How Well Do Health How Well Do Health Promotion “Best Practices” Promotion “Best Practices” Generalize from the Generalize from the Ideosyncracies of the Ideosyncracies of the Research? Research? Lawrence W. Green Lawrence W. Green American Academy of Health American Academy of Health Behavior Behavior Santa Fe, NM, September 24- Santa Fe, NM, September 24- 27, 2000 27, 2000
25
Embed
How Well Do Health Promotion “Best Practices” Generalize from the Ideosyncracies of the Research? Lawrence W. Green American Academy of Health Behavior.
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
How Well Do Health Promotion How Well Do Health Promotion “Best Practices” Generalize from the “Best Practices” Generalize from the
Ideosyncracies of the Research?Ideosyncracies of the Research?
Lawrence W. GreenLawrence W. GreenAmerican Academy of Health BehaviorAmerican Academy of Health Behavior
Santa Fe, NM, September 24-27, 2000Santa Fe, NM, September 24-27, 2000
9/8/00 LW Green
CDC Pronouncements & the CDC Pronouncements & the Paradox of Tobacco ControlParadox of Tobacco Control
““Tobacco control is one of the 10 great Tobacco control is one of the 10 great public health accomplishments of the public health accomplishments of the 20th century.” 20th century.” (CDC, (CDC, MMWRMMWR, 1999), 1999)
““Tobacco is the number one Tobacco is the number one preventable cause of death.” (William preventable cause of death.” (William Foege, 1989; Foege, 1989; McGinnis MJ, Foege WH. Review: Actual Causes of Death in the United States. JAMA 1993;270:2207-12))
0
1000
2000
3000
4000
5000
1900 1910 1920 1930 1940 1950 1960 1970 1980 1990
Nu
mb
er
of
Cig
are
tte
sAdult Per Capita Cigarette Consumption and Major
Smoking-and-Health Events -- United States, 1900-1998
Annual Deaths from Smoking Compared with Selected Other Causes in the United States
14 17 19 30 41
81
430
0
40
80
120
160
200
240
280
320
360
400
440
DrugInduced
AIDS Homicide Suicide MotorVehicle
Alcohol Smoking
Num
ber
of D
eath
s (t
hous
ands
)
Sources: (AIDS) HIV/AIDS Surveillance Report, 1998; (Alcohol) McGinnis MJ, Foege WH. Review: Actual Causes of Death in the United States.JAMA 1993;270:2207-12; (Motor vehicle) National Highway Transportation Safety Administration, 1998; (Homicide, Suicide) NCHS, vital statistics, 1997; (Drug Induced) NCHS, vital statistics, 1996; (Smoking) SAMMEC, 1995
A Model of the Cigarette Epidemic
Source: WHO, 1995, after Peto & Lopez
Debate in the American Journal of Public Health, Feb. 2000 issue,over whether the U.S. can expect to achieve the target of 12% prevalence by the year 2010.
9 Aug 2000 LW Green
What Worked?What Worked?
Comprehensive program Comprehensive program andand tax increases in tax increases in CA and MA resulted in: CA and MA resulted in: – 2 - 3 times faster decline in adult smoking 2 - 3 times faster decline in adult smoking
prevalenceprevalence– Slowed rate of youth smoking prevalence Slowed rate of youth smoking prevalence
compared to the rest of the nationcompared to the rest of the nation– Accelerated passage of local ordinancesAccelerated passage of local ordinances
Similar, though later, experience in OR & AZ, Similar, though later, experience in OR & AZ, and in population segments of FLand in population segments of FL
9 Aug 2000 LW Green
Change in Per Capita Cigarette ConsumptionChange in Per Capita Cigarette ConsumptionCalifornia & Massachusetts versus Other 48 States, 1984-1996California & Massachusetts versus Other 48 States, 1984-1996
-25
-20
-15
-10
-5
0
5
Pe
rce
nt
Re
du
cti
on
Other 48 States California Massachusetts
1984-1988 1990-1992 1992-1996
9 Aug 2000 LW Green
$0 $2 $4 $6 $8 $10 $12
Massachusetts
California
Arizona
Oregon
NCI/ RWJF
NCI
CDC/ RWJF
CDC
Per Capita Spending on TobaccoPer Capita Spending on TobaccoPrevention and Control--FY1997Prevention and Control--FY1997
Dollars Per Capita
9 Aug 2000 LW Green
Percent Reductions in Per Capita Cigarette Percent Reductions in Per Capita Cigarette Consumption Attributable to Non-Price Public Consumption Attributable to Non-Price Public
Health InterventionsHealth Interventions
Dollars Per Capita Annual Spending on Programs
0$2
$4
$6
$8
$10
80%
60%
40%
20%
Red
uct
ion
in
Sta
te C
on
sum
pti
on
70%
20%
55%
9 Aug 2000 LW Green
100-Percent Smokefree Ordinances, by Year of Passage
1985 1986 1987 1988 1989 1990 1991 1992*
0
2
4
6
8
10
12
14
16
18WorkplaceRestaurantRestaurant and Workplace
Number ofOrdinances
Year* Through September 1992.Source: National Institutes of Health, National Cancer Institute (1993). Smoking and Tobacco Control - Monograph 3. Major Local Tobacco Control Ordinates in the U.S. US Dept. of Health and Human Service. Public Health Service, National Institutes of Health. NIH Publ. No. 93-3532.
9 Aug 2000 LW Green
Tobacco Vending Machine Ordinances
1985 1986 1987 1988 1989 1990 1991 1992*
0
20
40
60
80
100
120
140
160
180
Total BanPartial Ban
Number ofOrdinances(Cumulative)
Year* Through September 1992.Source: National Institutes of Health, National Cancer Institute (1993). Smoking and Tobacco Control - Monograph 3. Major Local Tobacco Control Ordinates in the U.S. US Dept. of Health and Human Service. Public Health Service, National Institutes of Health. NIH Publ. No. 93-3532.
9 Aug 2000 LW Green
Tobacco control resources expanding Tobacco control resources expanding (CDC, excise taxes, MSA; World Bank)(CDC, excise taxes, MSA; World Bank)
Increasing technical assistance requests Increasing technical assistance requests CDC response: Best Practices for CDC response: Best Practices for
Comprehensive Tobacco Control Comprehensive Tobacco Control ProgramsPrograms
Demand for Demand for EvidenceEvidence-Based Tobacco -Based Tobacco Control Programs GrowingControl Programs Growing
9 Aug 2000 LW Green
9 Aug 2000 LW Green
Components of Components of Comprehensive Comprehensive Tobacco Control ProgramsTobacco Control Programs
Community ProgramsCommunity Programs Chronic Disease Chronic Disease
ProgramsPrograms School ProgramsSchool Programs EnforcementEnforcement Statewide ProgramsStatewide Programs
Counter-MarketingCounter-Marketing Cessation ProgramsCessation Programs Surveillance and Surveillance and
EvaluationEvaluation Administration and Administration and
ManagementManagement
9 Aug 2000 LW Green
The Remaining Challenges:The Remaining Challenges: The Need to Bridge Between... The Need to Bridge Between...
““best practices indicated by research and their best practices indicated by research and their application in practice in underserved areasapplication in practice in underserved areas
““best practices” from research and the most best practices” from research and the most appropriate adaptions for special populationsappropriate adaptions for special populations
The success of individual behavior changes of the The success of individual behavior changes of the affluent and the system changes needed to reach the affluent and the system changes needed to reach the less affluent, less educated…less affluent, less educated…
University-based, investigator-driven research to University-based, investigator-driven research to practitioner- & community-centered researchpractitioner- & community-centered research
9 Aug 2000 LW Green
Best Practice Must Be More Than...Best Practice Must Be More Than... Diffusion theory and dissemination researchDiffusion theory and dissemination research Cognitive & other single-factor approachesCognitive & other single-factor approaches Hard-nosed, trial-and-error, outcome-only RCT studies Hard-nosed, trial-and-error, outcome-only RCT studies
with their misplaced precision and theory-starved with their misplaced precision and theory-starved interventionsinterventions
Fuzzy systems research with immediate or intermediate-Fuzzy systems research with immediate or intermediate-only variables as outcomes, without clear linkage to healthonly variables as outcomes, without clear linkage to health
Investigator-centered studies in unrepresentative Investigator-centered studies in unrepresentative populationspopulations
9 Aug 2000 LW Green
Origins and Landmarks in Origins and Landmarks in “Best Practices” Thinking“Best Practices” Thinking
Engineering and product quality control Medicine and agriculture Clinical preventive services
– Canadian Task Force– US Preventive Services Task Force
Cochran systematic reviews (www.cochrane.org) From clinical (evidence-based medicine) to
community levels of intervention
9 Aug 2000 LW Green
Alternatives to Strict RCT-Alternatives to Strict RCT-Based InterpretationsBased Interpretations
Campbell Collaboration and joint Cochrane & Campbell Connections, Feb 2000 (http://campbell.gse.upenn.edu)
Consensus conference and expert panel or committee approaches of NIH, WHO, IUHPE and Royal commissions
CDC Tobacco Control and Community Preventive Services Guidelines
9 Aug 2000 LW Green
Problems Inherent in “Best Problems Inherent in “Best Practices” from ResearchPractices” from Research
Internal validity supreme over external Internal validity supreme over external validityvalidity
Human organism’s homogeneity Vs social Human organism’s homogeneity Vs social organizations’ heterogeneityorganizations’ heterogeneity
Historical, legal, and other contextual factors Historical, legal, and other contextual factors in health promotionin health promotion
Time as a variable: communities and Time as a variable: communities and populations change from day to daypopulations change from day to day
9 Aug 2000 LW Green
Alternatives to “Best Practices”Alternatives to “Best Practices” “Best practice” as process rather than packaged
interventions: the diagnostic-evaluative cycle Emphasize control by practitioner, patient, client,
community or population Emphasize local evaluation and self-monitoring More systematic study of place, setting, and culture Research on tailoring and new technologies (e.g.,
EMPOWER software) Synthesizing research other than randomized trials
LW Green 8/9/00
Breaking the Intervention-Based Planning Habit
1. Select off-the-shelf 1. Select off-the-shelf Intervention or Intervention or Service to be StudiedService to be Studied
2. Assess Response2. Assess Responseto the Intervention orto the Intervention orServiceService