Transcript Precede-Proceed Revisited

Behavior, Lifestyle, and Social
Determinants of Heart Health: From
Research to Policy, Planning,
Programs & Services
Lawrence W. Green
Office of Extramural Prevention Research
Public Health Practice Program Office
Centers for Disease Control and Prevention
U.S. Department of Health & Human Services
York University Forum, Toronto, Feb. 20, 2003
Health Promotion, Health Protection,
and Disease Prevention
Social
structure,
conditions
Culture, lifestyle,
attitudes &
policies about risk
Risk behaviors &
Environmental exposures
Adverse
health events
Health
Promotion
Primary Prevention &
Health Protection
Secondary Prevention
Self-care
Sequelae, Outcomes
Tertiary Prevention
Lesson 1. Social determinants operate as background & as distal
determinants on most of the proximal determinants of health.
Determinants of Health*
More Distal
Income & social status
 Gender
 Education
 Employment &
working conditions
 Physical environment
 Biology & genetic
endowment

More Proximal
Personal health practices
& coping skills
 Healthy child
development
 Health & social services
 Culture
 Social support networks
 Social environment

*Tonmyr et al., The population health perspective… Chronic Diseases
in Canada 23:123-129, Fall 2002.
Lesson 2: The Social Determinants
Imperative and Opportunity
 From
tobacco control experience, we know
that some work with other sectors and work
within the health sector on more distal
determinants is essential to long-term success
 Many, if not most, social determinants are:
– More proximal, and/or
– Amenable to health sector intervention, and/or
– Amenable to collaboration with other sectors
Achieving Health for All*
ACHIEVING HEALTH
FOR ALL
AIM
HEALTH
CHALLENGES
HEALTH
PROMOTION
MECHANISMS
IMPLEMENTATION
STRATEGIES
REDUCING
INEQUITIES
INCREASING
PREVENTION
ENHANCING
COPING
SELF-CARE
MUTUAL AID
HEALTHY
ENVIRONMENTS
FOSTERING
PUBLIC
PARTICIPATION
STRENGTHENING
COMMUNITY
HEALTH SERVICES
COORDINATING
HEALTHY PUBLIC
POLICY
*Epp, Jake. Achieving health for all: a framework for health promotion.
Ottawa: Minister of Supply and Services, 1986.
What is this public health achievement of the 20th Century?
What is the evaluation method to judge this an achievement?
5,000
Number of Cigarettes
4,000
35%
3,000
22%
2,000
1,000
0
1900
1910
1920
1930
1940
1950
1960
1970
1980
1990
Adult Per Capita Cigarette Consumption and
Major Historical Events—United States, 1900-2000
Broadcast
Ad Ban
1st World Conference
on Smoking and Health
5,000
4,000
Number of Cigarettes
1st Great American Smokeout
Nicotine
Medications
Available Over
the Counter
Master
Settlement
Agreement
Fairness Doctrine
Messages on TV
and Radio
1st SmokingCancer Concern
Surgeon General’s
Report on
Environmental
Nonsmokers’
Tobacco Smoke
Rights
1st Surgeon
General’s Report
End of WW II
3,000
2,000
1,000
Movement
Begins
Great Depression
0
1900
1910
1920
1930
Source: USDA; 1986 Surgeon General's Report
1940
1950
1960
1970
Federal
Cigarette
Tax Doubles
1980
1990
Lesson 3: Surveillance--Making
Better Use of Natural Experiments
 Key
to establishing baselines & trend lines
that can be projected to warn against neglect
 Key to putting an issue on the public policy
agenda
 Key to showing change in relation to other
trends, policy and program interventions
 Key to comparing progress in relation to
objectives and programs, over time and
between jurisdictions.
Lesson 4:
Evaluation of
ecological
approaches to
prevention on
community-wide or
province-wide scale
should not attempt
to isolate the
components.
Lesson 5: Comprehensiveness
 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
Cost (US$) Per Year of Life Saved
Smoking cessation
Low intensity interventions
Brief advice, MD
High intensity interventions
$100 - 500
$1,000 - 3,000
$6,000 - 15,000
Common disease prevention
$1,500 - 15,000
Secondary or tertiary care
$20,000 - 100,000
Source: Warner KE. Smoking cessation: Alternative strategies: Financial implications.
Tobacco Control , Autumn 1995.
Lesson 6: Effectiveness and benefit may increase with
intensity, but cost-utility and cost-effectiveness often
decline. Intensity limits reach. -->Issue of inequalities.
Estimated Efficacy (6-month quit rates),
Reach (number using), and Impact of
Main Cessation Strategies
Intervention Ef Reach #
Impact Impact
% us ing US
U.S.
B .C.
None (un aided)
3 22,800,000 684,000 7,600
R x NR T
14
2,500,000 280,000 3,111
O TC NR T
14
6,300,000 560,000 6,222
Behavioral
24
395,000
Inpatient Rx
32
500
94,800 1,053
160
2
Lesson 7: Cost-benefit and cost-effectiveness depend as
much on the reach as on the efficacy of interventions.
Change in Per Capita Cigarette Consumption
California & Massachusetts versus Other 48 States, 1984-1996
Percent Reduction
5
0
-5
-10
-15
-20
-25
Other 48 States
California
1984-1988
1990-1992
Massachusetts
1992-1996
What Worked? Making Better
Use of “Natural Experiments”
 Comprehensive
program and tax increases
in CA and MA resulted in:
– 2 - 3 times faster decline in adult smoking
prevalence
– Slowed rate of youth smoking prevalence
compared to the rest of the nation
– Accelerated passage of local ordinances
 Similar,
though later, experience in OR &
AZ, and in population segments of FL
Components of Comprehensive
Tobacco Control Programs
 Community
 Statewide
Programs
Programs
 Chronic
Disease
Programs
 School
Programs
 Enforcement
 Counter-Marketing
 Cessation
Programs
 Surveillance
and
Evaluation
 Administration
Management
and
Lesson 8: The Ecological
Imperative
 Need
–
–
–
–
–
to address the problem at all levels
Individual
Organizational, institutional
Community
State, regional
National, international
 Need
to make these levels of intervention
mutually supportive and complementary
Reduction in State Consumption
Percent Reductions in Per Capita Cigarette
Consumption Attributable to Non-Price Public
Health Interventions
80%
70%
60%
55%
40%
20%
0
20%
$
2
$
4
$
6
$
8
Dollars Per Capita Annual Spending on
Programs
$
10
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
Per Capita Spending on Tobacco
Prevention and Control--FY1997
CDC
CDC/ RWJF
NCI
NCI/ RWJF
Oregon
Arizona
California
Massachusetts
$0
$2
$4
$6
$8
Dollars Per Capita
$10
$12
Lesson 10: The Environmental
Imperative
 Environments
provide opportunities
 Environments provide cues
 Environments enable choices
 Social environments reinforce positive
behavior and punish negative behavior
 Legal penalties and financial incentives can
be built into environments
100-Percent Smokefree Ordinances, by Year of Passage
Number of
Ordinances
18
Workplace
Restaurant
Restaurant and Workplace
16
14
12
10
8
6
4
2
0
1985
1986
1987
* 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.
1988
US Dept. of Health and Human Service. Public Health
Service, National Institutes of Health. NIH Publ. No. 93-3532.
1989
1990
1991
1992*
Year
Tobacco Vending Machine Ordinances
Number of
180
Ordinances
(Cumulative)
160
Total Ban
Partial Ban
140
120
100
80
60
40
20
0
1985
1986
1987
1988
* 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.
1989
1990
1991
Year
1992*
Lesson 11: The Educational
Imperative
 Public
awareness of risks and benefits
 Public interest in lifestyle options
 Public understanding of behavioral steps
 Public attitudes toward the options & steps
 Public outrage at the conditions that have
put them at risk or in danger
 Personal and political actions
Lesson 12: The Evidence-Based
Imperative: The Need to Bridge...
 “best
practices” indicated by research to their
application in practice in underserved areas
 “best practices” from research to the most
appropriate adaptations for special populations
 The success of individual behavior changes of
the affluent to the system changes needed to
reach the less affluent, less educated…
 University-based, investigator-driven research
to practitioner- & community-centered research
Breaking the Intervention-Based
Research and Planning Habit
1. Select off-the-shelf
Intervention or
Service to be Studied
4. Evaluate Response to the
Intervention or Service
2. Assess Response
to the Intervention or
Service
3. Increase Dose
or Increase Demand
Strengthening Population-based,
Diagnostic Planning Approaches*
1. Assess Needs & Capacities
of Population
4. Evaluate
Program
Reassess causes
2. Assess Causes,
Set Priorities &
Objectives
Redesign
3. Design &
Implement
Program
*Procedural models, such as PRECEDE, PATCH, Intervention Mapping. See
Green & Kreuter, Health Promotion Planning, 3rd ed., Mayfield, 1999.
Uses of Evidence in PopulationBased Planning Models
A. Evidence
from community
or population
4. Evaluate
Program
D2
D. Program Evidence
1. Assess Needs & Capacities
of Population B. Evidence from
Research
Reconsider X
3. Design &
Implement
Program
From previous evaluations (D1)
2. Assess Causes (X)
& Resources
C. Evidence
from R&D
and Exp’tal.
Studies
Surveillance, Planning and Evaluating for Policy and
Action: PRECEDE-PROCEED MODEL*
Phase 5
Administrative &
policy assessment
Phase 4
Educational &
ecological
assessment
Health
Program
Predisposing
Intervention
Mapping
&
Tailoring
Phase 3
Behavioral &
environmental
assessment
Phase 2
Phase 1
Epidemiological
Social
assessment
assessment
Formative evaluation & baselines
for outcome evaluation
Health
education
Behavior
Reinforcing
Health
Policy
regulation
organization
Quality of
life
Environment
Enabling
Phase 6
Implementation
Phase 7
Process evaluation
Phase 8
Impact evaluation
Phase 9
Outcome evaluation
Monitoring & Continuous Quality Improvement
Input
Process
Output
Short-term
impact
Longer-term
health outcome
Short-term
social impact
*Green & Kreuter, Health Promotion Planning, 3rd ed., 1999.
Long-term
social impact
Towards an Integrated Model*
FRAMING
EVALUATING
Population Health
Social
Ecology
Life
Course
FOCUSING
Models of Change
Community
Partnering
Health Promotion
Planning
Best Practices
Dissemination
Policy
*A.Best, D.Stokels, L.Green, et al., AJHP, in press.
Analysis
and
Interpretation
Components of an Integrated Model
Social Ecology
- How do we see the problem?
 Life Course Health Development
- How do people and their health needs change?
 Health Promotion Planning & the PrecedeProceed Model
- How do we plan & promote change?
 Community Partnering
- How do we work together?

CIHR Knowledge Translation
KT Research Cycle
Research
Evaluation
of Uptake
Research
Priorities
Research
Open
Competition
Use
Communication
Marketing
Training
Knowledge
Distribution
& Application
Knowledge
Priority Setting
Knowledge
Synthesis
Expertise
Expertise
Research
Research
Dissemination Model
 Tends
to linear, one-way communication
 Presumes centrally defined needs
 Limited, inconsistent impact
 Incomplete monitoring and evaluation
capacity
 Disciplines and literatures isolated
 Lack of systems thinking
Evidence-Advocacy-Policy-Practice
Cycle*
External
Extramural
Research
Agenda
Setting
Advocacy
Commitment to
Develop Policy
and Action
Advocacy
Assessment of Need
Evidence
•Inequalities
•Refine programs
“Best Practices”
Diffusion research
Dissemination
Surveillance
and
Evaluation
Uptake & Outcomes
•Government
•Professionals
•Communities
Consultation
To frame policy
and action plan
To build support
Endorsement
•All agencies with
capacity to act or
Contribute (coalition)
The Lenses of Health
Professionals and Lay People
Subjective
Indicators
of Health
Professional
Layperson
“Objective”
Indicators
of Health
Adapted from Yukon Bureau of Statistics, Whitehorse, 1995
LW Green, Inst of Health Promotion Research, Univ. British Columbia, Vancouver, BC V6T 1Z3
Understanding Differences Among Public’s
Perception of Needs, the Health Sector’s
Assessments, and the Political Assessments
Public’s
perceived needs, C
priorities
“Actual
needs”
A
A
D
E
B
Resources,
feasibilities,
policy
LW Green, Inst of Health Promotion Research, Univ. British Columbia, Vancouver, BC V6T 1Z3
Strategies to Reconcile Perceived &
Actual Needs, & Resources
Participatory Research
A
A
Health Education
(advocacy)
Community mobilization
& organizational
development
LW Green & MW Kreuter, Health Promotion Planning: An Educational and Ecological Approach, 1999.
Definition of Participatory Research
(www.ihpr.ubc.ca/guidelines.html)
--Systematic investigation...
--Actively involving people in a learning process...
--For the purpose of social action (new services,
resource allocation, regulation or policy)
conducive to [their/their constituents’] health or
quality of life.
--What Participatory Research is not...
--not just involving people more intensively as
subjects of research