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Evidence-based Public Health

Richard Taylor, PhD, MPH

Learning Objectives
Explain the steps in evidence-based public health process. Describe a public health problem in terms of morbidity and mortality. Describe the public health approach to identify contributory causes of disease or other conditions and establish the efficacy of an intervention.

Learning Objectives (cont.)


Describe the process of grading evidencebased recommendations. Use an approach to identify options for intervention based on when, who, and how. Explain the role that evaluation plays in establishing effectiveness as part of evidence-based public health.

Evidence-based Public Health


Problem

Implementation

Etiology

Recommendations

Describe a Health Problem


What is the burden of disease in terms of morbidity and mortality and has it changed over time? Are there differences in the distribution of disease (person, place, time) and can these differences generate ideas or hypotheses about the diseases etiology? Are the differences or changes used to suggest group associations artifactual or real?

Rates
Incidence: measures the chances of individuals to develop a disease during a particular time period Prevalence: measures the proportion of individuals who have the disease at a point of time (or during a time period).

Incidence Rate
= # of new cases of a disease over a period of time # of people in the at-risk population

Often expressed per 10,000 or per 100,000 Expressed using a time period

Control of infectious diseases

Prevalence Rate
# living with a particular disease # in the at-risk population Usually describes a point in time Can use a period of time (period prevalence) Good for describing the total burden or impact of the health problem in the population at a given time

Relationship between Prevalence and Incidence

prevalence = incidence x duration of disease

Mortality Rates
Type of incidence that measures the rates of death in a population Cause of death is classified using International Classification of Diseases or (ICD codes)

Artifactual Changes in Rates


Changes in the interest in identifying the disease Changes in the ability to identify the disease Changes in the definition of the disease

Age-adjusted death rates for total cardiovascular disease, diseases of the heart, coronary heart disease, and stroke, by yearUnited States, 19001996

Group-level Associations
Determined using Ecologic studies or Population comparisons Associations at a group level may not hold true at the individual level May lead to hypothesis generation and further study to determine the existence of associations at the individual level

Evidence-based Public Health


Problem

Implementation

Etiology

Recommendations

Etiology: Contributory cause


REQUIREMENTS Cause is associated with the effect at the individual level Cause precedes the effect in time STUDY DESIGNS Cross-Sectional Case-Control, Retrospective

Cohort, Prospective

Altering the cause, alters the effect

Randomized Clinical Trials Natural Experiments

Hills Criteria for determining a causal association


1. Strength 2. Consistency 3. Specificity 4. Temporal relationship (Temporality) 5. Biological gradient (Dose-response relationship) 6. Plausibility (Biological plausibility) 7. Coherence 8. Experiment 9. Analogy (Consideration of alternate explanations)

Evidence-based Public Health


Problem

Implementation

Etiology

Recommendations

Recommendations
What works to reduce the health impact? Built on evidence from studies of interventions Summaries of the evidence of what works to reduce the health impact

Evidence-based Recommendations
Criteria 1: Quality of evidence
Good Fair Poor

Overall Recommendations
AMust BShould CMay DDont IIndeterminant, insufficient, dont know

Criteria 2 Magnitude of the impact (Net Benefit)


Substantial Moderate Small Negative/zero

Other considerations
Cost

Evidence-based Public Health


Problem

Implementation

Etiology

Recommendations

Implementation
When: timing of the intervention
Primary Secondary tertiary

Who: individuals targeted for the intervention


Vulnerable groups Entire population

How: process of implementing interventions


Information (Education) Motivation (incentives) Obligation (requirements)

Natural History of Disease


Exposure
Pathologic changes Onset of symptoms Usual time of diagnosis

Period of susceptibility

Subclinical disease

Clinical disease

Recovery, disability or death

PRIMARY PREVENTION

SECONDARY PREVENTION TERTIARY PREVENTION

EVALUATE, EVALUATE, EVALUATE


Magic bullets are rare Did the intervention work? How well did it work? How useful were strategies involving combinations of approaches?

Questions?

The 2-by-2 table


Outcome

Exposure

Yes No Total

Yes a
c a+c

No b
d b+ d

Total a+b
c+d a+b+c+d

Prevalence or cumulative incidence = a/(a+b) among exposed = c/(c+d) among unexposed = (a+c)/(a+b+c+d) among total population