Overview EvidenceBased Public Health: Improving Practice at the Community Level

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OverviewEvidence-Based Public HealthImproving
Practice at the Community Level

• Ross C. Brownson
• Saint Louis University
• School of Public Health

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WELCOME!!
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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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Public health workers deserve to get somewhere
by design, not just by perseverance. McKinlay
and Marceau
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Objectives for This Module

• Understand the rationale, basic concepts and
  processes of evidence-based decision making in
  community settings.
• Describe the activities, people and resources
  necessary for applying an evidence-based approach
  to public health decision-making.
• Introduce some sources and types of evidence
  (scientific and non-scientific sources).
• Understand concepts of research, grants, and
  knowledge generation.
• Choose and implement appropriate criteria and
  processes for prioritizing program and policy
  options.
• Begin to understand when and how to adapt
  interventions for different communities and
  cultures.

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Community Needs Values
Scientific Evidence
Resources
(adapted and modified from Muir Gray)
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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 community health practice, a collection of
• Data or scientific evidence (guidelines)
• Input from community members
• Input from other stakeholders
• Professional experience

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Are we talking only of scientific evidence?

• What about the fugitive literature?

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Advantages to Using Evidence-based Approaches

• High likelihood of success
• Identification of common indicators
• Defend/expand an existing program
• Advocate for new programs
• New knowledge is generated to help others
• Term is in vogue
• less understanding of precise meaning

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Growth of Evidence-based Medicine

• the integration of best research evidence with
  clinical expertise and patient values.
• First introduced in 1992
• Key reasons for EBM
• Overwhelming size and expansion of the medical
  literature
• Inadequacy of textbooks and review articles
• Difficulty in synthesizing clinical information
  with evidence from scientific studies

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Differences Between EBM EBPH
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The best is the enemy of the good-VoltaireTh
e problem of randomized trials and parachutes.
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• The effectiveness of parachutes has not been
  subjected to rigorous evaluation by using
  randomised controlled trials. We think that
  everyone might benefit if the most radical
  protagonists of evidence based medicine organised
  and participated in a double blind, randomised,
  placebo controlled, crossover trial of the
  parachute.
• Smith and Pell, BMJ, 2004

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Evidence Decisions

• Our commitment
• Improve community health in lean budget times
• Health problems well defined
• Our job
• Make a difference through programs
• Inaction is not an option
• Sometimes difficult to identify best evidence to
  inform decision making

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Types of Evidence
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More recently, type 3 evidence

• Focuses on carrying out type 2 interventions
• Implementation of the intervention
• Issues of context
• How the intervention is received from the target
  audience
• Involves how something should be done

Rychetnik et al, 2004
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How are decisions made in your settings?

• Anecdote or gut feeling/professional experience
• Press reports
• Pressure from policy makers or administrators
• History

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How are decisions made? (cont)

• Expert opinions
• Peer reviewed literature
• Funding availability
• OR
• Combined methods, based in sound science
• How to make the best use of multiple sources of
  information??

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Why do programs/policies fail to achieve maximum
potential?

• 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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Evidence-based Community Health Is a Process of

• Engaging stakeholders
• Assessing what influences health, health
  behaviors and community health (literature, local
  needs, academic theory)
• Developing programs based on assessment (science)
• Evaluating process, impact, and outcome
• Learning from our work and sharing it in ways
  that are accessible to ALL stakeholders

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Best Practices

• Applied across a variety of public health areas
• Vary widely in scope, methods, and quality
• Expert opinion to systematic methods
• Some are very influential
• Best Practices for Comprehensive Tobacco Control
  Programs

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How does the research process lead to
evidence-based programs?

• Research is discovery of new knowledge
• Mostly conducted in academic settings
• Largely driven by the grant process
• May or may not involve the community in
  meaningful ways

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Why write grants?

• Develop and advance knowledge in a field
• Support training and research activities
• Provide institutional support/prestige
• Expand opportunities for student education
• Promote individual advancement
• Build community partnerships and infrastructure

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Grantmanship Defined.

• the process of using knowledge and implementing
  a series of activities to obtain funding
• It is both an art and a skill
• Requires much trial and error prior to success
• Remember that rejection is common

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Often starts with an RFA or RFP

• Funders issue
• Requests for applications
• Requests for proposals
• Program announcements
• We will develop an RFA as part of this project

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Qualities of a successful proposal

• A good idea that is timely (innovation)
• Well expressed
• Clear indication of methods for pursuing the idea
• A strong team/community support
• A plan for evaluation
• A plan for disseminating the findings

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Parts of the Grant Proposal

• What is the project about?
• Why is it important?
• What will you do?
• What will it cost?
• Why will it cost what it does?
• Why are you the best one to do it?

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Funding Resources

• Office of Minority Health Resource Center
• Provides the most current grant making
  opportunities from federal, private and corporate
  grantmakers, non-profits and public charities
• Information specialists are just a phone call
  away
• www.omhrc.gov

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Once knowledge is developed, what do we (or
should we) do with it??
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What is our understanding of the black box?
Generation of new knowledge
Widespread use
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Making Sense of What Works

• Our lack of greater progress in tobacco
  control is more the results of failure to
  implement proven strategies than the lack of
  knowledge about what to do
• A Report of the Surgeon General

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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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Advocacy can be effective (but often not in
literature)MADD VIP

• Prevention of drunk driving recidivism through
  exposure to victim impact panels
• Bernalillo County, NM

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What are other examples of programs or policies
based on sound (or not so sound) evidence?How
do we begin to replicate these success stories?
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What are Some Useful Tools and Processes?

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

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What are limitations of/barriers to
evidence-based approaches?
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Barriers Challenges 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
• For health disparities issues, the concept of
  generalizable interventions

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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
• Emerging health issues
• Bioterrorism
• Community-based participatory approaches
• Key to PRC activities
• May seem counter-intuitive to a strict
  evidence-based process

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Prioritizing Issues and Adapting Programs
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How do we begin to address the importance of an
issue and the ability to make change?
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Policy and Program Planning Options
More Important Less Important More
Changeable Highest priority for program Low
priority except to focus demonstrate change
for political purpose Less
Changeable Priority for innovative No
intervention program programs with
evaluation essential
From Green and Kreuter. Am J Prev Med
200018(1S)7-9
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Matrix May Apply to

• Diseases
• Health Conditions, or
• Intervention Strategies

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Example, Changeability tableDiabetes prevention
in Rio Grande Pueblo communities
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How could we apply this matrix to the topic of
physical activity promotion?
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Local adaptation

• Scientific evidence is a starting point
• Realize that ALL programs need some level of
  adaptation (reinvention)
• Limits of scientific evidence should be noted
• Context (culture, local norms, history) is
  largely lacking in the scientific literature
• Understand cultural beliefs about health
• Work on lifestyle changes that are consistent
  with history and culture
• Seek out other forms of evidence, such as?

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Local adaptation

• Often a tension between fidelity and reinvention
• Fidelity altering a program from its original
  design and components may reduce its
  effectiveness upon replication
• Reinvention changes in programs are needed for
  replication in new settings
• Starting with a community needs assessment is
  often useful

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Local adaptation

• We have found usefulness in iterative, menu
  approach
• Group process to generate ideas on a particular
  topic
• Collect and value all ideas
• List approaches proven in scientific literature
• Look for common ground
• Allow plenty of time
• May not fit well with traditional biomedical
  funding approaches and cycles

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In your work

• Diverse set of issues/evidence base
• Tobacco
• Arthritis
• Cancer prevention control
• Obesity prevention
• Health disparities
• Poverty, social inequities
• Variability in staffing and training needs
• Turnover in community agencies
• Funds are limited in every program
• It may be essential to start with environmental
  and policy approaches (access)
• Places to find healthy foods or the environment
  for activity

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Other thoughts to consider thru this workshop

• Knowing what to do is helpful, how to do it may
  be more difficult
• Challenges for emerging health conditions
• Participatory approaches
• What types of evidence are most important for my
  issues?
• Remember, sound public health practice is a blend
  of art and science
• What might I take home with me to try out?
• How does this help inform SIP 13?
• There are no magic answers!!
• But a systematic process increases likelihood of
  success