How Well Do Health Promotion How Well Do Health Promotion “Best Practices” Generalize from the “Best Practices” Generalize from the

Ideosyncracies of the Research?Ideosyncracies of the Research?

Lawrence W. GreenLawrence W. GreenAmerican Academy of Health BehaviorAmerican Academy of Health Behavior

Santa Fe, NM, September 24-27, 2000Santa Fe, NM, September 24-27, 2000

9/8/00 LW Green

CDC Pronouncements & the CDC Pronouncements & the Paradox of Tobacco ControlParadox of Tobacco Control

““Tobacco control is one of the 10 great Tobacco control is one of the 10 great public health accomplishments of the public health accomplishments of the 20th century.” 20th century.” (CDC, (CDC, MMWRMMWR, 1999), 1999)

““Tobacco is the number one Tobacco is the number one preventable cause of death.” (William preventable cause of death.” (William Foege, 1989; Foege, 1989; McGinnis MJ, Foege WH. Review: Actual Causes of Death in the United States. JAMA 1993;270:2207-12))

0

1000

2000

3000

4000

5000

1900 1910 1920 1930 1940 1950 1960 1970 1980 1990

Nu

mb

er

of

Cig

are

tte

sAdult Per Capita Cigarette Consumption and Major

Smoking-and-Health Events -- United States, 1900-1998

1st SurgeonGeneral’s Report

Source: USDA; 1986 Surgeon General's Report & MMWR 1999.

Great Depression

End of WW II

NonsmokersRights

MovementBegins

1st Smoking-Cancer Concern

Fairness DoctrineMessages on TV

and Radio

Federal CigaretteTax Doubles

MasterSettlementAgreement

BroadcastAd Ban

MarlboroFriday

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

14 17 19 30 41

81

430

0

40

80

120

160

200

240

280

320

360

400

440

DrugInduced

AIDS Homicide Suicide MotorVehicle

Alcohol Smoking

Num

ber

of D

eath

s (t

hous

ands

)

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

A Model of the Cigarette Epidemic

Source: WHO, 1995, after Peto & Lopez

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.

9 Aug 2000 LW Green

What Worked?What Worked?

Comprehensive program Comprehensive program andand tax increases in tax increases in CA and MA resulted in: CA and MA resulted in: – 2 - 3 times faster decline in adult smoking 2 - 3 times faster decline in adult smoking

prevalenceprevalence– Slowed rate of youth smoking prevalence Slowed rate of youth smoking prevalence

compared to the rest of the nationcompared to the rest of the nation– Accelerated passage of local ordinancesAccelerated passage of local ordinances

Similar, though later, experience in OR & AZ, Similar, though later, experience in OR & AZ, and in population segments of FLand in population segments of FL

9 Aug 2000 LW Green

Change in Per Capita Cigarette ConsumptionChange in Per Capita Cigarette ConsumptionCalifornia & Massachusetts versus Other 48 States, 1984-1996California & Massachusetts versus Other 48 States, 1984-1996

-25

-20

-15

-10

-5

0

5

Pe

rce

nt

Re

du

cti

on

Other 48 States California Massachusetts

1984-1988 1990-1992 1992-1996

9 Aug 2000 LW Green

$0 $2 $4 $6 $8 $10 $12

Massachusetts

California

Arizona

Oregon

NCI/ RWJF

NCI

CDC/ RWJF

CDC

Per Capita Spending on TobaccoPer Capita Spending on TobaccoPrevention and Control--FY1997Prevention and Control--FY1997

Dollars Per Capita

9 Aug 2000 LW Green

Percent Reductions in Per Capita Cigarette Percent Reductions in Per Capita Cigarette Consumption Attributable to Non-Price Public Consumption Attributable to Non-Price Public

Health InterventionsHealth Interventions

Dollars Per Capita Annual Spending on Programs

0$2

$4

$6

$8

$10

80%

60%

40%

20%

Red

uct

ion

in

Sta

te C

on

sum

pti

on

70%

20%

55%

9 Aug 2000 LW Green

100-Percent Smokefree Ordinances, by Year of Passage

1985 1986 1987 1988 1989 1990 1991 1992*

0

2

4

6

8

10

12

14

16

18WorkplaceRestaurantRestaurant and Workplace

Number ofOrdinances

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.

9 Aug 2000 LW Green

Tobacco Vending Machine Ordinances

1985 1986 1987 1988 1989 1990 1991 1992*

0

20

40

60

80

100

120

140

160

180

Total BanPartial Ban

Number ofOrdinances(Cumulative)

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.

9 Aug 2000 LW Green

Tobacco control resources expanding Tobacco control resources expanding (CDC, excise taxes, MSA; World Bank)(CDC, excise taxes, MSA; World Bank)

Increasing technical assistance requests Increasing technical assistance requests CDC response: Best Practices for CDC response: Best Practices for

Comprehensive Tobacco Control Comprehensive Tobacco Control ProgramsPrograms

Demand for Demand for EvidenceEvidence-Based Tobacco -Based Tobacco Control Programs GrowingControl Programs Growing

9 Aug 2000 LW Green

9 Aug 2000 LW Green

Components of Components of Comprehensive Comprehensive Tobacco Control ProgramsTobacco Control Programs

Community ProgramsCommunity Programs Chronic Disease Chronic Disease

ProgramsPrograms School ProgramsSchool Programs EnforcementEnforcement Statewide ProgramsStatewide Programs

Counter-MarketingCounter-Marketing Cessation ProgramsCessation Programs Surveillance and Surveillance and

EvaluationEvaluation Administration and Administration and

ManagementManagement

9 Aug 2000 LW Green

The Remaining Challenges:The Remaining Challenges: The Need to Bridge Between... The Need to Bridge Between...

““best practices indicated by research and their best practices indicated by research and their application in practice in underserved areasapplication in practice in underserved areas

““best practices” from research and the most best practices” from research and the most appropriate adaptions for special populationsappropriate adaptions for special populations

The success of individual behavior changes of the The success of individual behavior changes of the affluent and the system changes needed to reach the affluent and the system changes needed to reach the less affluent, less educated…less affluent, less educated…

University-based, investigator-driven research to University-based, investigator-driven research to practitioner- & community-centered researchpractitioner- & community-centered research

9 Aug 2000 LW Green

Best Practice Must Be More Than...Best Practice Must Be More Than... Diffusion theory and dissemination researchDiffusion theory and dissemination research Cognitive & other single-factor approachesCognitive & other single-factor approaches Hard-nosed, trial-and-error, outcome-only RCT studies Hard-nosed, trial-and-error, outcome-only RCT studies

with their misplaced precision and theory-starved with their misplaced precision and theory-starved interventionsinterventions

Fuzzy systems research with immediate or intermediate-Fuzzy systems research with immediate or intermediate-only variables as outcomes, without clear linkage to healthonly variables as outcomes, without clear linkage to health

Investigator-centered studies in unrepresentative Investigator-centered studies in unrepresentative populationspopulations

9 Aug 2000 LW Green

Origins and Landmarks in Origins and Landmarks in “Best Practices” Thinking“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

9 Aug 2000 LW Green

Alternatives to Strict RCT-Alternatives to Strict RCT-Based InterpretationsBased 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

9 Aug 2000 LW Green

Problems Inherent in “Best Problems Inherent in “Best Practices” from ResearchPractices” from Research

Internal validity supreme over external Internal validity supreme over external validityvalidity

Human organism’s homogeneity Vs social Human organism’s homogeneity Vs social organizations’ heterogeneityorganizations’ heterogeneity

Historical, legal, and other contextual factors Historical, legal, and other contextual factors in health promotionin health promotion

Time as a variable: communities and Time as a variable: communities and populations change from day to daypopulations change from day to day

9 Aug 2000 LW Green

Alternatives to “Best Practices”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 8/9/00

Breaking the Intervention-Based Planning Habit

1. Select off-the-shelf 1. Select off-the-shelf Intervention or Intervention or Service to be StudiedService to be Studied

2. Assess Response2. Assess Responseto the Intervention orto the Intervention orServiceService

3. Increase Dose3. Increase Doseor Increase Demandor Increase Demand

4. Evaluate Response to the4. Evaluate Response to theIntervention or ServiceIntervention or Service

Strengthening Population-based, Strengthening Population-based, Diagnostic Planning Approaches*Diagnostic Planning Approaches*

1. Assess Needs & Capacities 1. Assess Needs & Capacities of Populationof Population

2. Assess 2. Assess Causes, Set Causes, Set Priorities & Priorities & ObjectivesObjectives

3. Design & 3. Design & ImplementImplementProgramProgram

4. Evaluate 4. Evaluate ProgramProgram

*Procedural models, such as PRECEDE, PATCH, Intervention Mapping. See*Green & Kreuter, Health Promotion Planning, 3rd ed., Mayfield, 1999.

Reassess causesReassess causes

RedesignRedesign

Uses of Evidence in Population-Based Planning Models

1. Assess Needs & Capacities of Population

2. Assess Causes (X) & Resources

3. Design & ImplementProgram

4. Evaluate Program

Reconsider X

D. Program Evidence

Evidence fromResearch

From previous evaluations (D1)

Evidencefrom communityor population

A.

B.

C. Evidence from R&D and Exp’tal. Studies

D2