EvidenceBased Public Health: A Course in Chronic Disease Prevention Module 1: Introduction

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Evidence-Based Public Health A Course in
Chronic Disease Prevention Module 1
Introduction
March 2004
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Acknowledgements

• National Work Group Members
• R. Brownson
• C. Maylahn
• D. Nichols
• M. ONeall
• D. Porterfield
• P. Siegel
• C. Stanwyck

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Acknowledgements

• Thanks to Garland Land Missouri Department of
  Health and Senior Services
• Funding and technical support from the Chronic
  Disease Directors and the Centers for Disease
  Control and Prevention
• A special plug for CDD

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Overview

• Introductions, Ground Rules, Course Objectives
• Notebooks/Readings
• Obesity, physical activity, nutrition, other
  examples
• Background and Definitions
• differences between EBM and EBPH
• contrast types of evidence
• selected definitions
• overview of tools/processes
• challenges and barriers

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Introductions

• Course Director
• Ross Brownson
• Course Coordinator
• Lori Hattan
• Distance technology/train-the-trainer
• Margret ONeall

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Instructors

• Ross Brownson
• Terry Leet
• Kathy Gillespie
• Beth Baker

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Overview (cont)

• Background and Definitions
• differences between EBM and EBPH
• contrast types of evidence
• selected definitions
• overview of tools/processes
• challenges and barriers

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Ground Rules

• Attendance
• leave cell phones, beepers on stun
• Active Participation is Sought
• all questions are welcome
• No Tests

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Ground Rules (cont)

• Formative Feedback to Instructors
• After Sessions, Commit to Trying It Out/Using
  Readings
• you and/or staff
• in many cases, we hope this amounts to
  train-the-trainer

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Participant Introductions

• Admiral Stockdale
• Examples of challenges apply evidence-based
  methods in public health practice

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. . . If we did not respect the evidence, we
would have very little leverage in our quest for
the truth. Carl Sagan
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Course Objectives

• MODULE 1 INTRODUCTION AND OVERVIEW
• Understand the basic concepts of evidence-based
  decision making.
• Introduce some sources and types of evidence.
• Describe several applications within public
  health practice that are based on strong evidence
  and several that are based on weak evidence.
• Define some barriers to evidence-based decision
  making in public health settings.

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Course Objectives

• MODULE 2 DEVELOPING AN INITIAL, CONCISE,
  OPERATIONAL STATEMENT OF THE ISSUE

• Understand the overall strategic planning process
  for setting priorities in public health.
• Develop a concise written statement of the public
  health problem, issue or policy under
  consideration in a measurable manner.
• 3. Understand a criterion for the components of a
  sound problem statement.

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Course Objectives

• MODULE 3 QUANTIFYING THE ISSUE
• 1. Understand the basic concepts of descriptive
  epidemiology.
• 2. Understand several major sources of public
  health surveillance data.
• 3. To understand the features of study designs
  used to evaluate the effectiveness of public
  health interventions

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Course Objectives

• MODULE 4 DETERMINING WHAT IS KNOWN THROUGH THE
  SCIENTIFIC LITERATURE
• To use recommended guidelines for searching the
  scientific literature
• To find scientific information from other sources
  that may not be available in bibliographic
  databases

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Course Objectives

• MODULE 5a DEVELOPING PRIORITIZING PROGRAM
  OPTIONS
• Review the sources of information on various
  public health programs.
• Describe the constraints on resources in public
  health settings and the need for careful decision
  making.
• Understand some of the criteria that may be
  invoked in prioritizing among options.
• Review several group processes that may be useful
  when developing program policy options.

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Course Objectives

• MODULE 5b DEVELOPING PROGRAM OR POLICY OPTIONS
• Know the fundamental purpose, the different types
  and common processes of systematic reviews
• Understand basic decision analysis
• Become familiar with the purpose, types, process
  and conceptual components of economic evaluation

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Course Objectives

• MODULE 6 DEVELOPING AN ACTION PLAN FOR THE
  PROGRAM OR POLICY
• Understand the purpose and use of analytic
  frameworks.
• Describe steps used in constructing analytic
  frameworks.
• Identify key characteristics of successful action
  planning.
• Explore the use of ecological frameworks with
  solid action planning.
• Discuss the use of theory in creating policies
  and programs.
• Review key elements for action planning and how
  these can be applied to developing
  programs/policies.
• Understand the purpose and use of analytic
  frameworks.

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Course Objectives

• MODULE 7a EVALUATING THE PROGRAM OR POLICY
• 1. Define program evaluation.
• 2. Describe the core components of program
  evaluation.
• 3. Distinguish among the different types of
  evaluations including process, impact, and
  outcome.
• 4. Differentiate between qualitative and
  quantitative approaches to data collection.
• 5. Explain the concepts of validity and
  reliability and their importance.

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Course Objectives

• MODULE 7b EVALUATING THE PROGRAM OR POLICY
• Understand the types of data that are appropriate
  for answering different evaluation questions.
• Understand some of the advantages and
  disadvantages of various types of qualitative
  data.
• Understand some of the steps involved in
  conducting qualitative evaluations.
• Gain experience in at least one type of
  qualitative analysis.

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Definitions and Background

• What is Evidence-Based Public Health (EBPH)?
• What are Contrasts with Evidence-Based Medicine
  (EBM)?
• What are Types of Evidence?
• What are Useful Tools and Processes?

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What is EBPH?
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What is Evidence?

• the available body of facts or information
  indicating whether a belief or proposition is
  true or valid.

• In public health practice, a collection
• Data or scientific evidence (guidelines)
• Input from community members
• Input from other stakeholders
• Professional experience

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How are Decisions Made?

• Anecdote or Gut Feeling
• Press Reports
• Pressure from Policy Makers or Administrators
• History

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How are decisions made? (cont)

• Expert Opinions
• Cost Minimization
• OR
• Combined Methods, Based in Sound Science
• How to craft message to real stakeholders??

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How do evidence (science) and policy inter-relate
most often in PH settings?
Science
Policy
A.
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Or??
Science
Policy
Policy
Science
B.
C.
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What is EBPH?

• ... the development, implementation, and
  evaluation of effective programs and policies in
  public health through application of principles
  of scientific reasoning, including systematic
  uses of data and information systems, and
  appropriate use of behavioral science theory and
  program planning models.
• Brownson RC, Baker EA, Leet TL, Gillespie KN.
  Evidence-Based Public Health. New York Oxford
  University Press 2003

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Some Key Characteristics of EBPH

• Intervention approaches developed based on the
  best possible scientific information
• Problem solving is multi-disciplinary
• Theory and systematic planning approaches are
  followed

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Key Characteristics of EBPH (cont)

• Sound evaluation principles are followed
• Results are disseminated to others who need to
  know

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Why do Programs/Policies Fail?

• Choosing ineffective intervention approach
• Selecting a potentially effective approach, but
  weak or incomplete implementation or reach
• Conducting and inadequate evaluation that limits
  generalizability
• This course deals with
• Finding and using scientific evidence
• Generating new evidence

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Examples Based on Varying Degrees of Evidence?

• California Proposition 99
• smoking as key public health issue
• effects of price increases
• 0.25 per pack increase in 1988
• earmarked for tobacco control with strong media
  component
• for 1988-93, doubling of rate of decline against
  background rate

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Late Bulletin From the Journal Newsroom

• 18 smoking prevalence in CA
• Can ? to 10 in 5 years save 50,000 lives IF
• CA returns to the aggressive program it ran in
  the early 1990s

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Examples Based on Varying Degrees of Evidence?

• Missouri TASP Program
• MO child restraint law in 1984
• After 8 years, compliance at 50
• TASP Program in 1992
• Report license plates of children not properly
  restrained
• In 1995, phone survey and observations showed low
  effectiveness

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What is EBM?

• Process Has Grown Recently
• pathophysiology
• cost-effectiveness
• patient preferences
• In Large Part, Learning to Read Journals

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What is EBM?

• Sackett Rosenberg
• convert information needs into answerable
  questions
• track down, with maximum efficiency, the best
  evidence with which to answer them (from the
  clinical examination, the diagnostic laboratory,
  the published literature, or other sources

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What is EBM? (cont)

• Sackett Rosenberg
• critically appraise that evidence performance for
  its validity (closeness to the truth) and
  usefulness (clinical applicability)
• apply the results of this appraisal in clinical
  practice and
• evaluate performance

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Differences Between EBPH and EMB?
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Differences Between EBM EBPH
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Types of Evidence
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Some General Considerations in Evaluating Evidence
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When Evidence is Not Enough

• Cultural and geographical limitations
• Largely western world phenomena
• Evidence may be a luxury in some parts of the
  world
• Bias in deciding what gets studied
• Community-based participatory approaches
• May seem counter-intuitive to a strict
  evidence-based process

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What are Some Useful Tools and Processes?

• Systematic Reviews
• e.g., Guidelines
• Meta-Analysis
• Economic Evaluation
• Risk Assessment

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Systematic Reviews One of the best

• Guide to Community Preventive Services
• sponsored by the CDC
• follows work from the US Preventive Services Task
  Force
• 15 member task force
• mainly HP 2010 areas of emphasis
• www.thecommunityguide.org

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Barriers to EBPH

• Lack of leadership in setting a clear and focused
  agenda for evidence-based approaches
• Lack of a view of the long-term horizon for
  program implementation and evaluation
• External (including political) pressures drive
  the process away from an evidence-based approach

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Barriers to EBPH (cont)

• Inadequate training in key public health
  disciplines
• Lack of time to gather information, analyze data,
  and review the literature for evidence
• Lack of comprehensive, up-to-date information on
  the effectiveness of programs and policies
  (overall and in special populations)

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1. Develop an initial statement of the issue
Tools rates and risks, surveillance data
Disseminate widely OR Discontinue program or
policy
2. Quantify the issue
Tools systematic reviews, risk assessment,
economic data
3. Search the scientific literature and
organize information
6. Evaluate the program or policy
Refine the issue
Re-tool
4. Develop and prioritize program options
Implement
5. Develop an action plan and implement intervent
ions
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Summary

• EBPH is growing
• When is evidence sufficient for action?
• Public health largely remains a zero-sum game
• Another broad goal
• put data/information at your fingertips and break
  down data silos

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Summary (continued)

• Numerous challenges and barriers
• course will highlight some
• course is only a beginning remember to try
  things out on regular basis
• Remember sound public health practice is a blend
  of art and science

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Ultimately, Shorten Latency