intake continues to ascent.

Counseling, either within or exterior the clinical context, is generally less constructive than other interventions; successfully inducing private behavioral modify is the exception rather than the dominion. For example, although clear, strong, and personalized smoking cessation advice, even in the absence of pharmacological treatment, doubles quit rates among smokers who desire to stop and should be the norm in medical intendance, it still fails to assistance 90% of those who are motivated to quit.^47,48

Still, educational interventions are oftentimes the just ones available, and when applied consistently and repeatedly may accept considerable impact. An case of a successful evidence-based educational intervention is trained peer counselors advising men who accept sex with men about reducing HIV gamble.⁴⁹

PROGRAM IMPLEMENTATION

Comprehensive tobacco command programs, which contain elements that work at all levels of the pyramid, illustrate the potential awarding of this paradigm and the synergies among unlike levels of intervention. People with low incomes and low educational attainment have college rates of smoking than do people with higher incomes and education.⁵⁰ Interventions that accost social determinants of wellness, such as increasing a population'due south educational and economic status, should therefore reduce smoking rates. Nevertheless, because these changes often require fundamental social alter, they are generally not within the traditional purview of tobacco command or public health programs.

Context-irresolute interventions, such equally increasing tobacco taxes, establishing smoke-free workplaces, and changing the social norms regarding smoking through hard-hitting antitobacco campaigns and elimination of advertising and promotional cues to smoke, are highly effective in reducing tobacco use.⁵¹ Difficult-hitting ad campaigns, particularly equally function of a comprehensive tobacco control program, not only reduce tobacco use past irresolute the social context of smoking⁵² just also provide in effect a social immunization against smoking that persists over time. Clinical intendance that includes cessation medications can triple quit rates in individual smokers, but even the all-time systems treat merely a pocket-sized proportion of smokers, and only one third of those who are motivated to quit and are treated will succeed.⁴⁸ Education about the harms of smoking provides people with data to assistance them change their behavior. Other examples of this v-tiered framework applied to communicable illness, chronic disease, and injury prevention are given in Table ane. Inevitably, some programs mistiness the distinctions between tiers. For case, mass media campaigns for tobacco control could be viewed equally an educational intervention (tier five), but if done effectively, such deportment can change the context by altering the social norms related to tobacco use (tier 2).

TABLE 1

Structural Approaches to Health Promotion for Communicable Affliction, Noncommunicable Disease, and Injury Prevention

Approaches to Prevention	Communicable Disease	Noncommunicable Disease	Injuries
Counseling and educational interventions	Behavioral counseling to reduce sexually transmitted infections	Dietary counseling Counseling to increase levels of physical action Public education well-nigh avoiding lifestyle-mediated disease	Counseling and public teaching to avoid drinking and driving and encourage compliance with traffic laws School-based programs to prevent or reduce trigger-happy beliefs
Clinical interventions	HIV treatment to decrease viral load and reduce transmission Treatment of tuberculosis, resulting in decreased spread of infection	Treatment of hypertension and hyperlipidemia Aspirin therapy for people with coronary heart disease	Methadone and buprenorphine handling to decrease opiate overdose Screening and treatment of women older than 65 years for osteoporosis to reduce fractures
Long-lasting protective interventions	Immunizations Male circumcision in countries with high HIV prevalence and significant female-to-male person transmission Mass antibiotics to prevent or treat tropical diseases (eastward.g., onchocerciasis)	Colonoscopy Treatment of tobacco addiction Surgical sterilization, intrauterine device insertion, or other long-acting contraception to reduce maternal mortality Dental sealants	Brief behavioral counseling to reduce alcohol consumption Dwelling modification, such as installation of catch bars and handrails, to prevent falls among the elderly
Changing the context	Clean h2o Reduced indoor fume pollution from biomass cooking Ubiquitous condom availability	Trans fatty elimination in candy food to reduce cardiovascular affliction Sodium reduction in packaged foods and food served in restaurants to reduce cardiovascular disease Fluoridation of water to prevent dental cavities Elimination of atomic number 82 paint and asbestos exposures Increased unit of measurement toll for tobacco, alcohol, and saccharide-sweetened beverages Fume-costless workplaces Community and transit design to promote greater physical activity	Road and vehicle pattern requirements to reduce crashes and protect pedestrians and bicyclists Laws prohibiting the sale of alcohol to minors and increased alcohol cost Laws prohibiting driving at even low blood alcohol levels Effectively implementing laws to mandate helmet use past motorcyclists and motorbike passengers Occupational safety requirements
Socioeconomic factors	Reduced poverty to improve immunity, decreased crowding and environmental exposure to communicable microbes, and improved nutrition, sanitation, and housing	Reduced poverty, increased instruction levels, and more nutritional options to reduce cardiovascular disease, some cancers, and diabetes	Reduced poverty levels to reduce drug use and violence, improved housing options, and lowered vulnerability to extreme atmospheric condition weather condition

Practical APPLICATION OF THE HEALTH IMPACT PYRAMID

The wellness impact pyramid, a framework for public health action, postulates that addressing socioeconomic factors (tier 1, or the base of operations of the pyramid) has the greatest potential to improve health. Interventions that change the context for individual beliefs (tier ii) are by and large the almost effective public wellness actions; 1-time clinical interventions (tier 3), such every bit immunizations, tin can be more finer applied than those requiring ongoing care; and clinical interventions (tier iv) are generally, although not inevitably, more than effective than counseling and instruction (tier 5).

Although the effectiveness of interventions tends to decrease at higher levels of the pyramid, those at the top oftentimes require the least political commitment. Achieving social and economical change might require central societal transformation. Contextual change is often controversial, equally evidenced past disputes over smoke-free laws, restrictions on artificial trans fatty, and h2o fluoridation.^53,54 One-time interventions tend to be less controversial, although immunization programs that attempt to accomplish all members of a gild often run across resistance arising from suspicion and disbelief.⁵⁵

Although the structure and financing of health intendance systems tin can be controversial, clinical intendance itself rarely is. While exceptions exist, health education usually requires minimal political backing. Hence the greater popularity of school-based antismoking programs (despite consequent evidence they provide fiddling to no do good⁵⁶) than of proven tobacco control interventions such as taxation, fume-gratis environments, and comprehensive marketing bans. Similarly, exhorting people to exercise more than and consume less is politically popular, but tax of soda and other carbohydrate-sweetened beverages,⁵⁷ bans on marketing junk nutrient to children, and community redesign to encourage walking and bicycling, although far more than effective, are also politically more hard.

Interventions that address social determinants of health have the greatest potential public health benefit. Action on these issues needs the support of government and ceremonious gild if it is to be successful.⁵⁸ The biggest obstacle to making cardinal societal changes is ofttimes not shortage of funds simply lack of political will; the health sector is well positioned to build the back up and develop the partnerships required for change.⁵⁹

To say that social and contextual changes are more effective at improving public health is not to imply that other interventions should be ignored. For different public health problems, different interventions may be the nearly constructive or feasible in any given context. Education to encourage safe use, although of simply limited effectiveness, tin reduce HIV transmission and save lives. Changing the context to brand condoms ubiquitously available and acceptable makes educational activity near their use more constructive. Comprehensive public health programs should generally attempt to implement measures at each level of intervention to maximize synergy and the likelihood of long-term success.

Acknowledgments

The writer thanks Kelly Henning for valuable insight and input and Drew Blakeman, Cheryl de Jong Lambert, Leslie Laurence, and Karen Resha for assist with article preparation and inquiry.

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