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3 Policy-Relevant Evidence for Population Health: Promise and Challenges
Pages 17-32

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From page 17...
... Ford School of Public Policy at the University of Michigan, discussed current definitions of population health and population health management, and the importance of targeting policy efforts upstream to address the fundamental drivers of population health inequities. Jennifer Doleac, associate professor of economics at Texas A&M University and director of the Justice Tech Lab, described ban-the-box policies and policies that increased access to naloxone as examples of how policy interventions can have unintended consequences.
From page 18...
... Health Impact in 5 Years (HI-5) website, which is a repository of data from numerous current population health interventions.1 He also drew attention to a recent report from the Yale Global Health Leadership Institute that summarizes the current state of evidence on the social determinants of health.2 Galea then described four key challenges to generating the evidence that is needed to inform population health initiatives: external validity, ubiquitous factors, thinking in dichotomies, and making predictions.
From page 19...
... As an example of why external validity matters, Galea described a hypothetical study to determine if a particular intervention results in nor mal blood pressure levels (see Figure 3-1) .3 A population is selected and individuals are sorted to one of four subgroups: diseased and exposed to the intervention; diseased and unexposed to the intervention; not diseased and exposed; and not diseased and unexposed.
From page 20...
... 20 FIGURE 3-1  Sampling different populations to determine if a certain intervention has an effect on bringing blood pressure to normal levels. SOURCE: Galea presentation, October 3, 2018.
From page 21...
... As an example of the errors that can happen when ubiquitous factors are ignored, Galea reminded participants of the early coverage of the risks of gestational crack cocaine in the 1980s. Despite early conclusions to the contrary, it later became clear that there was no difference in cognitive functioning between children exposed to crack cocaine in utero and children who were not exposed, Galea explained (Betancourt et al., 2011)
From page 22...
... . "A population health intervention approach should focus on shifting population curves," Galea said, but relative risk measures do not provide ­population level differentiation and curve separation (Pepe et al., 2004)
From page 23...
... . They found that, at every level of gene prevalence, "the risk ratio ultimately is driven not by the gene itself, but by the environment, and by the likelihood of particular factors such as the background rate of disease." Specifically, "the risk ratio increases as the prevalence of the environmental factor increases," and "the risk ratio decreases as the background rate of disease increases." The forces are ubiquitous, he said, and shifting a ubiquitous factor leads to a shift in the population's health.
From page 24...
... The World Health Organization conceptual framework for social determinants of health also shows the upstream structural determinants (e.g., the social and public policies that influence socioeconomic position) .4 Interest in the social causes of health spans centuries, and Lantz shared a quote from Johan Peter Frank in a book published in 1790: "The diseases caused by the poverty of the people and by the lack of all goods of life are exceedingly numerous." She suggested that the term population health really gained traction in 2007 with the development of the Institute for Healthcare Improvement Triple Aim framework.
From page 25...
... In this regard, she raised concerns that the focus of research, interventions, and policy are also moving downstream to the individual level. Shifting the focus of population health management to outcomes and individuals has implications for population health research and policy, Lantz said.
From page 26...
... Ban-the-Box Policies Ban-the-box policies are intended to help individuals with criminal records obtain employment. Specifically, the policies prohibit employers from asking about an applicant's criminal record until later in the hiring process (i.e., the policies ban including a box to check on a job application if one has a criminal history)
From page 27...
... Broadening Naloxone Access Opioid-related mortality has increased across the United States, Doleac said, and many states have broadened access to the opioid a­ ntagonist, naloxone, in an attempt to mitigate the deadly consequences of opioid abuse. There are a range of approaches to expanding access, from standing orders that allow a pharmacy to dispense without a patient having a prescription to distribution by community groups.
From page 28...
... She shared data from the Midwest that shows that opioid- and fentanyl-related mortality were both fairly steady in the year or so prior to implementation of expanded naloxone access policies. After the laws went into effect, however, mortality rates associated with use of both drugs increased (Doleac and Mukherjee, 2018)
From page 29...
... Finally, implementation should include a plan for evaluation, she said. DISCUSSION Tim Bruckner of the University of California, Irvine, commented that he has observed academic researchers downplaying potentially controversial study findings about the benefits or lack thereof of implemented policies.
From page 30...
... In response, Jeffrey Levi of The George Washington University referred to the presentations by the first panel of the symposium and said that they demonstrate that the field of population health is willing to acknowledge that there are problems and to discuss current findings that are not ideal. He also suggested that the association between the availability of HIV medication and risky sexual behaviors mentioned by Doleac is not commonly accepted, and wondered what other explanations might be plausible for the increased opioid mortality rates observed after implementation of expanded naloxone access.
From page 31...
... He observed that policy makers often fail to anticipate unintended consequences or to consider other outcomes that might be relevant to stakeholders beyond the health field. Doleac agreed that academic researchers need to expand beyond their silos, policy makers need to take research findings into account, and input from the community is needed to inform research and policy making.


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