Evidence Based Chronic Disease Prevention Module Five: Developing Evidence Based Program Options

1. Evidence Based ChronicDisease PreventionModule Five: Developing Evidence Based Program Options Presented by: Bill Baldyga, DrPH

2. Objectives • Review the sources of information on various public health programs. • Understand the criteria that is used in developing evidence based recommendations. • Locate and utilize evidence based recommendations for public health program development. Evidence Based Chronic Disease Prevention

3. Developing Recommendations • Types of recommendations • expert opinion • consensus conferences – generally federal • guidelines – generally clinically focused • best practices • evidence based recommendations • Not a linear process Evidence Based Chronic Disease Prevention

4. Remember Level One and Level Two Evidence!! Evidence Based Chronic Disease Prevention

5. Levels of Evidence Evidence Based Chronic Disease Prevention

6. Remember Decision Making • Process of choosing one alternative from among a set of rational alternatives • In public health, always in the context of uncertainty • making important decisions in light of imperfect information • evidence-based should not imply certainty • Knowledge is cumulative and time sensitive Evidence Based Chronic Disease Prevention

7. Major Considerations of Option Selection • Include both obvious and creative options • Generally, the more significant the decision, the more alternatives that should be developed • What are sources of information on program/policy options for interventions based level two evidence ? Evidence Based Chronic Disease Prevention

8. Ineffectiveness of Public Health Programs (IOM, 1988) • Choosing a program whose effectiveness is not established • Not achieving adequate implementation of the program • Conducting an evaluation that results in lack of generalized knowledge Choose, carry out and evaluate carefully Evidence Based Chronic Disease Prevention

9. Current Practices? • How do you and your agency now select among program options ? • Are unique programs developed or do you rely on tested strategies ? • What sources of information, personal and professional, do you rely on to develop programs ? Evidence Based Chronic Disease Prevention

10. Sources of Information on Program/Policy Options • Your own knowledge, education • Your colleagues, co-workers, ‘local experts’ • Talking with ‘outside’ experts/conferences • Program colleagues in other states or CDC, academics • Continuing education, local and national meetings • Mass mailings, listserve groups and email • Input from the public or policy makers • Peer reviewed literature – specifically review articles. Evidence Based Chronic Disease Prevention

11. Best Source of Information on Program Policy Options EVIDENCE BASED RECOMMENDATIONS

12. Using Evidence Based Recommendations • What are evidence based recommendations? • How are evidence based recommendations developed? • Where can evidence based recommendations be found? • How and under what circumstances should the recommendations be applied? Evidence Based Chronic Disease Prevention

13. What are Evidence Based Recommendations? “Evidence based healthcare is characterized by decision making in which the decision is based on a systematic appraisal of the best evidence available. The evidence alone rarely makes the decision, and those who make the decision also have to take into account the needs and values of the population they serve and the resources available” Muir Gray, unpublished. Evidence Based Chronic Disease Prevention

14. How are evidence based recommendations developed? • Form multi-disciplinary teams of experts • Develop conceptual approach to organizing, grouping, selecting and evaluating evidence • Search for and retrieve evidence • Select interventions to be evaluated • Summarize the information ( applicability to populations and settings, benefits/harms, barriers to implementation) Evidence Based Chronic Disease Prevention

15. How are evidence based recommendations developed? • Assessing the quality and summarizing the evidence of effectiveness. • Translating evidence of effectiveness into recommendations. • Considering information other than effectiveness (situational application) . • Identifying and summarizing gaps. Evidence Based Chronic Disease Prevention

16. The Six Stages of EBPH • Develop an issue statement • Use data to describe the issue • Search and organize information • Prioritize options • Develop and implement an intervention • Evaluate the program Evidence Based Chronic Disease Prevention

17. STAGE ONE – DEVELOP AN INITIAL ISSUE STATEMENT • Should result from a planning process • Derive from a SWOT or other analysis • Issue statement should include: • condition or risk factor • population affected • size and scope of problem • prevention approach Evidence Based Chronic Disease Prevention

18. STAGE TWO – QUANTIFY THE ISSUE Identify data, usually descriptive, that: • describes a pattern of occurrence or behavior (tells us who, what and/or where) • Provides baseline data for evaluation Where is this data ? Vital records, medical care, census, BRFSS, local planning organizations, local surveys http://phpartners.org/health_stats.html Evidence Based Chronic Disease Prevention

19. STAGE THREE – SEARCH AND ORGANIZE INFORMATION • Searching databases – National Library of Medicine http://www.nlm.nih.gov/ These sources give you information about a single study (or review article). This step can also help tailor a proposed intervention. Evidence Based Chronic Disease Prevention

20. STAGE FOUR – PRIORITIZE PROGRAM OPTIONS • Review articles – Annual Review of Public Health http://publhealth.annualreviews.org/ • Evidence based recommendations on the web http://www.thecommunityguide.org/ http://www.vichealth.vic.gov.au/ cochran/links/index.htm Evidence Based Chronic Disease Prevention

21. STAGE FIVE – DEVELOP AND IMPLEMENT AN INTERVENTION • Refer to original literature to help tailor the intervention • Develop specific goals and objectives • Use a logic model to tie objectives, implementation strategies, assessments, and outcomes together Evidence Based Chronic Disease Prevention

22. STAGE SIX – EVALUATE THE PROGRAM Measure the degree to which the program goal has been met • Use both qualitative and quantitative strategies • Capture immediate changes- may not have health or behavioral change data • Capture changes at multiple levels – individual, program, organizational, inter-organizational, community levels Evidence Based Chronic Disease Prevention

23. Where can evidence based recommendations be found? • The Cochrane Collaboration – the granddaddy of EBM • The Campbell Collaboration – the younger brother – focus on education, social work and criminal justice • The Guide to Community Preventive Services – the response in the US to the need for EBPH Evidence Based Chronic Disease Prevention

24. Where can evidence based recommendations be found? • Cochrane Health Promotion and Public Health Field http://www.vichealth.vic.gov.au/cochrane/ news/newsletters.htm • Access to Cochrane reviews and protocols • Covers topics such as tobacco, asthma, oral health, screening, nutrition, CVD • Locate information by review group Evidence Based Chronic Disease Prevention

25. Where can evidence based recommendations be found? • Effective Public Health Practice Project (Hamilton, Ontario), Canada http://www.hamilton.ca/PHCS/EPHPP/EPHPPResearch.asp • 45 reviews in public health topics, some have summaries only • Provides specific recommendations (where applicable) for PH programs Evidence Based Chronic Disease Prevention

26. Where can evidence based recommendations be found? • National Health Service, University of York http://www.york.ac.uk/inst/crd/ • Access to the DARE database • Primarily clinical, but with many public health topics • Can search for review articles Evidence Based Chronic Disease Prevention

27. Where can evidence based recommendations be found? • Health Development Agency, UK http://www.hda-online.org.uk/evidence/ • Searches HealthPromis database • Access to original articles • Limited availability of reviews Evidence Based Chronic Disease Prevention

28. Where can evidence based recommendations be found? • Health Evidence Bulletins- Wales http://hebw.uwcm.ac.uk/ • Very useful information in a limited range of topics • Searchable database provides a 2 X 2 table of results • Provides access to more European reports Evidence Based Chronic Disease Prevention

29. Where can evidence based recommendations be found? • University of London, SSRU, Evidence for Policy and Practice Information (EPPI) http://eppi.ioe.ac.uk/ • Reports on barriers and facilitators physical activity and health eating / adolescents; workplace health; older adult health • Searchable data base- not recommended Evidence Based Chronic Disease Prevention

30. Sources of/Where can evidence based recommendations be found? • Related Sites: • HCFA – Quality of Care • Medical Research Council (Scotland) • TRIP Database • Bandolier Database • Mental Health Dissemination Network of Arizona • Prevention Effects – forthcoming from CDC Evidence Based Chronic Disease Prevention

31. Sources of/Where can evidence based recommendations be found? • Other Sources: • Print documents • Best Practices for Comprehensive Tobacco Control Program (CDC) • The Compendium of Diabetes Best Practices (ADA and AAHP) • Review articles • Such as “Effectiveness of Self-Management Training in Type2 Diabetes” contain useable information, but usually no recommendations. Evidence Based Chronic Disease Prevention

32. http://www.thecommunityguide.org Evidence Based Chronic Disease Prevention

33. Guide to Community Preventive Services • Companion document to the ‘Guide to Clinical Preventive Services’ • Sponsored by CDC • 15 member task force (including UIC SPH Dean, Dr. Susan Scrimshaw and Dr. Ross Brownson, SLU SPH) • Mainly HP 2010 areas of emphasis http://www.thecommunityguide.org Evidence Based Chronic Disease Prevention

34. Guide to CommunityPreventive Services • Target date for completion was 2000 but stand-alone chapters earlier • e.g., vaccine preventable diseases, tobacco product use prevention and control • Developing an Evidence-Based Guide to Community Preventive Services – Reference: Am J Prev Med 2000; 18 (1S) • dissemination strategies currently being developed http://www.thecommunityguide.org Evidence Based Chronic Disease Prevention

35. Guide to Community Preventive Services - Timeline §Changing Health Risk Behaviors §        Tobacco product use prevention/control §        Alcohol abuse (Not started) §        Physical activity §        Sexual behavior (in progress) §Addressing Specific Health Conditions §        Vaccine preventable diseases §        Cancer (in progress) – inc. breast,cervical and colorectal; screening; UV §        Diabetes §        Mental Health (spring 2004) §        Motor vehicle occupant injury §        Oral health §        Violent and abusive behavior (spring 2003) §Addressing the Environment §        Sociocultural environment (Winter 2002*) Evidence Based Chronic Disease Prevention

36. Guide to Community Preventive Services • Charge • Summarize what is known about the effectiveness of population-based interventions for prevention and control • Summarize information on cost-effectiveness of these interventions, where data exist • Provide recommendations on population-based interventions and methods for their delivery, based on available evidence • Identify a prevention research agenda where gaps exist http://www.thecommunityguide.org Evidence Based Chronic Disease Prevention

37. Guide to Community Preventive Services • Audience • The guide’s primary audience is people involved in the planning, funding, and implementing of population-based services and policies to improve health at the community and state level. http://www.thecommunityguide.org Evidence Based Chronic Disease Prevention

38. Guide to Community Preventive Services • Assessing evidence • Number of studies • Quality of studies • Consistency of findings • Effect sizes • Other considerations • Cost-effectiveness • Harms • Generalizability • Effectiveness ratings • Strongly recommended, recommended, insufficient evidence • Recommendations include multi-component interventions http://www.thecommunityguide.org Evidence Based Chronic Disease Prevention

39. Guide to Community Preventive Services - Tobacco Recommendations • Recommendations regarding selected interventions to reduce exposure and to reduce tobacco use: • Strategies to reduce exposure to environmental tobacco smoke (ETS) • Strategies to reduce tobacco-use initiation • Strategies to increase tobacco-use cessation, appropriate for community wide use • Strategies to increase tobacco-use cessation, appropriate for health-care systems http://www.thecommunityguide.org Evidence Based Chronic Disease Prevention

40. What are the most effective ways to reduce the number of smokers in your community? http://www.thecommunityguide.org Evidence Based Chronic Disease Prevention

41. Guide to Community Preventive Services - Tobacco Recommendations http://www.cdc.gov/tobacco/research_data/environmental/MMWR_rr4912_factsheet.htm Evidence Based Chronic Disease Prevention

42. Guide to Community Preventive Services - Tobacco Recommendations http://www.cdc.gov/tobacco/research_data/environmental/MMWR_rr4912_factsheet.htm Evidence Based Chronic Disease Prevention

43. Evidence Based Health Promotion: Resources for Planning (Victorian Government – Australia) • Recommendations • Addresses adolescent health in six domains and thirteen intervention strategies • Also provides general recommendations about using evidence based strategies in practice • Evidence tables permit comparisons of the relative value of the various strategies http://www.dhs.vic.gov.au/phd/0003097 Evidence Based Chronic Disease Prevention

44. Evidence Based Health Promotion: Resources for Planning (Victorian Government – Australia) http://www.dhs.vic.gov.au/phd/0003097 Evidence Based Chronic Disease Prevention

45. Agency for Healthcare Research and Quality • Purpose • Evidence-based Practice Program • Fund 12 centers to do reviews • Guideline Clearinghouse • Same purpose as the Guide to Community Preventive Services • Limited applicability as topics are primarily clinical http://www.ahcpr.gov/clinic/dietsumm.htm Evidence Based Chronic Disease Prevention

46. Agency for Healthcare Research and Quality • Content Description • Each review has individual inclusion/exclusion criteria – may or may not have clinical settings only • Relevant topics covered include: • chronic asthma, repetitive motion disorders, osteoporosis, dietary interventions, etc. • Summaries provided in narrative form. • Evidence tables for individual studies only. http://www.ahcpr.gov/clinic/dietsumm.htm Evidence Based Chronic Disease Prevention

47. Agency for Healthcare Research and Quality • Example: Modify dietary behavior related to cancer risk – finding • Fruit and vegetable intake • Dietary interventions were positively associated with fruit and vegetable intake • Fruit intake changes were larger • Dietary fat • Interventions were associated with small decreases in fat intake • Interventions with higher risk group are more efficacious http://www.ahcpr.gov/clinic/dietsumm.htm Evidence Based Chronic Disease Prevention

48. BARRIER Lack of leadership Need for long term horizon for program External political pressure drives actions SOLUTION Commitment from all levels Use of theories and causal frameworks Communication and dissemination strategies Barriers and Solutions to the Use of EBPH Evidence Based Chronic Disease Prevention

49. BARRIER Inadequate training in public health Lack of information on effectiveness Lack of data for specific populations, settings SOLUTION Wider dissemination of existing programs Increased utilization of EBPH and population based strategies Increased funding for public health research Barriers and Solutions to the Use of EBPH Evidence Based Chronic Disease Prevention

50. Evidence  Program • Evidence based recommendations require implementation • Science + Art = Public Health. • Translating evidence (science) to local conditions, preferences, and groups. • (Art) No public health programs are overwhelmingly successful. • Creativity of implementation will influence success. Evidence Based Chronic Disease Prevention