Public Health and Epidemiology

In the ten years since the first edition of this book was published, there have been many important ethical developments in epidemiology and related fields in public health and medicine. These developments include implementation of the HIPAA privacy rules, the completion of the American College of Epidemiology (ACE) ethics guidelines and ACE policy statements on sharing data from epidemiologic studies, and the drafting of a public health code of ethics. This revised edition of the text includes selected chapters from the first edition, which have been updated and revised, along with several new chapters on issues concerning the ethics of public health practice, international health research, and genetic epidemiology. The chapters are organized topically and divided into four parts. The first part is titled “Foundations” because the chapters introduce basic and recurring concepts and principles. The subsequent parts deal with “Informed Consent, Privacy, and Confidentiality,” “Balancing Risks and Benefits,” and the “Regulatory Context and Professional Education.” The latter subject includes discussion of the institutional review board (IRB) system and issues surrounding scientific misconduct in epidemiologic research. The objective of this work foster greater awareness of situations that require moral reflection, judgment, or decision, while pointing to ways in which justified moral conclusions can be reached.

Most of the industrialized world now comprises of multi-ethnic societies, with people from widely varying ancestry, cultures, languages, and beliefs. With globalization of trade, increasing international travel, and migration, the whole world is destined to become multi-ethnic within the next twenty or thirty years. This poses huge challenges for doctors, nurses, public health practitioners, health care managers, and policy makers who have to meet legal and policy obligations to deliver health outcomes, and provide health care of equal quality and effectiveness. To achieve this, they need a solid understanding of the underlying concepts of race and ethnicity, and how these are applied to achieve better health for ethnic minority populations. They also need to have an awareness of the misuses of these concepts, particularly taking into account the history of racism that permeates many societies to this day. This book provides an introduction to these complex issues. The key concepts of race and ethnicity are explained in this book, including their uses and misuses. The strengths and weaknesses of these concepts in terms of epidemiology, policy making, health service planning, research, health care, and health promotion are illustrated. The book emphasises theory, ideas, and principles, and its aims are to help counteract the unethical and atheoretical methods often used to study ethnicity. Practical application of the theory is demonstrated through the use of examples. The conceptual frameworks of ethnicity and race required by practitioners and researchers are slightly different, including the nature of research questions, the relative value of various methods of classification, and the approach to data analysis, presentation, and interpretation, and these differences are made explicit.

Health Promotion is a relatively new discipline and there is little in the way of practical help for choosing and implementing appropriate evaluation methods. As the demands for rigorous evaluation and evidence-based decision-making increase, health promotion cannot ignore the need for accurate, reliable, and valid methods to carry out evaluation. This book provides clear descriptions (with plentiful practical examples) of such methods, and the problems that can arise from their implementation. Both qualitative and quantitative methods that are commonly used are described and the problems and benefits that arise with their use are explained. Experiences in the practical implementation of evaluation are explained, with examples from a variety of different social, economic, and cultural contexts.

Health promotion is a relatively new discipline and there is little in the way of practical help choosing and implementing appropriate evaluation methods. As the demands for rigorous evaluation and evidence-based decision-making increase, health promotion cannot ignore the need for accurate, reliable, and valid methods to carry out evaluation. This book provides descriptions (with plentiful practical examples) of such methods, and the problems that can arise from their implementation. The book sets the concepts of health promotion and evaluation in their historical context and highlights key issues in the evaluation of health promotion interventions. Both qualitative and quantitative methods that are commonly used are described and the problems and benefits that arise with their use are explained. Experiences in the practical implementation of evaluation are explained, with examples from a variety of different social, economic, and cultural contexts. In this edition new examples including evaluating social marketing and the difficulties of evaluating “hidden” problems such as intimate partner violence are explored.

This book aims to show the value of developing and applying an evidence base to public health. The application of evidence to clinical practice is well established, and the field of evidence-based medicine accepted as a basic clinical science, not so for public health. The book examines the methods used for Evidence Based Medicine, and shows how these can be applied to public health. In the process, a number of new measures are necessary to extend clinical measures to the population. Population impact measures are described and their value in public health policy-making described and discussed. The book identifies evidence for population health as an appropriate field of study. The chapters are divided in three sections to follow the structure of the Population Health Evidence Cycle: Ask the question, Collect the evidence, and Understand and use the evidence.

Public health decisions are often based on short-term demands rather than long-term study, and policies and programs are sometimes developed from anecdotal evidence. To enhance evidence-based practice, this book provides practical guidance on how to choose, carry out, and evaluate evidence-based programs and policies in public health settings. “Evidence” is central to our notion of justice, but is equally central to public health. In public health there are four principal user groups for evidence: public health practitioners with executive and managerial responsibilities; policy makers at local, regional, state, national, and international levels; key stakeholders including the public and interest groups; and researchers on population health issues. A step-by-step approach to compiling and assessing evidence of what works and what doesn't is explicated in this book. The book guides to how to use the results of search for evidence in developing program or policy options.

Evidence-Based Public Health: Effectiveness and Efficiency continues the themes raised in Public Health Evidence: tackling health inequalities. Written by the same team, this book is a comprehensive reference to evidence-based approaches in public health. It covers the context and role of evidence-based public health in England; frameworks for evaluating the effectiveness and cost effectiveness of public health policies and interventions; diversity, vulnerability and risk as a focus for understanding the role of social context in influencing health-related behaviours; approaches and methods to generate and synthesize evidence of what works to improve health and tackle health inequalities; current best available evidence on the effectiveness of a diverse range of interventions; and the role of evidence-based guidance and standards in changing policy and practice.

This second edition of this text returns to the question: How much of our work in public health is evidence based? The exact answer to that question can never be known, however, the answer would certainly include the words “not enough”. Public health has successfully addressed many challenges. Programs and policies have been implemented and, in some cases, positive results have been reported that show improvements in population health. Yet some populations still suffer health disparities and social inequalities. This leads us to questions such as: Are there ways to take the lessons learned from successful interventions and apply them to other issues and settings? Are we applying the evidence that is well established in scientific studies? How do we foster greater political will that supports evidence-based decision making? How do we develop incentives so practitioners will make better use of evidence? The format for this second edition is very similar to the approach taken in the course and the first edition. Chapter 1 provides the rationale for evidence-based approaches to decision making in public health. Chapter 2 presents concepts of causality that help in determining when scientific evidence is sufficient for public health action. Chapter 3 describes a set of analytic tools that can be extremely useful in finding and evaluating evidence—these include economic evaluation, health impact assessment, meta-analysis, and expert guidelines. The next seven chapters lay out a sequential framework which includes: conducting a community assessment, developing an initial statement of the issue, quantifying the issue, searching the scientific literature and organizing information, developing and prioritizing intervention options, developing an action plan and implementing interventions, and evaluating the program or policy.

The recent and rapid expansion of occupational and environmental epidemiology and health risk assessment looks set to continue in line with growing public, government, and media concern about occupational and environmental health issues, and a scientific need to better understand and explain the effects of occupational and environmental pollutants on human health. Risks associated with occupational and environmental exposure are generally small, but the exposed population, and hence the population attributable risk, may be large. To detect small risks, the exposure assessment needs to be very refined. Exposure assessment is the study of the distribution and determinants of potentially hazardous agents, and includes the estimation of intensity, duration, and frequency of exposure, the variation in these indices and their determinants. Epidemiological studies can utilize information on variation and determinants of exposure to optimize the exposure-response relations. Many methodological and practical problems arise when conducting an exposure assessment for epidemiological studies and these are addressed in the book, as is the issue of measurement error and exposure misclassification and its effect on exposure response relationships. The book outlines the basic principles of exposure assessment, in both occupational and environmental epidemiology, since there are many similarities but also some interesting differences. It examines the current status and research questions in the exposure assessment of occupational and environmental epidemiological studies of allergens, particulate matter, chlorination disinfection by-products, agricultural pesticides, and radiofrequencies.

Family based studies, including intergenerational, sibling and twin studies, are increasingly used to explore life course epidemiology. However, understanding the underlying assumptions of these studies and hence the inferences that can be drawn from them is complex. Further, there are issues relating to study design and the statistical analysis of family-based studies that are not well understood. This book provides in one volume the knowledge and skills required to design, analyse, and correctly interpret family based studies. The book is divided into four sections that cover the theoretical underpinning of using family based studies in life course epidemiology; practical issues of data collection, storage, and collaborative use (including a chapters on conducting such studies in low and middle income countries and the use of information provided by other family members); statistical analysis and correct interpretation of results from family based studies and a section that illustrates the use of these studies in life course epidemiology, with examples from three areas — cardiovascular disease, mental health and wellbeing, and reproductive health.