# Presentation: 205160

## Overview of Public Health Surveillance and Epidemiology of Substance Abuse Prevention

- Kevin P. Mulvey
- Chief, Practice Assessment and Applications Branch
- Division of Knowledge Application and Systems Improvement
- Centers for Substance Abuse Prevention

## Public Health Approach

- Problem

- Response

- Intervention
- Evaluation:
- What
- works?

- Implementation:
- How do you
- do it?

## Public Health Surveillance

**Ongoing, systematic collection, analysis, and interpretation of health-related data essential to the planning, implementation, and evaluation of public health practice, closely integrated with the timely dissemination of these data to those responsible for prevention and control.**

## Public Health Surveillance

**Systematic, ongoing**
**Collection**
**Analysis**
**Interpretation**
**Dissemination**
**Link to public health practice**

## Purposes of Public Health Surveillance

**Assess public health status**
**Define public health priorities**
**Evaluate programs**
**Stimulate research**

## Core Public Health Functions

**Assessment**
**Policy development**
**Assurance**

## Surveillance

**Information for Action**

## Uses of Public Health Surveillance

**Estimate magnitude of the problem**
**Determine geographic distribution of illness**
**Portray the natural history of a disease**
**Detect epidemics/define a problem**
**Generate hypotheses, stimulate research**
**Evaluate control measures**
**Monitor changes in infectious agents**
**Detect changes in health practices**
**Facilitate planning**

## Uses of Public Health Surveillance

**Estimate magnitude of the problem**
**Determine geographic distribution of illness**
**Portray the natural history of a disease**
**Detect epidemics/define a problem**
**Generate hypotheses, stimulate research**
**Evaluate control measures**
**Monitor changes in infectious agents**
**Detect changes in health practices**
**Facilitate planning**

## DATA PRESENTED 	

- SOME OF THE DATA PRESENTED ARE FICTICIOUS AND ARE SOLELY PRESENTED AS EXAMPLES.
- LOCAL RESOURCES AND DATA MUST BE SOUGHT OUT IN ORDER TO DEVELOP A LOCAL PICTURE.

##                                                                                                                                                                                                                                                                                 D

**Figure 1. Past Month Illicit Drug Use among Persons Aged 12 or Older, **
**by Age: 2004**
-                                                                                                                                                                                                                                                                                 _[D](http://oas.samhsa.gov/nsduh/2k4nsduh/2k4overview/fig1alt.htm)_
**Overview of Findings from the 2004 National Survey on Drug   **
**           ****Use and Health** (OAS Publications)

## Uses of Public Health Surveillance

**Estimate magnitude of the problem**
**Determine geographic distribution of illness**
**Portray the natural history of a disease**
**Detect epidemics/define a problem**
**Generate hypotheses, stimulate research**
**Evaluate control measures**
**Monitor changes in infectious agents**
**Detect changes in health practices**
**Facilitate planning**

## HEPATITIS A

**Reported cases per 100,000 population,**
**United States and U.S. territories, 2002**

- Source:  CDC. Summary of notifiable diseases. 2002.

## Uses of Public Health Surveillance

**Estimate magnitude of the problem**
**Determine geographic distribution of illness**
**Portray the natural history of a disease**
**Detect epidemics/define a problem**
**Generate hypotheses, stimulate research**
**Evaluate control measures**
**Monitor changes in infectious agents**
**Detect changes in health practices**
**Facilitate planning**

**Use and Health** (NHSDA/NSDUH)

**Figure 17. Past Month Marijuana Use among Youths Aged 12 to 17: 1971-2004**

## Methamphetamine Use

**Reported Admissions to Treatment, by year, **
**United States, 1993-2003**

- Source:  Data are fictitious.

## Uses of Public Health Surveillance

**Estimate magnitude of the problem**
**Determine geographic distribution of illness**
**Portray the natural history of a disease**
**Detect epidemics/define a problem**
**Generate hypotheses, stimulate research**
**Evaluate control measures**
**Monitor changes in infectious agents**
**Detect changes in health practices**
**Facilitate planning**

## The New DAWN Report – Special Topics

**Emergency Department Visits Involving Underage Drinking** (DAWN)

**Figure 1. Underage alcohol-related ED visits**

## Uses of Public Health Surveillance

**Estimate magnitude of the problem**
**Determine geographic distribution of illness**
**Portray the natural history of a disease**
**Detect epidemics/define a problem**
**Generate hypotheses, stimulate research**
**Evaluate control measures**
**Monitor changes in infectious agents**
**Detect changes in health practices**
**Facilitate planning**

## Overview of Findings from the 2004 National Survey on Drug   

**Overview of Findings from the 2004 National Survey on Drug   **
**Use and Health** (OAS Publications)

## Figure 2. Percentages of Males Aged 18 to 25 Who Reported Heavy Alcohol Use, Binge Alcohol Use, and Illicit Drugs in the Past Month, by Race/Ethnicity: 2002, 2003, and 2004 

## Uses of Public Health Surveillance

**Estimate magnitude of the problem**
**Determine geographic distribution of illness**
**Portray the natural history of a disease**
**Detect epidemics/define a problem**
**Generate hypotheses, stimulate research**
**Evaluate control measures**
**Monitor changes in infectious agents**
**Detect changes in health practices**
**Facilitate planning**

**Overview of Findings from the 2004 National Survey on Drug   **
**Use and Health** (OAS Publications)

## Uses of Public Health Surveillance

**Estimate magnitude of the problem**
**Determine geographic distribution of illness**
**Portray the natural history of a disease**
**Detect epidemics/define a problem**
**Generate hypotheses, stimulate research**
**Evaluate control measures**
**Monitor changes in drug use or infectious agents**
**Detect changes in health practices**
**Facilitate planning**

## 1993-2003 Treatment Episode Data Set (TEDS) Report of Substance Abuse Treatment Admissions

| Figure 1Primary substance of abuse at admission:TEDS 1993-2003 |
| --- |
|                                                                                                                                                                                           |

**Figure 1****Primary substance of abuse at admission:****TEDS 1993-2003**

## Uses of Public Health Surveillance

**Estimate magnitude of the problem**
**Determine geographic distribution of illness**
**Portray the natural history of a disease**
**Detect epidemics/define a problem**
**Generate hypotheses, stimulate research**
**Evaluate control measures**
**Monitor changes in infectious agents**
**Detect changes in health practices**
**Facilitate planning**

**Overview of Findings from the 2004 National Survey on Drug   **
**           ****Use and Health** (OAS Publications)

## Uses of Public Health Surveillance

**Estimate magnitude of the problem**
**Determine geographic distribution of illness**
**Portray the natural history of a disease**
**Detect epidemics/define a problem**
**Generate hypotheses, stimulate research**
**Evaluate control measures**
**Monitor changes in infectious agents**
**Detect changes in health practices**
**Facilitate planning**

## 1993-2003 Treatment Episode Data Set (TEDS) Report of Substance Abuse Treatment Admissions

**1993-2003 Treatment Episode Data Set (TEDS) Report of Substance Abuse Treatment Admissions**

**Figure 2****Co-abuse of alcohol and drugs at admission: TEDS 1993-2003**

## Causal Pathway of Disease or Disability

**Environment (pre-exposure)**
**Hazard/agent**
**Behavior/risk factor**
**Exposure**
**Pre-symptomatic phase**
**Apparent disease**
**Death**

## Selected Sources of Data

**Environmental monitoring systems**
**Animals/vectors**
**Individuals**
**Laboratories**
**Medical records**
**Administrative records**
**Police records**
**Birth/death certificates**

## Data Sources and Methods for Surveillance

**Notifiable diseases**
**Laboratory specimens**
**Vital records**
**Sentinel surveillance**
**Registries**
**Surveys**
**Administrative data systems**
**Other data sources**

## Passive vs. Active Surveillance

**Passive  **
**- Provider-initiated**
**Active  **
**- Health Department-initiated**

## Data Sources

**Notifiable diseases**
**Laboratory specimens**
**Vital records**
**Sentinel surveillance**
**Registries**
**Surveys**
**Administrative data systems**
**Other data sources**

## Use of Data Systems for Surveillance

**National Infant Mortality Surveillance (NIMS)**
**National Household Survey on Drug Use and Health**
**Drug Abuse Warning Network**
**Monitoring the Future**
**Youth Behavioral Risk Factors Survey**

## Data Sources

**Notifiable diseases**
**Laboratory specimens**
**Vital records**
**Sentinel surveillance**
**Registries**
**Surveys**
**Administrative data systems**
**Other data sources**

## Sentinel Surveillance

**Monitoring of key health events through sentinel:**
**Sites**
**Events**
**Providers**
**Vectors/animals**

##                                                                                                                                                                                                      Source: SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 2002 and 2003.

-                                                                                                                                                                                                      Source: SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 2002 and 2003.

## Data Sources

**Notifiable diseases**
**Laboratory specimens**
**Vital records**
**Sentinel surveillance**
**Registries**
**Surveys**
**Administrative data systems**
**Other data sources**

## HIV Cases

**HIV Cases**
**United States, 1973-1994**
** ****Incidence and U.S. Mortality**

## Monitoring Programs

**Vital records**
**Hospital discharge summaries**
**Hospital records (active abstraction)**

## Data Sources

**Notifiable diseases**
**Laboratory specimens**
**Vital records**
**Sentinel surveillance**
**Registries**
**Surveys**
**Administrative data systems**
**Other data sources**

## Use of NCHS Data Systems for Surveillance

**Population-based surveys**
**National Health Interview Survey**
**National Health and Nutrition Examination Survey**
**Provider-based surveys**
**National Hospital Discharge Survey**
**National Ambulatory Medical Care Survey**
** ****Drug Abuse Warning Network**

## Data Sources

**Notifiable diseases**
**Laboratory specimens**
**Vital records**
**Sentinel surveillance**
**Registries**
**Surveys**
**Administrative data systems**
**Other data sources**

## Data Sources

**Notifiable diseases**
**Laboratory specimens**
**Vital records**
**Sentinel surveillance**
**Registries**
**Surveys**
**Administrative data systems**
**Other data sources**

## Other Data Useful for Surveillance

**Monitoring the Future**
**Behavioral Risk Factors Survey**
**Youth Behavioral Risk Factors Survey**
**Miscellaneous**

## Information Loop of Public Health Surveillance

**Information Loop of Public Health Surveillance**

## Evaluation Research

- What is it, and what does it involve?
- A different example but the same principles

## Evaluation Research: What is it?

- It allows us to see if what we want a program to accomplish is being accomplished.

- In order to know whether social programs work, or how they work, we have to evaluate them systematically and fairly, whether we personally like the program or not.

**Notes:**
Evaluation research itself is really just a systematic approach to feedback; it strengthens the feedback loop through credible analyses of program operations and outcomes. 

## Here’s Your Mission:

**Here’s Your Mission:**

- You and your team of highly skilled social scientists have been hired to evaluate the effectiveness of a pet-assisted therapy program.

**Notes:**
also broadens this loop to include connections to parties outside of the program itself. A funding agency or political authority may mandate the research, outside experts may be brought in to conduct the research, and the evaluation research findings may be released to the public, or at least funders, in a formal report.  

##  The process of evaluation research is a simple systems model 

- 	In your mission, *nursing home patients,* who receive the pet-assisted therapy, are the cases or “inputs.” So are the *pets* and any other *resources* included in the process.

**Notes:**
First, clients, customers, students or some other persons or units - cases - enter the program, as “inputs.” (You’ll notice that this model regards programs as machines, with clients – people – seen as raw materials to be processed!) 

## The program process, the complete treatment or service delivered by the program, is...

- ...the act of bringing the pets to the nursing home to meet and interact with the patients.

**Notes:**
Next, some service or treatment is provided to the cases. This process of service delivery may be simple or complicated, short or long, but it is designed to have some impact on the cases, as “inputs” are consumed and outputs are produced. 

## The program outputs are the total number of patients who received pet-assisted therapy

**Notes:**
The direct product of the program’s service delivery process is its output.  Program outputs may include clients served, case managers trained, food parcels delivered, or arrests made. The program outputs may be desirable in themselves, but they primarily serve to indicate that the program is operating. 

## So then, what’s the outcome?

- Happier and healthier patients!

**Notes:**
Program outcomes indicate the impact of the program on the cases that have been processed. Outcomes can range from improved test scores or higher rates of job retention to fewer criminal offenses and lower rates of poverty. There are likely to be multiple outcomes of any social program, some intended and some unintended, some positive and others that are viewed as negative. 

## How in the world would you measure such an outcome?

- Ask them questions about their happiness.
- Monitor use of antidepressants, etc.
- Measure blood pressures, heart rates, and more!

**Notes:**
In other words, how would we operationalize the outcome of pet-assisted therapy?

## You and your team of social scientists might want to measure other feedback related to the therapy.

- In other words, you would want to collect information about:
-  how the pets interact with the patients
-  which pets seem to offer more or better therapy than others
-  which patients respond to pet-assisted therapy better than others and more.

**Notes:**
Variation in both outputs and outcomes in turn influence the inputs to the program through a feedback process.  Without feedback, if not enough clients are being served, recruitment of new clients may increase. If too many negative side effects result from a trial medication, the trials may be limited or terminated. If a program does not appear to lead to improved outcomes, clients may go elsewhere. 

## In the end, you will need to report your findings to all program stakeholders.

**Notes:**
The evaluation process as a whole, and the feedback in particular, can only be understood in relation to the interests and perspectives of program stakeholders. Stakeholders are those individuals and groups who have some basis of concern for the program. 

## In this case, who might they be?

- Medical professionals monitoring the patients
- Patients’ families
- Animal shelters or organizations providing the pets and handlers
- Any agency helping fund the program

**Notes:**
Some may fund the evaluation, some may provide research data, some may review, even approve, the research report (Martin and Kettner, 1996:3). Who the program stakeholders are, and what role they play in the program evaluation, can have tremendous consequences for the research.  

## Evaluation research itself is really just a systematic approach to feedback 

## For more information about pet-assisted therapy...

- ...contact your local animal shelter!