Emerging issues in understanding evidence from complex, public health interventions Présentation de Ross C. Brwnson au colloque "Recherche interventionnelle contre le cancer : Réunir chercheurs, décideurs et acteurs de terrain » - 17 et 18 novembre 2014, BnF, Paris

1. Emerging issues in
understanding evidence from
complex, public
health interventions
INCa Conference
Intervention Research Against Cancer
18 November 2014
Ross C. Brownson
Washington University in St.
Louis

2. Objectives
1. Describe sources and types of evidence for
complex, public health interventions.
2. Summarize emerging methods for studying
complex, public health interventions.
3. Integrate concepts using case study
examples to illustrate core issues (obesity in
youth).

3. Backdrop

4. Our multi-level world…

5. Very few Broad Street pump handles
left to remove
John Snow’s
Map of London
1849 proposed
1854 500
deaths to ~ 0
Removal of
Pump Led to
Immediate
Reduction in
Cholera Deaths

6. Too often, effective interventions are
not scaled up…
(e.g, the ExpandNet framework)

7. Sources and types of evidence

8. What is “Evidence”?
• Scientific literature in systematic reviews
• Scientific literature in one or more journal
articles
• Public health surveillance data
• Intervention effectiveness data
• Qualitative evaluation data
– Community members
– Other stakeholders
• Media/marketing data
• Word of mouth
• Personal experience
Objective
Subjective
Like beauty, it’s in the eye of the beholder…

9. Types of Evidence
Characteristic Type One Type Two Type Three
Typical Data/
Relationship
Size and strength of
preventable risk—disease
relationship (measures of
burden, etiologic research)
Relative effectiveness of
public health intervention
Information on the adaptation and
translation of an effective
intervention
Common setting Clinic or controlled community
setting
Socially intact groups or
community-wide
Socially intact groups or
community-wide
Example Smoking causes lung cancer Price increases with a
targeted media campaign
reduce smoking rates
Understanding the political
challenges of price increases
Quantity More Moderate Less
Action Something should be done. This particular intervention
should be implemented
How an intervention should be
implemented

10. Re-Defined: Evidence Typology
Level Description Sources Examples Indicators
Effective
(1st Tier)
Authoritative,
rigorous systematic
reviews
(2+ studies)
Published reviews
by an
independent
review group
Community
Guide
Cochrane
reviews
Design
Execution
Effectiveness
Reach
Effective
(2nd Tier)
High quality studies
with peer review
(1+ studies)
Published articles
Technical reports
Books or chapters
Journal articles
Government
reports
Design
Execution
Effectiveness
Reach
Promising Intervention
evaluations and
descriptive studies
Unpublished
dissertations/
theses
Reports
Case studies
Health
impact
assessments
Design
Effectiveness
Reach
Emerging Practice-based
summaries or
evaluation works in
progress
Websites
Demonstration
projects
Policy briefs
Professional
standards of
practice
Effectiveness
Reach

11. Often, relevant evidence
comes from policy settings…

12. For policy…
“Laws are like sausages.
You should never watch them
being made.”
- Honoré Mirabeau,
1918

13. Where am
I?
You’re 30
meters above
the ground in a
balloon
You must be a
researcher
Yes. How
did you
know?
Because what you
told me is
absolutely correct
but completely
useless
You must be a
policy maker
Yes, how
did you
know?
The problem

14. Domains of Evidence-Based Public Health
Policy
Domain Objective Data Sources
Process To understand approaches to enhance
the likelihood of policy adoption
• Key informant interviews
• Case studies
Content To identify specific policy elements that
are likely to be effective
• Systematic reviews
• Content analyses
Outcome To document the potential impact of
policy
• Surveillance systems
• Natural experiments
tracking policy-related
endpoints

15. 2
Problem stream
Policy stream
Policy Stream
Politics Stream
Kingdon’s Multiple Streams Model
No policy
adoption
Problem stream
Policy Stream
Politics Stream
B
Scenario 1: No Coupling of Streams or Window Closed > Policy Proposal Not Adopted
Scenario 2: Coupling of Streams and Window of Opportunity Open > Policy Proposal Adopted
Policy
Adoption
Politics stream
Policy stream
Politics stream

16. Emerging Methods

17. Systems Approaches
• A multilevel (ecological)
perspective of health
• Group model building
• Micro-simulation
• Agent based modeling

18. Group model building
• Development of conceptual systems science
models with community representatives
• Roots in community-based participatory
approaches
• Understand complex interactions of social,
political, economic, environmental, and health
conditions
• Foster co-learning, trust, and capacity building
among all partners
• Create greater balance between knowledge
generation and intervention for the mutual benefit
of all partners
• Resulting in
• Behavior Over Time Graphs

20. Healthy
Eating
Social Determinants
Active
Living
+
Demand for
Quality,
Affordable
Housing
+
Non-Nutritional Food
& Beverage
Demand for Healthy
Foods & Beverages
Access to Healthy
Foods & Beverages
-
+
Affordability of
Healthy Foods &
Beverages
+
School &
Afterschool/
Childcare Nutrition
Standards
+
+
Childhood
Obesity
-
-
-
School &
Community
Gardens/ Urban
Agriculture/ Local
Farms
+
+
Crime
+
+
Agency/ Org/
Community
Collaboration
Family
Spending
Local Economy
(Revenue)
Employment
Opportunities
Educational
Attainment
Hopelessness
-
-
+
Economic
+
Development
+
+
+
Mixed-Use &
Transit-Oriented
Development
+
Acceptance of
WIC/SNAP
-
Active Living
Committee/
Taskforce
Influence
Safe & Quality
Parks & Rec
+
+
+ +
+
Trust +
Parents'
Time with
Children
Facilities
+
Access to
+
Recreation Facilities
+
School & After
school/ Childcare
Physical Activity
Standards
Safe & Quality
Ped/Bike
Infrastructure
+
Screen
Time
School
support
+
Community
Representation
+
+
+
Resident
Displacement
-
Tax Base
Elected Officials &
Govt Agency Staff
Support
+
+
+
+
+
+
+
-
-
+
+
+
+
Private
Investment
Cultural
Competence
+
Civic and
Community
Engagement
+
In-Kind Services &
Resources
+
+
+
Urban
Sprawl
+
Active
Commuting
-
+
Commuting
Time
+
-
+
-
+
+
-
+
+
-
-
Quality of
Education
System
+
Outdoor
Recreation
+
+
-
+
-
-
-
+
Agribusiness
Quality Air,
Water & Soil
-
Neighborhood
Safety
+
+ +
Access to
Potable Water
+
+
+
Safe & Quality
Public
Transportation
System
+
+
<Quality Air,
Water & Soil>
+
-
Fossil Fuel
Consumption
<Economic
Development>
<Economic
Development>
+
-
+
+
+
+
<Economic
Development>
+
<Economic
Development>
<School & Afterschool/
Childcare Nutrition
Standards>
+
-
Healthy Food Retail
(stores & markets)
-
+
+
+
-
+
+
-
+
Poverty & Income
Inequality
-
-
-
-
-
+
-
+
+
+
+
+
<Economic
Development>
<Family
Spending>
+
-
<Agribusiness>
<Safe & Quality
Public Transportation
System>
+
+
+
<Mixed-Use &
Transit-Oriented
Development>
<Childhood
Obesity>
<Civic and
Community
Engagement>
-
Food Policy
Council Influence
+
<Food Policy
Council Influence>
Youth & Family
Advocacy
+
+
+
+
+
<School & Community
Gardens/ Urban
Agriculture/ Local
Farms>
+
+
<Food Policy
Council Influence>
+
+
-
Effective Allocation/
Appropriation of Funds/
Resources
+
+
+
+
+
+
+
<School & Afterschool/
Childcare Nutrition
Standards>
<School & After
school/ Childcare
Physical Activity
Standards>
+
+
Capacity
Active Living
Healthy Eating
Healthy Kids,
Healthy Communities

21. Microsimulation
• Often used in econometrics
• In many other fields: weather, crime,
education
• Interaction of individual "units" (e.g., people)
• Each unit treated as an autonomous entity,
interaction of the units is allowed vary
depending on stochastic (randomized)
parameters
• CISNET is an example
(http://cisnet.cancer.gov/)

23. Microsimulation (example)
• Reducing childhood obesity via national policy
• 3 policies to reduce childhood obesity
• afterschool physical activity programs
• $0.01/ounce sugar-sweetened beverage
(SSB) excise tax
• ban on child-directed fast food TV advertising
• Literature was reviewed from January 2000
through July 2012 to find evidence of
effectiveness and create average effect sizes
• Markov microsimulation model to estimate
impact

24. Microsimulation (example)
• Afterschool physical activity programs would
reduce obesity the most among children aged 6–
12 years (1.8 percentage points)
• Advertising ban would reduce obesity the least
(0.9 percentage points)
• The SSB excise tax would reduce obesity the
most among adolescents aged 13–18 years (2.4
percentage points).
Kristensen AH, Flottemesch TJ, Maciosek MV, Jenson J, Barclay G, Ashe M, et al. Reducing Childhood
Obesity through U.S. Federal Policy: A Microsimulation Analysis. Am J Prev Med. 2014 Nov;47(5):604-
12.

25. Summary
• Well-recognized that complex, multilevel
interventions are effective
• Mapping and intervening in a complex world
– New forces: climate change, social
media/informatics, health in all policies
• Departs from researchers usual skill sets
(politics)
• Parallel set of challenges in communicating
methods to policy makers
• Analytic tools may enhance scale up
– Translating analytic results into action is not

26. MERCI!!
Questions and discussion
(rbrownson@wustl.edu)