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ENHANCING HEALTH ENHANCING HEALTH POLICY THROUGH POLICY THROUGH EPIDEMIOLOGYEPIDEMIOLOGY

R.A. Spasoff, MDR.A. Spasoff, MD

University of OttawaUniversity of Ottawa

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PolicyPolicy

• A set of principles guiding decision-A set of principles guiding decision-makingmaking

• Public PolicyPublic Policy: policy of : policy of governmentsgovernments

• Health PolicyHealth Policy: health promotion, : health promotion, health protection, health services health protection, health services (plus…)(plus…)

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Healthy Public PolicyHealthy Public Policy

• From health promotion movementFrom health promotion movement• Use of policy in all sectors to Use of policy in all sectors to

promote healthpromote health• Policy can also contribute to Policy can also contribute to

disease prevention and treatment disease prevention and treatment at all levelsat all levels

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Policy InstrumentsPolicy Instruments

• Legislation and regulationsLegislation and regulations• Taxation and financial incentivesTaxation and financial incentives• Information and coordinationInformation and coordination• Provision of direct serviceProvision of direct service

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The Basis of PolicyThe Basis of Policy

• ValuesValues• IdeologyIdeology• PoliticsPolitics• EvidenceEvidence

– Not usually the main influence on Not usually the main influence on policy, but worth fighting forpolicy, but worth fighting for

– The main contribution of epidemiologyThe main contribution of epidemiology

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Premise of this Premise of this presentationpresentation

• Decisions must be made, Decisions must be made, regardless of the quality of the regardless of the quality of the supporting evidencesupporting evidence

• Some evidence is better than no Some evidence is better than no evidenceevidence

• Epidemiology can provide much of Epidemiology can provide much of the important evidencethe important evidence

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Policy AnalysisPolicy Analysis

• The process of predicting the The process of predicting the impacts of possible policies and impacts of possible policies and evaluating past policiesevaluating past policies

• Epidemiology can make a major Epidemiology can make a major contribution to both stepscontribution to both steps

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Tugwell’s Iterative Tugwell’s Iterative LoopLoop

• 1. Burden of illness1. Burden of illness• 2. Aetiology or causation2. Aetiology or causation• 3. Community effectiveness3. Community effectiveness• 4. Efficiency4. Efficiency• 5. Synthesis & Implementation5. Synthesis & Implementation• 6. Monitoring of Program6. Monitoring of Program• 7. Reassessment7. Reassessment

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Policy CyclePolicy Cycle

• 1. Assessment of population health1. Assessment of population health• 2. Assessment of potential 2. Assessment of potential

interventionsinterventions• 3. Policy choices3. Policy choices• 4. Policy implementation4. Policy implementation• 5. Policy evaluation5. Policy evaluation

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1. Assessment of 1. Assessment of population healthpopulation health

• Demography, population dynamicsDemography, population dynamics• Descriptive epidemiology:Descriptive epidemiology:

– Measure the health of the population Measure the health of the population – Identify trends and patterns Identify trends and patterns – Assess health risks Assess health risks – Assess health needsAssess health needs– Identify priority targets for policy developmentIdentify priority targets for policy development

• Analytical epidemiologyAnalytical epidemiology– Individual-level and population-level Individual-level and population-level

causescauses

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2. Assessment of 2. Assessment of potential interventionspotential interventions

• Identify potential policy Identify potential policy interventionsinterventions

• Synthesize existing knowledge Synthesize existing knowledge regarding their effectivenessregarding their effectiveness

• Contribute relevant new researchContribute relevant new research• Assess the potential of each Assess the potential of each

approachapproach

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3. Policy choices3. Policy choices

• Project impact of potential Project impact of potential interventions on the health of the interventions on the health of the populationpopulation– Computer simulations of different Computer simulations of different

interventionsinterventions

• Assist the process of consensus Assist the process of consensus developmentdevelopment

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4. Policy 4. Policy implementationimplementation

• Help to set targets for the chosen Help to set targets for the chosen policiespolicies

• Inform needs-based resource Inform needs-based resource allocation for health services allocation for health services

• Guide development of information Guide development of information systemssystems

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5. Policy evaluation5. Policy evaluation

• Assess the impacts of policies Assess the impacts of policies • Monitor future healthMonitor future health

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Epidemiology & Health Epidemiology & Health Policy: three examples Policy: three examples

• Healthy People 2010Healthy People 2010 (and (and Health Health 2121))– goal-setting, targetsgoal-setting, targets

• Global Burden of DiseaseGlobal Burden of Disease– ethical basis, DALYsethical basis, DALYs

• Public Health Status and Forecasts Public Health Status and Forecasts in the Netherlandsin the Netherlands– integrated processintegrated process

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Why epidemiology has Why epidemiology has had a limited influence had a limited influence

• Our faultOur fault– Emphasis on aetiologic researchEmphasis on aetiologic research– Grime avoidanceGrime avoidance– Focus on individual-level risk actorsFocus on individual-level risk actors

• Not our faultNot our fault– Different backgrounds from policy-Different backgrounds from policy-

makersmakers– Different valuesDifferent values– Different time scalesDifferent time scales– Lack of credibility (often not “real MDs”)Lack of credibility (often not “real MDs”)

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Towards a larger role: Towards a larger role: relevant expertiserelevant expertise

• Policy and its formation• Descriptive epidemiology• Population health data• Social determinants of health• Health and disease modelling• Geographical information systems• Multilevel modelling• Population dynamics

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Towards a larger role:Towards a larger role:a developing disciplinea developing discipline

• Teaching (see course description)Teaching (see course description)• Professional societiesProfessional societies• Broadened role for journalsBroadened role for journals• Policy-relevant researchPolicy-relevant research

– Inequalities in healthInequalities in health– Measuring health needsMeasuring health needs– Multilevel analyses of health Multilevel analyses of health – Health and disease modellingHealth and disease modelling

• Communication skills, research transferCommunication skills, research transfer• Working with policy-makersWorking with policy-makers

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Epidemiology for Epidemiology for Health Policy: Health Policy: ObjectivesObjectives

• To provide students with:To provide students with:• 1. knowledge of how health policy is 1. knowledge of how health policy is

developed and used;developed and used;• 2. knowledge of epidemiologic methods 2. knowledge of epidemiologic methods

relevant to the development of health relevant to the development of health policy; and policy; and

• 3. the skills to use that knowledge, in 3. the skills to use that knowledge, in collaboration with policy-makerscollaboration with policy-makers

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Epidemiology for Epidemiology for Health Policy: Topics Health Policy: Topics (1)(1)

• Policy and Health PolicyPolicy and Health Policy• Policy FormulationPolicy Formulation• Ethics, Politics & CommunicationEthics, Politics & Communication• Measuring Population HealthMeasuring Population Health• Health Burden and Health NeedsHealth Burden and Health Needs• Assessing CausationAssessing Causation• Assessing InterventionsAssessing Interventions

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Epidemiology for Epidemiology for Health Policy: Topics Health Policy: Topics (2)(2)

• Disease ControlDisease Control• Disease ModellingDisease Modelling• Priority-settingPriority-setting• Impact Assessment & Goal-settingImpact Assessment & Goal-setting• Resource AllocationResource Allocation• Policy EvaluationPolicy Evaluation

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Policy-relevant thesis Policy-relevant thesis topicstopics

• Small-area estimation of healthSmall-area estimation of health• Adapting “Prevent” to OntarioAdapting “Prevent” to Ontario• Small-area variations in health care Small-area variations in health care • Evaluating a restricted driver licensing Evaluating a restricted driver licensing

policypolicy• Modelling mammographic screening Modelling mammographic screening

beyond age 69beyond age 69• Economic burden of breast-feedingEconomic burden of breast-feeding• Income inequality and health (two theses, Income inequality and health (two theses,

one using multilevel analysis)one using multilevel analysis)

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Relevant resources: Relevant resources: BooksBooks

• Spasoff, Spasoff, Epidemiologic Methods for Epidemiologic Methods for Health PolicyHealth Policy, 1999, 1999

• Brownson/Petitti, Brownson/Petitti, Applied EpidemiologyApplied Epidemiology, , 19981998

• Young, Young, Population HealthPopulation Health, 1998., 1998.• Petitti, Petitti, Meta-Analysis, Decision Analysis, Meta-Analysis, Decision Analysis,

and Cost-effectiveness Analysisand Cost-effectiveness Analysis (2 (2ndnd ed), ed), 20012001

• Gray, Gray, Evidence-based HealthcareEvidence-based Healthcare, 1997, 1997

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Relevant resources: Relevant resources: JournalsJournals

• International Journal of EpidemiologyInternational Journal of Epidemiology• Journal of Epidemiology and Community Journal of Epidemiology and Community

HealthHealth• British Medical JournalBritish Medical Journal• Journal of Public Health PolicyJournal of Public Health Policy• Public Health ReportsPublic Health Reports• American Journal of Public HealthAmerican Journal of Public Health