IJE Advance Access originally published online on January 17, 2008
International Journal of Epidemiology 2008 37(3):683-684; doi:10.1093/ije/dym297
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Letters to the Editor |
Take a walk on the wild side of social epidemiology
Ben Gurion University of the Negev, Beer-Sheva, Israel.
E-mail: jcwikel{at}bgu.ac.il
The recently published review of my textbook, ‘Social Epidemiology: Strategies for Public Health Activism’1 by J. Michael Oakes has some serious misconceptions.2 Prof. Oakes's own edited volume ‘Methods of Social Epidemiology’3 (together with Jay S. Kaufman) was reviewed in this same issue by Carme Borrell.4 Discerning readers of both reviews might have the strong suspicion that Prof. Oakes found it difficult to provide a balanced review of my book while at the same time needing to promote his own. For a pithy, engaging evaluation of my book written by an unbiased public health observer, please see Cullen's recent review.5
While claiming to want to develop tools in order to address ‘the most important public health concerns’ (p. xxi),3 the methodological volume constructed by Oakes and Kaufman bypasses the difficult issues that social epidemiologists face when they move from descriptive or analytic epidemiology heavy on number crunching to accruing ‘robust evidence’ and translating it into intervention strategies, combining both the science and the art of public health practice.6 For this, the activist social epidemiologist needs theory, accumulated evidence of the efficacy of interventions in diverse populations (see for example, Chapters 9 and 10 on intervention theory and the uses and abuses of meta-analysis1) and a selection of tools for the design, conduct and interpretation of public health interventions. Even Prof. Lisa Berkman, arguably one of the most prominent social epidemiologists today found that moving from descriptive epidemiology into cognitive behavioural interventions to reduce depression and social isolation following myocardial infarction does not guarantee evidence of intervention efficacy.7
It appears from his review that Prof. Oakes's style of social epidemiology and public health intervention evaluation is limited to a quick peep at P values. Out of the hundreds of interventions evaluated in the book, he questions the evidence base of two seminal studies,8,9 chosen in the introductory chapter for their theory-based interventions addressing difficult public health problems among hard to access populations, as well as their program efficacy.
Prof. Oakes narrowly assessed the impact of the ASAP (Alcohol Substance Abuse Prevention Program), where a series of evaluation studies were undertaken9–11 on a group of adolescent students selected from over thirty schools and communities in New Mexico and where a quantitative evaluation of perceived risk provided evidence of a statistically significant treatment effect.11 This ground-breaking intervention study was the inspiration for many subsequent substance abuse community trials (note its high citation rate in Google Scholar—195!) as well as the participatory, community methods featured in Chapter 10 ‘Community-based participatory research’ (CBPR) written by Lantz, Israel, Schulz and Reyes in Oakes and Kaufman's very own book.3
Indeed, the Lantz and co-authors conclude in this CBPR review in response to the question ‘Does CBPR work?’: ‘In a recent evidence-based review of the CBPR literature related to health ... . found evidence of enhanced research quality in eleven of the twelve completed intervention studies reviewed ... and improved intervention outcomes in two studies’. (pp. 259–60). Is this ‘evidence of actual harm reduction’?
Prof. Oakes also mistakenly characterized the study of an outreach program (Sex Industry Study—SIS) that succeeded in reaching street-based prostitutes in the early years of the HIV epidemic in the San Francisco Bay Area8 as an ‘observational, mostly qualitative survey’. He failed to recognize that this was a mixed methods (combining between qualitative and quantitative data collection) program evaluation, designed to document how sex workers were enrolled, interacted with staff, their risk attitudes and behaviours and to devise methods to help them reduce their STD risk. The methods developed in this study became the basis for delivering AIDS prevention and testing in other San Francisco Bay Area counties (as stated clearly on p. 11 of my book) as well as in numerous locations around the world.
Furthermore, Dr Oakes' views the use of non-probability (i.e. purposive) sampling methods as evidence of lack of rigour and empirical support. It has been acknowledged that the construction of a probability sampling frame for persons who are living and working on the streets, highly mobile and apprehensive of anyone who wants to get their real name or permanent address is exceptionally difficult.12,13 As Mutaner points out, hard to access populations are more appropriate for qualitative research methods than survey research in social epidemiology.13 Qualitative methods should be an integral part of social epidemiology, particularly in descriptive epidemiological studies which try to fathom why patients do not conform to public health or medical advice e.g.,14,15 an issue that Prof. Oakes has grabbled with in his own intervention trial.16 Interestingly enough, browsing through Dr Oakes's other published work reveals that he and his colleagues chose to use a convenience sample (recognized as the least robust of all sampling methods) of fast-food consumers to test whether nutrition labeling is recommended.17
My view of social epidemiology and the appropriate methods for addressing the pressing global public health issues clearly differ from Prof. Oakes's perspective. The ‘mixed message’ that is conveyed stems from my critical stance with regard to every methodological approach. In my book I debate the biases and fallacies associated with all types of research designs from analytic, empirical studies through to different types of qualitative research including among many other examples: the healthy worker effect, non-response in survey research, genetic determinism, faddism in research paradigms and caveats in conducting screening of populations. Each research methodology has its strong points and weaknesses and no one method is appropriate for all issues and populations that social epidemiology of 2007 should be able to address.
In this post-modern world we live in, there is room for more than one model of social epidemiology. There are many valuable chapters in Prof. Oakes and Kaufman's edited book, but a full component of tools in social epidemiology requires the whole gamut—theory, evidence-based practice, methodological tools and above all, fairness in academic research and publishing.
References
1 Cwikel JG. A Textbook of Social Epidemiology – Strategies for Public Health Activism (2006) New York: Columbia University Press.
2 Oakes JM. An activist's guide to (social) epidemiology – a book review of Social Epidemiology: Strategies for Public Health Activism. Int J Epidemiol (2007) 36:1152–54.
3 Oakes JM, Kaufman JS, eds. Methods in Social Epidemiology (2006) San Francisco, CA.: John Wiley & Sons.
4 Borrell C. Methods in Social Epidemiology – Book Review. Int J Epidemiol (2007) 36:1153–54.
5 Cullen MR. Social epidemiology: strategies for public health activism – Book Review. J Occup Environ Med (2007) 1176.
6 Kasl SV, Jones BA. Social epidemiology: towards a better understanding of the field. Int J Epidemiol (2002) 31:1094–97.
7 Berkman LF, Blumenthal J, Burg M, et al. Effects of treating depression, and low perceived social support on clinical events after myocardial infarction: the Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) Randomized Trial. JAMA (2003) 289:3106–16.
8 Dorfman LE, Derish PA, Cohen JB. Hey girlfriend: an evaluation of AIDS prevention among women in the sex industry. Health Educ Q (1992) 19:25–40.[Web of Science][Medline]
9 Wallerstein N, Sanchez-Merki V. Freirian praxis in health education: research results from an adolescent prevention program. Health Educ Res (1994) 9:105–18.
10 Wallerstein N, Martinez L. Empowerment evaluation: a case study of an adolescent substance abuse prevention program in New Mexico. Am J Eval (1994) 15:131–38.[CrossRef]
11 Bernstein E, Woodall WG. Changing perceptions of riskiness in drinking, drugs, and driving: an emergency department-based alcohol and substance abuse prevention program. Ann Emerg Med (1987) 16:1350–54.[CrossRef][Web of Science][Medline]
12 Cwikel J, Hoban E. Contentious issues in research on trafficked women working in the sex industry: study design, ethics and methodology. J Sex Res (2005) 42:1–11.[Web of Science]
13 Muntaner C, Gomez MB. Qualitative and quantitative research in social epidemiology: is complementarity the only issue? Gac Sanit (2003) 17(Suppl 3):53–57.[CrossRef][Medline]
14 Pound P, Britten N, Morgan M, et al. Resisting medicines: a synthesis of qualitative studies of medicine taking. Soc Sci Med (2005) 61:133–55.[CrossRef][Web of Science][Medline]
15 Campbell R, Pound P, Pope C, et al. Evaluating meta-ethnography: a synthesis of qualitative research on lay experiences of diabetes and diabetes care. Soc Sci Med (2003) 56:671–84.[CrossRef][Web of Science][Medline]
16 Wu BC, Oakes JM. randomized controlled trial of sport helmet interventions in a pediatric emergency department. Pediatr Emerg Care (2005) 21:730–35.[CrossRef][Web of Science][Medline]
17 O’Dougherty M, Harnack LJ, French SA, Story M, Oakes JM, Jeffery RW. Nutrition labeling and value size pricing at fast-food restaurants: a consumer perspective. Am J Health Promot (2006) 20:247–50.[Web of Science][Medline]
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  J Michael Oakes Response to Cwikel: keeping it real on the wild side Int. J. Epidemiol., June 1, 2008; 37(3): 684 - 685. [Full Text] [PDF]
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