V Congresso Brasileiro de Epidemiologia Curitiba, Brazil March 25, 2002

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V Congresso Brasileiro de Epidemiologia
Curitiba, Brazil March 25, 2002

• Epidemiology and Health Promotion
• David V. McQueen
• Associate Director for Global Health Promotion
• Office of the Director
• NCCDPHP, CDC, Atlanta
• Department of Health and Human Services

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The Challenge for Public Health
Upon this gifted age, in its dark hour, Rains
from the sky a meteoric shower Of facts...they
lie unquestioned, uncombined. Wisdom enough to
leech us of our ill Is daily spun but there
exists no loom To weave it into fabric... Edna
St. Vincent Millay (1892-1950) Huntsman, What
Quarry? New York Harper Brothers, 1934
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Definitions of health promotion Lalonde, 1974 A
strategy aimed at informing, influencing and
assisting both individuals and organizations so
that they will accept more responsibility and be
more active in matters affecting mental and
physical health US Department of Health,
Education, and Welfare, 1979 A combination of
health education and related organizational,
political and economic programs designed to
support changes in behavior and in the
environment that will improve health Green,
1980 Any combination of health education and
related organizational, political and economic
interventions designed to facilitate behavioral
and environmental changes that will improve
health Green Iverson, 1982 Any combination
of health education and related organizational,
economic, and environmental supports for behavior
conducive to health
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Perry Jessor, 1985 The implementation of
efforts to foster improved health and well-being
in all four domains of health physical, social,
psychological and personal Nutbeam, 1985 The
process of enabling people to increase control
over the determinants of health and thereby
improve their health WHO, 1984, 1986 and Epp,
1986 The process of enabling people to increase
control over, and to improve, their
health Goodstadt et al., 1987 The maintenance
and enhancement of existing levels of health
through the implementation of effective programs,
services, and policies Kar, 1989 The
advancement of wellbeing and the avoidance of
health risks by achieving optimal levels of the
behavioral, societal, environmental and
biomedical determinants of health ODonnell,
1989 The science and art of helping people
choose their lifestyles to move toward a state of
optimal health Labonté Little, 1992 Any
activity or program designed to improve social
and environmental living conditions such that
peoples experience of well-being is increased
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The Historical Development of Health Promotion in
the 20th Century Two Traditions, Two Origins

• The continent

• North America

Framed by concerns with the social,economic and
political roots of health Focus on the
sociopolitical
Framed by the enlargement of the traditional
scope of health education Focus on the
individual
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The Historical Development of Epidemiology in the
20th Century Two Traditions, One Old, One Recent

• Epidemiology

• Social Epidemiology

Framed by concerns with etiology, traditional
bio-medical model and a developed disciplinary
base in scientific method
Framed by the enlargement of the traditional
scope of epidemiology Focus on the individual
plus focus on the sociopolitical
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Social Epidemiology As the Purported Overlap Area
Between Health Promotion and Epidemiology

Health Promotion
Z
Epidemiology
Social Epidemiology
Z zone of overlap between traditional
epidemiology and health promotion
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Comparison of Epidemiology with Health Promotion
Epidemiology
Health Promotion

• Established Paradigm
• A discipline
• Biomedical theory
• Scientific method
• Research based
• Established

• Multiple approaches
• Multi-disciplinary
• Social science theory
• Many methods
• Action based
• Recently developed

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Dominant Pattern of Work
Epidemiology
Health Promotion

• Methods
• Action
• Theory

• Action
• Concepts and Principles
• Methods

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Common Interests of Epidemiology and Health
Promotion

• Primary Prevention of Disease
• Population Health
• Surveillance of risk factors in health and
  illness

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Fact finding as the Cornerstone of Public
Health
Evidence seeking behavior

• Epidemiology based surveillance
• Evidence and evaluation

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Surveillance

• Survey Systems
• data collection
• data analysis
• interpretation
• data use
• time ...

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The spiral of surveillance (as LS)
New knowledge
data use
need for new
interpretation
data analysis
data collection
data collection
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Surveillance

• INFORMATION SYSTEM (IS)
• LEARNING SYSTEM (LS)
• an IS focused on knowledge development

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Making Data (evidence)
What is collected
Undue concern with

• atheoretical
• tradition
• biographical

• questionnaires
• sampling
• data quality
• bias

Lack of attention

• culture of respondent
• explaining variance

Data collection a Ding an sich
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Paradigm Lost The Epidemiologic Transition to
Health Promotion
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Three Paradigm Questions

• Ontological What is the nature of the knowable?
  Or, what is the nature of reality?
• Epistemological What is the nature of the
  relationship between the knower (the inquirer)
  and the known (or knowable)?
• Methodological How should the inquirer go about
  finding out about the world?

(adapted from Guba, 1990)
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Underlying Theoretical Orientations for Methods
in Health Promotion

• Positivist Emphasis on natural science
  methodology, quantitative methods, hypothesis
  testing, and objectivity.
• Idealist Emphasis on personal meanings and
  constructions, qualitative methods, emergent
  design, and making values explicit. A tendency
  towards individual-level focus with some emphasis
  on system-level issues.
• Realist Emphasis on system-level models of
  underlying process. Issues of power and control
  frequently made explicit. Critical tradition adds
  action component.
• Participatory/Action A concern with power and
  control. Frequently overtly political in values
  and orientation.

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Evidence Evaluation

• Limited term
• Implies rigor
• Strict rules
• Proof difficult
• Scientific literature

• Comprehensive term
• Anything can be evaluated
• Loose rules

The Health Promotion Perspective
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Rules of Evidence

• Tied to disciplines, not projects
• Scientific disciplines, e.g. physics, biology,
  epidemiology, have developed their standards for
  what constitutes proof of causation, effect, etc.
  in observation and experiment
• The appropriate scientific method is both a
  product of historical development and the
  characteristic observables in the discipline
• Many community-based public health prevention and
  health promotion projects are not
  discipline-based, but represent a field of
  action
• There is no discipline-based epistemological
  structure underlying the evaluation of effort in
  health promotion

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Hierarchy of Evidence in Health Promotion

• Premature to prioritize types in a linear
  hierarchy
• No consensus on any hierarchy of evidence
  between researchers and practitioners in the field

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Complexity and Methodology areIntertwined in
Health Promotion

• Most community-based health promotion
  interventions include a complex mixture of many
  disciplines, many variables of varying decrees of
  measurement difficulty, and dynamic changing
  settings
• Understanding multi variate fields of action may
  require a mixture of complex methodologies and
  considerable time to unravel any causal
  relationships
• Need to recognize the complexity issue as it
  pertains to community interventions and suggest
  areas needing development to better understand
  analytical challenges

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Examples of Efforts to Examine Evidence of Health
Promotion Type Initiatives

• CPSTF USA, Community Preventive Services Task
  Force, also called the Community Guide
• EWG Europe/Canada/USA
• IUHPE EU, International Advisory Committee
• Many others

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Strategies of EWG Adopted

• Start from HP Principles
• Focus on Community
• Focus on Participation
• Broad definition of evidence
• Recognize need to persuade policy makers

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Key Unresolved Issues in the Evidence Discussion

• Methods
• Populations
• Time
• Attribution of Effect
• Universality

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A Theoretical Base
BIG Theories
Little Theories

• Globalization
• Deprivation
• Migration
• Urbanization

• Risk Factors
• Social Determinants
• Lifestyle
• Personal Behavior

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Where are the facts

• Refereed literature (language)
• Published literature
• Fugitive literature
• Internet
• The community

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Evidence Iceberg in Health Promotion
RCTs Comparison Studies Observational Studies
Less Formal Observational Studies Participatory
Studies Fugitive Literature Hearsay
dvmcq 2001
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A Basis for the Rules of Evidence

• Many community-based public health prevention and
  health promotion projects are not discipline-
  based, but represent a field of action
• There is no discipline-based epistemological
  structure underlying the evaluation of effort in
  health promotion

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Principles for Evaluation of Health Promotion
Initiatives

• Participation
• Multiple methods
• Capacity-building
• Appropriateness

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The Knowledge Tree of Health Promotion
Health Promotion
Science
Ideology
Evaluation
Proof Evaluation
Success of a movement
RCT
Political Force
Scientific Studies
Emotion
ADGHP/2000
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Health Promotion Principles

• Empowering
• Participatory
• Holistic (involves whole population)
• Intersectoral
• Multi-strategy

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V Congresso Brasileiro de Epidemiologia
Curitiba, Brazil March 25, 2002

• Epidemiology and Health Promotion
• David V. McQueen
• Associate Director for Global Health Promotion
• Office of the Director
• NCCDPHP, CDC, Atlanta
• Department of Health and Human Services

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End of Presentation

• Keynote

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Surveillance Issues Arising

• A. What is knowledge?
• B. Where is the evidence?
• C. What are facts?
• D. Where are the facts?

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Surveillance

• The overall picture for surveillance links many
  different systems of data collection

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Behavioral Risk Factor Surveillance is one of the
Key Components of an Integrated, holistic,
chronic disease surveillance system
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Issues in Surveillance

• Time as a variable
• Sampling methods
• Data collection
• Questionnaire format
• Data analysis

• How data are used
• Examples of
• Ownership
• Limitations
• Complexity

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Chronic Disease Variables/Indicators

• Outcomes
• Death
• Disease/Condition
• Hospitalization
• Preventive Services
• Risk Behaviors
• Others, e.g. social determinants

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The Community Guide USA

• A set of recommendations
• Recommendations based on scientific evidence
• Evidence gleaned from systematic reviews
• Reviews coordinated by CDC scientists
• Recommendations determined by independent Task
  Force
• Sociocultural Environment

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Method for Conducting Systematic Reviews Consists
of Five Steps

• Develop conceptual framework
• Search for and retrieve evidence
• Rate quality of evidence
• Summarize evidence
• Translate strength of evidence into
  recommendation

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Objectives
WHO-EURO Working Group on Health Promotion
Evaluation

• Provide guidance to policy-makers and
  practitioners to foster the use of appropriate
  methods
• Examine current range of methods
• Provide guidance to policy-makers and
  practitioners to increase quality of health
  promotion evaluations

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Characteristics of Previous Working Groups on
Evidence and Evaluation in Health Promotion

• Multi-disciplinary
• Often multi-cultural/multiple nations
• Large endeavors
• Time consuming
• Raising many questions few answers
• Reviewing published, Western sources

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Essentials of a Sociobehavioral-based Monitoring
System

• A theoretical base
• Time as a variable
• A systems approach
• Partnership

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Two Major Concerns
Technical
Structural

• Questionnaire
• Sampling
• Data Collection Method
• Analysis
• Dissemination

• Buy in
• Public Health Infrastructure
• Social Science Infrastructure
• Link to Health Prom.
• Sustainable Resources