complex policy and practice questions require complex ......'what works' into practice and...
TRANSCRIPT
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Complex policy and practice questions require
complex evidence integration -
The case of early child health and development in Australia
John Lynch
Professor of Public Health, University of Adelaide Visiting Professor of Epidemiology, University of Bristol, UK
NHMRC Australia Fellow
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Research Production
Platforms
| Methods
| Evidence
| Synthesis
| Communication
Research Consumption
Implementation in Policy
Implementation in Practice
Translation
The Gap
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My question is: “Are we making an impact?”
Translation Anxiety
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National Collaborating Centre for Methods and Tools (Public Health Agency of Canada)
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”…there is nothing a government hates more than to be well-informed; for it
makes the process of arriving at decisions much more complicated and difficult.”
John Maynard Keynes
Skidelsky. John Maynard Keynes: a biography. Vol. 2: the economist as saviour, 1920-1937 (1992) London, p630
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Some Historical Examples of
Research Translation in Health
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Ambrose Paré 1575
Treating wounds with boiling oil did
more harm than good. Ligatures were
more effective but 100 years before it
was widely accepted
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• Scurvy Beneficial effects of citrus known for centuries, but Lind showed via an experiment on 12 sailors in 1747 how oranges and lemons eliminated scurvy, but 1864 before British Board of trade used citrus for all sailors • Smoking In 1950 Doll showed smoking and lung cancer linked but advertizing not completely banned in UK until 2002, US (2003), and Australia (1998). • Asbestos In 1955 Doll demonstrated relationship between asbestos and lung cancer but asbestos manufacture not banned in Australia until 1987 • Childhood obesity The first data about increases in childhood obesity appeared in the 1960s, certainly by the 1980s but still little systematic policy response to quell the ‘obesogenic environment’
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• MRFIT (1972) Individual RCT of those with CVD risk factors - 361,662 screened - 12,866 were eligible and randomized • Nth Karelia Study (1972) 180K intervention and 100K comparison community (Kuopio) • Stanford 5 City Project (1978)
N = 300K with comparison communities
• Pawtucket Heart Health Program (1980) N = 170K with comparison communities
• Minnesota Heart Health Program (1980) N = 400K with comparison communities
• COMMIT (1989) RCT of 22 communities involving 20K smokers
Large Scale Trials in CVD Prevention
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“The methodological issues we focus on here include randomization, statistical
power, cohort versus cross-sectional assessments, secular trends, outcome
measurement, and the role of conceptualization in methodological design.
Furthermore, the balance between scientific methodology and other practical issues
(e.g., economic and sociopolitical issues) is discussed.” pg. 72
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Harper, Lynch, Davey Smith. Annual Reviews Public Health (2011)
Major US Prevention Trials started
Nth Karelia Trial started
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Figure 2. Estimated percentage contribution of changes in risk factors and treatments to declines in IHD mortality. Sources (refs. 3, 9, 11, 19, 20, 49, 70, 80, 141, 147)
Harper, Lynch, Davey Smith. Ann Reviews Public Health (2011)
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“We need to fill in the gaps in current knowledge about the complex issues facing
children and young people as well as translate existing knowledge and evidence of
'what works' into practice and policy.”
ARACY
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Policy Frameworks for
Early Child Health and
Development
Learning readiness Social-emotional development
Schooling
Skills
Jobs
Incomes
Behaviour
Social exclusion
Productivity Social Participation
Cognitive Neuro- science
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“My first Report detailed the immense
penalties to society and to the individual
of failing to provide a strong foundation
of social and emotional capabilities early
in life.
This second Report focuses more on
addressing the vast financial and
economic costs.”
Letter to the Prime Minister, David Cameron, July 2011
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• Since 1999, there have been 20 national
policies (approximately one every 6 months)
aimed at improving the health of under-5s.
• In the last 10 years, £10.9 billion has been
invested in programs aimed at improving the
health of the under-5s, but this has not
produced widespread improvements in health
outcomes.
• Policy can be a problem, but here the big
problem is implementation – getting quality
on the ground
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2012
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DEEWR (2009)
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2012
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The Participation and Productivity Policy Environment
Early childhood, education, skills development
policies could boost participation by 0.7% and
productivity by up to 12% by 2030.
This corresponds to an increase in GDP of around
2.2% or around $25 billion in today’s dollars.
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Doyle et al. Economics Human Biol (2009)
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Lifecourse epidemiology
Cognitive Neurosceicne
Personality psychology
Early life nutrition
ECD interventions
e.g., Nurse Family
Partnership
Economics of investing in
ECD
Fetal origins hypothesis
Genes, epigenetics and
the “…omes”
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Doyle et al. Economics Human Biol (2009)
Requires more than evidence synthesis (combining - e.g., meta-analysis)
Requires complex evidence integration (making whole - e.g., simulation)
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An evidence jigsaw
for child health and development
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0 4wks 2 5 6 8 10 12 17 25 14
Midwives OBGYN
Child Health Nurses
General Practice / Pediatrics
Child Care
Preschool
Parents Carers
Child Protection and Social Work
“Proportionate Universalism”
Inte
nsi
ty o
f Se
rvic
e
“Need”
Early childhood
Teachers
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0 4wks 2 5 6 8 10 12 17 25 14
Perinatal factors and child health and development
Child care and cognitive development
Early life self regulation and cognitive, social emotional development
Family support programs
Early life social disadvantage, self regulation and school achievement, health behaviours and CVD risk
Early life diet and cognitive, social emotional development, and CVD risk factor
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0 4wks 2 5 6 8 10 12 17 25 14
Perintal factors and child health and development
Child care and cognitive development
Early life self regulation and cognitive, social emotional development
Family support programs
Self regulation and school achievement, health behaviours and CVD risk
Early life diet and cognitive, social emotional development, and CVD risk factors
Data linkage
Pragmatic RCTs and screening predictive validity
Cohorts studies - LSAC
Cohorts studies -ALSPAC
Data linkage and cohorts
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0 4wks 2 5 6 8 10 12 17 25 14
Data Linkage n= ~20,000 births per year in SA
Cohorts: LSAC and LSIC Cohorts: LSAY
RCTs
Interventions Integrated Children’s Centres (Sure Start) – childcare/preschool
Family Home Visiting; Weaning diet
ALSPAC
Screening Universal contact (4wks) – FHV; 4 yr health check; AEDI @ 5)
Natural Experiment Family Home Visiting
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0 4wks 2 5 6 8 10 12 17 25
• Perinatal (pregnancy) includes depression
• Universal Contact Visit (age 4-6 weeks) includes depression, weight, height, etc
• Age 4 – preschool health check includes height, weight
• AEDI (age 5) physical, language, social, emotional, communication
• NAPLAN (ages 8, 10, 12 14) reading, writing, literacy, numeracy
• Hospitalizations
• Emergency Dept
• Child care and preschool
• General Practice?
14
Data Linkage n= ~20,000 births per year
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~1.6 million
~230,000
~ 22 million people ~ 260,000 children aged 5 98% age eligible population
~ 7.2 million
~ 5.5 million
~ 4.5 million ~ 2.3 million
~530,000
ACT ~360,000
24.7
38.7
22.8
29.6
21.3
20.3 22.2
21.8
2009 AEDI % vulnerable on one or more
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0 4wks 2 5 6 8 10 12 17 25 14
RCTs
Interventions Integrated Children’s Centres – childcare/preschool
Family Home Visiting; Weaning diet
Family Home Visiting (FHV) • Evaluation of natural experiment roll-out 2009-2011, follow-up to 2014 • Pragmatic trial of universal contact visit • Planned RCT of ‘next gen’ FHV
Weaning Diet Trial – obesity prevention Evaluation of Intervention • Children’s Centres – integrate quality child care and preschool (Sure Start)
Natural Experiment Family Home Visiting Evaluation
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Perinatal Psychosocial Adversity Screen in 1st trimester
Lower adversity Higher Adversity
Follow-up at
3 mths
6 mths
9 mths
18 mths
Initial contact by CaFHS nurse 2-4 weeks after hospital separation
Prefer Home
Prefer Clinic+
Randomized Home
Randomized Clinic+
(n=240) (n=240) (n=150) (n=150)
Pragmatic Randomized Preference
Equivalence Trial of Nurse Home Visiting
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0 4wks 2 5 6 8 10 12 17 25 14
Screening
“Proportionate Universalism” – but who gets more intensive support? Screening for FHV at 3-4 weeks postpartum • Risk stratification
3-4 Year Old Health Check • Done by both GPs and Child Family Health Nurses (@ 4 yr immunization) • Care pathways? AEDI at age 5 • Risk stratification • Care pathways?
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Proportion of child outcome cases identified with each predictor
0
10
20
30
40
50
60
70
80
Age <20 years No partner ornot cohabitating
Financialdifficulties
Depression Smoking Education<O level
At least one
%
ADS 18m
SDQ 47m
SEA 4-5y
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0 4wks 2 5 6 8 10 12 17 25 14
ALSPAC
Cohorts: LSAC and LSIC Cohorts: LSAY
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0 4wks 2 5 6 8 10 12 17 25 14
Cohorts: LSAC and LSIC Cohorts: LSAY
National studies: LSAC (2004) LSIC (2008)
• ages 0-10 in 2 birth cohorts 0-6 and 4-10 (LSAC)
n=10,000
• ages 1-4 (LSIC) n= 1700
• behavioural and cognitive measures
• LSAC similar to Millenium cohort
National study: 1995
• ages 15-25 n= ~12,000
• since 2003 uses PISA sample
• youth transitions from school
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0 4wks 2 5 6 8 10 12 17 25 14
Data Linkage n= ~20,000 births per year in SA
Cohorts: LSAC and LSIC Cohorts: LSAY
RCTs
Interventions Integrated Children’s Centres (Sure Start) – childcare/preschool
Family Home Visiting; Weaning diet
ALSPAC
Screening Pregnancy, Universal contact (4wks) – FHV; 3 yr health check; AEDI @ 5)
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Doyle et al. Economics Human Biol (2009)
Requires more than evidence synthesis (combining)
Requires complex evidence integration (making whole)
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Evidence Integration
What if … ?
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Q5; n=231 (3.3%)
Q3,4; n=265 (3.8%)
Q1,2; n=81 (1.1%)
Q5; n=275 (3.9%)
Q3,4; n=393 (5.6%)
Q1,2; n=175 (2.5%)
Q5; n=255 (3.6%)
Q3,4; n=493 (7.0%)
Q1,2; n=278 (3.9%)
Q5; n=779 (11.0%)
Q3,4; n=2025 (28.7%)
Q1,2; n=1810 (25.6%)
0
10
20
30
40
50
60
70
80
90
100
Pro
po
rtio
n w
ho d
id n
ot achie
ve 5
+ G
CS
Es A
*-C
in
cl. E
ng
& M
ath
s
Parental education
Parental social classSEA quintile
< O level
O level or higher
IV/V
I/II/III
IV/V
I/II/III
ALSPAC Data (unpublished)
Parent Education
Parent Social class
Child school entry quintile
Population Average
20%
90%
55%
90%
70%
% with ‘low’ GCSE
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5+ A*-C GCSE including English and Maths
YesNo
52.847.2
School Entry Assessment quintile
Q1 or 2Q3 or 4Q5
33.045.121.9
Parental social class
I II IIIIV V
77.322.7
Parental education
O level or higherLess than O level
79.920.1
Sex
MaleFemale
50.749.3
Age at start of academic year (mths)
180 to 203 100
191.5 ± 6.6
Bayesian Network ALSPAC data, N=7060
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What do we mean?
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Research Production
Research Consumption
Translation
The Gap
Different concepts and uses of ‘evidence’
“Statistics are like a drunk with a lamp post: used more for support than illumination.” Winston Churchill
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Dr Perry was shown the transcript
along with three other examples …
Dr. Perry concluded Duncan Smith's
comments were an
"oversimplification" that "greatly
misrepresents the way we would
explain the impact of neglect or
trauma on the developing brain".
He added: "to oversimplify this way
is, essentially, to distort".
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“Uncomfortable science” – when there is a need to draw an
inference from a limited sample of data, where further samples
influenced by the same cause system will not be available.
John Tukey (1915-2000) - Princeton statistician
Uncomfortable Science
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“Far better an approximate answer to the right question, which is often vague,
than an exact answer to the wrong question, which can always be made precise.”
John Tukey. The future of data analysis. Ann Math Stat (1962)