How are multiple risk factors as established in social epidemiological studies translated into public health policy or clinical recommendations?

Starting point: “All risk factors are policy levers”  (HPSH epidemiologist 2005)

But consider:

* 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)

e.g., ?

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

e.g., ?

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.

e.g., ?

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.

References

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.

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