Improving the efficacy of public health programs: Insights from communitybased multilevel interventi

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Improving the efficacy of public health programs
Insights from community-based multilevel
interventions in the urban context

• Sarah Sisco, Sandro Galea, David Vlahov
• Center for Urban Epidemiologic Studies (CUES)
• New York Academy of Medicine

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Overview

• Disparities in health
• Interventions to address disparities
• Limitations of standard interventions
• Multilevel interventions as an alternative
• Challenges
• Conclusions

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Disparities in health

• differences in the incidence, prevalence,
  mortality and burden of disease and other adverse
  health conditionsexist among specific population
  groups in the United States. (NIH, 2003)
• Health disparities are observed across race,
  ethnicity, socioeconomic status (education,
  occupation, income), insurance, social status,
  etc.

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Disparities in health have been documented in

• Infant mortality
• Diabetes
• Cancer
• Cardiovascular disease
• HIV infection/AIDS
• Immunization
• Stroke
• Source NIH, 1998

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Causes of disparities in health include

• Availability of health services
• Education
• Access to resources
• Access to social networks
• Quality of health care

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Excess burden of disease among racial/ethnic
populations in Washington State
2001 Rate ratios for combined deaths from AIDS,
asthma, cervical cancer, diabetes, and TB Source
Washington State DOH
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Prevalence of diagnosed diabetes by age, race,
and sex, USA, 1998
Source National Health Interview Survey (NHIS)
and Indian Health Service outpatient database
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Disparities persist despite

• multiple interventions implemented in different
  populations.
• NIH and HHS plans to eliminate health disparities

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Standard public health interventions

• aim to implement interventions targeted at one
  facet of a health problem, e.g. increasing access
  to health insurance
• aim to evaluate the efficacy of an intervention
• follow specific principles, e.g. rigid study
  design, blinding techniques, etc.

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Standard public health interventionIncreasing
immunization rates in urban children

• Intervention reducing geographic, racial, and
  ethnic disparities in childhood immunization
  rates using reminder/recall/outreach intervention
  in urban primary care practices
• Setting inner city of Rochester, rest-of-city,
  and suburbs compared ( Medicaid), through PCPs
• Design immunization tracked via outreach to
  three cohorts of all 0-2 year olds, 1993, 1996,
  and 1999
• Measures immunization rates at 12 and 24 mos.

2002 Szilagyi, Schaffer, Shone, Barth, Humiston,
Sandler, and Rodewald, Pediatrics, Vol. 110, No.5
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Disparities for Blacks and Whites reduced from
13 in 1993 to 7 in 1999
2001 Szilagyi, Schaffer, Shone, Barth, Humiston,
Sandler, and Rodewald
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Impact of medicare-funded quality improvement
efforts on hemodialysis
Sehgal. JAMA 2003289996-1000
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Limitations of standard interventions

• Translation and application to the real world
• Efficacy does not translate to efficiency
• Poor adherence to protocols
• Changes in baseline make conditions not
  replicable
• Contribution of other community-level factors

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Our premise

• Complex web of social factors affect health
• Urban settings involve multiple competing forces,
  with direct and indirect effects
• Interventions that address single factors are not
  sustainable, especially in cities

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Social ecological model of health
Kaplan, 2000
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An alternativeMultilevel interventions

• Simultaneous targeting of individual and
  structural factors
• Adopt intervention trial principles to real-world
  complexity
• Frequently implemented with entire communities

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An example of a multilevel intervention

• The Expanded Syringe Access Program
• (ESAP)
• East and Central Harlem and the South Bronx, New
  York City

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Expanded Syringe Access Demonstration Program
(ESAP)

• From January 1, 2001, pharmacies and health care
  facilities registered with the NYSDOH to
  participate in ESAP.
• May sell up to 10 syringes per transaction
  without a prescription.
• May sell to people 18 years or older.
• Pharmacies may not advertise.
• Registered providers must provide the
  state-sponsored ESAP safety insert.

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East and Central Harlem ESAP Intervention Project

• Level Pre-Intervention Intervention Post-Interven
  tion
• East Central East/Central
• Harlem/Brooklyn East/Central Harlem/Brooklyn
• South Bronx Harlem South Bronx
• IDU Interview Outreach Interview
• Pharmacy Phone Survey Outreach Phone Survey
• Community RDD Outreach RDD

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Outreach intervention activities with injection
drug users

• ESAP education and information materials
  disseminated through
• Harlem community-based organizations servicing
  IDUs
• Focus Groups and Fitpack pizza parties
• 1-866-SAFE-SHOT

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Outreach intervention activities with pharmacists

• ESAP Pharmacist Forum
• ESAP Pharmacist Assistant Workshop
• Pharmacy visits to registered and non-registered
• Dissemination of ESAP educational materials
  targeting pharmacists
• 1-866-SAFE-SHOT

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Outreach intervention activities with community
members

• Outreach to East and Central Harlem police
  departments
• Visits to local churches
• ESAP Presentations at East and Central Harlem
  Community Boards
• Participation in all East and Central Harlem
  health fairs
• Visits to clinics, neighborhood associations, CBOs

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Challenges to Multilevel Trials

• Logistical
• Conceptualizing and identifying essential levels
  for intervention
• Coordinating application to multiple levels
• Maintaining participation and dialogue with
  community partners

• Methodological
• Implementation of the intervention
• Analytical issues, such as adequate sample sizes
  for comparing intervention and control groups
• Technical issues, such as spillover effects

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We suggest

• There is a role for multilevel community
  intervention trials in decreasing, and
  potentially eliminating, health disparities