1. Defining Evidence Talking Points:
In this session we will provide you with an overview of evidence-based practice and demonstrate how it is relevant to your work.
We will also describe the different categories of evidence-based interventions.
The Cancer Prevention and Control Research Network is supported by Cooperative Agreement Number 3 U48 DP S8 from the Centers for Disease Control and Prevention’s Prevention Research Centers Program and the National Cancer Institute. The content of this curriculum is based upon findings and experiences of workgroup members and does not necessarily represent the official position of the funders. 

2. Session Objectives Define evidence-based practice
Discuss the Social Ecological Model as a framework for selecting evidence-based interventions
Describe three main categories of evidence-based interventions: Programs, Policies, and Strategies
Talking Points:
The session objectives are:
Describe evidence-based practice
Discuss the Social Ecological Model (SEM) as a framework for planning evidence-based interventions, and
Describe three main categories of evidence-based interventions: Programs, Policies, and Strategies
*Questions welcome throughout.

3. What do you think of when you hear “evidence-based”?
Question
What do you think of when you hear “evidence-based”?
Ask the Audience
Before we get started, take a moment to think about this question: “What do you think of when you hear the term “evidence-based”? Is this something that is required for your work?
Now think about your agency - how do others at your agency think about evidence?
As we go through this session, you will be shown examples of how evidence-based public health can be relevant to your work as a program planner, program developer, implementer, and evaluator.

4. What is Evidence-Based Practice?
Best available research evidence
Resources, including practitioner expertise
Population characteristics, needs, values, and preferences
Environment and organizational context
Decision-making
Talking Points:
Let’s start first with understanding the various types of evidence used in evidence-based practice.
Evidence-based practice incorporates multiple types of evidence, as seen in this graphic. Evidence-based practice draws on strategies that are based on the best available evidence from research. However, for those strategies to be effective, they need to be integrated with evidence that is specific to your population.
Ask yourself: Does the strategy fit the population’s risk factors and disease prevalence? Does it fit their needs and values?
Implementing evidence based strategies require resources. Therefore it is important to ask: “Does the strategy fit with the expertise of those who will be delivering or implementing the strategy, and the resources they have available?”
Finally, the evidence-based strategy needs to fit the overall environmental and organizational context.
Source: Jacobs et al. 2012

5. What are Evidence-Based Interventions?
A program, policy, or strategy that has been found to be effective in one or more well-designed research studies 
Ask the Audience
How would you define evidence-based interventions?
Talking Points:
Historically, the push for routine application of evidence in practice began in medicine. Over time, evidence-based practice has gained acceptance in many fields, including public health.
Evidence-based public health interventions include programs, policies, and strategies that have been found to be effective in well-designed, rigorous research studies.
You will often see these strategies referred to as evidence-based interventions.

6. Expert opinion or personal experience
Sources of Evidence
Systematic reviews
Research studies
Practitioner reports
Expert opinion or personal experience
Scientifically Supported
“Best” or “Proven”
Some Evidence
Practice-Tested:
“Promising”
Strategies             
Programs
Talking Points:
Evidence to guide practice can be derived from different types of research as well as practical experience. Health professionals make decisions based on various types of evidence, spanning the spectrum from more subjective evidence—such as their direct experience with the populations they work with—to more objective sources of evidence—including the results of well-designed research studies.
Systematic Reviews are generated by a team of researchers and practitioners who examine methods and findings of multiple, rigorously conducted studies to summarize evidence into recommendations for what works, such as recommendations related to worksite wellness programs to reduce obesity. The Community Guide, a collection of evidence-based findings from the Community Preventive Services Task Force, is one example.
Research studies refer to individual studies that test the efficacy of a specific strategy. The results might be packaged for dissemination or described in a peer-reviewed journal publication.
Practitioner reports of implementation: include reports on the findings of an evaluation of a strategy. As a practitioner, this could also be your own program evaluation. These might be shared through reports, briefs, or success stories.
Expert opinion or personal experience: could be recommendations made by credible groups in support of strategies that have not yet been tested. An example of this is “Complete Street” policies, which are policies and design strategies that require streets to be planned, designed, operated, and maintained to be safe and convenient for all users regardless of their mode for transportation. Many credible experts recommend “Complete Street” policies, but it will take years for these strategies to be tested. You might also use personal experience. For example, you might have discovered that text message reminders are more effective than phone calls for reminding parents in your population to bring adolescents in for vaccinations.
It is important to note that only the top two tiers—Systematic Reviews and Research Studies—are generally referred to as “evidence-based interventions”.

7. Research and Practice Create Evidence
Interventions that have been tested in a research study 
Systematic review of multiple interventions
Policy analysis
Evidence derived from research
Intervention developed, implemented and evaluated in an organization, community or geographic region
Evidence derived from practice
Talking Points:
A point to emphasize here is that research and practice both can generate evidence. 
Evidence derived from research can include strategies that have been tested in a research study, systematic reviews of multiple studies, or as we will talk about more in detail soon, policy analysis.
Evidence derived from practice can include interventions that have been developed, implemented, and evaluated in an organization, community, or geographic region.  Research generally provides strong evidence for the effectiveness of an intervention strategy. Evidence from practice can provide additional evidence on what is feasible in a real world setting or how best to adapt or implement an intervention in a specific population or setting. 

8. Social Ecological Model
Talking Points:
When examining the types of evidence-based interventions to select for your setting, you may want to consider what levels of the Social Ecological Model, or SEM, you want to affect. The SEM was developed to better understand the factors that influence health and can serve as a framework for planning evidence-based interventions. The Model can help us explore a variety of factors that can effect health, including individual characteristics, attitudes of friends, the environment where people live, cultural norms, and public policies.
Individual: The individual level refers to the characteristics of a specific person. It includes factors such as knowledge, attitudes, beliefs, personality, biology, and genetics, all of which can influence a person’s health and health practices.
Interpersonal: The interpersonal level refers to the influence of an individual’s family, peers, and social networks on lifestyle choices.
Organizational: The institutional or organizational level refers to programs, policies, and informal structures in settings such as worksites, schools, or religious groups.
Community: The community level—which is often referred to as the environment level—includes partnerships, assets, infrastructure, cultural norms, and standards in a person's community and physical environment.
Public Policy: The policy, or systems level, refers to the policies and laws at the local, state, and federal level that regulate or impact the health behaviors of citizens.

9. Change at Multiple Levels
Health is affected by a variety of factors:
Individual characteristics
Attitudes and behaviors of peers
Physical surroundings/environment
Community norms
Public policy
Consider evidence-based interventions that produce change at multiple levels
Talking Points:
Knowing that individual health is influenced by a variety of factors, including individual characteristics, attitudes and behaviors of peers, the environment, and policies in the community—interventions should include activities that produce change at multiple levels of the Social Ecological Model.
Here’s how you can use the Social Ecological Model to examine and target the types of evidence-based interventions using colorectal cancer screening as an example. Let’s start by looking at the three center rings. Interventions can directly target the behavior of individuals, people that make up one’ social network, or the organizations that one is associate with. Interventions that target the individual level might include education or counseling around the benefits of CRC screening. Interventions that target social networks might include interventions that work with couples, families, or worship groups to effect change, and remove barriers. Interventions can also target organizational change or public policy change. Organizational change might include developing relationships with specialists in the community who are willing to do colonoscopies for a specified number of uninsured patients who need diagnostic tests following a positive screening.
In addition to the inner rings of the Model, you may also want to target factors occurring in the outer rings. Interventions may target cultural values and norms at the community level by working with coalitions or collaboratives to promote colorectal cancer screening or conducting public awareness campaigns. You may also want to target changes to public policy by, for example, changing regulations governing Medicaid reimbursement for different types of care.
In short, evidence-based interventions can include activities that produce change at more than one level of the model. Individual health, at the center, is going to be influenced by a variety of factors, certainly including those occurring in the outer rings of the Model at the policy level.

10. Evidence-based Interventions for Promoting Public Health
Environment or Individual Behaviors
Policies
Evidence-based Interventions
Packaged Programs
Strategies
(based on systematic reviews)
Talking Points:
Now that we understand the importance of examining and targeting strategies around the multiple levels that influence health, let’s take a moment to describe what we mean by evidence-based strategies.
You can summarize interventions in three main categories: packaged programs; policies, at both public policy and organizational levels; and strategies, primarily those derived from systematic reviews, such as the Community Guide.
These distinctions can also be useful during discussions about finding, adapting, and evaluating evidence-based interventions.

11. Packaged Programs
Interventions that include instructions and specify materials needed to implement with success
Talking Points:
Packaged programs are interventions that include instructions for carrying out the intervention and specify the materials that are needed to implement a program with success. Here are three examples of evidence-based programs, all based on research studies and now packaged for dissemination.
Pool Cool is a skin cancer prevention program
Body and Soul is a church-based, healthy eating program; and
Pathway to Freedom is a smoking cessation program
All are products of research studies conducted under carefully controlled conditions—in terms of who they recruited to participate, how the programs were implemented, and how the evaluation data were analyzed–to make sure it was the program, not other factors, that accounted for the observed effect.
Body and Soul
available on rtips.cancer.gov
Pathways to Freedom
available on rtips.cancer.gov
Pool Cool
edu/poolcool/

12. Packaged Program Example: Pool Cool
At a glance
Aim: increase awareness, motivation, and sun protection practices to reduce incidence of skin cancer
Setting: swimming pools
Target Audience: children (age 5-10) enrolled in swimming lessons
Program components:
Eight 5-minute lessons during swim class
Five optional sun-safe poolside activities
Sun safety signs
Program materials
Developed in efficacy and diffusion trials and process evaluations
Available online for free
Talking Points:
Since programs are based on a single intervention, they can be assembled into a well-documented package. Here’s a more detailed example of one of the packaged program mentioned on the previous slide—Pool Cool.
If you visit the Pool Cool website, you can find details about this program including its:
Program aim;
Suitable settings;
Target population;
Program components or implementation “essentials”; and
Program materials - available as downloadable files. The materials include a Facilitator’s Guide, signage to post at the pool, and an instructional manual for lifeguards implementing sun-safety activities as part of their normal duties.
At the website, you also can see photos and read testimonials from organizations or people who use Pool Cool.
Source:

13. Policies
A system of laws, regulatory measures, courses of action, and funding priorities concerning a given topic
Public policy: regulation set by government or local authorities (e.g., laws for coverage, ordinances)
Organizational policy: organizational rule or regulation
Talking Points:
Another evidence-based intervention is policies. Policies are a system of laws, regulatory measures, courses of action, and funding priorities concerning a given topic.
Policies can include:
Public policies set at the national, state, or local levels. One example of a public policy is an ordinance that you cannot smoke in public places in a city.
Policies can also include organizational policy rules or guidelines within organizations. For example, you can set rules about not smoking in your organization or what types of healthy food options to offer at the worksite.

14. Public Policy Example: NC Driver License Redesign
North Carolina enacted legislation that prohibits the purchase of tobacco products by persons under 18 years
Talking Points:
Here is an example of a policy intervention to reduce the harmful effects of tobacco. This intervention includes public policy – or in this case legislation – that prohibits minors from buying tobacco. The legislation included the redesign of the driver license in North Carolina. The design makes it easier for retailers to identify underage consumers of both alcohol and tobacco. Anyone under 21 is issued a vertical license. An added red strip identifies those under 18.
Policies can be supplemented with other types of interventions, such as a media campaign targeting retailers. In the media campaign example shown here, retailers know if they “see red, the tobacco sale is dead.”

15. Organizational Policy Example: Dietary Recommendations for Workplaces
Food Item
Recommendation
Rationale
Examples of what would be IN and OUT
Beverages
Contain 100% fruit juice with no added sweetener
Fruits/vegetables contain necessary nutrients
IN: Vegetable and fruit juice
Snacks, sweets, and sides
Sugar: No more than 35% by weight
Eliminate foods that
Are high in calories
Are low in nutrients
Promote dental caries
IN: Some granola bars, trail mix, animal crackers, fat-free fudge bar, frozen fruit bar
OUT: Some granola bars, some cookies, all candy
Talking Points:
Policies also can be implemented at more local levels of the Social Ecological Model, including worksites.
This is an example from the state of Utah. This table offers simple guidance to food service managers on what types of beverages, snacks, sweets, and sides would comply (or not) with new dietary recommendations for cafeterias, vending machines, and break rooms in workplaces in Utah.

16. Evidence-Based Strategies
Broad recommendation based on systematic review of multiple studies
Talking Points:
The final category of evidence-based interventions is evidence-based strategies.
A recommendation is a broadly defined action that is recommended on the basis of having been proven effective in multiple studies. Since the recommended action synthesizes findings from a collection of interventions, recommendations lack implementation details, such as those provided for the Pool Cool packaged program. In other words, recommendations are less prescriptive.
The Task Force on Community Preventive Services is one group that conducts systematic reviews of studies on Adolescent Health, Asthma, Diabetes and Cancer—including Breast, Cervical, Colorectal Cancer Screening, and Skin Cancer Prevention. These recommendations are published in The Community Guide. The US Preventive Services Task Force also disseminates clinical recommendations derived from systematic reviews, and the Cochrane Collaborative conducts systematic reviews on a range of both clinical and public health topics where the evidence-to-date has been unclear.

17. Evidence-Based Strategy Example: The Community Guide
Aim: Increase physical activity
Aim: Increase CRC screening
Environmental strategy:
Point-of-decision prompts
Program material:
Individual strategy:
Small media
Program material:
Talking Points:
The Community Guide is an example of evidence-based interventions that can guide intervention planning and development.
For example, a search for strategies to increase physical activity will uncover “point-of-decision prompts” – as just one example of an effective environmental strategies. With that information, you may develop a strategy that includes posting signs, like the one shown on the left, that prompt people to take the stairs.
If you consult the Community Guide about how to increase colorectal cancer screening, one strategies is to use “small media,” which is defined as videos, brochures, flyers, and newsletters that convey educational and motivational information that can be tailored to individuals or targeted to priority populations.
On the right, you can see an example of small media developed through an interactive website called miyo—make it your own, which allows users to merge their agency or community information with research-tested image and message templates.
A key point to remember is that if you select an evidence-based strategy instead of a packaged program, you will need expertise and time to develop your materials and protocols.

18. Advantages of Evidence-based Interventions
Add value to a grant application
Save time and resources during planning and implementation
Help focus your evaluation
Increase your likelihood of success
Talking Points:
There are benefits to all three types of evidence-based interventions: Programs, Policies, and Strategies. Evidence-based programs have been shown to work in the specific populations and settings in which they were evaluated or studied, and may need to be adapted. Evidence-based policies and recommendations often have been demonstrated to work under more diverse settings.
As public health practitioners, we always want to demonstrate that prevention interventions are a worthwhile investment. Most practitioners agree that using evidence-based interventions:
Add value to a grant application
Can increase cost benefits, by saving time and resources during planning and implementation
Focus your evaluation procedures
Increase your likelihood of success

19. Take Home Points
There are different types of evidence- based interventions 
Interventions may include activities that produce change at multiple levels of the Social Ecological Model
Evidence-based interventions can:
Increase your likelihood of success
Save time and resources
Talking Points:
There are three types of evidence-based interventions—package programs, policies, and strategies.
Knowing that individual health is influenced by a variety of factors, strategies should include activities that produce change at multiple levels of the Social Ecological Model.
Using evidence-based interventions can not only increase your likelihood of success, but also help save time and resources in terms of new program development.

20. Questions?
Ask the Audience:
Do you have any questions?

21. References
Jacobs JA, Jones E, Gabella BA, Spring B, Brownson RC. (2012). Tools for Implementing an Evidence-Based Approach in Public Health Practice. Prev Chronic Dis, 9:
Brownson RC, Baker EA, Leet TL, Gillespie KN. (2003). Evidence-Based Public Health. New York: Oxford University Press.
Brownson RC, Fielding JE, Maylahn CM. (2009). Evidence-Based Public Health: A fundamental concept for public health practice. Annu. Rev. Public Health, 30:175–201.
McLeroy KR, Steckler A, and Bibeau D. (Eds.) (1988). The social ecology of health promotion interventions. Health Education Quarterly, 15(4):
National Cancer Institute. Using What Works. Accessed July 13, 2016.
Lesesne CA, Lewis KM, Moore C, Fisher D, Green D, Wandersman A. (2007). Promoting science-based approaches to teen pregnancy prevention using Getting to Outcomes. Unpublished manual.