Starting point: “All risk factors are policy levers” (HPSH epidemiologist 2005)
* ease of change (or not) of risk factor as policy lever?
* risk factors as proxies for other risk factors/ policy levers (e.g., class -> smoking -> lung cancer & CHD)
-> Q: How often are multiple risk factors as established in social epidemiological studies translated into public health policy or clinical recommendations?
Initial responses from social epidemiologists to my inquiries during summer/fall 07 => anecdotes of policy makers ignoring most of their work or adopting their work incorrectly.
More systematic look for reviews, examples, discussions => no yield?
(There’s a field of “knowledge translation research”)
-> Taxonomy of how multiple risk factors as established in social epidemiological studies might be translated into public health policy or clinical recommendations
1. Multiple risk factors -> Contributions to the overall burden of disease -> General wellness recommendations that apply to many diseases
e.g. Rachel Jenkins (2003) on mental health policy, tailored to cultural specifics using r.f.’s
2. Multiple risk factors -> Multifactorial interventions (e.g., UK youth suicide prevention[?]).
a. fuzzy relationship between r.f.’s and interventions (see #1)
b. precise (specific combination of factors from the overall ball of things to reduce risk)
3. Multiple risk factors -> Risk scores for interventions that have better type I and II errors.
e.g., Framingham score for CVD risk -> Reynolds risk scores (Ridker 2007) (large populations needed)
3a. Multiple risk factors -> separate interventions ….> unintended consequences
4. Parallels drawn between multiple risk factor results and results of policy that was pursued independently of the risk factor research.
e.g., Jenkins on crowding & stress from epi and from community surveys
5. Critique of policies based on single or simple risk factors.
6. Critique of fixed ideas for evidence-based health policy, ideas that constrain innovation in light of new research (including multiple risk factors).
e.g., WHO protocol for treating TB exacerbated problem when there’s drug-resistant TB
e.g., suicide research -> pilot studies in one place -> extended to other places
-> Counter-moves to looking for Multiple risk factors
1. Focus on proximal -> inattention to persistent structural conditions
e.g., Link & Phelan (1995) on “fundamental social causes” -> access to resources to avoid r.f.’s even when the r.f.’s change
2. Focus on proximal -> inattention to Rosean population health strategies (Rose 1985)
e.g., compulsory seat belts use, fluoridization, smoking cessation, …
2a. Focus on proximal reason for disparities (relative, not absolute risk) -> distraction from health strategies for populations
e.g., John Lynch 2007 video, http://www.sph.umn.edu/cpheo/healthdisparities/forum_032307.html
Notes 8 Sep 08 (with thanks to Louisa Holmes), with ?s indicating areas to be filled in.
Jenkins, R. (2003). “Supporting governments to adopt mental health policies.” World Psychiatry 2(1): 14-19.
Link, B. G. and J. Phelan (1995). “Social Conditions as Fundamental Causes of Disease.” Journal of Health and Social Behavior(Extra Issue): 80-94.
Ridker, P. M., J. E. Buring, et al. (2007). “Development and Validation of Improved Algorithms for the Assessment of Global Cardiovascular Risk in Women: The Reynolds Risk Score.” Journal of the American Medical Association 297: 611-619.
Rose, G. (1985). “Sick individuals and sick populations.” International Journal of Epidemiology 14: 32-38.