WELCOME!!

1. Evidence-Based Public Health: A Course in Chronic Disease Prevention MODULE 1: Introduction & OverviewRoss BrownsonMarch 2013

2. WELCOME!!

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

4. “Public health workers… deserve to get somewhere by design, not just by perseverance.” McKinlay and Marceau

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

6. Introductions • Course Director • Ross Brownson • Course Coordinator • Wes Gibbert

7. Instructors • Ross Brownson • AnjaliDeshpande • Darcy Scharff • Kathy Gillespie

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

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”

10. Our training framework…

11. Discontinue Disseminate widely Retool

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.

14. Others with each module

15. What is “Evidence”?

16. What is “Evidence”? Objective • 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 Subjective Like beauty, it’s in the eye of the beholder…

17. What are the evidence domains?

18. Best available research evidence Environment and organizational context Decision-making Population characteristics, needs, values, and preferences Resources, including practitioner expertise

19. Are we talking only of scientific evidence?

20. Because what you told me is absolutely correct but completely useless Where am I? Yes, how did you know? You must be a researcher Because you don’t know where you are, you don’t know where you’re going, and now you’re blaming me The problem Yes. How did you know? You’re 30 yards above the ground in a balloon You must be a policy maker

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

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??

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

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);

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.

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?

28. 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

29. Prevalence (%) <= 19.0 19.1 - 20.0 20.1 - 21.0 21.1 - 22.0 >= 22.1 California adult smoking prevalence by region, 1990

30. Del Norte Siskiyou Modoc Shasta Lassen Trinity Humboldt Tehama Plumas Butte Mendocino Sierra Glenn Nevada Colusa Yuba Placer Sutter Lake El Dorado Yolo Alpine Sonoma Napa Sacramento Amador Solano Calaveras Marin Tuolumne San Joaquin Contra Costa Mono San Francisco Alameda Mariposa Stanislaus San Mateo Santa Clara Merced Santa Cruz Madera Fresno San Benito Inyo Tulare Monterey Kings Prevalence (%) San Luis Obispo Kern <= 19.0 San Bernardino Santa Barbara 19.1 - 20.0 Ventura Los Angeles 20.1 - 21.0 Riverside Orange 21.1 - 22.0 San Diego Imperial >= 22.1 California adult smoking prevalence by region, 1996

31. Prevalence (%) <= 19.0 19.1 - 20.0 20.1 - 21.0 21.1 - 22.0 >= 22.1 California adult smoking prevalence by region, 1999

32. Prevalence (%) <= 19.0 19.1 - 20.0 20.1 - 21.0 21.1 - 22.0 >= 22.1 California adult smoking prevalence by region, 2002

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

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

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

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

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;

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

39. Differences Between EBPH and EMB?

40. Characteristics EBM EBPH Quality & volume of evidence experimental studies quasi-experimental studies Time from intervention to outcome shorter interval longer interval Training more formal – certification required less formal – no certification required Decision making individual group Differences Between EBM & EBPH

41. Types of Evidence

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….

44. 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

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

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

48. Training Resources

49. On Line Resource Both individual level and community level issues Sample modules: www.ebbp.org

50. Challenges & Barriers