1.
EVIDENCE FOR HEALTH DECISION MAKING
EVIDENCE
BASED
PUBLIC HEALTH

2.
CONTENTSINTRODUCTION
• Need for EBPH
• History of EBPH
• EBM vs EBPH Framework for EBPH
• Barriers for EBPH
• CONCLUSION

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.
The mainstay of EBM
Places RCTs on a pedestal above all other forms of evidence

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.
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.
‘‘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.
The Evidence-Based Movement
EBM → EBPH
A shift of emphasis from RCTs to more relevant evidence when
assessing public health issues

9.
HISTORY

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.
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.
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.
EBM Vs EBPH

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.
EBPH FRAMEWORK

16.
COMMUNITYASSESSMENT
“A balance of stories and studies”

17.
A systematic way to identify needs and resources to improve the health of a
community by using a health framework or model.

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.
Models that support community assessment
SOCIO ECOLOGICAL
MODEL

20.
QUANTIFYING THE ISSUE
EPIDEMIOLOGY PUBLIC HEALTH
SURVEILLANCE

21.
DESCRIPTIVE EPIDEMIOLOGY

22.
DEVELOPINGACONCISE STATEMENT OF THE
ISSUE
“If you don’t know where you are going, you might wind up at somewhere else”

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.
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.
SEARCHING THE LITERATURE
EVIDENCE SYNTHESIS

26.
WHAT IS EVIDENCE?
“Like beauty, it’s in the eye of
the beholder”

27.
Public
Health
Evidence
Pyramid

28.
DATA
SOURCES

29.
SYSTEMATIC REVIEWS
Inform public health practice and
policy
Help select proven interventions
Provide direction for innovations
into unknown frontiers of
knowledge

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.
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.
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.
RECOMMENDATION OUTCOME
Recommended with strong evidence
Recommended with sufficient evidence
Recommended against due to lack
of effect, cost, harms
Insufficient evidence

34.
PRE FORMULATED SEARCHES

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.
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.
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.
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.
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.
Prioritization Methods
• Multi-voting Technique
• Strategy Grids
• Nominal Group Technique
• Hanlon Method

41.
Multi-Voting Technique

42.
STRATEGY GRID

43.
NOMINAL GROUP TECHNIQUE

44.
HANLON METHOD

45.
ECONOMIC EVALUATION
• It is one decision-making tool
• There are several different types of EE

46.
Types of economic evaluation

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.
LOGIC MODEL TEMPLATE
Source: Colorado Department of Public Health and Environment, Prevention Services Division, Epidemiology, Planning and

49.
WORK PLAN TEMPLATE

50.
PROGRAM EVALUATION
“… a process that attempts to determine as systematically
and objectively as possible the relevance, effectiveness, and
impact of activities”

51.
FRAMEWORK

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.
RE-AIM MODEL
Glasgow RE et al. Am J Public Health. 1999;89:1322-7.

54.
GATHERCREDIBLE EVIDENCE
QUALITATIVE APPROACH
-Interview Guide
-Focus groups
-Recording analysis
QUANTITATIVE APPROACH
-Validity
-Reliability

55.
JUSTIFY EVIDENCE

56.
ENSURE USEAND SHARE LESSONS
• Evaluation findings need to reach all stakeholders and be
understandable and timely
• Program maintenance/adaptation
• Broader dissemination
DISSEMINATION

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.
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.
• 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.
• 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.
• 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.
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!