Population Health and Human Population Health and Human Development, 1987-2007Development, 1987-2007

Clyde HertzmanClyde Hertzman

Director, Human Early Learning Director, Human Early Learning PartnershipPartnership

Determinants of HealthDeterminants of Health

Life expectancy and income per capita Life expectancy and income per capita for selected countries and periodsfor selected countries and periods

30

40

50

60

70

80

00 5,0005,000 10,00010,000 15,000 15,000

LifeLifeExpectancyExpectancy(years)(years)

Income per capita (1991 international dollars)Income per capita (1991 international dollars)

Source: World Development Report, 1993Source: World Development Report, 1993

19901990

19601960

About 1930About 1930

About 1900About 1900

.. ..... .

. .. .....

. .. . .... .... ..

......

....

........... . . .

....

..

.. .. .. .. .... .. ..

.. ........

.. .. ......

..

..

..

. .. .

..

..

..

....

Gradients in HealthGradients in Health

Index of InequalityIndex of Inequality

Hertzman, American Scientist, 2001, p 543Hertzman, American Scientist, 2001, p 543

U.K. Civil Service U.K. Civil Service Mortality - All CausesMortality - All Causes

CHD Mortality - UK Whitehall StudyCHD Mortality - UK Whitehall Study

A Developmental PerspectiveA Developmental Perspective

Infant MortalityInfant Mortality

0

2

4

6

8

10

12

14

16

18

20

1971 1976 1981 1986 1991 1996

Q1 - Richest

Q2

Q3

Q4

Q5 - Poorest

per 1,000

Mortality by Neighbourhood Income in Urban Canada, Wilkins R, Berthelot JM, Ng E, March 2001

Report: Raising Young Children, p 18, HRDC, 2003

Quantitative Literacy Scores for Youth Aged 16-25. Quantitative Literacy Scores for Youth Aged 16-25. International Adult Literacy Study, 1994International Adult Literacy Study, 1994

-1.5

-1

-0.5

0

0.5

1

1.5

6 7 8 9 10 11 12 13 14 15 16 17

Parents’ Level of EducationParents’ Level of Education

Eff

ect

Siz

eE

ffec

t S

ize

L

evel

1

L

evel

2

L

evel

3

Lev

el 4

Lev

el 1

Lev

el 2

Lev

el 3

L

evel

4

SwedenSweden

SwitzerlandSwitzerland

NetherlandsNetherlands

GermanyGermany

BelgiumBelgiumCanadaCanada

USAUSAPolandPolandIrelandIreland

N IrelandN Ireland G BritainG Britain

New ZealandNew Zealand

Organisation for Economic Co-operation and Development and Statistics Canada. (1995) Literacy, economy, and society: results of the first international adult literacy survey. OECD/Ministry of Industry Canada, p 151.

The Challenge of the GradientThe Challenge of the Gradient

• • ubiquitous in wealthy and majority world countriesubiquitous in wealthy and majority world countries

• • cuts across a wide range of disease processescuts across a wide range of disease processes

• • not explained by traditional risk factorsnot explained by traditional risk factors

• • replicates itself on new conditions as they emergereplicates itself on new conditions as they emerge

• • occurs among males and femalesoccurs among males and females

• • begins life as gradient in ‘developmental health’begins life as gradient in ‘developmental health’

• • gradients appear to ‘flatten up’gradients appear to ‘flatten up’

BirthBirth DeathDeathSocio-EconomicEnvironment

OR=1.87

Civil Society OR=2.05

Social

Network

OR=n.s.

““pathway/cumulative” pathway/cumulative” factors: OR=6.15factors: OR=6.15

Contributions to Self-rated Health at Age 33, Contributions to Self-rated Health at Age 33, 1958 Birth Cohort1958 Birth Cohort

““latent” factors: latent” factors: OR=5.03OR=5.03

““Intersecting” factors: Intersecting” factors: OR=3.83OR=3.83

Health Problems Related to Early Life

Coronary Heart Disease

Non-insulin Dependent Diabetes

Obesity

Blood Pressure

Aging and Memory Loss

Mental Health (depression)

‘‘Sensitive periods’ in early Sensitive periods’ in early brain developmentbrain development

Binocular vision

0 1 2 3 7654

High

Low

Years

Habitual ways of respondingLanguage

Emotional controlSymbol

Peer social skillsRelative quantity

Central auditory system

Effects of Mothers’ Speech on Infant VocabularyEffects of Mothers’ Speech on Infant Vocabulary

Source: Huttenlocher et al., 1991Source: Huttenlocher et al., 1991

0

600

1200

12 16 20 24 28 32 36

High SES

Middle SES

Low SES

Age - Months

Literacy – Early Vocabulary Growth

B. Hart & T. Risley, Meaningful Differences in Everyday Experiences of Young American Children, 1995

Cum

ulat

ive

Voc

abul

ary

03-08903-089

Serotonin Gene and DepressionAge 26

None Moderate Severe

.30

.50

.70

A. Caspi, Science, 18 July 2003, Vol 301.

Depression Risk

LL

SS

SL

S = Short Allele L = Long Allele

Early Childhood Abuse

SES Differences in Prefrontal Cortex SES Differences in Prefrontal Cortex ActivityActivity

The Dynamic Epigenome andThe Dynamic Epigenome andModulation of Gene ExpressionModulation of Gene Expression

The ‘Meaney-Szyf Paradigm’The ‘Meaney-Szyf Paradigm’

• • critical periods of brain developmentcritical periods of brain development

• • differential qualities of nurturancedifferential qualities of nurturance

• • epigenetic modification through methylationepigenetic modification through methylation

• • lifelong change in HPA axis functionlifelong change in HPA axis function

• • inter-generational transmission of nurturanceinter-generational transmission of nurturance

Kindergarten: Kindergarten: Early Development Instrument (EDI)Early Development Instrument (EDI)

1.1. 5 domains:5 domains:

Physical health and well beingPhysical health and well being Social knowledge and competenceSocial knowledge and competence

Emotional health and maturityEmotional health and maturity Language and cognitive developmentLanguage and cognitive development Communication skills and general Communication skills and general

knowledgeknowledge“Developmental Readiness”

Percentage of Students Vulnerable on One or More scales of the Percentage of Students Vulnerable on One or More scales of the EDI EDI

Based on Provincial cutoffs, Based on Provincial cutoffs, WaveWave 1 1

Percentage of Students Vulnerable on One or More Percentage of Students Vulnerable on One or More Scales of the EDI Scales of the EDI Based on Provincial cutoffs, Based on Provincial cutoffs, Wave 2Wave 2

Ever at risk Ever at risk VulnerableVulnerable

Average Score Average Score Emotional Maturity scale of the EDI, Emotional Maturity scale of the EDI, Cycle 1Cycle 1

Proportion of Variation in EDI Vulnerability across 470 Neighbourhoods ‘Explained’ by SES

• physical health and well-being -- 31%• social competence -- 24%

• emotional maturity -- 22%

• language and cognitive development -- 27%

• communication skills and general knowledge -- 46%

• one or more vulnerability -- 43%

Map 4.7.2: Vulnerability on Any EDI Map 4.7.2: Vulnerability on Any EDI Scale and Socioeconomic Status in BCScale and Socioeconomic Status in BC

Map 4.7.2-Highlight1: Vulnerability on Map 4.7.2-Highlight1: Vulnerability on Any EDI Scale and Socioeconomic Status Any EDI Scale and Socioeconomic Status

in BCin BC

Map 4.7.2-Highlight2: Vulnerability on Map 4.7.2-Highlight2: Vulnerability on Any EDI Scale and Socioeconomic Status Any EDI Scale and Socioeconomic Status

in BCin BC

Map 4.7.2-Highlight3: Vulnerability on Map 4.7.2-Highlight3: Vulnerability on Any EDI Scale and Socioeconomic Status Any EDI Scale and Socioeconomic Status

in BCin BC

Variation in SES-Vulnerability Linkage in British Variation in SES-Vulnerability Linkage in British Columbia:Columbia:

SES-Typical and -Atypical CommunitiesSES-Typical and -Atypical Communities

Defining Off-/On-DiagonalityDefining Off-/On-Diagonality

• Better than expected:Better than expected:– Low SES Low SES / / Low EDI vulnerability Low EDI vulnerability (Group 1)(Group 1)

• Worse than expected: Worse than expected: – High SES High SES // High EDI vulnerability High EDI vulnerability (Group 2)(Group 2)

• As expected: As expected: – High SES High SES // Low EDI vulnerability Low EDI vulnerability (Group 3)(Group 3)– Medium SES Medium SES / / Medium EDI vulnerability Medium EDI vulnerability (Group 4)(Group 4)– Low SES Low SES / / High EDI vulnerability High EDI vulnerability (Group 5)(Group 5)

Off-Diagonal:

On-Diagonal:

J

SES Data SourcesSES Data Sources

• EDI Wave 0/1 (1999/2000, 2000/1, 2001/2, 2002/3, 2003/4)

• 2001 Census

• Child Care Data (1999 to 2003)

• 1998 Taxfiler Data

• EDI Wave 2 (2004/5, 2005/6, 2006/7)

• 2001 Census

• Child Care Data (1999 to 2003)

• 1998 Taxfiler Data

• Change from 1998 to 2004 in Taxfiler Data

Year EDI became a systemic

program in BC

B

Conceptual Diagram: Conceptual Diagram: Off- and On-Diagonal GroupingsOff- and On-Diagonal Groupings

Group 2:

Worse than expected

(OFF)

Group 1:

Better th

an expected

(OFF)

Group 3:

Left, regression lin

e

(ON)

Group 4:

Centre, re

gression line

(ON)

Group 5:

Right, regression lin

e

(ON)

Predicted vulnerability

Act

ua

l vu

lne

rab

ility

Let’s not forget

Group 0: “other”

n’hoods.

J

NeighbourhoodsNeighbourhoods Identified as Identified as Off- & On-DiagonalOff- & On-Diagonal

B

Cohorts of InterestCohorts of Interest

2007/2008

2006/2007

2005/2006

2004/2005

2003/2004

Wave 2:

FSA (Gr. 4)

2002/2003

2000/2001

2003/2004

2001/2002

1999/2000

Wave 1:

EDI (K)

= focus of our current

work

EDI-to-FSA Data Linkage RatesEDI-to-FSA Data Linkage Rates

5076

26502

3416

3411

4044

PEN Found

3172 +/-

3783 +/-

FSA Score Found

275062002/2003

36432000/2001

53742003/2004

40082001/2002

4267 1999/2000

EDI

95%

94%

85%

96%

96%

Kindergarten Grade 4

89%

87%

Data Unavailable

Data Unavailable

Data Unavailable

The EDI has Predictive Validity (but there’s more The EDI has Predictive Validity (but there’s more to it than that!)to it than that!)

# of Vulnerabilities % Not ‘Successful’ = ‘Not Pass’

Numeracy

0 12.31 22.22-3 33.84-5 55.6

Reading0 17.81 33.92-3 43.14-5 68.3

(EDI) (Grade 4)

Understanding C-to-B RatiosUnderstanding C-to-B Ratios

VULNERABLE

NOT VULNERABLE

EDI

DID NOTPASSED

FSALet’s see how these deflections appear graphically…

= “off diagonals”

A – Positive (Normal)A – Positive (Normal)

B – Negative DeflectionB – Negative Deflection

C – Positive DeflectionC – Positive Deflection

D- Negative (Normal)D- Negative (Normal)

Calculating C-to-B RatiosCalculating C-to-B Ratios

DCVULNERABLE

BANOT VULNERABLEEDI

NOT PASSEDPASSED

FSARecall that…

/ ( + ) / ( + )

CBR=

In essence, the CBR represents the ratio of positive to negative

deflections

VancouverVancouver

Divergence: The development of children from higher vulnerability neighbourhoods, over time, falls behind that of children from lower vulnerability neighbourhoods.

Howe SoundHowe Sound

Convergence: Children from higher vulnerability neighbourhoods tend to catch up, over time, with children from lower vulnerability neighbourhoods.