Different Ways to Improve Public Health

1. 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

2. Social Environment Physical Environment Genetic Environment • Individual • Response • Behavior • Biology Health and Function Disease and Injury Health and Medical Care Well-Being Prosperity Underlying Health Determinants

3. 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.

4. 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.

5. 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.

6. 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.

7. 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

8. TASK FORCE REVIEWS AND RECOMMENDATIONS www.thecommunityguide.org • Results of all reviews to date • Frequent updating • Downloadable Slide Sets

9. 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

10. 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?

11. 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

12. 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

13. Deciding on Interventions • Consider effect size • Median • Consistency • Consider breadth of target population • Together effect size and target population define the overall population effect

14. 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!)

15. 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

16. 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)

17. 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.

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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