| Framingham Concept Paper
RESILIENCE THROUGH HEALTHY AGING:
FROM FRAMINGHAM TO PHOENIX
Written by Alex Zautra, John
Hall, Linda Luecken, John Reich, Kathy Lemery, Mary Davis,
and Felipe
Gonzalez
Castro professors of Arizona State University Download
this paper as a pdf
EXECUTIVE SUMMARY
This is a request
for first phase “seed” funding
to develop a Phoenix area Resilience Project. We are
confident that investment in this project will yield
substantial returns in the form of federal grant support,
and substantial immediate and long term benefits to the
community. In addition, this project has the potential
to make significant contributions to knowledge about
health and wellness and healthy behavior by close interdisciplinary
examination and intervention with a sample panel of participants
over a long period. Resilience is at the
heart individual and community health, and the two are intimately connected. What makes
some people and communities more resilient than others?
Can greater resilience be developed, nurtured, implanted?
These are the kinds of questions that guide our work,
answers to them will unlock unused but existing health
capacity. Consequences for personal quality of life,
ability to retain health and independence among the tidal
wave of baby boomers about to retire, and viability of
public budgets are enormous. If resilience is the iron spike unifying
this project, “Framingham” provides
the model and the method. Following the approach of this
famous and invaluable contribution to science and public
health, we propose to recruit a sample of Phoenix area
residents to learn about cause and effect of resilience
and how people might develop greater resilience for better
health, particularly as they age. Simultaneously we will
examine community resilience and community sources of
personal resilience, and their interactive effects. More than research, this project
will offer interventions to promote resilience within
the sample and among people
in the community to understand most effective resilience
strategies. In the near term, our efforts will focus
on the careful creation of a project team with needed
blend of interdisciplinary insights combined with general
commitment to the resilience theme, crafting of large
and long term proposals to sustain the project, and development
of diverse and robust sample of people and communities.
All of this will proceed with building of genuine community
partnerships and collaboration around the project. Immediate
benefits from our first phase would include community “Resilience
Dialogues” designed to develop community leadership
and support and facilitate exchange between people in
the community and university team members with intervention
ideas, technologies, and strategies. A Community Forum
at the end of our first phase is also proposed to place
the resilience project firmly at the center of the Phoenix
public health agenda. Overtime, our project will become a well from which
many will drink. We are confident that this initial investment
would leverage ten to twenty times this amount resulting
in multiple direct public health and quality of life
benefits for individual and community participants as
well as indirect and immensely important benefits associated
with better understanding and promotion of resilience.
Return
to Top PROPOSAL - The Heart of
the Matter Alexis Tocqueville was the first to note that Americans are a nervous
people. Nowhere is this more evident than in the rapidly changing communities
of the Southwestern United States, and no metropolitan area better represents
emergent restlessness of urban peoples of 21st century America than
Phoenix, Arizona. This is a metropolis on the run: Quick to develop,
anxious to grow, eager to build. It has been in an expansive mood for
30 years. Not all forward moves are forward-looking, however. When rushed, our
community leaders can look more desperate and eager to please than thoughtful
about growth. In everyday life, we may find that many people react rather
than act, with defensive reflex rather than rational choice. The nervous
push takes its toll on the health and wellbeing of whole communities.
A good example is our penchant for fast food. The 99-cent burger on
virtually every major intersection in Phoenix attests to the popularity
of one-minute solutions to a fundamental human need for nourishment.
The 33% rate of obesity and consequences of a tripled risk for diabetes,
threats of cardiovascular disease, and soaring rates of impaired functioning
from osteoarthritis are testimony to the health consequences of the
quick fix for human appetites. In one study, just the simple instruction
to be more patient with consumption, to pay attention to the taste of
the food, and be mindful of one’s satiety, produces significant
improvements in people’s health. Many problems come down to this:
The failure to look into the heart of things before acting to fill a
need. Individually and collectively, we seem to live for the moment,
and to base decisions on “wishful thinking,” more than rational
choice. From fast food to public budget decisions, we seem compelled
to avoid consideration of long-term consequences, to aim for the quick
fix. Our understanding of people’s health cannot be hurried either.
We need to study our people’s problems conscientiously, and guide
people to see themselves as worthy enough to be thoughtful about their
present health and self-reliant enough to take charge of their future
health. Lessons in thoughtfulness might be enough if our world stood still.
But change, not stability, is more the norm, and for some members of
our communities, change is highly stressful, and their environments
less sustaining for health during times of upheaval. There are certain
inevitabilities in all our lives. We will all face highly stressful
situations, we will all experience profound loss, and we will all see
our family members become ill. Instead of running from these darker
times, or pretending they will not affect us, we need to foster awareness
of these naturally occurring difficulties in the lives of all within
our communities. The real test of a thriving community of people is
how its members are able to continue on a forward path, and persevere
in the face of these inevitabilities, not how capable they are of avoiding
challenges altogether. We cannot outmaneuver illness, aging, and death.
What we can do is observe and learn how to adapt best following calamities
that affect the mind and the body. We need to know how to bounce back,
reestablish our balance after losing our footing, and rise again from
the ashes after our fall. This symbol of the Phoenix can serve us well.
In the science of human health it is the study of the capacity of the
mind and body to regain homeostasis following stress. In the language
of everyday life, resilience is at the heart of it all. And community
is at the heart of capacity. Resilience is intimately connected to social
context, to the values and behaviors of larger communities and groups.
Tocqueville also described with a mixture of admiration and anxiety,
American “habits of the heart”—his expression for
the mix of traits of the American people. He warned of potential conflict
between the American ability to build strong communities through the
interlacing of voluntary associations of citizens and the potentially
isolating features of American individualism. In the decades following
Tocqueville, major books (e.g. Bellah et al., 1985, Putnam, 2000) have
documented the conflict between fierce American individualism and urgent
needs for community and commitment and the serious decline in social
capital and community values needed to reinforce resilience. Individual
capacity is to some degree dependent on community capacity, which raises
the question: Can significant gains in resilience be made without building
healthier communities? Return
to Top The focus of health care has also been on the quick fix, the symptom-cure,
rather than on the building of resourcefulness with the
person, family, work and community. To advance our community’s
health, we need to embrace a new model of health, one that focuses less
on the presence
or absence of disease and more on the preservation of
health and quality of life. Health cannot be defined as the absence
of pathology but as
a way of life that promotes a sustained capacity for
well-being even as people age. Health may best be seen as a resourceful
integration
of mind with body within a responsive community. For
this health, there must be internal fortifications to defend against
the inevitable stresses
of life, and social resources that can nurture healing
among those struck down by forces beyond their own restorative capacities.
What we can
do is prolong this form of good health, and reduce the
severity of illness through building and sustaining resilient communities.
Two recent St. Luke’s Health Initiatives publications
point the way to new understandings and action in public
health. In The Coming of Age, John Hall and his team
present the challenges that confront the urban communities
within Arizona. They show that the shift to high proportions
of elders within our communities in the coming decades
is undeniable. Baby-boomers are just now beginning
to find themselves with chronic illnesses or with heightened
vulnerability to those illnesses. Biotechnology and
medical advances hold much promise for the future.
But reliance solely on biomedical approaches to treat
those who become ill will not solve this dilemma. Furthermore,
the changing demography is not proportional across
ethnic and cultural lines. One statistic stands out
in this report, in particular. In 50 years, the authors
project that Hispanic elders will increase in population
by 593%. In contrast, the increase is 82% for European
Americans. But even as the authors present these sobering
figures, they retain optimism for our collective futures,
provided we find a better approach to health care.
They note “disease and disability are not the
inevitable consequences of getting older.” New
technologies, applied in partnership with community,
coupled with an awareness and commitment to promoting
a healthy lifestyle for all our residents, can enable
us to meet the challenges as we age. In a second Arizona Health Futures report, Building a Public Health
Movement in Arizona, the authors identify two fundamental requirements
for us to transform the future of public health in our communities:
Leadership and partnership. To develop health care practices that extend
beyond the physician’s office and put in place preventative programs
that strengthen resistance to disease and promote resilient lifestyles,
we need people with ideas to lead and collaborative partnerships among
our institutions. As the authors state we need to foster a culture within
which public health can flourish. What Arizona’s Universities can do. The University, through the strength of its faculty and readiness to
work with community partners, is poised to take a leadership role as “citizen-scientists” in
the development of this vision. We need a bold approach, one that extends
beyond the standard public health model and embraces knowledge-based
interventions informed by the best of social-behavioral science, biotechnology
and medicine (see McKinlay & Marceau, 2000). Multi-level models
are needed to track the trajectory of health and illness with our communities,
refined by scientists and practitioners working within interdisciplinary
teams. We propose to develop a new, interactive type of “urban
observatory” to test and refine our models of prevention of disease
and disablement and the promotion of health through longitudinal study
of the course of healthy aging in our communities. We also need to do
more than observe. We propose to develop community-based “community
resilience centers” that will offer and test interventions that
inform the public of methods for sustaining health and fostering resilience
within themselves, their families and their communities. Our plan is
an ambitious one, never before attempted on the scale that we propose.
It is a vision commensurate in scope with the challenges that confront
our communities in the coming decades. Return
to Top
Framingham: A Framework for Observation and Participation There are several examples of successful university-community partnerships
to study public health. The best known and arguably the most fruitful
of these University-community engagements has been the Framingham study.
This investigation began in 1948 in Framingham Massachusetts as a study
of the onset of heart disease with the recruitment of 5,209 healthy
men and women between the ages of 30 and 60 years. The United States
Public Health Service and the National Heart Institute (now NHLBI) worked
with Boston University to build and sustain this study for over 50 years,
following these residents with biannual assessments, and adding their
children along with other cohorts over time. The accomplishments of
Framingham have been remarkable. Among them were discoveries of the
increase in heart disease due to cigarette smoking, the identification
of cholesterol and blood pressure as risk factors, the benefits of exercise
and weight management in reducing vulnerability to disease and the association
of psychosocial factors to heart disease onset and progression. These
relationships are well known today. But, only through careful methods
of epidemiological inquiry with a large, randomly selected cohort, was
the Framingham group able to verify their results and recommend public
health initiatives designed to reduce the incidence of heart disease. Framingham is a valuable model to follow, but not to copy. We would
follow their lead in the grand design of their epidemiological work.
Their assessment of both biological and behavioral data is an essential
multidisciplinary focus to retain in future studies, as is the use of
repeated measurement for an extended period in order to chart the course
of health and illness systematically. Modern methods of inquiry would
include many features not available at the time that Framingham studies
were launched. Genetic testing, psychological, hormonal and immune profiles
of people at rest and during stress challenges, and the study of physical
environment and culture have all emerged from the 20th century with
valid instruments with which to examine the health and illnesses of
peoples over the life course. We propose multilevel assessments that
examine factors at the level of molecules, behavior, culture and community
to obtain data needed to inform interventions that target health and
illness risk factors and resistance resources that appear at different
levels of analysis of the problem. Further, we plan to simultaneously
assess individuals across the lifespan in a “cross-sequential” longitudinal
design. This design has the advantage of almost immediately yielding
results on all ages and stages of functional health and disease. These
initial results can then inform community-based interventions. Adding
the longitudinal component then permits us to test causal models and
examine the relative contribution of various risk factors and resilience
resources in the preservation of health and well-being as people age. We would draw several key distinctions between what we are advocating
and the original Framingham study: 1. Framingham was known for identifying individual vulnerabilities
to disease. Indeed, some scholars attribute the coinage of the phrase “risk
factor” to the Framingham investigators. A modern study would
focus not only on factors that place people at risk, but also factors
that are protective, and that promote resiliency. Attention to the positive
is needed if we are to build a model of health instead of one focused
solely on illness. Modern research has opened up this revolutionary “dual
approach to health and illness. One of our group, Professor Alex Zautra,
summarizes this new perspective in a book just released by Oxford University
Press entitled, Emotion, Stress and Health. 2. The original Framingham cohort was European American, almost exclusively.
In Phoenix, we have communities with many diverse cultures, and ethnicities.
One in three Arizonans are members of a racial/ethnic minority group,
with Hispanics making-up two thirds of this group. The patterns of health,
illness, healthcare utilization and predetermined level of risk for
disease is highly variable across these groups. Many racial/ethnic minority
persons are uninsured leading to significant disparities in health care
have been documented across racial/ethnic groups, and the factors that
perpetuate these inequalities need to be addressed if we are to take
seriously the task of enhancing the health futures for all Arizonans.
We have more to learn as well of the strengths of cultural traditions.
From a research perspective, epidemiological paradoxes including the
robust health profiles of low-income traditional Mexican American mothers
and their infants despite their low-income status, and the lower rates
of mental disorder among new immigrant populations, constitute research
areas worthy of study to understand the mechanisms that contribute to
these healthy outcomes despite their disadvantaged status. Within communities
with diverse cultures, people have much to learn from one another about
preserving health and sustaining quality of life.
3. Framingham focused on the prediction of a single
set of diseases: those of the cardiovascular system.
They now have expanded the range of their research
to other illnesses. We think the focus of our efforts
ought to be on a wide range of determinants of health
through the many stages of life, not on single disease
entities. Therefore, the focus of our efforts is on
the preservation of functioning. Physical illness and
mental disorders are among the outcomes we will monitor,
with the ultimate goal being the prevention of disablement
in all its forms, and the promotion of resilience. 4. Framingham did not introduce interventions to further the public
health of the community under study. Though the studies were of great
scientific value, and eventually helped many reduce risk of heart disease,
it did not offer programs to the Framingham community itself. As citizen-scientists
we ask ourselves what Robert Lynd would have asked at this juncture, “Knowledge
for What?” A true partnership between the interdisciplinary team
of scientists and its study population is one in which there is give
and take. There is much that can be done now, without waiting for new
discoveries. Indeed, the methods of introducing and testing the efficacy
of behavioral interventions has been developed in years of careful work
by NIH Prevention Centers around the country including one such center
housed with the Department of Psychology at Arizona State University.
We propose the development of “Community Resilience Centers.” These
centers will be dedicated to the development and testing of interventions
will target known risk and resilience factors responsible for onset
and progression of the most prevalent disabling illnesses. 5. Framingham examined the psychophysiological risk factors among people
of a single community. The Phoenix metropolitan area is not a single
homogeneous cluster. The City of Phoenix alone has been divided into
14 distinct urban villages. We advocate the selection of at least two
of these villages for our projects. Doing so allows development of models
of health that take into account the cultural and physical environmental
contexts within which people live and work, and permits the shaping
of interventions that are culturally responsive, and pass the test of
relevance as defined by the communities themselves. Return
to Top
The First Steps We plan to carry out our goals for this project in two initial phases.
The steps and
time-lines for the completion of this work are detailed
below. Phase I: Project Development Phase: July, 2003 to December, 2004. • Identification of candidate sites for community study and intervention
•
Initiate resilience dialogues with community leaders
of urban sites under consideration
•
Visit “urban observatories” and “healthy community
programs” that developed from university-community partnerships
in other states
•
Build interdisciplinary teams to construct assessment
and intervention strategies
•
Conduct needs assessment of candidate sites
•
Select urban villages for healthy communities program
•
Hold community forum to present program plan
•
Establish a sampling framework for individual health
and lifestyle assessments
•
Develop detailed proposal for Phase II
Phase II: Initiation of a “Community Resilience” Program:
December 2004 to June 2006.
• Evaluate state of individual health, risks of disease and disablement
•
Assess individual capacity for adaptation and resiliency
•
Evaluate state of community health and preventive resources
•
Develop “Community Resilience Centers” perhaps as partnerships
with existing community centers for the promotion of healthy communities
within each urban village
•
Develop NIH proposals for funding of longitudinal studies
and intervention research The benefits of a “Framingham” for Arizona Throughout these phases our team of researchers will be developing
proposals, culminating in the receipt of NIH-level funding to extend
our projects for an additional five years. Our ultimate goal is to follow
our study participants for a lifetime, evaluating existing hypotheses
and developing new knowledge about the coming of age, offering participants
programs that promise to advance their health futures, and establishing
a lasting partnership between Arizona State University and their community. By the end of Phase I we plan to create strong, multidisciplinary teams
able to evaluate health at multiple levels of analysis (e.g., microbiological,
biological, behavioral, mental) and develop community-based interventions. In addition to success in obtaining extensive funding for the longitudinal
portion of our studies, we will be able to point to a number of accomplishments
by the end of Phase II. Among those accomplishments will be: • Develop a baseline inventory of resilience among people and
communities in the sample
•
Complete an initial assessment of the health of individuals
as it exists within the broader context of family, social relationships,
culture, and community, leading to the development of innovative, testable
models of health that consider social, physical, community and cultural
environments.
•
We will be able to answer one of the key questions first
raised in Coming of Age: Are Arizona’s “Baby boomers” in
better health than previous generations, and are those gains distributed
equally across socioeconomic and ethnic groups within the community?
•
Identify culturally responsive and valid methods for
enriching the health futures of individuals, families, and community
groups.
•
Report on disparities in health, access to preventive
health resources, and health-related quality-of-life across racial,
ethnic, and socioeconomic groups in Phoenix communities.
•
Lay the groundwork for long-lasting, mutually beneficial,
collaborative relationships between Arizona State University, local
businesses, and the community. Project Partnership To launch this work, a partnership between St. Luke’s Health
Initiatives and Arizona State University has been forged. Each partner
would provide a share of the financial resources required in phase 1.
More importantly, the partners would interact from the beginning of
the project forward over critical project issues and decisions such
as selection of the community samples. Because of their important and
on-going community efforts, St. Luke’s will provide invaluable
connections to community organizations, leaders, programs that are all
part of community resilience fabric to be incorporated in resilience
inventories and designs of the project. The ASU team will rely on this
community knowledge in its development of proposals for federal funding,
which are both methodologically sound and meaningful. Return
to Top The Citizen-Scientist Team: Founding members Professors Alex Zautra and John Hall are the leaders of the team, but
all members bring unique expertise, past success in leading large-scale
health research and community programs as well as considerable enthusiasm
for the project. The different interests, experience and expertise the
complement one another, and each member will take a leadership role
in developing those specific aspects of the program where they have
the most to contribute. In addition, we will also be identifying additional
partners during Phase I to broaden the scope of our multidisciplinary
efforts. Alex J. Zautra is Professor of Psychology at Arizona State University.
He has published over 80 scientific papers, and is the recent author
of Emotions, Stress and Health, published by Oxford University Press,
February 2003. He is currently the principal investigator on four multi-year
national grants. His work focuses on the role of stress and resilience
in the health and well-being of older adults. He has established expertise
in methods of assessing psychosocial risks and the design of preventive
interventions. He will oversee the development of projects focused on
assessment and intervention with individuals and their families John Stuart Hall is Professor of Public Affairs and Public Service.
He has written numerous articles, books and reports about applied urban
public policy issues. Hall has directed over 20 large scale, funded
interdisciplinary public policy research projects. Most recently he
served as project director and principal investigator of The Coming
of Age, an interdisciplinary inquiry and analysis of multiple dimensions
and impacts of aging and health in Arizona. He will oversee the examination
of community-level factors and the development of community-level interventions. Mary Davis is Associate Professor of Clinical Psychology. She examines
how individual differences in physiological, emotional, and behavioral
responses to stress are related to subsequent health and quality of
life. She is currently Co-PI on three 5 year grants designed to explore
the longitudinal relationship between stress responses and adaptation
in chronic pain patients, and testing interventions designed to increase
resiliency in the face of stress and pain. She will assist the team
by visiting sites that have developed successful, ongoing community-university
partnerships, and developing methods for assessing the physiological
stress responses of community members. Linda Luecken is Assistant Professor of Clinical Psychology.
She has research and clinical expertise in the impact of stress on
cardiovascular and hormonal function, and the long-term impact on
physical and psychological health. Dr. Luecken has current funding
from the American Heart Association and NIH/NIMH for ongoing studies
on the long-term impact of family stressors on health. Her efforts
for the team will include assisting with selection of candidate sites,
conducting needs assessment of the sites, and developing the Community
Resilience Centers. Kathryn S. Lemery is Assistant Professor of Developmental
Psychology, specializing in early risk and resiliency factors for
later psychological and physical health. Currently she is funded by
the National Institute of Mental Health to study genetic and environmental
precursors to childhood mood and behavioral disorders. She will assist
the team in the development of an assessment methodology to examine
genetic and social environment factors contributing to risk of disease
and functional impairment within the family. Felipe Gonzalez Castro is Professor of Clinical Psychology. His work
focuses on the design and evaluation of health promotion and disease
prevention interventions that promote healthy lifestyles in a culturally
proficient manner for Hispanics and other minority populations, and
persons at high risk for major chronic diseases such as cardiovascular
disease, cancer, diabetes, and substance abuse. He will help the team
develop culturally relevant community and individual interventions. John W. Reich is Professor of Social Psychology with expertise is in
the relationship between physical, social and emotional well-being.
Dr. Reich has a record of substantial accomplishment in funded research,
and is currently a co-investigator on three federal grants investigating
the role of social stress in adaptation to chronic illness among older
adults. He will assist this team by coordinating the submission of interdisciplinary
grant proposals. Return
to Top References Bellah, Robert N. et al (1985). Habits of the Heart: Individualism
and Commitment in American Life. Berkeley: University of California
Press Hall, J. et al. (2002). The Coming of Age: A Research Report on Aging,
Health and Arizona’s Capacity to Care. Phoenix, AZ: Arizona Heath
Futures, St. Luke’s Health Initiatives. Lockhart, C.A. & Hughes, R.A. (2002). Building a Public Health
Movement in Arizona. Phoenix, AZ: Arizona Heath Futures, St. Luke’s
Health Initiatives. Lynd, R.S. (1939). Knowledge for What? The Place of Social Science
in American Culture. Princeton, NJ: Princeton University Press.
McKinlay, J.B. & Marceau, L.D. (2000). “To
Boldly Go.” American Journal of Public Health,
90, 25-33. Putnam, Robert D. (2000). Bowling Alone: The Collapse and Revival of
American Community. New York: Simon & Schuster. Tocqueville, A. (1969). Democracy in America, trans George Lawrence,
Ed., J.P. Mayer. New York: Doubleday, Anchor Books. Zautra, A. (2003). Emotions, Stress and Health. New York: Oxford University
Press.
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