Different Ways to Improve Public Health

Focus on diseases/ injuries e.g. sexually transmitted diseases, intentional injury, diabetes

Focus on risk factors e.g. tobacco use, nutrition, physical activity

Focus on underlying factors that impact multiple dimensions of health e.g. poverty, social isolation

SocialEnvironment

GeneticEnvironment

IndividualResponse

• Behavior• Biology

Healthand

Function

Diseaseand

Injury

Healthand

Medical Care

Well-Being Prosperity

PhysicalEnvironment

Underlying Health Determinants

Impact of Early Childhood Home Visitation Programs

Program can prevent child maltreatment in high-risk families. In studies reviewed, home visiting resulted in a

40% reduction in child maltreatment episodes. Longer duration programs produce larger effects;

programs of less than 2 years duration did not appear to be effective.

Professional home visitors may be more effective than trained paraprofessionals but longer-duration programs with trained

paraprofessionals can also be effective.

Impact of Early Childhood Home Visitation Programs

All programs reviewed were directed at families considered to be at high risk of child maltreatment, (e.g., single or young mothers, low-income households, families with low birth weight infants).

Other benefits Health benefits for premature, low birth weight

infants and for disabled and chronically ill children

Improved maternal educational attainment, reduced public support, improved child educational performance, reduction in drug use and contact with juvenile justice etc.

Tenant-based Rental Voucher Programs

BackgroundTenant-based vouchers allow very low

income families to rent safe, decent, and affordable privately owned housing in neighborhoods of their choice.

Rental voucher programs, known as “housing mobility programs,” work with landlords and tenants to find rental property outside of neighborhoods of concentrated poverty and relocate families to neighborhoods of greater prosperity.

Tenant-based Rental Voucher Programs

Findings from the Systematic Review 6 studies: rental voucher programs

resulted in decreases in victimization of tenants or their property

Families enrolled in rental voucher programs who moved to better areas were

• 6% less likely to have a household member victimized

• 15% less likely to experience neighborhood social disorder.

Changes in victimization in both urban and suburban settings.

General Comments on Evidence Based Reviews

More evidence than sometimes expected, however

Insufficient evidence common outcome Very resource intensive process Quality of studies vary widely Economic data still uncommon Important to consider harms even

though uncommon

TASK FORCE REVIEWS AND RECOMMENDATIONS

www.thecommunityguide.orgResults of all reviews to dateFrequent updatingDownloadable Slide Sets

How Evidence Can Improve Public Health Infrastructure

Explore evidence underlying options to reach each public health goal

e.g. smoking control, reducing disparities in infant mortality, increasing physical activity, increasing immunization rates

Comprehensively review the best sources of evidence reviews

Community Guide (best source when topic of interest has been covered)

Recent review articles in peer reviewed journals Other meta-analyses funded by responsible federal

agencies Compare results and recommendations of different

sources

Use evidence to decide among possible interventionsHow does each possible intervention suit

the problem and the population? • E.g. was it tried on particular racial/

ethnic/ age/ gender groups?• Is there reason to belief it would not be as

effective for some of these on whom it was not tried?

• Is the problem now similar to what it was when the major studies took place?

How Evidence Can Improve Public Health Infrastructure

Deciding on Interventions

Single versus multiple component interventionsSingle component interventions

easier to develop, implement, control and assess, but

Multi-component interventions usually more effective

• E.g. Tobacco control in California

Deciding on Interventions Consider both policies and programs Programs

Greater control over all aspects Organizational unit has primary

responsibility for design, implementation and outcomes

PoliciesControl varies: broad policies often made

by elected officialsPolicies have potential for greater public

health impactCredit needs to be shared e.g. LAUSD

Nutrition Policies, increase in tobacco tax

Deciding on Interventions

Consider effect sizeMedianConsistency

Consider breadth of target population

Together effect size and target population define the overall population effect

How Evidence Can Improve Public Health Infrastructure

Use evidence to determine realistic goals by estimate effect size (i.e.. how much you move the needle!)

Deciding on Interventions

What is the slope of the effect curve? • Larger initial effects with significant recidivism

• Smaller initial effects with Increasing impact over time

What is the time frame for observed health benefits?

• How long were the follow-up periods for the best studies?

• For equal benefit, shorter is better, but

• Long term benefit is primary interest

Deciding on Interventions

What is the cost of the intervention?PersonnelDollars i.e. contractsTime to implementLikelihood of funding for sufficient period

to get effectPotential for dedicated or incremental

fundingOpportunity cost (i.e. cost of not doing

other things)

Deciding on Interventions Relative cost-effectiveness

Cost effectiveness is dollar cost per health outcome (including clear intermediate outcomes) e.g. smoker prevented

lead poisoning prevented STD cured drug treatment completed

Note: some interventions have multiple health benefits e.g. smoking affects CVD, some cancers, respiratory disease etc.

Deciding on Interventions Who else needs to be involved to be successful?

Within public healthWithin personal health services Voluntary agenciesHealth care organizationsHealth plansEmployers

How difficult is it to get agreement on:Roles and responsibilitiesInterventions?

Time cost versus partnership benefit

How Evidence Can Improve Public Health Infrastructure

Use evidence to help decide on construction of intervention

Interventions with same name can be very different

Follow the design used in most successful interventions

Talking to those who did the studies is very helpful in refining intervention

Using the Evidence

Use evidence to frame objectives Use evidence to develop evaluation plan

and related evaluation Approach Measures Data collection plan

Develop internal evidence through performance measurement system

Frequent monitoring essential

What more is needed? More research on public health practice; for many

interventions---insufficient evidence Increased funding for evidence based reviews using

consistent methodologies More training on appropriate sources and uses of

evidence in schools of public health and others training public

health professionals in public health practice settings e.g. state and local

health departments Political leaders and others who influence the decision

making process to improve health

DHS Public Health Opportunities

Become sophisticated user of evidence based information and recommendations

Make use of best evidence key aspect of performance of program directors and key managers

Contribute to the literature on what works in public health practice

Resources

Getting People to Want Sliced Bread – An Update on Dissemination of the Guide to Community Preventive Services, J Public Health Management and Practice, 2003, 9(6), 545-551

Also see Evidence-Based Public Health, Ed. Ross C. Brownson, Elizabeth Baker, Terry L. Leet etc. Oxford University Press, 2003