Different Ways to Improve Public Health

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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

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Underlying Health Determinants
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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.

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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.

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Tenant-based Rental Voucher Programs

• Background
• Tenant-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.

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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.

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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

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TASK FORCE REVIEWS AND RECOMMENDATIONS

• www.thecommunityguide.org
• Results of all reviews to date
• Frequent updating
• Downloadable Slide Sets

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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

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How Evidence Can Improve Public Health
Infrastructure

• Use evidence to decide among possible
  interventions
• How 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?

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Deciding on Interventions

• Single versus multiple component interventions
• Single component interventions easier to develop,
  implement, control and assess, but
• Multi-component interventions usually more
  effective
• E.g. Tobacco control in California

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Deciding on Interventions

• Consider both policies and programs
• Programs
• Greater control over all aspects
• Organizational unit has primary responsibility
  for design, implementation and outcomes
• Policies
• Control varies broad policies often made by
  elected officials
• Policies have potential for greater public health
  impact
• Credit needs to be shared e.g. LAUSD Nutrition
  Policies, increase in tobacco tax

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Deciding on Interventions

• Consider effect size
• Median
• Consistency
• Consider breadth of target population
• Together effect size and target population define
  the overall population effect

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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!)

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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

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Deciding on Interventions

• What is the cost of the intervention?
• Personnel
• Dollars i.e. contracts
• Time to implement
• Likelihood of funding for sufficient period to
  get effect
• Potential for dedicated or incremental funding
• Opportunity cost (i.e. cost of not doing other
  things)

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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.

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Deciding on Interventions

• Who else needs to be involved to be successful?
• Within public health
• Within personal health services
• Voluntary agencies
• Health care organizations
• Health plans
• Employers
• How difficult is it to get agreement on
• Roles and responsibilities
• Interventions?
• Time cost versus partnership benefit

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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

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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

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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

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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

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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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