evidence-based public health tpha 2014 paul campbell erwin, md, drph professor and department head...
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Evidence-Based Public HealthTPHA 2014
Paul Campbell Erwin, MD, DrPHProfessor and Department Head
Department of Public Health, University of Tennessee
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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.
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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?
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Evidence-Based Public Health the process of integrating science-
based interventions with community preferences to improve population health.
Dr. Ross Brownson
Acknowledgment: To Dr. Ross Brownson and team, for all EBPH Framework slides and general approach
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
SubjectiveLike beauty, it’s in the eye of the beholder…
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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
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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
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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?
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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
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EBPH begins with The QuestionFor 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?
Quantifying the issue
• Disease/condition vs. Death
• Incidence/Prevalence vs. Mortality
• Problem of small numbers
• Types of rates
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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
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Downloaded from: StudentConsult (on 4 September 2008 03:58 PM)© 2005 Elsevier
In a steady state: P = I x D
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?
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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
TennCareTHA
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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
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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
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How can we create a sustainable network of partnerships that effectively contributes to improved community health?
STRATEGICISSUES
www.healthyknox.org
How can we achieve equitable health outcomes for all community members?
STRATEGICISSUES
www.healthyknox.org
How can we position health as a consideration in community policy and planning decisions?
STRATEGICISSUES
www.healthyknox.org
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What’s the issue?
How big is it?
How important is it?
What is the cause?What should we do about it?
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?
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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?
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Evidence-Based Public Health
http://www.thecommunityguide.org/index.html
http://prcstl.wustl.edu/training/Pages/Evidence-Based-Public-Health-Course.aspx
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
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Administrative Evidence-Based Practices
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Domain Evidence-Based Practice
Workforce development Training
Access to technical assistance
Leadership Skills and background of leaders
Values and expectations of leaders
Participatory decision-making
Organizational climate and culture Access and free flow of information
Support of innovation and new methods
Learning orientation
Relationships and partnerships Interorganizational relationships
Vision and mission of partnerships
Financial Allocation and expenditure of resources
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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?
Developing & Prioritizing Options
1. Multi-voting Technique2. Strategy Grids3. Nominal Group Technique4. The Hanlon Method5. Prioritization Matrix
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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?
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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?
Logic models document your theory of change: how your program works
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SpecifiedInterventionComponents
AndActivities
SpecifiedInterventionComponents
AndActivities
ChosenDeterminants
(Risk & ProtectiveFactors)
ChosenDeterminants
(Risk & ProtectiveFactors)
Outcomes
Interventions• Inputs• Activities
OutcomesProximalDeterminants• Behaviors• Outputs
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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?
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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?
Why Evaluate?
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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.
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Early detection of breast cancer
Outcomes
Breast cancer screening by mammography
Determinants
Provider reminder and recall systems
Activities
Evaluation Strategy 1: Start with Outcomes
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.”
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Evaluation Strategy 2: Start Building the Model with Activities
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SpecifiedActivitiesSpecifiedActivities
Immediate or short-term outcomes
(Exactly the sameas proximaldeterminants)
SpecifiedOutcomesSpecifiedOutcomes
Evaluation Strategy 2: Start Building the Model with Activities
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!
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