Assignment: Evidence Based Public Health Discussion

Assignment: Evidence Based Public Health Discussion ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS ON Assignment: Evidence Based Public Health Discussion Read “Evidence-Based Public Health – A Fundamental Concept for Public Health Practice” by Brownson, et al., 2009, located in the Reading & Study folder for this module/week. Discuss the following points in your initial thread. Review the discussion board instructions before posting your initial thread.Assignment: Evidence Based Public Health Discussion What is evidence-based public health (EBPH), and why does it matter? Compare and contrast the analytical tools of EBPH (systematic reviews, public health surveillance, economic evaluation, health impact assessment, and participatory approaches). In what ways do systematic reviews provide better evidence on which to base intervention decisions than personal experience? Why should qualitative data from community members be considered in the mix of evidence when planning a community-based intervention How does Christianity blend historical reviews and personal experience as credentials of its authenticity? annurev.publhealth.031308.100134.pdf Annu. Rev. Public Health 2009.30:175-201. Downloaded from Access provided by Liberty University on 12/05/20. For personal use only. ANRV370-PU30-10 ARI 15 February 2009 12:1 Evidence-Based Public Health: A Fundamental Concept for Public Health Practice Ross C. Brownson,1 Jonathan E. Fielding,2 and Christopher M. Maylahn3 1 Prevention Research Center in St. Louis, George Warren Brown School of Social Work, Department of Surgery and Alvin J. Siteman Cancer Center, Washington University School of Medicine, Washington University in St. Louis, St. Louis, Missouri 63110; email: [email protected] 2 Los Angeles Department of Health Services, Los Angeles, California 90012; School of Public Health, University of California, Los Angeles, California 90095-1772; email: [email protected] 3 Of?ce of Public Health Practice, New York State Department of Health, Albany, New York 12237; email: [email protected] Annu. Rev. Public Health 2009. 30:175–201 Key Words First published online as a Review in Advance on January 14, 2009 disease prevention, evidence-based medicine, intervention, population-based The Annual Review of Public Health is online at This article’s doi: 10.1146/annurev.publhealth.031308.100134 c 2009 by Annual Reviews. Copyright All rights reserved 0163-7525/09/0421-0175$20.00 Abstract Despite the many accomplishments of public health, a greater attention to evidence-based approaches is warranted. This article reviews the concepts of evidence-based public health (EBPH), on which formal discourse originated about a decade ago. Key components of EBPH include making decisions on the basis of the best available scienti?c evidence, using data and information systems systematically, applying program-planning frameworks, engaging the community in decision making, conducting sound evaluation, and disseminating what is learned. Three types of evidence have been presented on the causes of diseases and the magnitude of risk factors, the relative impact of speci?c interventions, and how and under which contextual conditions interventions were implemented. Analytic tools (e.g., systematic reviews, economic evaluation) can be useful in accelerating the uptake of EBPH. Challenges and opportunities (e.g., political issues, training needs) for disseminating EBPH are reviewed. The concepts of EBPH outlined in this article hold promise to better bridge evidence and practice. 175 ANRV370-PU30-10 ARI 15 February 2009 12:1 INTRODUCTION Public health research and practice are credited with many notable achievements, including much of the 30-year gain in life expectancy in the United States over the twentieth century (124). A large part of this increase can be attributed to provision of safe water and food, sewage treatment and disposal, tobacco use prevention and cessation, injury prevention, control of infectious diseases through immunization and other means, and other population-based interventions (34). Despite these successes, many additional opportunities to improve the public’s health remain. To achieve state and national objectives for improved population health, more widespread adoption of evidence-based strategies has been recommended (19, 57, 64, 109, 119). Increased focus on evidence-based public health (EBPH) has numerous direct and indirect bene?ts, including access to more and higher-quality information on what works, a higher likelihood of successful programs and policies being implemented, greater workforce productivity, and more ef?cient use of public and private resources (19, 77, 95). Ideally, public health practitioners should always incorporate scienti?c evidence in selecting and implementing programs, developing policies, and evaluating progress (23, 107). Assignment: Evidence Based Public Health Discussion Society pays a high opportunity cost when interventions that yield the highest health return on an investment are not implemented (55). In practice, intervention decisions are often based on perceived short-term opportunities, lacking systematic planning and review of the best evidence regarding effective approaches. These concerns were noted two decades ago when the Institute of Medicine determined that decision making in public health is often driven by “crises, hot issues, and concerns of organized interest groups” (p. 4) (82). Barriers to implementing EBPH include the political environment and de?cits in relevant and timely research, information systems, resources, leadership, and the required competencies (4, 7, 23, 78). Annu. Rev. Public Health 2009.30:175-201. Downloaded from Access provided by Liberty University on 12/05/20. For personal use only. EBPH: evidencebased public health 176 Brownson · Fielding · Maylahn It is dif?cult to estimate how widely evidence-based approaches are being applied. In a survey of 107 U.S. public health practitioners, an estimated 58% of programs in their agencies were deemed evidence-based (i.e., using the most current evidence from peerreviewed research) (51). This ?nding in public health settings appears to mirror the use of evidence-based approaches in clinical care. A random study of adults living in selected metropolitan areas within the United States found that 55% of overall medical care was based on what is recommended in the medical literature (108). Thacker and colleagues (159) found that the preventable fraction (i.e., how much of a reduction in the health burden is estimated to occur if an intervention is carried out) was known for only 4.4% of 702 population-based interventions. Similarly, costeffectiveness data are reported for a low proportion of public health interventions. Several concepts are fundamental to achieving a more evidence-based approach to public health practice. First, we need scienti?c information on the programs and policies that are most likely to be effective in promoting health (i.e., undertake evaluation research to generate sound evidence) (14, 19, 45, 77). An array of effective interventions is now available from numerous sources including the Guide to Community Preventive Services (16, 171), the Guide to Clinical Preventive Services (2), Cancer Control PLANET (29), and the National Registry of Evidence-Based Programs and Practices (142). Second, to translate science to practice, we need to marry information on evidence-based interventions from the peer-reviewed literature with the realities of a speci?c real-world environment (19, 69, 96). To do so, we need to better de?ne processes that lead to evidence-based decision making. Finally, wide-scale dissemination of interventions of proven effectiveness must occur more consistently at state and local levels (91). This article focuses particularly on state and local public health departments because of their responsibilities to assess public health problems, develop appropriate programs ANRV370-PU30-10 ARI 15 February 2009 12:1 or policies, and assure that programs and policies are effectively implemented in states and local communities (81, 82). We review EBPH in four major sections that describe (a) relevant background issues, including concepts underlying EBPH and de?nitions of evidence; (b) key analytic tools to enhance the adoption of evidence-based decision making; (c) challenges and opportunities for implementation in public health practice; and (d ) future issues. Annu. Rev. Public Health 2009.30:175-201. Assignment: Evidence Based Public Health Discussion Downloaded from Access provided by Liberty University on 12/05/20. For personal use only. EVOLUTION OF THE TENETS OF EVIDENCE-BASED PUBLIC HEALTH Formal discourse on the nature and scope of EBPH originated about a decade ago. Several authors have attempted to de?ne EBPH. In 1997, Jenicek de?ned EBPH as the “conscientious, explicit, and judicious use of 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)” (84). In 1999, scholars and practitioners in Australia (64) and the United States (23) elaborated further on the concept of EBPH. Glasziou and colleagues posed a series of questions to enhance uptake of EBPH (e.g., “Does this intervention help alleviate this problem?”) and identi?ed 14 sources of high-quality evidence (64). Brownson and colleagues described a six-stage process by which practitioners can take a more evidence-based approach to decision making (19, 23). Kohatsu and colleagues broadened earlier de?nitions of EBPH to include the perspectives of community members, fostering a more population-centered approach (96). In 2004, Rychetnik and colleagues summarized many key concepts in a glossary for EBPH (141). There appears to be a consensus among investigators and public health leaders that a combination of scienti?c evidence and values, resources, and context should enter into decision making (Figure 1) (19, 119, 141, 151, 152). In summarizing these various attributes of EBPH, key characteristics include Making decisions using the best available peer-reviewed evidence (both quantitative and qualitative research), Using data and information systems systematically, Applying program-planning frameworks (that often have a foundation in behavioral science theory), Engaging the community in assessment and decision making, Conducting sound evaluation, and Disseminating what is learned to key stakeholders and decision makers. Accomplishing these activities in EBPH is likely to require a synthesis of scienti?c skills, enhanced communication, common sense, and political acumen. Defining Evidence At the most basic level, evidence involves “the available body of facts or information indicating whether a belief or proposition is true or valid” (85). The idea of evidence often derives from legal settings in Western societies. In law, evidence comes in the form of stories, witness accounts, police testimony, expert opinions, and forensic science (112). For a public health professional, evidence is some form of data—including epidemiologic (quantitative) data, results of program or policy evaluations, and qualitative data—for uses in making judgments or decisions (Figure 2). Public health evidence is usually the result of a complex cycle of observation, theory, and experiment (114, 138). However, the value of evidence is in the eye of the beholder (e.g., usefulness of evidence may vary by stakeholder type) (92). Medical evidence includes not only research but characteristics of the patient, a patient’s readiness to undergo a therapy, and society’s values (122). Policy makers seek out distributional consequences (i.e., who has to pay, how much, and who bene?ts) (154), and in practice settings, anecdotes sometimes trump empirical data (26). Evidence is usually imperfect and, as noted by Muir Gray,Assignment: Evidence Based Public Health Discussion “[t]he absence of excellent evidence does not make evidence-based decision making • Evidence-Based Public Health 177 ANRV370-PU30-10 ARI 15 February 2009 12:1 Annu. Rev. Public Health 2009.30:175-201. Downloaded from Access provided by Liberty University on 12/05/20. For personal use only. Best available research evidence Environment and organizational context Decision-making Population characteristics, needs, values, and preferences Resources, including practitioner expertise Figure 1 Domains that in?uence evidence-based decision making [from Spring et al. (151, 152)]. • Scientific literature in systematic reviews • Scientific literature in one or more journal articles • Public health surveillance data • Program evaluations • Qualitative data Objective – Community members – Other stakeholders • Media/marketing data • Word of mouth • Personal experience Figure 2 Different forms of evidence. Adapted from Chambers & Kerner (37). 178 Brownson · Fielding · Maylahn Subjective ANRV370-PU30-10 Annu. Rev. Public Health 2009.30:175-201. Downloaded from Access provided by Liberty University on 12/05/20. For personal use only. Table 1 ARI 15 February 2009 12:1 Comparison of the types of scientific evidence Characteristic Type One Typical data/ relationship Size and strength of preventable risk—disease relationship (measures of burden, etiologic research) Relative effectiveness of public health intervention Information on the adaptation and translation of an effective intervention Common setting Clinic or controlled community setting Socially intact groups or community wide Socially intact groups or community wide Example Smoking causes lung cancer Price increases with a targeted media campaign reduce smoking rates Understanding the political challenges of price increases or targeting media messages to particular audience segments Quantity More Less Less Action Something should be done This particular intervention should be implemented How an intervention should be implemented impossible; what is required is the best evidence available not the best evidence possible” (119). Several authors have de?ned types of scienti?c evidence for public health practice (Table 1) (19, 23, 141). Type 1 evidence de?nes the causes of diseases and the magnitude, severity, and preventability of risk factors and diseases. It suggests that “something should be done” about a particular disease or risk factor. Type 2 evidence describes the relative impact of speci?c interventions that do or do not improve health, adding “speci?cally, this should be done” (19). There are different sources of Type 2 evidence (Table 2). These categories build on work from Canada, the United Kingdom, Australia, the Netherlands, and the United States on how to recast the strength of evidence, emphasizing the weight of evidence and a wider range of considerations beyond ef?cacy. We de?ne four categories within a typology of scienti?c evidence for decision making: evidence-based, ef?cacious, promising, and emerging interventions. Adherence to a strict hierarchy of study designs may reinforce an inverse evidence law by which interventions most likely to in?uence whole populations (e.g., policy change) are least valued in an evidence matrix emphasizing randomized designs (125, 127). Type 3 evidence (of which we have the least) shows how and under which contextual conditions interventions were implemented and how they were received, thus Type Two Type Three informing “how something should be done” (141). Studies to date have tended to overemphasize internal validity (e.g., well-controlled ef?cacy trials) while giving sparse attention to external validity (e.g., the translation of science to the various circumstances of practice) (62, 71). Understanding the context for evidence. Type 3 evidence derives from the context of an intervention (141). Although numerous authors have written about the role of context in informing evidence-based practice (32, 60, 77, 90, 92, 93, 140, 141), Assignment: Evidence Based Public Health Discussion there is little consensus on its de?nition. When moving from clinical interventions to population-level and policy interventions, context becomes more uncertain, variable, and complex (49). One useful de?nition of context highlights information needed to adapt and implement an evidence-based intervention in a particular setting or population (141). The context for Type 3 evidence speci?es ?ve overlapping domains (Table 3). First, characteristics of the target population for an intervention are de?ned such as education level and health history (104). Next, interpersonal variables provide important context. For example, a person with a family history of cancer might be more likely to undergo cancer screening. Third, organizational variables should be considered. For example, whether an agency is successful in carrying out an evidence-based • Evidence-Based Public Health 179 ANRV370-PU30-10 Table 2 Annu. Rev. Public Health 2009.30:175-201. Downloaded from Access provided by Liberty University on 12/05/20. For personal use only. Category ARI 15 February 2009 12:1 Typology for classifying interventions by level of scientific evidence Considerations for the level of scientific evidence How established Data source examples Evidencebased Peer review via systematic or narrative review Based on study design and execution External validity Potential side bene?ts or harms Costs and cost-effectiveness Community Guide Cochrane reviews Narrative reviews based on published literature Effective Peer review Based on study design and execution External validity Potential side bene?ts or harms Costs and cost-effectiveness Articles in the scienti?c literature Research-tested intervention programs (123) Technical reports with peer review Promising Written program evaluation without formal peer review Summative evidence of effectiveness Formative evaluation data Theory-consistent, plausible, potentially high-reach, low-cost, replicable State or federal government reports (without peer review) Conference presentations Emerging Ongoing work, practicebased summaries, or evaluation works in progress Formative evaluation data Theory-consistent, plausible, potentially high-reaching, low-cost, replicable Face validity Evaluability assessmentsa Pilot studies NIH CRISP database Projects funded by health foundations a A preevaluation activity that involves an assessment is an assessment prior to commencing an evaluation to establish whether a program or policy can be evaluated and what might be the barriers to its evaluation (145). program will be in?uenced by its capacity (e.g., a trained workforce, agency leadership) (51, 77). Fourth, social norms and culture are known to shape many health behaviors. Finally, larger political and economic forces affect context. For example, a high rate for a certain disease may in?uence a state’s political will to address the issue in a meaningful and systematic way. Particularly for high-risk and understudied populations, there is a pressing need for evidence on contextual variables and ways of adapting programs and policies across settings and population subgroups. Contextual issues are being addressed more fully in the new realist review, which is a systematic review process that seeks to examine not only whether an intervention works but also how interventions work in realworld settings (134). Triangulating evidence. Triangulation involves the accumulation of evidence from a variety of sources to gain insight into a particular topic (164) and often combines quantitative and qualitative data (19). It generally uses multiple 180 Brownson · Fielding · Maylahn methods of data collection and/or analysis to determine points of commonality or disagreement (47, 153). Triangulation is often bene?cial because of the complementary nature of information from different sources. Although quantitative data provide an excellent opportunity to determine how variables are related for large numbers of people, these data provide little understanding of why these relationships exist. Qualitative data, on the other hand, can help provide information to explain quantitative ?ndings, or what has been called “illuminating meaning” (153). One can ?nd many examples of the use of triangulation of qualitative and quantitative data to evaluate health programs and policies including AIDS-prevention programs (50), occupational health programs and policies (79), and chronic disease prevention programs in community settings (66). Audiences for EBPH There are four overlapping user groups for EBPH (56). The ?rst includes public health Annu. Rev. Public Health 2009.30:175-201. Downloaded from Access provided by Liberty University on 12/05/20. For personal use o … Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10

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