TUNE My Life: Lessons We’re Learning about Life Course PlanningKathy Karsting, RN, MPHProgram Manager Maternal Child Adolescent Health Nebraska DHHS Division of Public Health

ObjectivesIdentify the function of life course

planning in promoting preconception health among adolescents and young adults

Describe the evolution of Nebraska’s approaches to life course planning

Discuss the role of life course planning in engaging youth in reflection, introspection, expression, sequential and longitudinal thinking, delayed gratification, and executive function

Objectives Identify the function of life course

planning in promoting preconception health among adolescents and young adults

Describe the evolution of Nebraska’s approaches to life course planning

Discuss the role of life course planning in engaging youth in reflection, introspection, expression, sequential and longitudinal thinking, delayed gratification, and executive function

Outline – Where we are

Definition and ScopeKey MessagesAdolescent Brain Development

Where we’ve beenTUNE My Life 1.1 and 1.2

Where we’re goingTUNE My Life 2.0Strategic planning

Maternal Child Adolescent Health (MCAH)

As a team, we support holistic life course development, pregnancy through young adulthood. 

Health is developmental.

Laying the Foundation #1

LIFE COURSE HEALTH DEVELOPMENT?

Life Course Development Theory

Our life course is a trajectory punctuated by critical and sensitive

periods Height of the trajectory represents

functional development/capacity Length of the trajectory represents

life span Influenced negatively by risk factors

and positively by protective factors Influenced by economic, social, and

environmental factors

8

How Risk Reduction and Health Promotion Strategies Influence Health Development

FIGURE 4: This figure illustrates how risk reduction strategies can mitigate the influence of risk factors on the developmental trajectory, and how health promotion strategies can simultaneously support and optimize the developmental trajectory. In the absence of effective risk reduction and health promotion, the developmental trajectory will be sub-optimal (dotted curve). From: Halfon, N., M. Inkelas, and M. Hochstein. 2000. The Health Development Organization: An Organizational Approach to Achieving Child Health Development. The Milbank Quarterly 78(3):447-497.

Trajectory Without RR and HP Strategies

0 20

Hea

lth

Dev

elop

men

t

40 60 80Age (Years)

HP

RR Risk Reduction StrategiesHealth Promotion Strategies

Optimal Trajectory

Protective Factors

HP HPHP

RR

RR

RR

Risk Factors

Protective Factors

HP HPHP

RR

RR

RR

Risk Factors

Life Course Development Theory – The Effects of Stress

Stress is cumulative and creates genetic and biological wear and tear (the allostatic load)

Stress is psychosocial, physiological, and/or environmental in nature

“Toxic stress” (Shonkoff) impacts neurochemical development of the brain and relates to Chronic Inflammation, Adaptability, Resilience, Adoption of Risk Behaviors, and Poor Health and Social Outcomes

Particularly telling in pregnancy and birth outcomes; infancy

A Life Course Perspective for Maternal Health

Powerful influences shape pregnancy outcomes long before conception

Pregnancy outcomes are shaped by social, psychological , behavioral, environmental and biologic factors

Preconception care has traditionally focused on factors a few weeks or months prior to conception by women planning pregnancy. Nearly 1/3 of pregnancies are unintended The influence of many factors, such as

nutritional status, begins in childhood.

Life Course Development and Health Disparities Disparities in birth outcomes result

from differential developmental trajectories over the life course.

While race as a biological concept may have little scientific meaning, as a social construct it may have profound health consequences.

The effect of race on birth outcome is likely mediated in part through (the) weathering of racism and racial discrimination over the life course.

Lu and Halfon (2003)

Resources: Life Course Implications of Health at Birth

Abundant evidence emphasizing the significance of health at birth and early childhood

Number of prenatal care visits may not have an effect on a child’s birth outcomes (Or, it takes more than 9 months to make a healthy baby)

Health disparities begin at birth (Or, the future of civilization is in the health of our girls)

Address health disparities by improving management of chronic disease and overweight; substance use; stress; mental health; environments; poverty… well before pregnancy

Preconception Health and Health Care and Early Childhood Comprehensive Systems: Opportunities for Collaboration. National Center for Children in Poverty http://nccp.org/publications/pub_1063.html

Recommended Resources – Life Course Development and Maternal Health

Misra, Dawn. 2006. Racial disparities in perinatal health; a multiple determinants perinatal framework with a lifespan approach. Harvard Health Policy Review. 7(1): 72 -90.

Grason, Holly and Dawn Misra. 2006. Application of a lifecourse and multiple determinants framework to improve maternal health. Baltimore MD. Womens’ and Children’s Health Policy Center. Johns Hopkins Bloomberg School of Public Health. http://www.jhsph.edu/research/centers-and-institutes/womens-and-childrens-health-policy-center/publications/Lifecourse_and_Mult_Determinats_Frmwk_brief.pdf

Lu M, Halfon N. Racial and ethnic disparities in birth outcomes: a life course perspective. Maternal and Child Health Journal 2003:7(1):13-30.

Contra Costa Health Dept. 2010. A 12-point plan to close the black-white gap in birth outcomes http://cchealth.org/lifecourse/pdf/12_point_plan_fact_sheet.pdf

What is …

Preconception Health

?

Working Definition of Preconception Health

Preconception Health encompasses the key health skills and behaviors for youth* aged 12-19 years, necessary to promote optimal life course outcomes for self and offspring during (future) reproductive years.

* Female and Male

The Purpose of Preconception Health Promotion

To prepare youth to be physically, emotionally, and mentally healthy, and to be empowered with information and resources before the onset of sexual activity.

Our Vision of Preconception HealthWe address preconception health as a holistic approach to support young people growing up in the adolescent years: embracing behaviors contributing to healthy relationships, healthy pregnancy, healthy parenting, and success for both parent and child.

Look to the Future Key message development

Resources

Evaluation by Youth

Look to the Future Preconception Fact Sheets

The “vehicle” for development of Key Messages

Resource Page

Evaluation questions, convenience sample

Evaluation FindingsToxic exposuresSupport your partnerDental careLiving with violenceFolic Acid

Resources - CDC http://

www.cdc.gov/preconception/index.html

http://www.cdc.gov/preconception/documents/reproductivelifeplan-worksheet.pdf

http://www.cdc.gov/preconception/documents/rlphealthproviders.pdf

Resources – ACOG Feb. 2012

Preconception = Preparing for Pregnancy Weight Vitamins and supplements Exercise Substance Abuse Environment – toxins and violence Chronic conditions Medications, Herbals, Supplements Infections Past Pregnancies Family Health History

Pregnancy AP056 Good Health Before Pregnancy: Preconception Health

Resources – Preconception Health and Health Care Reform

Increase the number of women covered by Medicaid

Improve preventive care Address health disparities through

improved pregnancy outcomesImprove knowledge, attitudes and

behaviors of men and women related to preconception health

Association of Maternal and Child Health Programs (AMCHP) Opportunities and Strategies for Improving Preconception Health through Health Care Reform Jan. 8, 2013

Resources – AMCHPFamily Planning counseling and

use of reproductive life planPhysical activityNutritionNutrient IntakeImmunizationsInfectious DiseaseParental Exposures to drugs and

alcoholAssociation of Maternal and Child Health Programs (AMCHP) Opportunities and Strategies for Improving Preconception Health through Health Care Reform Jan. 8, 2013

Social Marketing – Short-term Communication Goals• Increase awareness of preconception health

behaviors• Increase awareness that there is a

preconception time period• Increase awareness that what happens pre-

pregnancy (maternal and paternal) can affect health of baby

• Increase awareness about where to find more information

http://www.cdc.gov/preconception/showyourlove/index.html

Outline – Where we are

Definition and ScopeLife Course Health

DevelopmentKey MessagesAdolescent Brain Development

The Adolescent Brain and Life Course Planning The science of brain development

The impacts of adversity on brain development

The reality of Executive Function

Can we help make it happen?

The Adolescent Brain – Anterior cortex Sequential development to higher

levels of integration of information The impact of role models, or lack

thereof The connection between health and

executive function The role of education and learning

Executive Function A neuropsychological concept referring

to the high level cognitive processes required to plan and direct activities, including task initiation and follow-through, working memory, sustained attention, performance monitoring, inhibition of impulses, and goal-directed persistence.

Self-regulation

Four Executive Functions related to Life Course Planning Planning/Prioritization – The ability to

create a roadmap to reach a goal or to complete a task. (PL)

Time Management – the capacity to estimate how much time one has, how to allocate it, and how to stay within time limits and deadlines. How to monitor progress and stay on schedule. (TM)

Four Executive Functions related to Life Course Planning Goal-Directed Persistence – the

capacity to have a goal, follow through to the completion of the goal, and not be put off or distracted by competing interests (GDP)

Metacognition – The ability to stand back and take a bird’s eye view of oneself in a situation, the ability to self-monitor and self-evaluate (M)

Examples of Strategies to Model and Train Executive Function Break long-term projects into clearly

defined subtasks and give each a time frame (PL)

Use an analogy of a roadmap. Identify the destination. Visualize the path needed to reach the destination (PL)

When making a plan, include the amount of time involved for each step (TM).

Identify likely distractors, diversions, and roadblocks and how they may impact schedule and time estimates (TM).

Examples of Strategies to Model and Train Executive Function If a young person is unable to establish

goals, offer a menu of choices for what they might want to work toward (GDP)

Make the goal real and visible as possible with images or experiences (GDP)

Make measures of progress visible (GDP) Embed questions designed to elicit self-

evaluation or self-assessment (M) Ask, “How did you solve that problem?”

and “Can you think of another way of doing that?” (M)

Examples of Strategies to Model and Train Executive Function

Make tasks shortMake steps explicitMake tasks closed-endedBuild in variety or choice

The Adolescent Brain – and Adverse Childhood Experiences Reframing child – and parent – wellbeing

Trauma-informed care

Call to Action: Addressing Toxic Stress and Health

Disparities across the Lifespan

Recommended Resources - Brain Development Harvard University Center on the

Developing Child http://developingchild.harvard.edu/

Recommended Resources – Learning Executive Function Dawson, Peg and Richard Guare. 2010.

Executive Skills in Children and Adolescents: A Practical Guide to Assessment and Intervention 2nd Ed. Guilford Press: New York.

Where We’ve Been TUNE My Life 1.0

Observations If adults love it… ask yourself if

you’re on the right track If adults review and critique it… ask

yourself if kids will accept it If adults direct action from it… ask

yourself if anybody is still in the room

TUNE My Life 2.0 Key Messages

Multiple Choices

Guided Self-interpretation

Resources

Incorporate Health Literacy

Demonstrate Cultural and Linguistic Intelligence and Sensitivity

Reproductive Life Plans

Where We’re Going: Project LIFECOURSE

Brain Development + TUNE My Life = Executive Function

Look to the Future: Implementing the Key Messages as program activities

Steering Committee

Reaching Youth, Improving Life Course Outcomes

Where Will YOU Go?

Where Will YOU Go? Is there something about this

session you will apply?

Is there something you will research or think about further?

Are you interested in joining a steering committee?

THANK YOU!

kathy.karsting@nebraska.gov