Skill building: Determining priorities and
decision making:
Using the best evidence and
mindful community process
Sharon McDonnell MD MPH
Objectives
• Discuss issues- what = success in the
process of decision-making in short and long
term?
• Review processes and programs set up to
facilitate community prioritization such as
MAPP, APEX, Assessment initiative.
• Evidence based epidemiological approach
using PAR analysis
– What is PAR, how calculated, data
needed?
– Comparing different problems and
approaches to decide “best” decision
Decision-making and priority setting
• Discuss issues- what = success in the
process of decision-making in short and long
term?
Decision-making and priority setting
• Formal processes and programs designed to
facilitate community prioritization:
–
–
–
–
MAPP - includes a data collection and comparison process
APEX,
Assessment initiative.
Other myriad methods emphasizing one or more of following
elements
–
–
–
–
–
Community participation & Process
Political support and engagement of institutions
Evidence-based
Outcomes
Sustainability
Priority setting
• Emphasizing different weights of “so what
test”
–
–
–
–
–
–
–
Magnitude
Severity
feasibility
Acceptability
Political support
Economics/cost
others
Evidence based Public health
Population attributable risk (PAR)
• To improve evidence for magnitude and
effect
• To improve evidence about
effectiveness
Population Attributable Risk
If we ask ourselves what proportion of disease
in the population is a result of a specific exposure or risk?
Pe (relative Riska – 1)
-------------------------1 + Pe (relative Riska – 1)
Where Pe = proportion of the population that is exposed
Relative Riska = the Relative Risk of the specific condition
Population Attributable Risk for death from CVD selected cardiovascular Risk Factors
Risk Factor
RR
Prevalence
PAR
High blood pressure
2-4
42% of population in US
25 (20-29)
Cigarette smoking
15
20% in US (**)
22 (17-25)
High cholesterol
2-4
28% US (**)
43 (39-47)
Diabetes (fasting glucose (140
mg/dL)
2-4
6.4% in US (**)
8 (1-15)
Obesity
<2
31% of population (**)
17 (7-32)
Physical inactivity
<2
35 (23-46)
Environmental tobacco smoke
<2
18 (8-23)
Poor Social Support
1.5 or 2.42
High Perceived mental Stress
(Japanese women)
2.28 (1.17–
4.43)
Adjusted risk factors. 20% (n=43,244)
had high stress
Anxiety
3.77 (1.648.64)
Dose response
Inadequate health literacy elderly
1.56
25% of Medicare enrollees
Anger
2.66 (1.265.6)
Dose response with hostility
17
Population Attributable Risk II for death from CVD selected cardiovascular Risk Factors
Risk Factor
RR
Prevalence
PAR
Poor self-rated and objectively
measured health,
2.0?
See BRFSS
Social class
1.5
1/2 of study insofar as either manual or
non-manual Similar results were obtained
.
for all-cause mortality
Depression
Multiplier effect of all other risk factors
Social networks
2.1
Poor Social Support
1.5 or 2.42
Cat ownership
30-40%
reduced risk
of all CVD
Low socioeconomic status
22% or 14.5 if
adjust for CR
factors (but
watch out)
Syme and Berkman
Study among 4000 US over 10 years ? Is
it owning the cat or the type of people
what own cats? Does not extend to dogs
17
a.6903 first stroke events registered by
the FINMONICA Stroke Register in 3
areas of Finland during 1983 to 1992
36% 1st
stroke for
both sexes.
from first
ischemic
stroke,
For the death it was 56% for both
sexes.
• Inadequate social connection or social isolation
increases all cause mortality (2-2.8 times)
• Inadequate health literacy increases all cause
mortality nearly twofold.
• ADD in Alameda tables and syme re various data
sets on social isolation
• How social isolation defined
• Smoking and lung cancer slide with
determinants
• Terms- determinant, risk, influencing
factor etc
• Culture - how to measure and watch?
• Make a commercial targeted to ill health
• The opposite of a risk factor is not a
health factor
Risk factor
Measure of
Risk (RR or
OR)
%
population
exposed
Estimated
PAR
Intervention
Efficacy of
Intervention
See word file table for preferred table
Thacker paper
Community guide
QuickTime™ and a
decompressor
are needed to see this picture.
Efficacy and effectiveness
• Efficacy –refers to the impact of an intervention in a
clinical trial, differing from 'effectiveness' which
– Immunization in the laboratory or clinical trial
• Effectiveness – refers to the impact in real world
situations.
– immunization in real world
Influences on Efficacy
• Efficacy:
– Inherent to drug/intervention
– Interacting with human(s)
– In a context
Influences on effectiveness
• Effectiveness:
– Human resources and training
• Recruitment, qualifications, didactic and applied training, continuing
education
– Infrastructure
• Supplies and equipment, salary, transportation, supervision
– Community support
• Access and demand
Good Health (p=0.87)
exercise
Infarction or other CHD (p= 0.09)
Death from CHD (p = 0.03)
Population
35 y/o men
(20 yrs)
Good Health (p = 0.74)
No exercise
Infarction or other CHD (p = 0.12)
Death from CHD (p = 0.06)
Hyptothetical population used to apply probabilities of various events
Good Health
Immunization
Side effects
Measles
Population
US
Good Health
Side effects
No immunization
Measles
Efficacy of measles immunization = 98% (administered twice)
Effectiveness of measles immunization = something much smaller than efficacy