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Evidence for Public Health Decision Making

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The presentation gives an overview of evidence based public health with emphasis on the seven steps of EBPH Framework. It also includes the data sources to search for evidence and relevant articles explaining the current trend in decision making. One of the sources of the presentation is from EBPH training series by Rocky Mountain foundation. The link is provided in the end slide. Do contact me if you need any help with the resources.

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Evidence for Public Health Decision Making

  1. 1. EVIDENCE FOR HEALTH DECISION MAKING EVIDENCE BASED PUBLIC HEALTH
  2. 2. CONTENTSINTRODUCTION • Need for EBPH • History of EBPH • EBM vs EBPH Framework for EBPH • Barriers for EBPH • CONCLUSION
  3. 3. INTRODUCTION Evidence-based medicine (EBM) has greatly advanced the scientific validity, and presumably the effectiveness, of medical practice. RANDOMIZED CONTROL TRIAL Strong ‘‘internal validity’’ to answer precise questions under narrow conditions
  4. 4. The mainstay of EBM Places RCTs on a pedestal above all other forms of evidence
  5. 5. WHO GRADE SYSTEM Paramount importance to RCTs, to develop recommendations for public health issues …strong temptation to apply EBM methods and standards reflexively to public health.
  6. 6. SCALE Public health interventions usually operate at a larger scale, and address issues that span clinical, behavior, and structural dimensions. SITUATIONALVARIABILITY Because situations can vary so widely in public health, the ‘‘external validity’’ or generalizability of evidence to other situations is absolutely crucial for public health applications. COMPLEXITY What is the best set of interventions for particular settings? • How should the interventions be organized and delivered within existing systems? • What will make the intervention sustainable? What makes public health different?
  7. 7. ‘‘external validity’ Severe weakness of the RCT methodology We need to know not just whether something works under narrowly prescribed circumstances but also how, when, and why it can work for broad application.
  8. 8. The Evidence-Based Movement EBM → EBPH A shift of emphasis from RCTs to more relevant evidence when assessing public health issues
  9. 9. HISTORY
  10. 10. HISTORY • In 1997, Jenicek published a review discussing the links between EBM and EBPH. • He noted that the foundation for both EBM and EBPH was epidemiology. • While acknowledging many parallels with EBM, Jenicek observed that EBPH had unique challenges due to its often complex interventions and involvement with multiple community and societal issues.
  11. 11. DEFINITION Evidence-based Public Health is defined as the conscientious, explicit, and judicious use of the current best evidence in making decisions about the care of communities and populations in the domain of health protection, disease prevention, health maintenance and improvement (health promotion). It is the process of systematically finding, appraising, and using contemporaneous research findings as the basis for decisions in public health." (Jenicek, M. (1997).
  12. 12. STEPS IN EBPH 1. Framing a clear question 2. Searching for evidence 3. Appraisal of evidence 4. Selection of best evidence for public health decision 5. Linking evidence with public health practice 6. Evaluation 7. Teaching others to practice evidence based public health One of the greatest challenges of the evidence-based approach appears in the domain of Health Promotion (Maintain and improve health of individuals and communities) To measure and evaluate such dependent and independent variables is much more difficult than in the domain of disease prevention, where one or more determining factors are related usually to one particular health problem only.
  13. 13. EBM Vs EBPH
  14. 14. While the framework is useful to organize the concepts, EBPH in practice is a dynamic nonlinear process, largely because it occurs in communities that are neither static nor controlled scientific environments.
  15. 15. EBPH FRAMEWORK
  16. 16. COMMUNITYASSESSMENT “A balance of stories and studies”
  17. 17. A systematic way to identify needs and resources to improve the health of a community by using a health framework or model.
  18. 18. Types of community assessment HEALTH ASSESSMENT Describes health status NEEDS ASSESSMENT Defines needs related to actual or perceived problem CAPACITY ASSESSMENT Identifies actual or potential resources
  19. 19. Models that support community assessment SOCIO ECOLOGICAL MODEL
  20. 20. QUANTIFYING THE ISSUE EPIDEMIOLOGY PUBLIC HEALTH SURVEILLANCE
  21. 21. DESCRIPTIVE EPIDEMIOLOGY
  22. 22. DEVELOPINGACONCISE STATEMENT OF THE ISSUE “If you don’t know where you are going, you might wind up at somewhere else”
  23. 23. A concise statement has one goal… Addressing the right problem with the best strategy. Epidemiologic What is the relationship of x to health condition y? Intervention What is the best approach to decreasing risk factor x? How do I implement the intervention? Evaluation Is program y effective? Managerial Why did x go wrong? Policy-related What will be the impact of changing policy z? KEYS  Avoid early judgments  Encourage creative thinking  Make problem statements quantifiable early on, use data to frame the issue  Include stakeholders in this process
  24. 24. COMPONENTS OFAN ISSUE STATEMENT • Who is smoking? • Who is exposed to secondhand smoke? • What’s the impact? • Effective interventions? • Cost? • Resources needed? • What is the best approach to decreasing risk factor x? • How do I implement the intervention? • Is program y effective? • Asthma • Lung cancer • Vulnerable populations • Quit attempts • Visits to the Emergency Room
  25. 25. SEARCHING THE LITERATURE EVIDENCE SYNTHESIS
  26. 26. WHAT IS EVIDENCE? “Like beauty, it’s in the eye of the beholder”
  27. 27. Public Health Evidence Pyramid
  28. 28. DATA SOURCES
  29. 29. SYSTEMATIC REVIEWS Inform public health practice and policy Help select proven interventions Provide direction for innovations into unknown frontiers of knowledge
  30. 30. Aimed at increasing the quality and quantity of systematic reviews that can be used to provide evidence to answer practical, public health questions. In addition to evidence, “politics and timeliness” are factored into public health decision making. - Waters and Doyle EBPH must currently work with a smaller evidence base; serve a broader, more diverse field; and use a wider range of scientific approaches to gather information for practice improvement - Glasziou P, Longbottom H.
  31. 31. EVIDENCE BASED GUIDELINES The community guide Is a free resource for evidence-based recommendations and findings from the community preventive services task force which is an independent, nonfederal, volunteer body of public health and prevention experts. • Initiative of the Department of Health and Human Services (DHHS) • Coordinated by the Centers for Disease Control and Prevention (CDC) • Recommendations based on systematic reviews
  32. 32. The independent Task Force on Community Preventive Services, makes its recommendations based on systematic reviews of topics in three general areas: changing risk behaviors; reducing diseases, injuries and impairments; and addressing environmental and ecosystem challenges
  33. 33. RECOMMENDATION OUTCOME Recommended with strong evidence Recommended with sufficient evidence Recommended against due to lack of effect, cost, harms Insufficient evidence
  34. 34. PRE FORMULATED SEARCHES
  35. 35. Successful implementation/positive deviance. One major way of addressing the crucial issues of scale and complexity is examining what actually works (or not) at scale, and then parsing the details. ‘‘case study’’ or positive deviance approach is a backbone of major business school which is comparative to public health decisions. When a repeated pattern of success is seen across many different situations, it provides confidence in the general approach.
  36. 36. Systematic trials and program tests • Wide variety of methodologies, ranging from randomized trials and quasi-experimental designs to demonstration projects. • Such investigations (including RCTs) should provide extensive detail on what did and did not work, as well as how.
  37. 37. Additional epidemiologic methods These include cohort and case-control studies to help assess factors predicting health, disease, and adverse outcomes, as well as phylogenetic studies to assess patterns of disease transmission.
  38. 38. DevelopandPrioritizeProgramandPolicyOptions There is no “one best way” to set public health priorities. What is essential, however, is that a process or method be adopted that is systematic, objective, and allows for standardized comparison of problems or alternatives that incorporate the scrutiny of science and the realities of the environment. Vilnius & Dandoy, 1990
  39. 39. Common Elements of Criteria: Prioritizing Public Health Issues at the Community Level  Measure of burden mortality, morbidity, years of life lost  Quantifying preventability potential effects of the intervention  Resources cost of intervention, resources needed to carry out a program or policy
  40. 40. Prioritization Methods • Multi-voting Technique • Strategy Grids • Nominal Group Technique • Hanlon Method
  41. 41. Multi-Voting Technique
  42. 42. STRATEGY GRID
  43. 43. NOMINAL GROUP TECHNIQUE
  44. 44. HANLON METHOD
  45. 45. ECONOMIC EVALUATION • It is one decision-making tool • There are several different types of EE
  46. 46. Types of economic evaluation
  47. 47. Develop anAction Plan • Good planning can lead to improved implementation • Improved implementation = improved outcomes = Logic Model Work Plan Evaluation Clearly linked goals, objectives, and strategies Basis in evidence and assessment Clear roles and responsibilities Clear mechanisms for tracking progress
  48. 48. LOGIC MODEL TEMPLATE Source: Colorado Department of Public Health and Environment, Prevention Services Division, Epidemiology, Planning and
  49. 49. WORK PLAN TEMPLATE
  50. 50. PROGRAM EVALUATION “… a process that attempts to determine as systematically and objectively as possible the relevance, effectiveness, and impact of activities”
  51. 51. FRAMEWORK
  52. 52. Engage stakeholders • Who are the stakeholders for your programs? • What are some of their key questions/ outcomes? Describe the program There are clear, measurable intended effects: • Program delivery (process) • Short-term outcomes (impact) • Long-term outcomes (outcome) Focus evaluation design
  53. 53. RE-AIM MODEL Glasgow RE et al. Am J Public Health. 1999;89:1322-7.
  54. 54. GATHERCREDIBLE EVIDENCE QUALITATIVE APPROACH -Interview Guide -Focus groups -Recording analysis QUANTITATIVE APPROACH -Validity -Reliability
  55. 55. JUSTIFY EVIDENCE
  56. 56. ENSURE USEAND SHARE LESSONS • Evaluation findings need to reach all stakeholders and be understandable and timely • Program maintenance/adaptation • Broader dissemination DISSEMINATION
  57. 57. 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 • Inadequate training in key public health disciplines • Lack of time to gather information, analyze data, and review the literature for evidence • Lack of comprehensive, up-to-date information on the effectiveness of programs and policies (overall and in high-risk populations)
  58. 58. Evidence-based public health is a process of: • Engaging stakeholders • Assessing what influences health, health behaviors and community health (literature, local needs, academic theory) • Developing programs based on assessment (science) • Evaluating process, impact, and outcome • Learning from our work and sharing it in ways that are accessible to ALL stakeholders
  59. 59. • Jenicek M. Epidemiology, evidenced-based medicine, and evidence-based public health. Journal of epidemiology. 1997;7(4):187-97. • Brownson RC, Fielding JE, Maylahn CM. Evidence-based public health: a fundamental concept for public health practice. Annual review of public health. 2009 Apr 21;30:175-201. • Task Force on Community Preventive Services. The guide to community preventive services: what works to promote health?. Oxford University Press; 2005 Feb 17. • Wahabi HA, Siddiqui AR, Mohamed AG, Al-Hazmi AM, Zakaria N, Al-Ansary LA. Evidence-based decision making in public health: capacity building for public health students at King Saud University in Riyadh. BioMed research international. 2015;2015. REFERENCES
  60. 60. • Friedrich V, Brügger A, Bauer GF. Worksite tobacco prevention: a randomized, controlled trial of adoption, dissemination strategies, and aggregated health-related outcomes across companies. BioMed research international. 2015;2015. • Hanquet, G., Stefanoff, P., Hellenbrand, W., Heuberger, S., Lopalco, P. and Stuart, J.M., 2015. Strong public health recommendations from weak evidence? Lessons learned in developing guidance on the public health management of meningococcal disease. BioMed research international, 2015. • Duvall S, Thurston S, Weinberger M, Nuccio O, Fuchs-Montgomery N. Scaling up delivery of contraceptive implants in sub-Saharan Africa: operational experiences of Marie Stopes International. Global Health: Science and Practice. 2014 Feb 1;2(1):72-92.
  61. 61. • Shelton JD. Evidence-based public health: not only whether it works, but how it can be made to work practicably at scale. Glob Health Sci Pract. 2014; 2 (3): 253–258. doi: 10.9745. GHSP-D-14-00066. pmid: 25276583;. • Lhachimi SK, Bala MM, Vanagas G. Evidence-based public health. BioMed research international. 2016;2016. • Kohatsu ND, Robinson JG, Torner JC. Evidence-based public health: an evolving concept. American journal of preventive medicine. 2004 Dec 1;27(5):417-21. • Frieden TR. Evidence for health decision making—beyond randomized, controlled trials. New England Journal of Medicine. 2017 Aug 3;377(5):465-75.
  62. 62. Training modules Evidence-Based Public Health Training Series Northwest Center for Public Health Practice, the Rocky Mountain Public Health Training Center, and the Prevention and Research Center in St. Louis, Missouri. ACKNOWLEDGEMENT Dr. Chandrashekar Janakiram For Logic Model Template THANK YOU!

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