If We Want More Evidence-Based Practice, We Need More Practice-Based Evidence Lessons from Public Health Successes of the Last Third of the 20 th Century Ontario Agency for Health Protection & Promotion Toronto, 3 March 2010 Prof. Lawrence W. Green (lgreen@cc.ucsf.edu) Department of Epidemiology & Biostatistics School of Medicine & Comprehensive Cancer Center University of California at San Francisco
What is this public health achievement of the 20th Century? What is the evaluation method to judge this an achievement? 5,000 4,000 Number of Cigarettes 3,000 2,000 1,000 0 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990
Number of Cigarettes Adult Per Capita Cigarette Consumption and Major Historical Events United States, 1900-2000 5,000 4,000 3,000 2,000 1,000 0 1st Surgeon General s Report End of WW II (Social norms) WW II Great Depression (Economics) 1st World Conference on Smoking and Health Fairness Doctrine Messages on TV and Radio 1st Smoking- Cancer Concern Nonsmokers Rights Movement Begins Broadcast Ad Ban 1st Great American Smokeou Nicotine Medications Available Over the Counter Master Settlement Agreement Surgeon General s Report on Environmental Tobacco Smoke Federal Cigarette Tax Doubles 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 Source: USDA; 1986 Surgeon General's Report. MMWR 2001.
Lesson 1. The Informed Electorate Imperative: Public Health Education Making citizens aware of what is happening Alerting them to growing problems, trends Building their understanding of consequences Making the public aware of its relevance to them Belief in their or their children s susceptibility Belief in seriousness/severity of the problem Making the public aware of causes, culprits, counter-actions, and community capacities Building community capacity for communications
Lesson 2: The Surveillance Imperative: Making Better Use of Our Natural Experiments Key to establishing baselines & trend lines that can be projected to warn against neglect Key to putting an issue on the advocacy and policy agenda Key to showing change in relation to other trends, policies, and program interventions Key to comparing progress in relation to objectives and programs, over time and between jurisdictions or settings. Community capacity issue: Local data are scarce.
Emergence of a Sedentary Society 2.3 Millions of Person-Miles in Automobiles, 1970-1990 1.4 60% of kids walked to school in 1970. 13% do now Hours of TV Viewed Daily 1960-1992 5:06 1.8 6:07 7:04 800 k-calories/day decrease in 20 years 3000 2200 58% Percent of Workforce in Sedentary Occupations, 1950-1996 36% 45% 1970 1990 Source: Schroeder, 2003
Lessons from the Successes IMPERATIVES Public health education Surveillance and context Comprehensiveness Economic imperative Advocacy imperative Funded mandate Objectives, priorities Ecological imperative TRADE-OFFS, COROLARIES Reach vs effectiveness Population effect vs disparities Evidence- vs process-based Threshold spending Intersectoral collaboration Referendum with earmark Programs need time to work Centralization/decentralization Infrastructure, workforce
Lesson 3: The Context Imperative What Moderates the Mediating Variables? Intervention or Program Mediator Outcome Variable(s) Mediator Moderators Moderators Green & Kreuter, Health Program Planning. 4 th ed. NY: McGraw-Hill, 2005, p. 204.
Change in Per Capita Cigarette Consumption California & Massachusetts vs Other 48 States, 1984-1996 5 Percent Reduction 0-5 -10-15 -20-25 Other 48 States California Massachusetts 1984-1988 1990-1992 1992-1996
http://www.cdc.gov/tobacco
Lesson 4: The Comprehensiveness Imperative Efficacy-tested interventions by themselves ineffective when taken to scale In trying to isolate the essential components of tobacco control programs that made them effective, none could be shown to stand alone Any combination of methods was more effective than the individual methods The more components, the more effective The more components, the better coverage Local AND state AND national advocacy, initiative
Components of Comprehensive Tobacco Control Programs* Community Programs Statewide Programs Clinical Programs School Programs Enforcement Counter-Marketing Cessation Programs Surveillance and Evaluation Administration and Management *Office on Smoking and Health. Best Practices for Comprehensive Tobacco Control Programs. Atlanta: CDC, USDHHS, 1998; 2008.
Lessons 5, 6 & 7: The Economic Imperative, Advocacy and a Funded Mandate California in 1988: Population: 28,400,000 Adult smoking prevalence: 22.8% 4.8 million adult smokers California in 2002-2006: Population: 35,893,799 Overweight or obese: 59% Children overweight: 18%, rank 48
Lessons 6 : Sustained Advocacy and & 7: a Funded Mandate Voters approved ballot initiative in November, 1988 Excise tax increase of 25 cents/pack Earmarked funding (20%) for a statewide program, provided $150 million Governor and State Legislature sought to claw back the 20% Advocacy efforts framed the issue and succeeded in over-turning the reallocations Advocates also helped fuel the local ordinances for smoke-free environments
Lesson 8: Setting Objectives, Priorities Explicit, measurable goals and objectives Provide focus and specificity Provide a basis for accountability Compensates for long-term roil-out Set priorities among the objectives Assists in allocation of resources Maintains focus
Lesson 9: Threshold Spending A critical mass of personal exposure is needed for individuals to be influenced A critical mass of population exposure is necessary to effect detectable community response A critical distribution of exposure is necessary to reach segments of the population who are less motivated Community capacity issue: Depend on local resources or reach out for state, national, or foundation funding
Per Capita Spending on Tobacco Prevention and Control--FY1997 CDC CDC/ RWJF NCI NCI/ RWJF Oregon Arizona California Massachusetts $0 $2 $4 $6 $8 $10 $12 Dollars Per Capita
Lesson 10: The Ecological Imperative Need to address the problem at all levels Individual Organizational, institutional (settings) Community State, provincial or regional National, international Need to make these levels of intervention mutually supportive and complementary Capacity: Need evidence from ecological designs
*Green & Kreuter, Health Program Planning: An Educational and Ecological Approach. 4th ed. New York: McGraw-Hill, 2005, Chapter 5. Green & Glasgow, 2006. Lesson 11: Use Evidence-Based Practices, but Get More Practice-Based Evidence Matching ecological levels of a system or community with evidence of efficacy for interventions at those levels Mapping theory to the causal chain to fill gaps in the evidence for effectiveness of interventions Pooling experience to blend interventions to fill gaps in evidence for the effectiveness of programs in similar situations Patching pooled interventions with indigenous wisdom and professional judgment about plausible interventions to fill gaps in the program for the specific population
2c. Select Intervention Approaches Influence Governments Phase 2. Intervention Planning 2b. Select Channels and Mediators Community Leaders 2a. Select Intervention Objectives Healthful policies Phase 1. Select Health Goals Phase 3. Development Phase 4. Implementation Influence Communities Influence Organizations Community Norm Shapers Organization Decision-Makers Healthful Communities Healthful Organizations Influence Individuals 5a. Conduct Process Evaluation Individuals at Risk 5b. Conduct Impact Evaluation Phase 5. Evaluation Healthful behavior 5c. Conduct Outcome Evaluation *Adapted from Simons-Morton, Greene, & Gottlieb,1995; in Green & Kreuter, Health Program Planning, 4 th ed. NY: McGraw-Hill, 2005. Health Status
California Department of Public Health s Tobacco Denormalization Strategy To prevent young people from starting by first changing the world defined by adult behavior As community norms change and smoking becomes increasingly inconvenient, less acceptable and less common among adults, fewer children will [start]. By exposing the tobacco industry s practice of callously exploiting teenagers for profit, the program encourages youth to boycott tobacco products Bal DG Lloyd JC Roeseler A & Shimizu R. California as a Model. J Clinical Oncology 2001;19:69s-73s
Evidence of the Change in Norms in Adults 60 50 Home Smoking Restrictions Reported by California Smokers 1993 1996 1999 2002 % 40 30 20 10 0 Smoke-free Some Restrictions No Restrictions
Evidence of Norm Change in Adolescents: Perception of Ease of Buying Cigarettes, by Age 90 80 70-40.7 Age Group 12-14 15-17 - 51.0 60-56.3 50 % 40-69.7 30 20 10 0 1996 1999 2002 1996 1999 2002 A Few Cigarettes SOURCE: CTS 1990, 1993, 1996, 1999, 2002 A Pack of Cigarettes
Lesson 12: Health Promotion Programs Need Time to Work Chronic disease more than other public health, because of behavioral and social change latency in relation to disease Launch and roll out time: planning, hiring, training, etc. The tobacco control effect on adolescents did not occur until the program had been in operation for 6 years - initial interventions were not as successful e.g. school programs were on a per capita basis until 1994 then on a competitive basis Tobacco industry mounted a new effective campaign that needed to be countered Lag time between changing social norms and impacting behavior. The denormalization influence may be strongest on pre-adolescents The lag works in both directions
Lesson 10: Programs Need Time to Work Packs per Month 16 14 12 10 8 6 4 2 California 5/88 27% US - California 5/93 49% 5/02 95% 0 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2005
Lesson 13: Efficacy vs. Effectiveness: Need for a Balanced Research Agenda Efficacy. The tested impact of an intervention under highly controlled circumstances. Effectiveness. The tested impact of an intervention under more normal circumstances (relatively less controlled, real-time, typical setting, population, and conditions). Broad Program Evaluation. The tested impact of a blended set of interventions on larger systems and populations. Natural Experiments with minimal control.
Green & Glasgow, Eval. & the Health Professions, 2006 Lesson 14: The Trade-offs, Best Practices Vs Best Processes Efficacy. Maximizes internal validity, i.e., the degree to which one can conclude with confidence that the intervention caused the result. Effectiveness. Maximizes external validity, i.e., the degree to which one can generalize from the test to other times, places, or populations. Program Evaluation. Maximizes reality testing in particular settings, & with the combination of interventions required for public health effect.
Lessons from the Successes IMPERATIVES Public Health Education Surveillance Comprehensiveness Economic imperative Advocacy imperative Funded mandate Objectives, priorities Ecological imperative TRADE-OFFS, COROLLARIES Participatory approach Reach vs effectiveness Efficacy vs effectiveness Threshold spending Separation of public health Referendum with earmark Programs need time to work Centralization/decentralization Infrastructure, workforce
Some Benefits of Participatory Research in Practice-Based Evidence Results are relevant to interests, circumstances, and needs of those who would apply them Results are more immediately actionable in local situations for people and/or practitioners Generalizable findings more credible to people, practitioners and policy makers elsewhere because they were generated in partnership with people like themselves Helps to reframe issues from health behavior of individuals to encompass system and structural issues. Green LW, Mercer SL. Am J Public Health Dec. 2001.
Definition and Standards of Participatory Research for Health* Systematic investigation Actively involving people in a co-learning process For the purpose of action conducive to health** --not just involving people more intensively as subjects of research or evaluation *Green, George, Daniel, et al., Participatory Research Ottawa: Royal Society of Canada, 1997. www.lgreen.net/guidelines.html
The Lenses of Scientists, Health Professionals and Lay People Subjective Indicators of Health Professional, Scientific Layperson Objective Indicators of Health