How Well Do Health Promotion “Best Practices” Generalize from the Ideosyncracies of the Research?

1. How Well Do Health Promotion “Best Practices” Generalize from the Ideosyncracies of the Research? Lawrence W. GreenAmerican Academy of Health Behavior Santa Fe, NM, September 24-27, 2000

2. CDC Pronouncements & the Paradox of Tobacco Control • “Tobacco control is one of the 10 great public health accomplishments of the 20th century.” (CDC, MMWR, 1999) • “Tobacco is the number one preventable cause of death.” (William Foege, 1989; McGinnis MJ, Foege WH. Review: Actual Causes of Death in the United States. JAMA 1993;270:2207-12) LW Green

4. Annual Deaths from Smoking Compared with Selected Other Causes in the United States 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

5. A Model of the Cigarette Epidemic Source: WHO, 1995, after Peto & Lopez

6. 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.

7. What Worked? • 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 LW Green

8. 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 LW Green

9. Per Capita Spending on TobaccoPrevention and Control--FY1997 CDC CDC/ RWJF NCI NCI/ RWJF Oregon Arizona California Massachusetts $0 $2 $4 $6 $8 $10 $12 Dollars Per Capita LW Green

10. Percent Reductions in Per Capita Cigarette Consumption Attributable to Non-Price Public Health Interventions 80% 70% 60% 55% 40% Reduction in State Consumption 20% 20% $2 $4 $6 $8 $10 0 Dollars Per Capita Annual Spending on Programs LW Green

11. 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 1988 1989 1990 1991 1992* 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. LW Green

12. Tobacco Vending Machine Ordinances Number of Ordinances (Cumulative) 180 Total Ban Partial Ban 160 140 120 100 80 60 40 20 0 1985 1986 1987 1988 1989 1990 1991 1992* 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. LW Green

14. Demand for Evidence-Based Tobacco Control Programs Growing • Tobacco control resources expanding (CDC, excise taxes, MSA; World Bank) • Increasing technical assistance requests • CDC response: Best Practices for Comprehensive Tobacco Control Programs LW Green

15. LW Green

16. Community Programs Chronic Disease Programs School Programs Enforcement Statewide Programs Counter-Marketing Cessation Programs Surveillance and Evaluation Administration and Management Components of Comprehensive Tobacco Control Programs LW Green

17. The Remaining Challenges: The Need to Bridge Between... • “best practices indicated by research and their application in practice in underserved areas • “best practices” from research and the most appropriate adaptions for special populations • The success of individual behavior changes of the affluent and the system changes needed to reach the less affluent, less educated… • University-based, investigator-driven research to practitioner- & community-centered research LW Green

18. Best Practice Must Be More Than... • Diffusion theory and dissemination research • Cognitive & other single-factor approaches • Hard-nosed, trial-and-error, outcome-only RCT studies with their misplaced precision and theory-starved interventions • Fuzzy systems research with immediate or intermediate-only variables as outcomes, without clear linkage to health • Investigator-centered studies in unrepresentative populations LW Green

19. Origins and Landmarks in “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 LW Green

20. Alternatives to Strict RCT-Based 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 LW Green

21. Problems Inherent in “Best Practices” from Research • Internal validity supreme over external validity • Human organism’s homogeneity Vs social organizations’ heterogeneity • Historical, legal, and other contextual factors in health promotion • Time as a variable: communities and populations change from day to day LW Green

22. 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

23. Breaking the Intervention-Based 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 LW Green 8/9/00

24. Strengthening Population-based, Diagnostic Planning Approaches* 1. Assess Needs & Capacities of Population Reassess causes 2. Assess Causes, Set Priorities & Objectives 4. Evaluate Program Redesign 3. Design & Implement Program *Procedural models, such as PRECEDE, PATCH, Intervention Mapping. See *Green & Kreuter, Health Promotion Planning, 3rd ed., Mayfield, 1999.

25. Uses of Evidence in Population-Based Planning Models 1. Assess Needs & Capacities of Population A. Evidence from community or population B. Evidence from Research 2. Assess Causes (X) & Resources Reconsider X 4. Evaluate Program C. Evidence from R&D and Exp’tal. Studies D2 3. Design & Implement Program D. Program Evidence From previous evaluations (D1)