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 P e (relative Risk a – 1) P e (relative Risk a – 1) Where P e = proportion of the population that is exposed Relative Risk a = the Relative Risk of the specific condition If we ask ourselves what proportion of disease in the population is a result of a specific exposure or risk?

Risk FactorRRPrevalencePAR High blood pressure2-442% of population in US25 (20-29) Cigarette smoking1520% in US (**)22 (17-25) High cholesterol2-428% US (**)43 (39-47) Diabetes (fasting glucose (140 mg/dL) % in US (**)8 (1-15) Obesity<231% of population (**)17 (7-32) Physical inactivity<235 (23-46) Environmental tobacco smoke<218 (8-23) Poor Social Support1.5 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 17 Anxiety3.77 ( ) Dose response Inadequate health literacy elderly1.5625% of Medicare enrollees Anger2.66 ( ) Dose response with hostility Population Attributable Risk for death from CVD selected cardiovascular Risk Factors

Risk FactorRRPrevalencePAR Poor self-rated and objectively measured health, 2.0?See BRFSS Social class1.51/2 of study insofar as either manual or non-manual Similar results were obtained for all-cause mortality. 22% or 14.5 if adjust for CR factors (but watch out) DepressionMultiplier effect of all other risk factors Social networks2.1Syme and Berkman Poor Social Support1.5 or 2.42 Cat ownership30-40% reduced risk of all CVD 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 Low socioeconomic statusa.6903 first stroke events registered by the FINMONICA Stroke Register in 3 areas of Finland during 1983 to 1992 For the death it was 56% for both sexes. 36% 1st stroke for both sexes. from first ischemic stroke, Population Attributable Risk II for death from CVD selected cardiovascular Risk Factors

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 factorMeasure of Risk (RR or OR) % population exposed Estimated PAR InterventionEfficacy of Intervention See word file table for preferred table

Thacker paper Community guide

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

Population 35 y/o men (20 yrs) exercise No exercise Death from CHD (p = 0.06) Death from CHD (p = 0.03) Good Health (p=0.87) Good Health (p = 0.74) Infarction or other CHD (p= 0.09) Infarction or other CHD (p = 0.12) Hyptothetical population used to apply probabilities of various events

Population US Immunization No immunization Measles Good Health Side effects Efficacy of measles immunization = 98% (administered twice) Effectiveness of measles immunization = something much smaller than efficacy