1 / 34

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

Investing in multi-level and multi-strategy disease and illness prevention. Banff Conference Nancy Edwards, RN, PhD Professor CHSRF/CIHR Nursing Chair. Objectives. Multiple Intervention Programs (MIPs) the gold standard But, disappointing results from research

lobo
Download Presentation

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

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  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

More Related