1. Evidence-Based Public Health TPHA 2014 Paul Campbell Erwin, MD, DrPH Professor and Department Head Department of Public Health, University of Tennessee 1

2. Learner Objectives 1.Identify and describe the domains of EBPH; 2.Understand the applicability of EBPH to improving the efficiency, effectiveness, and accountabilities of public health practice; 3.Describe how EBPH concepts can provide the basis for stating the value of local public health to stakeholders. 2

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4.  Why do we do the things we do?  How do we decide what to do? 4

5. Why do we do the things at WORK the way that we do? Among competing priorities, how do we decide what to do, and why? 5

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8. Evidence-Based Public Health  the process of integrating science-based interventions with community preferences to improve population health.  Dr. Ross Brownson 8 Acknowledgment: To Dr. Ross Brownson and team, for all EBPH Framework slides and general approach

9. Retool Discontinue Disseminate widely 9

10. What is “Evidence”? 10

11. 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 Objective Subjective Like beauty, it’s in the eye of the beholder… 11

12. How much Evidence is enough? 12 “The best is the enemy of the good” Voltaire

13. 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 13

14. How are decisions generally made in public health settings? 14

15. How are decisions generally made in public health settings?  History/inertia  Anecdote  Pressure from policy makers or administrators  Media driven  Resources/funding availability  Peer reviewed literature/systematic reviews  Expert opinions (e.g., academics, community members) OR  Combined methods, based in sound science  The challenge is in how to make the best use of multiple sources of information & limited resources. 15

16. Small Group Work  What was the most recent NEW thing you did at work?  Why did you do it?  What was the Evidence-Base for decision-making? 16

17. EBPH is NOT Rocket Science **  What’s the problem?  How big is it?  What’s the cause?  What do I do about it?  Once I do something, how do I know I’ve made a difference? ** But rocket science depends on the use of evidence 17

18. EBPH begins with The Question 18

19. 19 What’s the issue?

20. EBPH begins with The Question For example…..  What are the most important health problems in our community?  Given the problems of Obesity, Chronic Disease, Child Health and Health Disparities, and Substance Use, what should we focus on? And once we decide, what should we do?  What’s the best way to reduce tobacco use in our community? In our health department?  How do we reduce no-show rates in Family Planning? 20

21. 21 What’s the issue? How big is it?

22. Quantifying the issue Disease/condition vs. Death Incidence/Prevalence vs. Mortality Problem of small numbers Types of rates 22

23. Quantifying the issue Incidence = new cases; a measure of risk Prevalence = existing cases; a measure of the overall burden of disease P = I x D 23

24. Downloaded from: StudentConsult (on 4 September 2008 03:58 PM) © 2005 Elsevier In a steady state: P = I x D

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28. Quantifying the issue  A program to address cardiovascular disease was put in place twenty years ago. An evaluation of the program showed that the prevalence of cardiovascular disease remained the same after twenty years. The program director was convinced this was a good program, but the evaluator retorted – “20 years and no improvement in prevalence?” How can you help this program director out – i.e., how could you explain that the program has indeed been successful despite a stable prevalence rate? 28

29. P = I x D Time 1: __ = 10 x 5 50 = 10 x 5 Time 2: __ = 5 x 10 50 = 10 x 5 29

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31. Where do we get good data on Disease/Condition Population-based Vital Statistics Birth and death Reportable diseases Registries Birth defects Cancer Immunizations Trauma Representative Samples National Health Interview Survey (NHIS) National Health and Nutrition Examination Survey (NHANES) Behavioral Risk Factor Surveillance System (BRFSS) Youth Risk Behavior Survey (YRBS) Hospital/facility- based TennCare THA 31

32. Quantifying the issue  The problem of small numbers: most challenging when expressed as rates, when the multiplier is large and the actual numerators and denominators are relatively small 32

33. Quantifying the issue  The problem: a call from central office to alert me that the 1992 female African- American mortality rate for diabetes was higher in Claiborne County than for any county in the state, including Shelby County.  http://hit.state.tn.us/index.shtml http://hit.state.tn.us/index.shtml 33

34. 34 What’s the issue? How big is it? How important is it?

35. Data Synthesis in MAPP What are we synthesizing?

36. http://healthyknox.org/home.html

37. How can we create a sustainable network of partnerships that effectively contributes to improved community health? STRATEGIC ISSUES www.healthyknox.org

38. How can we achieve equitable health outcomes for all community members? STRATEGIC ISSUES www.healthyknox.org

39. How can we position health as a consideration in community policy and planning decisions? STRATEGIC ISSUES www.healthyknox.org

40. 40 What’s the issue? How big is it? How important is it? What is the cause? What should we do about it?

41. Determining what is known using scientific literature  Do immunizations work?  Does family planning work?  Does WIC work?  Does restaurant inspection work?  Do County Health Councils work? 41

42. Small Group Work  What was the most recent NEW thing you did at work?  Why did you do it?  What was the Evidence-Base for decision-making?  Where did you (do you) go to get information to help you decide on evidence-based strategies? 42

43. Evidence-Based Public Health http://www.thecommunityg uide.org/index.html http://prcstl.wustl.edu/tr aining/Pages/Evidence- Based-Public-Health- Course.aspx

44. Ok…Programs…but what about evidence for how we operate? Fostering more effective public health by identifying administrative evidence-based practices. Brownson RC, Allen P, Duggan K, Stamatakis KA, Erwin PC. Am J Prev Med 43(3):309 – 319, 2012 44

45. Administrative Evidence- Based Practices 45 DomainEvidence-Based Practice Workforce developmentTraining Access to technical assistance LeadershipSkills and background of leaders Values and expectations of leaders Participatory decision-making Organizational climate and cultureAccess and free flow of information Support of innovation and new methods Learning orientation Relationships and partnershipsInterorganizational relationships Vision and mission of partnerships FinancialAllocation and expenditure of resources

47. 47 What’s the issue? How big is it? How important is it? What is the cause? What should we do about it? What are we going to do about it?

48. Developing & Prioritizing Options 1. Multi-voting Technique 2. Strategy Grids 3. Nominal Group Technique 4. The Hanlon Method 5. Prioritization Matrix 48

49. Small Group Work  What was the most recent NEW thing you did at work?  Why did you do it?  What was the Evidence-Base for decision-making?  Among competing priorities, HOW did you decide what to do or focus on? 49

50. 50 Developing & Prioritizing Options

52. 52 What’s the issue? How big is it? How important is it? What is the cause? What should we do about it? What are we going to do about it? How are we going to do it, when, with what results?

53. Logic models document your theory of change: how your program works 53 Specified Intervention Components And Activities Specified Intervention Components And Activities Chosen Determinants (Risk & Protective Factors) Chosen Determinants (Risk & Protective Factors) Outcomes Interventions Inputs Activities OutcomesProximal Determinants Behaviors Outputs

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55. 55 What’s the issue? How big is it? How important is it? What is the cause? What should we do about it? What are we going to do about it? How are we going to do it, when, with what results? How will we know if we have made a difference?

56. Small Group Work  What was the most recent NEW thing you did at work?  Why did you do it?  What was the Evidence-Base for decision-making?  Did it make a difference? 56

57. Why Evaluate? 57  What funders want: – Prove that their money is making a big difference in outcomes of their choice.  What grantees/people who receive funds want: – Show that they should be given more money to continue and expand the good work they are doing.

58. 58 Early detection of breast cancer Outcomes Breast cancer screening by mammography Breast cancer screening by mammography Determinants Provider reminder and recall systems Provider reminder and recall systems Activities Evaluation Strategy 1: Start with Outcomes

59.  We are used to thinking about activities first.  That’s OK! Build the model from left to right.  But you still need to think through why your activities “make a difference.” 59 Evaluation Strategy 2: Start Building the Model with Activities

60. 60 Specified Activities Specified Activities Immediate or short-term outcomes (Exactly the same as proximal determinants) Immediate or short-term outcomes (Exactly the same as proximal determinants) Specified Outcomes Specified Outcomes Evaluation Strategy 2: Start Building the Model with Activities

61. Evaluation Words of Wisdom  Don’t worry about the labels – Determinants are often called outputs – Outcomes are sometimes called impacts – Sometimes logic models have separate columns for inputs, activities, outputs, short-term outcomes, long-term outcomes, and impacts (whew!).  Focus instead on the causal mechanisms. – If you think through the logic of why your program works, you can fill in any format the funder/evaluator requires of you. – ….and actually benefit from the experience! 61

62. Evidence-Based Decision Making

63. 63 What’s the issue? How big is it? How important is it? What is the cause? What should we do about it? What are we going to do about it? How are we going to do it, when, with what results? How will we know if we have made a difference?