824
INTERNATIONAL JOURNAL OF EPIDEMIOLOGY
multiplicative relative risks I do not believe that the reinterpretation that they suggest is necessary. In answer to Holman and Armstrong's final question, I would reply that a real practical problem exists when a prestigious government report concludes that of the 197 male pharyngeal cancer deaths, 127 were caused by alcohol and 151 by tobacco. REFERENCES 1
2
3
Walter S D. Prevention for multifactorial disease. Am J Epidemiol 1980; 112: 409-16. Collins D C, Lapsley H. Estimating the Economic Costs of Drug Abuse in Australia. Commonwealth Department of Community Services and Health, Australian Government Publishing Service, Canberra, March 1991. Coughlin S S, Nass C C, Pickle L W el al. Regression methods for estimating attributable risk in population-based case-control studies: A comparison of additive and multiplicative models. Am J Epidemiol 1991; 133: 305-13.
Utilization of Research From MALCOLM MACLURE Sir—In the column 'News from the World Health Organization',1 the authors from the Unit of Strengthening of Epidemiological and Statistical Services at WHO lamented the fact that epidemiological data are under-used by policy-makers. They said 'The reasons for this inadequate linkage of science and health care policy have not been adequately explored, but it would be reasonable to assume that they might include one or more of the following: the quality of the data, their analyses or their presentation; a lack of understanding on the part of decision-makers of the value, actual or potential, of epidemiological information; and poor communication between providers of epidemiological information and decision-makers.' In fact, a good deal of research has been done on the topic of research utilization. In the 1970s, several US agencies that sponsored research, including the National Institute of Mental Health, became disappointed with the low impact of expensive research projects they had supported. The agencies then sponsored some case studies, user surveys and workshops on utilization of research. A small literature developed.2"10 The following are some findings:
Nature of Research: Whether research was high or low in quality was not a major influence on utilization. Qualitative research had more impact than quantitative research because users could relate to concrete examples better than to abstract numbers.
Department of Epidemiology, Harvard University School of Publk Health, Boston, MA 02115, USA. Current address: Research and Evaluation Branch, Ministry of Health Victoria, British Columbia, V8W 3C8, Canada,
Organizational Context: Utilization was low if there was a policy vacuum or unclear jurisdictions.
Interface between Researcher and Decision-maker: Some authors report that the development of the role of knowledge-broker (i^e. an interpreter or translator) between researcher and user did not solve the problem. Go-betweens tended to be co-opted by the decision-maker and the communication gap recurred. Existence of a cultural difference between supplier and user was a factor, but not a sufficient explanation because lack of utilization often occurred when decision-makers were former researchers. A major predictor of utilization was relevance to narrow self-interest of decision-makers. Involvement of decision-makers at the beginning, even if their contribution was minimal, greatly increased their receptiveness later.
Downloaded from http://ije.oxfordjournals.org/ at University of California, Santa Barbara on July 3, 2015
worth noting that the overallfiguresare extremely sensitive to assumptions concerning IHD. For all diseases other than IHD Holman and Armstrong obtained post 65 risks by extrapolating pre 65 risks, while for IHD they set the post 60 relative risk to 1. If IHD had been treated in a consistent manner to the other diseases then instead of causing 5360 deaths overall, alcohol would have been found to save 1050 lives overall. Because of this extreme sensitivity of the overall figure to IHD assumptions it may not be useful to debate the fine points of the other diseases. However, I agree with Holman and Armstrong that their analysis considerably understates the IHD deaths caused by tobacco. I have tried a variety of adjusted estimators on this data and obtained a reduction in the alcohol deaths and a large increase in the tobacco deaths. Holman and Armstrong also question my use of multiplicative relative risk. Since I have assumed
825
LETTERS TO THE EDITOR
Utilization was facilitated by the researcher understanding the processes by which an organization changes its behaviours. Authors of a thorough review3 made some apt recommendations which can be summarised as follows:
Discussion Many of the conclusions are reminiscent of the fallacy that 'the world will beat a path to the door of the inventor of a better mouse trap.' If researchers want their consumers to use their products, they need to do market research, consider the timing and context of users' decisions, promote demand not just the supply side, understand the emotions of users, help users to use the products after they have bought them, involve users in the design, and solicit continual feedback from the user. As in marketing, the best mix of these tools for increasing utilization is found by trial
REFERENCES 1
Anonymous. Newi from the World Health Organization. Int J Epidemiol 1992; 21: 195. 2 Bedell J R. Ward J C Jr, Archer R P, Stokes M K. An empirical evaluation of a model of knowledge utilization. Eval Rev 1985; 9: 109-26. 3 Beyer J M, Trice H M. The utilization process: a conceptual framework and synthesis of empirical findings. Admin Sci Q 1982; 27: 951-22. 4 Bigdow D A. The impact of therapeutic effectiveness data on community mental health center management: the ivstcmi evaluation project. Comm Ment Health J 1975; 11: 64-73. 5 Corwin R C, Louis K S. Organizational barriers to the utilization of research. Admin Scl Q 1982; 27: 623-40. 6 Leviton L C, Hughes E F X. Research on utilization of evaluations: a review and synthesis. Eval Rev 1981; S: 525-48. 7 Majchrazak A. Information focus and data sources: when will they lead to use? Eval Rev 1986; 10: 193-215. 8 Morgan T K. Research and managerial strategies for integrating evaluation research into agency decision making. Eval Rev 1987; 11: 612-30. ' Patton M Q. Utilization-Focused Evaluation. Second edition. London: Sage, 1987. 10 Siegd K, Tuckel P. The utilization of evaluation research: a caseanalysis. Eval Rev 1985; 3: 307-28. " Goodman C, Baratz S R (ed). Improving Consensus Development for Health Technology Assessment: A n International Perspective. Washington: National Academy Press, 1990. 12 Lomas J, Enkin M, Anderson O M, Hannah W J, Vayda E, Singer J. Opinion leaders vs audit and feedback to implement practice guideline!: delivery after previous cesarean section. JAMA 1991; 165: 2202-07.
Privacy, Confidentiality and Epidemiology: The Dutch Ordeal From J P VANDENBROUCKE Sir—A spectre haunts Europe. While political sensitivity to privacy and confidentiality varies greatly according to times and countries, unprecedented heights are being reached in the Netherlands. The greatest danger is not anymore to epidemiology in that small country, but the spill-over to the remainder of Europe. Department of Clinical Epidemiology, Leiden University Hospital, Bldg 1, CO - P, PO Box 9600, 2300 RC Leiden, The Netherlands. * Available on request from IJE Editorial Assistant or from Professor J P Vandenbroucke.
Roughly two decades ago population census surveys weTe judged unnecessary intrusions in the private lives of citizens and are no longer held in the Netherlands. More recently, completely anonymous HIV seroprevalence surveys have been pronounced unlawful by the Ministry of Health. In the Central Bureau of Statistics, the repository of Dutch death certificates, a modicum of liberal common sense still prevailed in the 1970s—nowadays, the negotiations that are necessary to link death certificates to other information have
Downloaded from http://ije.oxfordjournals.org/ at University of California, Santa Barbara on July 3, 2015
(a) Information processing: Researchers should be self-advocates; they should use qualitative information to make quantitative results more convincing. (b) Affective bonding: Researchers should understand the self-interest of users; involvement of users in research may be as important for the bonding between researcher and user as for its impact on cognition. (c) Strategy formulation and control: Researchers should avoid absolutes and explore political realities before proposing designs; they should use their knowledge to negotiate the conflict between research principle and narrow self-serving interests. (d) Action generation: Researchers should immerse themselves in their phenomena; they should not delegate all data collection but do some themselves; they should cultivate opportunities to observe people behaving in organizations.
and error, and depends on the type of product and application, and the personalities of users. However, the onus is on researchers to learn the general principles from the research on utilization. New lines of research on utilization include evaluation of consensus conferences" and methods for implementing medical practice guidelines.12
INTERNATIONAL JOURNAL OF EPIDEMIOLOGY
multiplicative relative risks I do not believe that the reinterpretation that they suggest is necessary. In answer to Holman and Armstrong's final question, I would reply that a real practical problem exists when a prestigious government report concludes that of the 197 male pharyngeal cancer deaths, 127 were caused by alcohol and 151 by tobacco. REFERENCES 1
2
3
Walter S D. Prevention for multifactorial disease. Am J Epidemiol 1980; 112: 409-16. Collins D C, Lapsley H. Estimating the Economic Costs of Drug Abuse in Australia. Commonwealth Department of Community Services and Health, Australian Government Publishing Service, Canberra, March 1991. Coughlin S S, Nass C C, Pickle L W el al. Regression methods for estimating attributable risk in population-based case-control studies: A comparison of additive and multiplicative models. Am J Epidemiol 1991; 133: 305-13.
Utilization of Research From MALCOLM MACLURE Sir—In the column 'News from the World Health Organization',1 the authors from the Unit of Strengthening of Epidemiological and Statistical Services at WHO lamented the fact that epidemiological data are under-used by policy-makers. They said 'The reasons for this inadequate linkage of science and health care policy have not been adequately explored, but it would be reasonable to assume that they might include one or more of the following: the quality of the data, their analyses or their presentation; a lack of understanding on the part of decision-makers of the value, actual or potential, of epidemiological information; and poor communication between providers of epidemiological information and decision-makers.' In fact, a good deal of research has been done on the topic of research utilization. In the 1970s, several US agencies that sponsored research, including the National Institute of Mental Health, became disappointed with the low impact of expensive research projects they had supported. The agencies then sponsored some case studies, user surveys and workshops on utilization of research. A small literature developed.2"10 The following are some findings:
Nature of Research: Whether research was high or low in quality was not a major influence on utilization. Qualitative research had more impact than quantitative research because users could relate to concrete examples better than to abstract numbers.
Department of Epidemiology, Harvard University School of Publk Health, Boston, MA 02115, USA. Current address: Research and Evaluation Branch, Ministry of Health Victoria, British Columbia, V8W 3C8, Canada,
Organizational Context: Utilization was low if there was a policy vacuum or unclear jurisdictions.
Interface between Researcher and Decision-maker: Some authors report that the development of the role of knowledge-broker (i^e. an interpreter or translator) between researcher and user did not solve the problem. Go-betweens tended to be co-opted by the decision-maker and the communication gap recurred. Existence of a cultural difference between supplier and user was a factor, but not a sufficient explanation because lack of utilization often occurred when decision-makers were former researchers. A major predictor of utilization was relevance to narrow self-interest of decision-makers. Involvement of decision-makers at the beginning, even if their contribution was minimal, greatly increased their receptiveness later.
Downloaded from http://ije.oxfordjournals.org/ at University of California, Santa Barbara on July 3, 2015
worth noting that the overallfiguresare extremely sensitive to assumptions concerning IHD. For all diseases other than IHD Holman and Armstrong obtained post 65 risks by extrapolating pre 65 risks, while for IHD they set the post 60 relative risk to 1. If IHD had been treated in a consistent manner to the other diseases then instead of causing 5360 deaths overall, alcohol would have been found to save 1050 lives overall. Because of this extreme sensitivity of the overall figure to IHD assumptions it may not be useful to debate the fine points of the other diseases. However, I agree with Holman and Armstrong that their analysis considerably understates the IHD deaths caused by tobacco. I have tried a variety of adjusted estimators on this data and obtained a reduction in the alcohol deaths and a large increase in the tobacco deaths. Holman and Armstrong also question my use of multiplicative relative risk. Since I have assumed
825
LETTERS TO THE EDITOR
Utilization was facilitated by the researcher understanding the processes by which an organization changes its behaviours. Authors of a thorough review3 made some apt recommendations which can be summarised as follows:
Discussion Many of the conclusions are reminiscent of the fallacy that 'the world will beat a path to the door of the inventor of a better mouse trap.' If researchers want their consumers to use their products, they need to do market research, consider the timing and context of users' decisions, promote demand not just the supply side, understand the emotions of users, help users to use the products after they have bought them, involve users in the design, and solicit continual feedback from the user. As in marketing, the best mix of these tools for increasing utilization is found by trial
REFERENCES 1
Anonymous. Newi from the World Health Organization. Int J Epidemiol 1992; 21: 195. 2 Bedell J R. Ward J C Jr, Archer R P, Stokes M K. An empirical evaluation of a model of knowledge utilization. Eval Rev 1985; 9: 109-26. 3 Beyer J M, Trice H M. The utilization process: a conceptual framework and synthesis of empirical findings. Admin Sci Q 1982; 27: 951-22. 4 Bigdow D A. The impact of therapeutic effectiveness data on community mental health center management: the ivstcmi evaluation project. Comm Ment Health J 1975; 11: 64-73. 5 Corwin R C, Louis K S. Organizational barriers to the utilization of research. Admin Scl Q 1982; 27: 623-40. 6 Leviton L C, Hughes E F X. Research on utilization of evaluations: a review and synthesis. Eval Rev 1981; S: 525-48. 7 Majchrazak A. Information focus and data sources: when will they lead to use? Eval Rev 1986; 10: 193-215. 8 Morgan T K. Research and managerial strategies for integrating evaluation research into agency decision making. Eval Rev 1987; 11: 612-30. ' Patton M Q. Utilization-Focused Evaluation. Second edition. London: Sage, 1987. 10 Siegd K, Tuckel P. The utilization of evaluation research: a caseanalysis. Eval Rev 1985; 3: 307-28. " Goodman C, Baratz S R (ed). Improving Consensus Development for Health Technology Assessment: A n International Perspective. Washington: National Academy Press, 1990. 12 Lomas J, Enkin M, Anderson O M, Hannah W J, Vayda E, Singer J. Opinion leaders vs audit and feedback to implement practice guideline!: delivery after previous cesarean section. JAMA 1991; 165: 2202-07.
Privacy, Confidentiality and Epidemiology: The Dutch Ordeal From J P VANDENBROUCKE Sir—A spectre haunts Europe. While political sensitivity to privacy and confidentiality varies greatly according to times and countries, unprecedented heights are being reached in the Netherlands. The greatest danger is not anymore to epidemiology in that small country, but the spill-over to the remainder of Europe. Department of Clinical Epidemiology, Leiden University Hospital, Bldg 1, CO - P, PO Box 9600, 2300 RC Leiden, The Netherlands. * Available on request from IJE Editorial Assistant or from Professor J P Vandenbroucke.
Roughly two decades ago population census surveys weTe judged unnecessary intrusions in the private lives of citizens and are no longer held in the Netherlands. More recently, completely anonymous HIV seroprevalence surveys have been pronounced unlawful by the Ministry of Health. In the Central Bureau of Statistics, the repository of Dutch death certificates, a modicum of liberal common sense still prevailed in the 1970s—nowadays, the negotiations that are necessary to link death certificates to other information have
Downloaded from http://ije.oxfordjournals.org/ at University of California, Santa Barbara on July 3, 2015
(a) Information processing: Researchers should be self-advocates; they should use qualitative information to make quantitative results more convincing. (b) Affective bonding: Researchers should understand the self-interest of users; involvement of users in research may be as important for the bonding between researcher and user as for its impact on cognition. (c) Strategy formulation and control: Researchers should avoid absolutes and explore political realities before proposing designs; they should use their knowledge to negotiate the conflict between research principle and narrow self-serving interests. (d) Action generation: Researchers should immerse themselves in their phenomena; they should not delegate all data collection but do some themselves; they should cultivate opportunities to observe people behaving in organizations.
and error, and depends on the type of product and application, and the personalities of users. However, the onus is on researchers to learn the general principles from the research on utilization. New lines of research on utilization include evaluation of consensus conferences" and methods for implementing medical practice guidelines.12
