Evidence-Based Public Health: A Course in Chronic Disease Prevention MODULE 1: Introduction Overview Ross Brownso

1. Evidence-Based Public Health: A Course in Chronic Disease Prevention   MODULE 1: Introduction & OverviewRoss BrownsonMarch 2011

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5. Acknowledgements Thanks to Garland Land & Missouri Department of Health and Senior Services Terry Leet, Saint Louis University Funding and technical support from the MDHSS, Chronic Disease Directors and the Centers for Disease Control and Prevention, and the World Health Organization, CINDI Austria, CINDI Lithuania 5

6. Introductions Course Director Ross Brownson Course Coordinators Linda Dix Lauren Carothers 6

7. Instructors Ross Brownson Anjali Deshpande Beth Baker Kathy Gillespie 7

8. Ground Rules Attendance leave cell phones, beepers on stun Active participation is sought all questions are welcome No tests 8

9. 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� 9

10. Our training framework� 10

12. Course Objectives

13. 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. 13

14. Others with each module

15. What is �Evidence�? 15

16. What is �Evidence�? Scientific literature in systematic reviews Scientific literature in one or more journal articles Public health surveillance data Program evaluations Qualitative data Community members Other stakeholders Media/marketing data Word of mouth Personal experience 16

17. What are the evidence domains? 17

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19. Are we talking only of scientific evidence? 19

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21. How are decisions generally made in public health settings? Resources/funding availability (C-E) Peer reviewed literature/systematic reviews Media driven Pressure from policy makers or administrators 21

22. How are decisions made? (cont) Expert opinions (e.g., academics, community members) History/inertia Anecdote OR Combined methods, based in sound science How to make the best use of multiple sources of information & limited resources?? 22

23. EB Decision-Making Understanding a process Finding evidence for decisions Creating new evidence for decisions 23

24. Some Key Characteristics of EBPH Making decisions based on the best available peer-reviewed evidence (both quantitative and qualitative research); Using data and information systems systematically; Applying program planning frameworks (that often have a foundation in behavioral science theory); 24

25. Some Key Characteristics of EBPH Engaging the community in assessment and decision making; Conducting sound evaluation; and Disseminating what is learned to key stakeholders and decision makers. 25

26. 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 Paying inadequate attention to adapting an intervention to the population and context of interest

27. Examples Based on Varying Degrees of Evidence? 27

28. Examples Based on Varying Degrees of Evidence? The WHO Framework Convention on Tobacco Control 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 28

29. 29 This next series of charts depict how prevalence has decreased across the state over a 12 year period with the coast areas of the state being much more progressive and rural areas in Northern California and the Central Valley lagging, but eventually making progress.This next series of charts depict how prevalence has decreased across the state over a 12 year period with the coast areas of the state being much more progressive and rural areas in Northern California and the Central Valley lagging, but eventually making progress.

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33. What Worked? Comprehensive program and tax increases in CA and MA resulted in: 2 - 3 times faster decline in adult smoking prevalence Slowed rate of youth smoking prevalence compared to the rest of the nation Accelerated passage of local ordinances Similar, though later, experience in OR & AZ, and in population segments of FL CA and MA were the first states to have adequate resources to conduct evaluation of their comprehensive excise tax funded programs, and have served as models for the nation. We now have information from evaluations of OR�s tax funded program, and Florida�s settlement funded program. CA and MA were the first states to have adequate resources to conduct evaluation of their comprehensive excise tax funded programs, and have served as models for the nation. We now have information from evaluations of OR�s tax funded program, and Florida�s settlement funded program.

34. 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 34

35. 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 35

36. What is EBM? Process has grown recently pathophysiology cost-effectiveness patient preferences In large part, learning to read & assimilate information in journals 36

37. 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; 37

38. 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 38

39. Differences Between EBPH and EMB? 39

40. Differences Between EBM & EBPH 40

41. Types of Evidence 41

42. In our research paradigms we may rely too heavily on randomized designs for community-based studies

43. �The best is the enemy of the good�-VoltaireThe problem of randomized trials and parachutes�.

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45. What are Some Useful Tools? Systematic reviews e.g., Guidelines meta-analysis Economic evaluation Risk assessment Public health surveillance 45

46. 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 46

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48. Training Resources 48

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50. Challenges & Barriers 50

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52. 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

53. 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 incentives

54. When evidence is not enough Cultural and geographical limitations Formal approaches, largely western world phenomena Evidence is often a luxury in many parts of the world Bias in deciding what gets studied Emerging health issues Disaster preparedness Community-based & participatory approaches May seem counter-intuitive to a strict evidence-based process 54

55. In your work� Diverse set of issues/evidence base Tobacco Cancer prevention & control Environmental health Genomics Obesity prevention Poverty, social inequities War Variability in staffing and training needs Turnover in agencies Funds/infrastructure are limited in every program, country 55 IDENTIFY: The first step is to explicitly delineate ALL possible intervention alternatives being considered by the decision maker. MEASURE: EE involves the use of quantitative techniques (descriptive epidemiology, decision analysis, economic evaluation, meta-analysis) VALUE: EE necessarily provides estimates of probabilities, costs, and outcomes for each alternative. COMPARE: Final step in an EE is to answer the question: how do the intervention outcomes compares with the costs. By combining basic components of applied research on epidemiology, (i.e. efficacy and effectiveness), with the economic component (i.e. costs), Economic evaluations allow one to develop a summary statement of the implications of choosing one particular course of action or decision over another. IDENTIFY: The first step is to explicitly delineate ALL possible intervention alternatives being considered by the decision maker. MEASURE: EE involves the use of quantitative techniques (descriptive epidemiology, decision analysis, economic evaluation, meta-analysis) VALUE: EE necessarily provides estimates of probabilities, costs, and outcomes for each alternative. COMPARE: Final step in an EE is to answer the question: how do the intervention outcomes compares with the costs. By combining basic components of applied research on epidemiology, (i.e. efficacy and effectiveness), with the economic component (i.e. costs), Economic evaluations allow one to develop a summary statement of the implications of choosing one particular course of action or decision over another.

56. 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 56