- Email: [email protected]
The Multiple Layers of Prevention Science Research
Letters to the Editor
The Multiple Layers of Prevention Science Research To the editors: I read with interest the paper by MacQueen and Cates1 in the June 2005 issue of the American Journal of Preventive Medicine, which proposed a “systematic framework for prevention science clinical research.” I share their frustration with the current status of preventive and public health research, but urge consideration of a different approach to this problem. Their model may be a poor fit with the environmental constraints of state and local public health settings. The MacQueen and Cates1 model involves five elements (advocacy, community awareness, theory, acceptability, and operations), each with three phases (conceptual, experimental, and applied). While this model may fit pharmaceutical interventions that can be readily studied by traditional randomized control trials, such as two examples that they provide (emergency contraception and topical microbicides), preventive interventions involving health education, behavioral change, environmental modification, and changes in the way health services are reimbursed do not easily lend themselves to experimental manipulation. This is especially true if one considers that many such interventions, to be effective, must be customized to the local community, and must also be integrated with multiple simultaneous interventions if substantive changes in behavior and improved clinical outcomes are to be secured. I suggest a different approach to prevention research, along the following lines: In place of the current five elements of the MacQueen–Cates model, four domains could be considered: (1) “political,” having to do with value judgments and the self-interest of the various major stakeholders; (2) “administrative,” having to do with cost-related and pro-
gram management issues; (3) “technical,” related to medical and public health science; and (4) “personal idiosyncrasy,” having to do with organizational culture, internal and external to medical, public health and academic institutions, and fixed beliefs by key individuals that may be strongly held, but have little to do with the mission of the sponsoring agency or organization. These four domains would then be addressed in a sequential manner—technical, followed by administrative, political, and personal idiosyncrasy, in that order—to conceptualize the desired program, and then work through the levels needed to implement the program to see if it works. Research based on this model would be more qualitative than quantitative. For the technical domain, the focus would be on the biological plausibility of the proposed intervention or sets of interventions generating the desired health benefits, with quantitative estimates of such benefits based on other research and our best understanding of the etiology and natural history of the condition in question. The other three domains would have to be addressed on the basis of theoretical considerations drawn from qualitative and quasiexperimental methods of research in political science, public administration, and related fields of study. The final step in adopting this model would be development of appropriate study design and reporting guidelines that would facilitate comparison of studies that employed this approach. Joel L. Nitzkin, MD, MPH, DPA JLN, MD Associates, LLC, New Orleans, Louisiana E-mail: [email protected]
Reference 1. MacQueen KM, Cates W Jr. The multiple layers of prevention science research. Am J Prev Med 2005;28:491–5.
Am J Prev Med 2006;30(1) © 2006 American Journal of Preventive Medicine • Published by Elsevier Inc.
0749-3797/06/$–see front matter doi:10.1016/j.amepre.2005.10.010
101
The Multiple Layers of Prevention Science Research To the editors: I read with interest the paper by MacQueen and Cates1 in the June 2005 issue of the American Journal of Preventive Medicine, which proposed a “systematic framework for prevention science clinical research.” I share their frustration with the current status of preventive and public health research, but urge consideration of a different approach to this problem. Their model may be a poor fit with the environmental constraints of state and local public health settings. The MacQueen and Cates1 model involves five elements (advocacy, community awareness, theory, acceptability, and operations), each with three phases (conceptual, experimental, and applied). While this model may fit pharmaceutical interventions that can be readily studied by traditional randomized control trials, such as two examples that they provide (emergency contraception and topical microbicides), preventive interventions involving health education, behavioral change, environmental modification, and changes in the way health services are reimbursed do not easily lend themselves to experimental manipulation. This is especially true if one considers that many such interventions, to be effective, must be customized to the local community, and must also be integrated with multiple simultaneous interventions if substantive changes in behavior and improved clinical outcomes are to be secured. I suggest a different approach to prevention research, along the following lines: In place of the current five elements of the MacQueen–Cates model, four domains could be considered: (1) “political,” having to do with value judgments and the self-interest of the various major stakeholders; (2) “administrative,” having to do with cost-related and pro-
gram management issues; (3) “technical,” related to medical and public health science; and (4) “personal idiosyncrasy,” having to do with organizational culture, internal and external to medical, public health and academic institutions, and fixed beliefs by key individuals that may be strongly held, but have little to do with the mission of the sponsoring agency or organization. These four domains would then be addressed in a sequential manner—technical, followed by administrative, political, and personal idiosyncrasy, in that order—to conceptualize the desired program, and then work through the levels needed to implement the program to see if it works. Research based on this model would be more qualitative than quantitative. For the technical domain, the focus would be on the biological plausibility of the proposed intervention or sets of interventions generating the desired health benefits, with quantitative estimates of such benefits based on other research and our best understanding of the etiology and natural history of the condition in question. The other three domains would have to be addressed on the basis of theoretical considerations drawn from qualitative and quasiexperimental methods of research in political science, public administration, and related fields of study. The final step in adopting this model would be development of appropriate study design and reporting guidelines that would facilitate comparison of studies that employed this approach. Joel L. Nitzkin, MD, MPH, DPA JLN, MD Associates, LLC, New Orleans, Louisiana E-mail: [email protected]
Reference 1. MacQueen KM, Cates W Jr. The multiple layers of prevention science research. Am J Prev Med 2005;28:491–5.
Am J Prev Med 2006;30(1) © 2006 American Journal of Preventive Medicine • Published by Elsevier Inc.
0749-3797/06/$–see front matter doi:10.1016/j.amepre.2005.10.010
101