Colloque RI 2014 : Intervention de Ross C. BROWNSON (Washington University in St. Louis)

Emerging issues in

understanding evidence from

complex, public

health interventions

INCa Conference

Intervention Research Against Cancer

18 November 2014Ross C. Brownson

Washington University in St.

Louis

1. Describe sources and types of evidence for

complex, public health interventions.

2. Summarize emerging methods for studying

complex, public health interventions.

3. Integrate concepts using case study

examples to illustrate core issues (obesity in

youth).

Objectives

Backdrop

Our multi-level world…

Very few Broad Street pump handles

left to remove

John Snow’s

Map of London

1849 proposed

1854 500

deaths to ~ 0

Removal of

Pump Led to

Immediate

Reduction in

Cholera Deaths

Too often, effective interventions are

not scaled up…

(e.g, the ExpandNet framework)

Sources and types of evidence

What is “Evidence”?

• Scientific literature in systematic reviews

• Scientific literature in one or more journal articles

• Public health surveillance data

• Intervention effectiveness data

• Qualitative evaluation data– Community members

– Other stakeholders

• Media/marketing data

• Word of mouth

• Personal experience

Objective

Subjective

Like beauty, it’s in the eye of the beholder…

Types of Evidence

Characteristic Type One Type Two Type Three

Typical Data/

Relationship

Size and strength of

preventable risk—disease

relationship (measures of

burden, etiologic research)

Relative effectiveness of

public health intervention

Information on the adaptation and

translation of an effective

intervention

Common setting Clinic or controlled community

setting

Socially intact groups or

community-wide

Socially intact groups or

community-wide

Example Smoking causes lung cancer Price increases with a

targeted media campaign

reduce smoking rates

Understanding the political

challenges of price increases

Quantity More Moderate Less

Action Something should be done. This particular intervention

should be implemented

How an intervention should be

implemented

Re-Defined: Evidence TypologyLevel Description Sources Examples Indicators

Effective

(1st Tier)

Authoritative,

rigorous systematic

reviews

(2+ studies)

Published reviews

by an

independent

review group

Community

Guide

Cochrane

reviews

Design

Execution

Effectiveness

Reach

Effective

(2nd Tier)

High quality studies

with peer review

(1+ studies)

Published articles

Technical reports

Books or chapters

Journal articles

Government

reports

Design

Execution

Effectiveness

Reach

Promising Intervention

evaluations and

descriptive studies

Unpublished

dissertations/

theses

Reports

Case studies

Health

impact

assessments

Design

Effectiveness

Reach

Emerging Practice-based

summaries or

evaluation works in

progress

Websites

Demonstration

projects

Policy briefs

Professional

standards of

practice

Effectiveness

Reach

Often, relevant evidence

comes from policy settings…

For policy…

“Laws are like sausages.You should never watch them

being made.”

- Honoré Mirabeau,

1918

Where am

I?

You’re 30

meters 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?

The problem

Domains of Evidence-Based Public Health

PolicyDomain Objective Data Sources

Process To understand approaches to enhance

the likelihood of policy adoption

• Key informant interviews

• Case studies

Content To identify specific policy elements that

are likely to be effective

• Systematic reviews

• Content analyses

Outcome To document the potential impact of

policy

• Surveillance systems

• Natural experiments

tracking policy-related

endpoints

2

Problem stream

Policy Stream

Politics Stream

Kingdon’s Multiple Streams Model

No policy

adoption

Problem stream

Policy Stream

Politics Stream

B

Scenario 1: No Coupling of Streams or Window Closed > Policy Proposal Not Adopted

Scenario 2: Coupling of Streams and Window of Opportunity Open > Policy Proposal Adopted

Policy

Adoption

Politics stream

Policy stream

Policy stream

Politics stream

Emerging Methods

Systems Approaches

• A multilevel (ecological)perspective of health

• Group model building

• Micro-simulation

• Agent based modeling

Group model building

• Development of conceptual systems science

models with community representatives

• Roots in community-based participatory

approaches

• Understand complex interactions of social,

political, economic, environmental, and health

conditions

• Foster co-learning, trust, and capacity building

among all partners

• Create greater balance between knowledge

generation and intervention for the mutual benefit

of all partners

• Resulting in• Behavior Over Time Graphs

HealthyEating

ActiveLiving

Demand forNon-Nutritional Food

& Beverage

Demand for HealthyFoods & Beverages

Access to HealthyFoods & Beverages

-

Affordability ofHealthy Foods &

Beverages

+

+

School &Afterschool/

Childcare NutritionStandards

+

+

ChildhoodObesity

-

-

-

School &Community

Gardens/ UrbanAgriculture/ Local

Farms

+

+

Crime

+

Agency/ Org/Community

Collaboration

FamilySpending

Local Economy(Revenue)

EmploymentOpportunities

EducationalAttainment

Hopelessness

-

-

+

EconomicDevelopment

+

+

+

Mixed-Use &Transit-Oriented

Development

Acceptance ofWIC/SNAP

+

Active LivingCommittee/TaskforceInfluence

Parents'Time withChildren

Safe & QualityParks & Rec

Facilities

+

Access toRecreation Facilities

+

School & Afterschool/ ChildcarePhysical Activity

Standards

Safe & QualityPed/Bike

Infrastructure

ScreenTime

Schoolsupport

+

CommunityRepresentation

+

+Trust

+

+

ResidentDisplacement

Quality,AffordableHousing

+

-

Tax Base

Elected Officials &Govt Agency Staff

Support

+

+

+

+

+

+

+

+

-

-

++

+

+

PrivateInvestment

CulturalCompetence

+

Civic andCommunityEngagement

+

In-Kind Services &Resources

++

+

UrbanSprawl

ActiveCommuting

-

+

CommutingTime

+

-

+

-

+

+

-

+

+

-

-

Quality ofEducationSystem

+

+

OutdoorRecreation

+

+

+

-

+

-

-

-

+

Agribusiness

Quality Air,Water & Soil

-

NeighborhoodSafety

-

+

Access toPotable Water

+

+

Safe & QualityPublic

TransportationSystem

+

+

+

+

<Quality Air,Water & Soil>

+

Fossil FuelConsumption

-

<EconomicDevelopment>

<EconomicDevelopment>

+

-

+

+

+

+

<EconomicDevelopment>

+

+

<EconomicDevelopment>

+

<School & Afterschool/Childcare Nutrition

Standards>

+

-

Healthy Food Retail(stores & markets)

-

+

+

+

-

+

+

-

+

Poverty & IncomeInequality

-

-

--

-

+

-

+

+

+

+

<EconomicDevelopment>

+

<FamilySpending>

+

+

-

<Agribusiness>

+

<Safe & QualityPublic Transportation

System>

+

+

<Mixed-Use &Transit-OrientedDevelopment>

+

<ChildhoodObesity>

<Civic andCommunity

Engagement>

-

Food PolicyCouncil Influence

+

<Food PolicyCouncil Influence>

+ +

Youth & FamilyAdvocacy

++

+

++

+

+

+

<School & CommunityGardens/ Urban

Agriculture/ LocalFarms>

+

+

<Food PolicyCouncil Influence>

+

+

-

Effective Allocation/Appropriation of Funds/

Resources

+

+

+

+

+

+

+

<School & Afterschool/Childcare Nutrition

Standards>

<School & Afterschool/ ChildcarePhysical Activity

Standards>

+

+

Social Determinants

Capacity

Active Living

Healthy Eating

Healthy Kids,

Healthy Communities

Microsimulation

• Often used in econometrics

• In many other fields: weather, crime, education

• Interaction of individual "units" (e.g., people)

• Each unit treated as an autonomous entity, interaction of the units is allowed vary depending on stochastic (randomized) parameters

• CISNET is an example(http://cisnet.cancer.gov/)

Microsimulation (example)

• Reducing childhood obesity via national policy

• 3 policies to reduce childhood obesity

• afterschool physical activity programs

• $0.01/ounce sugar-sweetened beverage

(SSB) excise tax

• ban on child-directed fast food TV advertising

• Literature was reviewed from January 2000

through July 2012 to find evidence of

effectiveness and create average effect sizes

• Markov microsimulation model to estimate

impact

Microsimulation (example)

• Afterschool physical activity programs would

reduce obesity the most among children aged 6–

12 years (1.8 percentage points)

• Advertising ban would reduce obesity the least

(0.9 percentage points)

• The SSB excise tax would reduce obesity the

most among adolescents aged 13–18 years (2.4

percentage points).

Kristensen AH, Flottemesch TJ, Maciosek MV, Jenson J, Barclay G, Ashe M, et al. Reducing Childhood Obesity through U.S. Federal Policy: A Microsimulation Analysis. Am J Prev Med. 2014 Nov;47(5):604-12.

Summary

• Well-recognized that complex, multilevel

interventions are effective

• Mapping and intervening in a complex world

– New forces: climate change, social

media/informatics, health in all policies

• Departs from researchers usual skill sets

(politics)

• Parallel set of challenges in communicating

methods to policy makers

• Analytic tools may enhance scale up

– Translating analytic results into action is not

MERCI!!Questions and discussion

(rbrownson@wustl.edu)