1. Evidence-Based Public Health: A Course in Chronic Disease Prevention MODULE 1: Introduction & Overview Ross Brownson March 2013

2. WELCOME!! 2

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

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

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 Coordinator –Wes Gibbert 6

7. Instructors Ross Brownson Anjali Deshpande Darcy Scharff 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

11. Retool Discontinue Disseminate widely

12. Course Objectives

13. MODULE 1: Introduction And Overview 1.Understand the basic concepts of evidence-based decision making. 2.Introduce some sources and types of evidence. 3.Describe several applications within public health practice that are based on strong evidence and several that are based on weak evidence. 4.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 Objective Subjective Like beauty, it’s in the eye of the beholder…

17. What are the evidence domains? 17

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

19. Are we talking only of scientific evidence? 19

20. Where am I? You’re 30 yards above the ground in a balloon You must be a researcher Yes. How did you know? Because what you told me is absolutely correct but completely useless You must be a policy maker Yes, how did you know? The problem 20

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 1.Making decisions based on the best available peer-reviewed evidence (both quantitative and qualitative research); 2.Using data and information systems systematically; 3.Applying program planning frameworks (that often have a foundation in behavioral science theory); 24

25. Some Key Characteristics of EBPH 4.Engaging the community in assessment and decision making; 5.Conducting sound evaluation; and 6.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? 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. Prevalence (%) <= 19.0 19.1 - 20.0 20.1 - 21.0 21.1 - 22.0 >= 22.1 California adult smoking prevalence by region, 1990 29

30. California adult smoking prevalence by region, 1996 Prevalence (%) <= 19.0 19.1 - 20.0 20.1 - 21.0 21.1 - 22.0 >= 22.1 30

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

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

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 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: 1.convert information needs into answerable questions; 2.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: 3.critically appraise that evidence performance for its validity (closeness to the truth) and usefulness (clinical applicability); 4.apply the results of this appraisal in clinical practice; and 5.evaluate performance 38

39. Differences Between EBPH and EMB? 39

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

41. Types of Evidence 41 CharacteristicType OneType TwoType Three Typical Data/ Relationship Size and strength of preventable risk—disease relationship (measures of burden, etiologic research) Relative effectiveness of public health intervention Information on the adaptation and translation of an effective intervention Common setting Clinic or controlled community setting Socially intact groups or community-wide Example Smoking causes lung cancer Price increases with a targeted media campaign reduce smoking rates Understanding the political challenges of price increases QuantityMoreLess ActionSomething should be done.This particular intervention should be implemented How an intervention should be implemented

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” -Voltaire The 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 44

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

47. 47

48. Training Resources 48

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

50. Challenges & Barriers 50

51. “Getting a new idea adopted, even when it has obvious advantages, is often very difficult.” -- Everett Rogers, Diffusion of Innovations 51

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

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