A Framework for Public Health Action: The Health Impact Pyramid

A 5-tier pyramid best describes the impact 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 potential impact, are efforts to address socioeconomic determinants of health. In ascending order are interventions that change the context to make 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 because they reach broader segments of society 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 nearly 80 years today.¹ The greatest improvement occurred in the first 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 clean water and rapid declines in infectious disease,³ as well as broad economic growth, rising living standards, and improved nutritional status.⁴ Smaller gains in the latter half of the 20th century resulted primarily from advances in treatment of cardiovascular disease and control of its risk factors (i.e., smoking, high blood pressure, and high cholesterol).⁵The traditional depiction of the potential impact of health care interventions is a four-tier pyramid, with the bottom level representing population-wide interventions that have the greatest impact and ascending levels with decreasing impact that represent primary, secondary, and tertiary care.⁶ Other frameworks more specific to public health have been proposed. Grizzell''s 6-tier intervention pyramid emphasizes policy change, environmental enhancement, and community and neighborhood collaboration.⁷ Hamilton and Bhatti''s 3-dimensional population health and health promotion cube incorporates 9 health determinants (e.g., healthy child development, biology and genetics, physical environments, working conditions, and social support networks) and evidence-based actions to address them (e.g., reorienting health services, creating supportive environments, enacting healthy public policy, and strengthening community action).⁸ The maternal 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 building (e.g., monitoring, training, systems of care, and information systems) is at the bottom of the pyramid, followed by population-based services (e.g., newborn screening, immunization, and lead screening) and enabling services (e.g., transportation, translation, case management, and coordination with Medicaid), with direct health care 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 society form the underpinnings of the determinants of health, yet they are often overlooked in the development frameworks to describe health system structures. As a result, existing frameworks accurately describe neither the constituent elements nor the role of public health.     

Mobility and Aging: New Directions for Public Health Action

Optimal mobility, defined as relative ease and freedom of movement in all of its forms, is central to healthy aging. Mobility is a significant consideration for research, practice, and policy in aging and public health. We examined the public health burdens of mobility disability, with a particular focus on leading public health interventions to enhance walking and driving, and the challenges and opportunities for public health action. We propose an integrated mobility agenda, which draws on the lived experience of older adults. New strategies for research, practice, and policy are needed to move beyond categorical promotion programs in walking and driving to establish a comprehensive program to enhance safe mobility in all its forms.A significant challenge for public health is to develop effective and efficient strategies to promote health and well-being in a growing and increasingly diverse aging population. Healthy aging, a term that is used to refer to this public health objective, is defined by the Centers for Disease Control and Prevention as the “development and maintenance of optimal physical, mental and social well-being and function in older adults.”1^(p3) Healthy aging is

likely to be achieved when physical environments and communities are safe, and support the adoption and maintenance by individuals of attitudes and behaviors known to promote health and well-being, and by the effective use of health services and community programs to prevent or minimize the impact of acute and chronic disease on function.1^(p3)

Optimal mobility, defined simply as being able to safely and reliably go where you want to go, when you want to go, and how you want to get there, is a key component of healthy aging. Mobility refers to movement in all of its forms, including basic ambulation, transferring from a bed to a chair, walking for leisure and the completion of daily tasks, engaging in activities associated with work and play, exercising, driving a car, and using various forms of public transport.Just as negative health outcomes are associated with impaired mobility, health and well-being are enhanced through strategies to optimize mobility. As evidence of the growing interest in the health effects of mobility, the American Public Health Association recently released Transportation and Health Toolkit,2 and the Environment and Policy Change for Healthy Aging Initiative, sponsored by the Centers for Disease Control and Prevention Healthy Aging Research Network, produced Optimal Living: Getting Around.3Mobility has significance for research, practice, and policy in aging and public health. Walking and driving are the 2 leading forms of mobility among older adults in neighborhood settings.4,5 Here we (1) review the public health burdens of mobility disability as well as some of the key epidemiological findings in this area, (2) identify leading public health interventions to enhance walking and driving in older populations, (3) discuss challenges and opportunities for public health action, and (4) recommend new directions for public health action, including the development of an integrated mobility agenda to guide the examination and promotion of safe walking and driving as part of the everyday lives of older adults. Although the study of mobility among institutionalized older adults is also an important area of research, it is beyond the scope of this article.     

Critical Opportunities for Public Health Law: A Call for Action

Although legal interventions are responsible for many sentinel public health achievements, law is underutilized as a tool for advancing population health. Our purpose was to identify critical opportunities for public health lawmaking. We articulated key criteria and illustrated their use with 5 examples. These opportunities involve significant health problems that are potentially amenable to change through law and for which an effective legal intervention is available: optimizing graduated driver licensing laws, increasing tax rates on alcoholic beverages, regulating sodium in foods, enacting laws to facilitate reversal of opioid overdoses, and improving mental health interventions in the college setting. We call for a national conversation about critical opportunities for public health law to advance evidence-based policymaking.Many of the greatest public health achievements in the United States are the result of legal interventions.1,2 From the control of infectious diseases, to the reduction of coronary heart disease, to improvements in maternal and child health, the law has exerted a powerful effect on environmental and behavioral health risks. Evidence continues to mount about law’s effectiveness in addressing a gamut of health problems, with recent successes including prevention of childhood lead poisoning and workplace injuries.3In light of such achievements, law’s role in advancing public health is receiving greater attention by agenda-setting organizations such as the Centers for Disease Control and Prevention4 and the Institute of Medicine (IOM).5 Last year, an IOM committee recommended with “a sense of urgency” that government at all levels “make the most of … law and public policy to improve population health.”^5(p14) To advance this goal, the Robert Wood Johnson Foundation now supports a national program in Public Health Law Research,6 focusing on evaluation of legal interventions to improve population health, and the Network for Public Health Law,7 which provides legal technical assistance. The Centers for Disease Control and Prevention operates a Public Health Law Program8 and the American Public Health Association recently elevated its Health Law Special Primary Interest Group to the status of a full-fledged Law Section.9Despite this attention, law remains an underutilized resource in public health. Because of information gaps, opposition from industry, failure to capture lawmakers’ attention, and other factors, there are legal interventions that could have powerful effects on a wide range of health threats yet are not widely disseminated or well implemented. Some interventions require new law, whereas others simply require stronger or more creative use of existing authority. At the same time, some laws with unintended adverse effects have not been amended, clarified, or repealed.What are the most promising legal interventions to address important health problems? Where is the evidence for likely benefit most compelling and the barriers to policy change least formidable? Answering these questions successfully requires a framework in which researchers and policymakers can think strategically, apply common criteria, and bring evidence to bear to highlight the most fruitful areas of action. A national discussion to identify and prioritize critical opportunities for public health law is therefore needed.We have aimed to stimulate such a conversation and offer a framework for organizing it. We have proposed criteria for identifying critical opportunities, illustrated with 5 diverse examples. Our purpose is not merely to advance these particular examples on the policy agenda but to encourage policymakers and scholars to further engage in a public dialogue about how legal authority can be used for maximum population health impact.     

Urgent Need to Orient Public Health Response to Rapid Nutrition Transition

India is currently undergoing a rapid transition on economic, demographic, epidemiologic, nutrition, and sociological fronts. There is evidence of a decline in undernutrition with a simultaneous escalation in overnutrition and associated non-communicable diseases (NCDs). However, the current concern and national policy response for tackling malnutrition in India is still primarily restricted to undernutrition diagnosed on the basis of body size (anthropometry). A complex range of interacting factors have been linked to the rising trend of overnutrition and associated NCDs from a global perspective. The burden of overnutrition and associated morbidities is rapidly escalating to alarming proportions, particularly in urban areas and high socio-economic status groups. The poor are not spared from this transition. It is predicted that a more rapid transition may occur amongst poor populations in future with higher economic development. The need of the hour is to launch an integrated public health response to the dual burden beginning from pregnancy and early life. This will obviously require careful deliberation of the strategy and interventions, and a multi-sectoral approach, especially involving the health, women and child development, nutrition, education, agriculture, food processing, trade, architecture, water supply and sanitation, community and non-governmental organizations.     

SARS-CoV-2 Wastewater Surveillance for Public Health Action

Wastewater surveillance for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has garnered extensive public attention during the coronavirus disease pandemic as a proposed complement to existing disease surveillance systems. Over the past year, methods for detection and quantification of SARS-CoV-2 viral RNA in untreated sewage have advanced, and concentrations in wastewater have been shown to correlate with trends in reported cases. Despite the promise of wastewater surveillance, for these measurements to translate into useful public health tools, bridging the communication and knowledge gaps between researchers and public health responders is needed. We describe the key uses, barriers, and applicability of SARS-CoV-2 wastewater surveillance for supporting public health decisions and actions, including establishing ethics consideration for monitoring. Although wastewater surveillance to assess community infections is not a new idea, the coronavirus disease pandemic might be the initiating event to make this emerging public health tool a sustainable nationwide surveillance system, provided that these barriers are addressed.