Investing in multi-level and multi-strategy disease and illness prevention

1. Investing in multi-level and multi-strategy disease and illness prevention Banff Conference Nancy Edwards, RN, PhD Professor CHSRF/CIHR Nursing Chair

2. Objectives • Multiple Intervention Programs (MIPs) • the gold standard • But, disappointing results from research • Why? Exploring reasons for failures • Rethinking the “investment” part of the equation

3. Multiple Interventions: Key Features • Multiple strategies and channels targeting multiple layers of the system • Individuals, social networks, organizations, communities, policy networks, & political institutions • Optimal blend of strategies (timing, intensity, frequency) • Based on a systems view

4. MIPs – the “gold” standard • Comprehensive programs • Integrated programs • A caution: • Abundance of promising versus “proven” interventions (Smedley & Syme, 2000)

5. Principles for Comprehensive Program Design • Programs must be of sufficient intensity, breadth and duration to reduce risks (Pelletier, 1999) • Linked, multi-level interventions should be the norm rather than the exception (Smedley & Syme, 2000) • Use multiple points of leverage (e.g. individual-level attributes, social supports, social norms, family and neighbourhood factors, coalitions, environmental and social policies, media) (Smedley & Syme, 2000)

6. But, disappointing research results

7. Critiques of Multiple Intervention Research Studies • Heart Health (Emmons, 2000; Dobbins et al., 2002) • Worksite Heart Health (Heaney & Goetzel, 1997; Pelletier, 1999) • Low birthweight (Stevens-Simon & Orleans, 1999) • Smoking (COMMIT Study Group, 1994, 1995) • Intervention strategies from social and behavioural research (Smedley & Syme, Eds., 2000) • Systematic review of multiple intervention programs (Merzel & D’Afilitti, 2003)

8. Why? Exploring reasons for failures

9. Critique of Multiple Intervention Studies(Edwards, Mill & Kothari, 2003) • Intervention strategies generalized from individual, single-component effectiveness studies (diluted when targeted to large population) • Focus is predominantly individual behaviour change - few target physical, social, organizational or policy environment (intervention design, outcome measurement) • Tendency to use the complete arsenal of strategies rather than “active” ingredients (dilutes intensity of potent strategies) • Use of population health interventions too weak or diffuse to produce systems change • 3-4 year funding cycles for many studies

10. Grading Evidence and Recommendations for Public Health • Should interventions be categorized (individual, policy, community etc.): • Consensus that these are appropriate, however many interventions will cross these groupings • What are the most appropriate types of evidence for different types of interventions? • Narrow consensus to use RCTs whenever feasible, but unlikely to be the case for socio-political interventions

11. Level of Intevention #1Merzel & D’Affiliti, AJPH, 2003

12. Community Participation #2Merzel & D’Affiliti, AJPH, 2003

13. The COMMIT TrialDecreasing Smoking RatesCOMMIT Group, 1994, 1995 • Randomized controlled trial of 11 matched pairs of communities over 4 years • Intervention target – heavy smokers • Multiple channel interventions delivered using a community-based approach • Protocol included 58 activities, annual cost of $240,000 per community (1 hospital bed)

14. Decreasing Smoking RatesCOMMIT Group, 1994, 1995 • No significant increases in quit rates among heavy smokers (18% vs 18.7%) • Significant increase in 6 month quit rates among light-moderate smokers (30.6% vs 27.5%)

15. CAVEATSCOMMIT Group, 1994, 1995 • Standardized, fixed protocol & lack of feedback on quit rates limited community buy-in • Brief intervention period - effectively 18-24 months: difficult to get smoking on the community agenda, change worksite smoking policies, alter practices of health care providers and community organizations; no time for a “snowballing effect” • Smokers not engaged in process of intervention development • Impact of COMMIT obscured by changes in broader system context (e.g. taxes, advertising)

16. Reasons for MIP Trial Failures • Theory failure • Program failure • Intervention fidelity • Intervention dose & intensity • Intervention protocols not adapted to community context • Policy windows of opportunity not open • Lack of community engagement in planning and implementation • Investment failure – short-term and inadequate investments

17. Investment Failures in Multiple Interventions

18. Securing Good Health for the Whole Population(Wanless Report, 2004) • “Public health does not usually offer the commercial and financial rewards that research into pharmaceutical and health technology interventions can offer” • Private sector reluctant to invest in public health interventions – no patents, consumers unwilling to purchase, interventions are part of the “public good”

19. Securing Good Health for the Whole Population(Wanless Report, 2004) • Identifying largest possible improvement in public health with finite resources requires a body of knowledge about which interventions are most cost-effective

20. Learning from Sustained MIPs with Substantial Investments • Lessons from Tobacco (Yach et al, 2005) • Fluoridated water supplies • Traffic injuries - seat belt use • Eradication of smallpox and polio

21. Change in Per Capita Cigarette ConsumptionCalifornia & Massachusetts versus Other 48 States, 1984-1996 5 0 -5 Percent Reduction -10 -15 -20 -25 Other 48 States California Massachusetts 1984-1988 1990-1992 1992-1996

22. Why? Exploring reasons for success with tobacco (Yach, 2005) • Evidence of harm is necessary but not sufficient to motivate policy change • Address individual responsibility versus collective environmental action early • Comprehensive package of measures have greater impact • Rules of engagement with industry need careful consideration

23. Investment Successes in Multiple Interventions

24. Investment Successes in Multi-Strategy Primary Care Interventions

25. Dose, Intensity and Reach:Matching Expectations & Realities • Prominent numerators and invisible denominators • Overly optimistic estimates of returns • You get what you pay for • Trickle-down theory is dead

26. Investment Patterns • Closed-ended historical budgeting • Share of resources for public health is fixed in contrast with activity-related and open-ended methods associated with curative programs (Deeble, 1999; Bennett, 2003) • Imagine a health department with a deficit budget!!

27. Public Health Messaging

28. Assembling Budgets – Contrasting Approaches

29. Would you invest in a program with “soft” descriptors?

30. “Probability” of Success

31. MIP Investment Counter Forces:The Obesity Epidemic • Cold beverage agreement with Coke at University Alberta generated 2.5 million • High school vending machines in Ottawa generate $10,000-$15,000 per school per year

32. Alternatives • Present the compelling evidence from natural “experiments” • Recalibrate time windows required to demonstrate effectiveness • Consider when information about a population-wide improvement “trumps” findings from an RCT with a sample of 200 • Provide the cost estimates required to gauge adequate levels of investment • Routinely calculate per capita cost of interventions

33. Conclusions (1) • Sustained & long-term investments • Cross-sectoral investments • Harness resources of industry • Engage in the debate about public health as a public good

34. Conclusions (2) • Provide adequate levels of investment for both research and programs (defined by population denominators, not numerators) • Identify natural “experiments” with promising MIP-design features • Invest research funds to examine multi-level intervention implementation processes & counter forces, and measure costs & outcomes