Module 3 Elaine A. Borawski, PhD

Overview Understand what “evidence-based” means Become familiar with evidence-based programs and how to locate them Understand why evidence-based practices are important in public and community health Become familiar with strategies for selecting an appropriate evidence-based practice for your own project.

What do you think of when you hear the term “evidence-based”?

Answer An evidence-based program has been: Implemented with a group Evaluated Found to be effective.

What is Evidence? Surveillance Data Systematic Reviews of Multiple Intervention Studies An Intervention Research Study Program Evaluation Word of Mouth Personal Experience OBJECTIVE SUBJECTIVE

Why the Fuss? More Federal funders are requiring program planners to use evidence-based programs. Some consider evidence that is proven through research (explicit). Some consider evidence that is derived from experience or practice (tacit). The best evidence may be a combination of research and practice.

Your Experience What has your experience been with evidence-based programs? Where have you heard of them before? Have any of you used these programs in the past? Are any of YOUR programs considered evidence-based?

Advantages to Using Evidence-Based Programs Effective in the study populations Cost effective Shorten the time it takes to develop a program Reduce the time it takes to research a community Help narrow the evaluation.

Barriers to Evidence-Based Programs May limit my/our creativity. Take too much time and/or money. Often difficult to replicate in community settings (translation). Too scientific. My community is unique. An evidence-based program will not be as appropriate as if I developed the program myself. I do not know what evidence-based programs are or where to find them.

Evidence Based Program Levels Evidence based programs have been through different “levels” of research There are multiple levels of programs Theory-based Best practices Evidence-based Research-tested

Objectives Be able to find evidence-based program resources. Know how to use search options to narrow your program choices and find out what programs will and will not work with your community. Alternative Sources for Evidence-Based Programs Talking With the Principal Investigator Finding an Evidence-Based Program: Case Study.

Selecting Evidence-Based Community Programs Peer reviewed literature and research National Registry of Evidence-Based Programs and Practices (NREPP) Research-Tested Intervention Programs (RTIPs) Guide to Community Preventive Services

Criteria for Selecting a Program Thinking about your organization and the target population for your project: Was the program conducted with people who had similar Socioeconomic status Resources Ethnicity Traditions Priorities Community structure and values. Is the program appropriate for the age of your audience? Choose a program that is well-matched with: Your health topic (e.g., breast or cervical cancer, nutrition, physical activity) What your audience is already doing about the health issue.

Criteria for Selecting a Program Context for intervention Coverage across the range of populations or setting involved in a health concern Knowledge of what populations or settings involved in a health concern Knowledge of what populations interventions will be effective for and under what conditions Role of race, ethnicity, and culture Staff creativity, experience Balancing fidelity and adaptation (Allensworth & Fertman, 2010)

Criteria for Selecting a Program These strategies can include: Giving information Enhancing skills Improving the services and/or support systems that exist Changing incentives or barriers that maintain the problem Promoting access Making suggestions for policy changes.

Resources Remember to avoid a program that takes more resources than you have. Different evidence-based programs will take different amounts of money, labor, and/or time. Whenever you can, speak with the team that developed the program or product in which you are interested. They can share information about the program that may be helpful.

What is LifeSkills Training? Substance Abuse Prevention and Personal Development Curriculum Developed by Dr. Gilbert Botvin in late 1970’s Identified as a “Program that Works” by the Centers for Disease Control and Prevention Effective substance abuse prevention focuses on changing behavior

The 6 Fundamentals of LST There are three Domains of Cognitive Behavioral Theory LST is an evidence-based program LST changes thinking and behavior (cognitive- behavioral skills) Booster sessions increase effectiveness Interactive teaching methods enhance learning Less is more

Summary of Evaluation Results Middle/High School Curriculum  Reduces substance abuse by up to 87%  Effective in reducing tobacco, alcohol, marijuana, inhalants, narcotics & hallucinogens  Effects last for at least 6 years  Effective in reducing aggressive / violent behavior  Researched and proven effective with African- American, Hispanic, White, Urban, Suburban and Rural Youth

Summary of Evaluation Results Elementary School Results  Reduces annual smoking rates by up to 63%  Increases self-esteem  Findings show that the evidence-based LST model is equally effective at the Elementary level

Summary of Evaluation Results Evidence of Effectiveness ◦ Effectiveness established through rigorous scientific inquiry ◦ Durability of effects ◦ Learn, retain, transfer Ease of Implementation ◦ Fits with existing infrastructures

Case Study Scenarios Scenario 1: You want to adapt an evidence-based program in Cameron County, Texas. This is a county that borders Mexico. You have chosen cervical cancer as your health topic. What are your goals and objectives for this program? Scenario 2: You searched for evidence-based programs in the Research-tested Intervention Programs (RTIPs) section of Cancer Control PLANET ( There are several programs having to do with cancer. How might you narrow your search?

Scenario 1: Goals The goal for the program is based on: Location Health issue Population. Goal: Reduce cervical cancer mortality among Mexican American women, ages 18–65, in Cameron County.

Scenario 1: Developing Objectives Needed a program that would raise awareness of the Pap test (primary method for detecting cervical cancer). When to first get tested How often to be tested Understand the link between HPV and cervical cancer

Scenario 1: Objectives Objective 1: Increase the number of women who receive Pap test screening by 20 percent during the life of the program Objective 2: Find out about the cervical cancer screening behaviors of this group of women in Cameron County Objective 3: Increase the number of Mexican American/Tejana women who can state that HPV is linked with cervical cancer by 20 percent.

Scenario 2: Narrowing the Search Refine your search by age, race/ethnicity, or setting on Cancer Control PLANET ( Narrow your search by: Resources Number of products Number of interventions Education level Needs of your audience.

Group Activity: Which Would You Pick? Program A: African American women Ages 40+ Live in low-income housing Distrust physicians Have limited access to medical care Conducted in churches, community centers, homes, and clinics Included a church program and educational brochures and training health care providers who work with the target audience. Program B: Cambodian women, refugees Ages 18+ Live in a farming community Limited English skills Unfamiliar with Western medicine Conducted in home and community settings Included an outreach worker manual and letters to the target audience, a clinical resource manual, and a Khmer-language video. You want to adapt an evidence-based program for use in Cameron County, Texas. You have selected cervical cancer as your health topic. You have narrowed your search to two evidence-based programs, Program A and Program B.

Program Forsyth County Cancer Screening Project (Program A) Cambodian Women’s Health (Program B) Target audience Ages 40+ African American Low-income housing communities Ages 18+ Cambodian women Cancer type Breast and cervicalCervical Setting Community centers Individual homes Community churches Clinic waiting and exam rooms Home-based Community-based “The need” (reasons why underscreened) Limited access and referral to preventive and treatment services Fear and fatalistic views of breast cancer Distrust of medical community Doctors may be less likely to recommend screening to older or minority women Refugees, relocated to mainly farming communities, not familiar with Western medicine, services, and prevention Low levels of being absorbed into the culture; limited English-language skills Limited access to preventive care Program scores Dissemination capability: 3.0 Cultural appropriateness: 5.0 Age appropriateness: 5.0 Gender appropriateness: 5.0 Integrity: 3.3 Utility: 3.3 Dissemination capability: 4.0 Cultural appropriateness: 5.0 Age appropriateness: 4.5 Gender appropriateness: 5.0 Integrity: 2.8 Utility: 2.5

Group Activity: Program Selection Selected the Cambodian Women’s Health Project because: Target age: 18+ Cancer type: Cervical “Need”: Immigrants, limited sense of belonging to majority community, limited English, farming community. See Handout #5: Finding an Evidence-Based Program: Case Study.

What does this mean to you?

Adaptation definition Microsoft Encarta Dictionary Definition: The process or state of changing to fit new circumstances or conditions, or the resulting change Something adapted to fit need: something that has been modified for a purpose

Example: LST Fidelity Guidelines Teach the full scope and sequence of the LST Curriculum. Teach all lessons in the order given, making all of the teaching points in each lesson. The effectiveness of the program is compromised when lessons are deleted or taught out of sequence. Teach at least one time per week for consecutive weeks until all units are taught. The curriculum may be taught more than one time per week but must be taught at least one time per week in consecutive sessions.

LST Fidelity Guidelines Use interactive teaching strategies. Students acquire skills when interactive teaching skills (coaching, facilitation, behavioral rehearsal, and feedback) are used. Teach the booster sessions. LST is a three-year program. Levels 2 and 3 are booster sessions. Research has established that booster sessions increase the effectiveness of the program.

LST Fidelity Guidelines The LST curriculum may not be combined with or integrated with any other prevention or core curriculum lesson. In general, extensions or additions should be carefully thought out and where questions arise, technical assistance from NHPA should be sought. A favorite activity or lesson may seem congruent with LST, but in actuality may compromise the effectiveness of the program or contradict its theory and design

LST: Adaptation Guidelines Ask yourself the following questions when considering whether to make deletions, additions, or modifications to the program: Does the activity meet the learning objectives stated in the LST lesson? Does the activity present opportunity for peer-to-peer practice and acquisition of a cognitive or behavioral skill? Does the activity present information that focuses on short term or immediate effects and is developmentally appropriate and relevant to the age group?

LST Adaptation Guidelines Does the activity provide modeling and practice of pro- health, pro-social choices and behaviors? Does the activity use interactive teaching strategies? Do I have time to do this activity and does it meet the fidelity guidelines for teaching the full scope and sequence of the lesson

Things that can be modified Names of healthcare centers or systems Pictures of people and places Incentives for participation Reading level of written content Ways to reach your audience Cultural adaptations Timeline

Things that cannot be modified Health topic Whole sections of the program Changing the communication model Adding strategies

Use the nine guidelines in the handout to develop your adaptations

Your program Should now include: Summary of the data you have collected Program goals and objectives from the evidence based program Program management needs – timeline, staff, budget, resources

Adapting the Cambodian Women’s Health Project (Program B) Before Neighborhood based program Increase cervical cancer screening rates among Cambodian women 18 years and older Includes home visit, group meetings, and help getting to a Pap test Given by bilingual bicultural Cambodian women

The Mexican American Women’s Health Project After Neighborhood Program Increase cervical caner screening rates among Mexican American/Tejana women Includes a home visit, group meetings, and help getting to a Pap test Given by bilingual bicultural Mexican American/Tejana women

Questions?

References Powerpoint presentation adapted from “Using What Works: Adapting Evidence-Based Programs to Fit Your Needs. U.S. Department of Health and Human Services. National Cancer Institute Health Promotion Programs: From Theory to Practice. Carl I. Fertman (Editor), Diane D. Allensworth (Editor), Society for Public Health Education ISBN:

AN INTRODUCTION

Why a Group Project? Get you acquainted with the research process as soon as possible. Use step-by-step process Help to see the process from beginning to end before you start your own project. Help you get to know each other – cohort bonding!

Provide hands-on experience with: generation of research questions conducting literature review developing construct tables writing survey questions creating survey questions and their formats subject recruitment data entry descriptive and inferential statistics hands-on data analysis and output interpretation making inferences and generating conclusions from findings.

Picking A Topic Help the process along – introducing some constructs to get us started: STRESS SNACKING SLEEP What’s the relationship these constructs have with each other? What relationship do they have with health?

Step-by-Step What do we want to study? Population? What do we want to know/find out? What are the research questions? Review the literature – what is already out there? Decide on the variables Create a construct table – link to the research questions Developing the format of the data collection tool (survey) – format, order, context, etc. Create the survey – online and on paper Collect the data Enter the data (extra cases on paper) Clean the data Analyze the data Disseminate the results

Your Homework Using the internet, see what you can learn about sleep, snacking, and stress. Are they related? Do they impact health, and if so, how?

Next Week Develop our general research questions – what would we like to study? To learn about? Are there any specific hypothesis that we’d like to test?