Using Evidence Based Public Health Policy to Prevent and Control Cancer

Using Evidence Based Public Health Policy to Prevent and Control Cancer

Elizabeth DodsonMay 19, 2011

ICC Annual Meeting, Indianapolis, IN

“Science can identify solutions to pressing public health problems, but only politics can turn most of those solutions

into reality.”

Thomas Oliver, PhDJohns Hopkins Bloomberg School of Public Health

Objectives

1. Understand the definition of evidence-based policy

2. Understand some important barriers and challenges

3. Explore how to overcome some of these barriers4. Illustrate principles with recent research results

What is a health policy?

Definitions

• “those laws, regulations, formal and informal rules and understandings that are adopted on a collective basis to guide individual and collective behavior”– Policies tend to influence the environment (legal,

social, economic, and physical)– Importance noted in the definitions of core

functions of public health

At least 3 types of policy

• Formal laws, codes, regulations– Clean indoor air policy

• Written standards that guide choices– Engineering standards that guide street design

• Unwritten social norms– Not ticketing for speeding 6-7 MPH above limit– Harder to evaluate, often culturally driven

How has health (or other) policy, today, already affected your life?

Policy potential

Top 10 public health achievements

• Examples– Vaccination– Motor-vehicle safety– Safer workplaces– Fluoridation of drinking water– Recognition of tobacco use as a health hazard

• Each of these advances involved policyCenters for Disease Control and Prevention. Ten great public health achievements--United States, 1900-1999. MMWR 1999 Apr 2;48(12):241-3

Understanding evidence-based approaches

A simple definition of evidence-based public health

“Evidence-based public health is the process of integrating science-based interventions with community preferences to improve the health of populations.”

Kohatsu, et al. Am J Prev Med 2004.

Elements of evidence-based policy

• Process

• Content

• Outcomes

Domains of Evidence-based Public Health Policy

Domain Objective Data Sources

Process To understand approaches to enhance the likelihood ofpolicy adoption

• Key informant interviews • Case studies

Content To identify specific policyelements that are likelyto be effective

• Systematic reviews • Content analyses

Outcome To document the potentialimpact of policy

• Surveillance systems • Natural experiments tracking policy-related endpoints

Why worry about research & policy/practice?

“… as the pressure on resources increases, decisions will have to be made explicitly and publicly, those who make decisions will need to be able to produce and describe the evidence on which each decision is based.” (Gray, 1997)

What do policymakers want or need from practitioners and

researchers?

Three Fundamental Questions

1. Is there a problem?2. Do we know how to fix it (intervention)?3. How much will it cost (financially, politically)?

- What do all of these questions mean in the context of where we live and work?

Challenges and opportunities for evidence-based policy

Finding the research-policy nexus

Where am I?

You’re 30 yards above the

ground in a balloon

You must be a researcher

Yes. How did you know?

Because what you told me is

absolutely correct but completely

useless

You must be a policy maker

Yes, how did you know? Because you don’t

know where you are, you don’t know where you’re going, and now

you’re blaming meThe problem

What are we learning about translating evidence to policy?

Examples of Policy Translation Challenges

1. Clash of cultures

2. Poor timing

3. Ambiguous findings

4. Balancing objectivity and advocacy

5. Lack of relevant data

From Brownson et al. AJPM 2006

Cancer Control Dissemination among State-level Policymakers

Results from an ongoing project

Increase the dissemination of evidence-based interventions to control cancer focusing on

the uptake of effectiveenvironmental and policy approaches

among state-level policymakers

Primary Project Goal

Phase 1: Audience Research Most policy briefs are text heavy and not “brief” Randomized experiment

Compare data vs. narrative Three key groups of policymakers Read a brief then responded to a short questionnaire

Methods: Conveying information via policy briefs

Phase 1: State SelectionDemocratic

House/SenateRepublican

House/SenateSplit

House/Senate

Larger State AL, CA, CO, IL, LA, MD, MA, NJ, NC, WA, MN

AZ, FL, GA, MO, OH, TX,

IN, KY, MI, NY, TN, PA, VA, WI

Smaller State AR, CT, HI, IA, ME, NH, OR NM, RI, VT, WV

AK, ID, KS, NE, ND, SC, UT, WY, SD

DE, MS, MT, NV, OK

Phase 1: Policy Brief Design

Data Narrative

Local

State

Page 1Narrative Data

Page 2Narrative Data

Page 2Local

Pages 3 and 4

Phase 1: Data Collection Pre-calls to legislators,

staffers, and executives

Mailed policy briefs and surveys

Follow-up phone calls

Emailed PDF of brief and link for online survey

Personal visits

Selected results

Responses from 288 individuals in: Mississippi, Missouri, South Carolina, Pennsylvania, New Jersey, Oregon

Legislators (n=75) Staffers (n=125) Executives (n=91)

Overall, 35% response rate

Participation

ResultsWhat influences legislators’ health agenda?

Rank order of importance (%)

FactorsTotal N=75

Constituents' needs or opinions 1 (64)

Evidence of scientific effectiveness 2 (62)

Data on health impact in my local area 3 (44)

A local leader I trust 4 (26)

My personal interest in the health issue 5 (25)

Position of advocacy groups 6 (22)

Legislators:"How important are the following factors in determining what health

issues you work on?"

Data trees on brief usefulness

Qualitative interviews with health committee members

When you hear the term “scientific evidence” what does that mean to you?

• “Not much. The term is thrown around a lot. Science doesn’t mean it is good science.”

• “I like to see things that are evidence-based and peer-reviewed.”

• “Scientific is the opposite of anecdotal evidence, so anecdotal evidence is what we rely on …to make our decisions, unfortunately.”

Where do you go for scientific information?

• “My most trusted source…I have a lot of constituents who bring items to me or ask me about things and I collect data from them…”

• “We get info from the various entities and the lobbyists as well as the other organizations that are in support or against a particular issue.”

• “We always check the internet first…”

• “Well I have not…I don’t think I’ve ever thought I needed scientific evidence…”

What can you do to bridge the chasm between evidence and policy?

1. Understand the process2. Find a way to be involved in the process3. Communicate information more effectively4. Utilize analytic tools5. Educate a range of “players” (staffers, advocates)6. Provide training and education programs

What can you do to bridge the chasm between evidence and policy?

• Vast literature in social psychology suggests policymakers mainly rely on– Habit, stereotypes, cultural norms– Sender credibility

• Factors affecting receptivity of policymakers to info-bearers– Transparency of methods – Plausibility of analysis – Experts’ credentials – Perceived impartiality – Perceived track record – Perceived honesty

Understand the process

Understand the process

Political context • policy-making less a rational act than a process of social influence• “policy windows open infrequently and do not stay open long”

(Kingdon, 1995)• important to understand which policy options have the greatest

potential for adoption and when small incremental changes are the preferred option

• use of rhetoric, art of persuasion, and ability to relate to the media (so called media or policy advocacy)

Be involved in the process

Five key areas predict health policy capacity in public health practice:

1) a well-organized agency including an effective organizational structure and central liaison responsibilities

2) talented staff3) clear communications between the public health agency and

policymakers4) effective negotiation skills5) active participation

• Consider a continuum of advocacy– Raise general awareness

• Publish an article• Present at a professional meeting

– Communicate findings to policymakers• Develop short policy summaries• Make data understandable to policymakers

– Actively lobby for a particular issue• Conduct media advocacy

Be involved in the process

• “All politics is local.” – The policy choices of elected officials are often designed to support

their interest in being re-elected or re-appointed– Agenda often don’t drive re-election, rather political parties

• Calculate statistics at the voting district or even precinct level than at the city level– Make personal contact

• Break material down into bulleted or otherwise highlighted text (policy briefs)– Use charts or graphs illustrating key points– Explore the use of storytelling

Communicate information more effectively

• Systematic reviews (like the Community Guide: www.thecommunityguide.org)• Cost data• Cost-effectiveness data• Health impact assessments

Better utilize analytic tools (resources)

• For example, legislative staff members– Gatekeepers and opinion shapers– Often have a great deal of influence in forming the

priorities of an elected official

• Build their knowledge and understanding of evidence-based approaches to policymaking– Legislative staff seem to prefer longer, detailed reports– Elected officials prefer short summaries

• Educate and engage the media

Educate/advocate with a range of “players”

• Most public health training programs focus on more analytic methods– Yet lack more applied skills

• Look for models– Many advocacy groups sponsor meeting and trainings to

demonstrate the value of academic, industry, and government research

• Informal approaches may be even more effective– One on one meetings– What works in your own setting?

Provide training and education programs

Overall Summary

Health policy development is crucial to health yet not always rationale and timely

To make progress it is important to understand barriers and all three domains of EB policy

Try to understand what is reasonable and potentially effective in your local situation

Find a way to be an advocate!

Collaboration with Indiana State Department of Health

Activities addressing all goals:

1. Evaluation of five-year health policy work plan3. Baseline survey to assess: skills and competencies in EBPH, translating science to policy; communicating with media & policymakers/doing

advocacy4. MIYO training for health department5. Creation/sharing of Netscan tool for partner use

Overarching goal: Build capacity to design, implement, and evaluate evidence-based public health policy

Activities

Create policy briefs for lobby day with Indiana Campaign for Smokefree Air ( ICSA)

Working with Indiana Tobacco Prevention and Cessation (ITPC) to create and update several sets of briefs for local settings

Activities Activities

Working with health department to

create policy briefs

Activities

Working with health department to create

policy briefs

Indiana’s policy goals and PRC goal-specific activities

Phase 2: Collaboration with Indiana State Public Health Department

GoalComprehensive

statewide smokefree air

GoalIncrease

tobacco taxes

GoalComplete

Streets

GoalIncrease

elementary school PE to 30

minutes/day

Acknowledgements

Project TeamRoss Brownson

Matt KreuterDebra Haire-Joshu

Doug LukeTim McBride

Katie StamatakisMike ElliottNora GearyChris Casey

Tim PoorNikki Caito

Chris WintrodeStephanie Chalifour

Funding National Cancer Institute

CollaboratorNational Conference of State

Legislatures

Acknowledgements

How do your experiences with policymakers compare with ours and our findings?

How do the various levels at which policy is made (local, state, federal) impact your involvement with the policy process?

Questions and notes from the field

Elizabeth Dodsonedodson@wustl.edu

314.362.9652http://prcstl.wustl.edu

Thank you!