Systematic reviews of health promotion and public health interventions

1. Systematic reviews of health promotion and public health interventions Rebecca Armstrong Elizabeth Waters Cochrane Health Promotion & Public Health Field

2. Overview • Overview of systematic reviews • Outline of The Cochrane Collaboration • Role of the HPPH Field • Function of systematic reviews in informing policy and practice • Key elements of systematic reviews • Asking answerable questions • Searching for evidence • Assessing quality • Synthesising results • Applicability and transferability

3. Types of reviews Reviews (narrative/literature/ traditional) Systematic reviews Meta-analysis

4. Narrative reviews • Usually written by experts in the field • Use informal and subjective methods to collect and interpret information • Usually narrative summaries of the evidence Read: Klassen et al. Guides for Reading and Interpreting Systematic Reviews. Arch Pediatr Adolesc Med 1998;152:700-704.

5. What is a systematic review? A review of the evidence on a clearly formulated question that uses systematic and explicit methods to identify, select and critically appraise relevant primary research, and to extract and analyse data from the studies that are included in the review* *Undertaking Systematic Reviews of Research on Effectiveness. CRD’s Guidance for those Carrying Out or Commissioning Reviews. CRD Report Number 4 (2nd Edition). NHS Centre for Reviews and Dissemination, University of York. March 2001.

6. Key elements of a systematic review Structured, systematic process involving several steps : • Formulate the question • Plan the review • Comprehensive search • Unbiased selection and abstraction process • Critical appraisal of data • Synthesis of data (may include meta-analysis) • Interpretation of results All steps described explicitly in the review

7. Scientific approach to a review article Criteria determined at outset Comprehensive search for relevant articles Explicit methods of appraisal and synthesis Meta-analysis may be used to combine data Depend on authors’ inclination (bias) Author gets to pick any criteria Search any databases Methods not usually specified Vote count or narrative summary Can’t replicate review Systematic vs. Narrative reviews

8. Advantages of systematic reviews • Reduce bias • Replicability • Resolve controversy between conflicting studies • Identify gaps in current research • Provide reliable basis for decision making

9. Limitations of systematic reviews specific to health promotion • Results may still be inconclusive • There may be no trials/evidence • The trials may be of poor quality • The intervention may be too complex to be tested by a trial • Practice does not change just because you have the evidence of effect/effectiveness

10. Consider these interventions… • Interventions to promote smoke alarm ownership and function • School-based driver education for the prevention of traffic crashes • Helmets for preventing head and facial injuries in bicyclists Do you think the results identified in SRs will be good, promising or absent (and potentially harmful)?

11. Results from systematic reviews • Helmets reduce bicycle-related head and facial injuries for bicyclists of all ages involved in all types of crashes including those involving motor vehicles. • The results provide no evidence that drive education reduces road crash involvement, and suggest that it may lead to a modest but potentially important increase in the proportion of teenagers involved in traffic crashes. • Results from this review suggest that area-wide traffic calming in towns and cities may be a promising intervention for reducing the number of road traffic injuries and deaths. However, further rigorous evaluations of this intervention are needed.

12. The Cochrane Collaboration International non-profit organisation that prepares, maintains, and disseminates systematic up-to-date reviews of health care interventions

13. Cochrane Collaboration Named in honour of Archie Cochrane, a British researcher In 1979: “It is surely a great criticism of our profession that we have not organised a critical summary, by specialty or subspecialty, adapted periodically, of all relevant randomised controlled trials”

14. The Cochrane Library • Cochrane Systematic reviews : Cochrane reviews and protocols • Database of Reviews of Effects: Other systematic reviews appraised by the Centre for Reviews and Dissemination. • Cochrane Central Register of Controlled Trials: Bibliography of controlled trials (some not indexed in MEDLINE). • Health Technology Assessment Database: HTA reports • NHS Economic evaluation database: Economic evaluations of health care interventions.

15. The Cochrane Library www.thecochranelibrary.com

17. Cochrane HPPH Field • Represent the needs and interests of those in health promotion and public health in Cochrane matters • Represent Cochrane in health promotion and public health forums • In transition from Field to Review Group • Will edit PH reviews for the Cochrane Library

18. Cochrane Collaboration Structure Steering Group Review Groups Centres Fields Methods Groups Consumer Network

19. Collaborative Review Groups (50) • Produce systematic reviews relevant to a particular disease or health issue for inclusion in the Cochrane Library • Examples • Airways Group • Drug and Alcohol Group • Heart Group • Injuries Group • Skin Group • Pregnancy and Childbirth Group • Stroke Group • Breast Cancer Group

20. Methods Groups (12) • Provide advice and support in the development of the methods of systematic reviews • Examples • Non-Randomised Studies • Screening and Diagnostic Tests • Empirical Methodological Studies • Qualitative Methods

21. Cochrane Centres (14) • Work to assist all Cochrane entities within a specific geographical area • Examples • Australasian Cochrane Centre (at Monash) • South African Cochrane Centre • Italian Cochrane Centre • Chinese Cochrane Centre

22. Cochrane Fields/Networks (9) • Represent an area of interest which spans a number of health problems - and hence a number of Review Groups • Examples • Health Promotion and Public Health Field • Primary Health Care Field • Cancer Network • Child Health Field

23. Cochrane HPPH Field • Cochrane Fields represent a population group, or type of care that overlaps multiple Review Group areas • HPPH Field • Registered in 1996 • Administered from Melbourne • Funded by VicHealth • Over 400 members on contact database across >30 countries

24. Staff • Elizabeth Waters (Director) • Jodie Doyle (Coordinator) • Rebecca Armstrong (Senior Research Fellow) • Naomi Priest (Research Fellow)

25. Asking an answerable question

26. Questions of interest Effectiveness: • Does the intervention work/not work? • Who does it work/not work for? Other important questions: • How does the intervention work? • Is the intervention appropriate? • Is the intervention feasible? • Is the intervention and comparison relevant?

27. Answerable questions EFFECTIVENESS A description of the populations P An identified interventionI An explicit comparison C Relevant outcomes O

28. A PICO question Time-consuming question: What is the best strategy to prevent smoking in young people?

29. An answerable question Q. Are mass media (or school-based or community-based) interventions effective in preventing smoking in young people?

30. The PICO(T) chart

32. Finding the evidence

33. Systematic review process • Well formulated question • Comprehensive data search • Unbiased selection and abstraction process • Critical appraisal of data • Synthesis of data • Interpretation of results

34. A good search • Clear research question • Comprehensive search • All domains, no language restriction, unpublished and published literature, up-to-date • Document the search (replicability)

35. Components of electronic searching • Describe each PICO component • Start with primary concept • Find synonyms • Identify MeSH / descriptors / subject headings • Add textwords • Add other components of PICO question to narrow citations (may use study filter) • Examine abstracts • Use search strategy in other databases (may need adapting)

36. So you want to do a ‘quick & dirty’? • DARE • CENTRAL • PubMed (clinical queries, related records) • CDC • NICE • Organisations who do work in your area • …google

37. The Cochrane Library: www.thecochranelibrary.com

38. Cochrane HPPH Field

39. Health-evidence.ca

40. The Guide to Community Preventive Services http://www.thecommunityguide.org/

41. National Institute for Health and Clinical Excellence http://www.publichealth.nice.org.uk/page.aspx?o=home

42. Evidence for Policy and Practice Information and Co-ordinating Centre (EPPI-Centre) http://eppi.ioe.ac.uk

43. Effective Public Health Practice Project (EPHPP) http://www.myhamilton.ca/myhamilton/CityandGovernment/HealthandSocialServices/Research/EPHPP/

44. Centre for Reviews and Dissemination http://www.york.ac.uk/inst/crd

45. Other sources of primary research

46. Searching • www.google.com.au • The order of terms will effect the results so start with the obvious or key concept • No need for ‘and’ • Google will ignore common words • If they are important use + (e.g. policy + 3) • Phrase searching is useful eg “suicide prevention” • Google searches for variations on words eg diet, dietary

47. Searching • Where terms have multiple meanings you can direct google to remove sites you want to avoid (e.g. bass –music) • Keep your search strings brief • Mental health promotion initiatives to prevent suicide in young people • Compartmentalise your search strings • “mental health promotion” suicide • “Suicide prevention” “young people” • Prevention and suicide and youth

48. Searching • http://www.ncbi.nlm.nih.gov/entrez/query.fcgi • Use the same principles for google – keep it short and sweet. • Key features • Journals DatabaseMeSH DatabaseSingle Citation MatcherClinical Queries

49. Searching

50. Searching