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
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