1 Evidence-Based Public Health Prof.Dr.Surasak Taneepanichskul MD. M. Med(PH) LL.B FRTCOG FRTCPM

2 Rise of Evidence-Based Medicine and Public Health

3 Objectives and Competencies  Describe evidence-base in public health.  Searching EBPH  Analytic assessment: Identifies relevant and appropriate data and information sources.

4 Definitions  Evidence-based Public Health

5 Definition: Evidence-based Public Health  “the development, implementation, and evaluation of effective programs and policies in public health through application of principles of scientific reasoning, including systematic uses of data and information systems, and appropriate use of behavioral science theory and program planning models” Source: Brownson, R.C. et al, Evidence-based public health, Oxford University Press, 2003.

6 Why EBPH?  Need credible filtered information to make informed decisions.  Research evidence is valued.  So much information, too little time!

7 Why is EBPH important?  provides assurance that decision making is based on scientific evidence and effective practices;  helps ensure the retrieval of up-to-date and reliable information about what works and doesn’t work for a particular public health question;  provides assurance that one’s time is being used most efficiently and productively in reviewing the “best of the best” information available on the particular public health question.

8 When is EBPH used?  when it’s important to have scientific evidence to support decision making;  when evaluating the effectiveness and cost benefits of health programs;  when establishing new health programs;  when policies are being implemented; and  when conducting literature reviews for grant projects.

9 The EBPH Model Based on Brownson et al., 2002 Evidence-Based Public Health

10 Evidence-Based Public Health Decisions for Public Health Practice Interventions Programs Policies Social values, Politics, Economics $ Expertise, Knowledge Best Evidence from Research

11 Source: Guide to Research Methods: The Evidence Pyramid:.

12 Hierarchy of Research Designs  Category I: Evidence from at least one properly randomized controlled trial.  Category II-1: Evidence from well-designed controlled trials without randomization.  Category II-2: Evidence from well-designed cohort or case- control analytic studies, preferably from more than one center or research group.  Category II-3: Evidence from multiple times series with or without intervention or dramatic results in uncontrolled experiments such as the results of the introduction of penicillin treatment in the 1940s.  Category III: Opinions of respected authorities, based on clinical experience, descriptive studies and case reports, or reports of expert committees. Source: Harris, R.P. et al. (2001). Current methods of the U.S. Preventive Services Task Force: a review of the process. American Journal of Preventive Medicine. April 20 (3 Supplement):

13 Types of Evidence  Systematic Review: critical assessment and evaluation of research that attempts to address a focused question using methods designed to reduce the likelihood of bias.  Meta-Analysis: overview that incorporates a quantitative strategy for combining the results of several studies into a single pooled or summary estimate. Source: R.C. Brownson et al, Evidence-Based Public Health, Oxford: Oxford University, 2003.

14 Types of Evidence  Risk Assessment: systematic approach to characterizing the risks posed to individuals and populations by environmental pollutants and other potentially adverse exposures. Source: R.C. Brownson et al, Evidence-Based Public Health, Oxford: Oxford University, 2003.

15 Types of Evidence  Decision Analysis: systematic approach to decision making under conditions of uncertainty; involves identifying all available alternatives and estimating the probabilities of potential outcomes associated with each alternative, valuing each outcome, and, on the basis of the probabilities and values, arriving at a quantitative estimate of the relative merit of the alternatives. Source: R.C. Brownson et al, Evidence-Based Public Health, Oxford: Oxford University, 2003.

16 Types of Evidence  Economic Evaluation: comparative analysis of alternative courses of action in terms of both their costs and consequences.  Expert Panels: examination of research studies and their relevance to health conditions, diagnostic and therapeutic procedures, planning and health policy, and community interventions. Source: R.C. Brownson et al, Evidence-Based Public Health, Oxford: Oxford University, 2003.

17 Types of Evidence  Practice Guidelines: systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances; may be developed by government agencies, institutions, or by the convening of expert panels. Source: R.C. Brownson et al, Evidence-Based Public Health, Oxford: Oxford University, 2003.

18 Evidence for Public Health Practice and Policy Decisions  “I make a lot of decisions about how money is going to be spent, and I would like to always be able to back it up and say that this is proven, or evidence-based.”  Politicians need evidence to make decisions about public health programs.

19 Findings from Study of Public Health Workforce Information Needs  There are many relevant websites to search: need for one portal access.  Bombarded with unfiltered, irrelevant information: need filtered searches.  Too little information on legislation and policy change and newly identified health threats.

20 Findings Continued  Need information from areas beyond biomedical domains.  Need access to systematic reviews and summary information.  Need access to full-text journal articles, government reports (grey literature), and conference proceedings.  Need for training in accessing evidence- based resources.

21 Identifying Evidence-Based Resources in Public Health

22 Public Health: Health of Populations Clinical Medicine: Health of Individuals

23 The Public Health Workforce Epidemiologists Statisticians Environmental Engineers Animal Control Officers Sanitarians Food Scientists Industrial Hygienists Health Care Administrators Health Economists Politicians Social Workers Mental Health Workers Substance Abuse Counselors Doctors Nurses Teachers Disaster Relief Workers Nutritionists Lab Technicians Librarians

24 General Public Health Epidemiology Biostatistics Vital Statistics & Surveillance Environmental Health Occupational Health Health Services Administration Social & Behavioral Sciences Health Promotion & Education Community Health Maternal & Child Health Public Health Nursing Disaster Control & Emergency Services Communicable Diseases HIV/AIDS Nutrition Chronic Diseases Public Health Laboratory Sciences Public Health Informatics Global Health Identified Knowledge Domains Public Health

25 Sources of Public Health Evidence Journal literature Books Conference proceedings & abstracts Dissertations & theses Unpublished scientific papers Government reports Policy statements, laws & regulations Surveillance data Newsletters Teleconferences & webcasts Alert systems Listservs Internet sources Expert knowledge & opinion

26 1.Define the public health problem. 2.Search and find the best evidence. 3.Critically appraise the evidence for validity and relevance. 4.Apply the evidence to practice. 5.Evaluate the results. Evidence-Based Public Health Process Adopted from: Source: Sackett DL, Rosenberg WM. The need for evidence-based medicine. J R Soc Med. Nov 1995;88(11): Sibbald WJ. Some opinions on the future of evidence-based medicine. Crit Care Clin. 1998;14(3):

27 Define the public health problem Convert the information needs into focused questions

28 Forming a Searchable Public Health Question PICO P - Population I - Intervention C - Comparison O - Outcome

29 Sample Question You will be working with health teachers in a rural Southern high school. They have heard girls talking about what sounds like STD symptoms and you the teachers want to start teaching safer sex education. The principal espouses abstinence-only education. You want to compile some evidence about the effectiveness of sex education curricula to bring to a discussion with the superintendent and the principal.

30 Search and find the best evidence Critically appraise the evidence for validity and relevance

31 Search Pathway 1.Evidence-Based Guidelines 2.Systematic Reviews 3.Pre-formulated Searches 4.Best and Model Practices 5.Bibliographic Databases 6.Public Health Journals 7.Health Data and Statistics 8.Legislation and Policy 9.Government Reports

32 EBPPH Project Web Site:

33 Evidence-Based Resources for Public Health Practice 1.Evidence-Based Guidelines 2.Systematic Reviews 3.Pre-formulated Searches 4.Best & Model Practices 5.Public Health Bibliographic Databases 6.Public Health Journals Project Web Site:

34 Guide to Community Preventive Services

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36 Tobacco Use Prevention & Control

37 Guide to Community Preventive Services Summary of Findings: Tobacco Use Prevention and Control

38 Link to Full-Text Article from the American Journal of Preventive Medicine

39 National Guideline Clearinghouse

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41 National Guideline Clearinghouse

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43 Evidence-Based Resources for Public Health Practice 1.Evidence-Based Guidelines 2.Systematic Reviews 3.Pre-formulated Searches 4.Best & Model Practices 5.Public Health Bibliographic Databases 6.Public Health Journals Project Web Site:

44 Cochrane Health Promotion and Public Health activities/reviews.htm activities/reviews.htm

45 Cochrane Library bin/mrwhome/ /HOME?CRETRY=1&SRETRY=0 bin/mrwhome/ /HOME?CRETRY=1&SRETRY=0

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47 Health-Evidence.ca

48 heath-evidence.ca

49 health-evidence.ca search tool

50 health-evidence.ca search tool

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52 Evidence-Based Resources for Public Health Practice 1.Evidence-Based Guidelines 2.Systematic Reviews 3.Pre-formulated Searches 4.Best & Model Practices 5.Public Health Bibliographic Databases 6.Public Health Journals Project Web Site:

53 Healthy People 2010 Information Access Project

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57 Evidence-Based Resources for Public Health Practice 1.Evidence-Based Guidelines 2.Systematic Reviews 3.Pre-formulated Searches 4.Best & Model Practices 5.Public Health Bibliographic Databases 6.Public Health Journals Project Web Site:

58 Model Practices Database

59 Model and Promising Practices

60 Example of Model Practice

61 Promising Practices Network on Children, Families and Communities

62 Big Brothers Big Sisters of America Promising Practices Network on Children, Families and Communities

63 Evidence-Based Resources for Public Health Practice 1.Evidence-Based Guidelines 2.Systematic Reviews 3.Pre-formulated Searches 4.Best & Model Practices 5.Public Health Bibliographic Databases 6.Public Health Journals Project Web Site:

64 Evidence-Based Practice for Public Health Project – Bibliographic Databases

65 Maternal and Child Health Library

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67 PubMed (MEDLINE)

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69 Details of PubMed Search Mapped to Medical Subject Heading (MeSH) teen pregnancy = pregnancy in adolescence

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73 PubMed Limits

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77 History of PubMed Search Session

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81 Evidence-Based Resources for Public Health Practice 1.Evidence-Based Guidelines 2.Systematic Reviews 3.Pre-formulated Searches 4.Best & Model Practices 5.Public Health Bibliographic Databases 6.Public Health Journals Project Web Site:

82 Evidence-Based Practice for Public Health– Public Health Journals

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84 Evidence-Based Practice for Public Health– Maternal & Child Health Journals ournalsKNaction.cfm ournalsKNaction.cfm

85 Evidence-Based Practice for Public Health– Free Public Health Journals urnals.cfm urnals.cfm

86 Evidence-Based Practice for Public Health Project Web Site:

87 EBPPH Project Web Site:

88 Continuing the Pathway: Evidence-Based Resources for Public Health Practice 7.Health Data and Statistics 8.Legislation and Policy 9.Government Reports Public Heath Web Portal:

89 Public Health Web Portal:

90 List of Partners

91 Public Health Web Portal:

92 PHPartners.org Suggest a Link

93 PHPartners.org: Public Health Tutorial

94 Training and Resources from the National Network of Libraries of Medicine

95 Continuing the Pathway: Evidence-Based Resources for Public Health Practice 7.Health Data and Statistics 8.Legislation and Policy 9.Government Reports Public Heath Web Portal:

96 Public Health Web Portal: Health Data & Statistics

97 PHPartners.org: Health Data Tools & Statistics

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99 Child Trends Data Bank

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101 National Survey of Children’s Health Data Resource Center

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104 Continuing the Pathway: Evidence-Based Resources for Public Health Practice 7.Health Data and Statistics 8.Legislation and Policy 9.Government Reports Public Heath Web Portal:

105 Public Health Web Portal: Legislation and Policy

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107 Maternal and Child Health Policy Research Center

108 Maternal and Child Health Policy Research Center

109 Maternal and Child Health Policy Research Center State Medicaid Coverage of Selected Services Important to Children in the Absence of the EPSDT Mandate, 2005

110 AMCHP Legislative Center

111 Continuing the Pathway: Evidence-Based Resources for Public Health Practice 7.Health Data and Statistics 8.Legislation and Policy 9.Government Reports Public Heath Web Portal:

112 Public Health Web Portal: Government Reports

113 PHPartners.org: Government and Other Reports

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116 PHPartners.org: Reports & Other Publications

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118 Search Pathway 1.Evidence-Based Guidelines 2.Systematic Reviews 3.Pre-formulated Searches 4.Best and Model Practices 5.Bibliographic Databases 6.Public Health Journals 7.Health Data and Statistics 8.Legislation and Policy 9.Government Reports

119 Case Presentation

120 Case Presentation  Assume that you are the health director of a local health department.  A community in your jurisdiction is concerned with its high rate of childhood obesity and requests your help.  How do you proceed to develop the program?

121 Develop an Initial Statement of the Issue  The prevalence of obesity among the 327 elementary school children in the community is 35%. With the support of parents, school staff, and community-based organizations, how can this obesity rate be reduced through lifestyle interventions?

122 Quantify the Issue  The prevalence of obesity was determined by a special survey.  The rate of obesity was found to increase by grade level.  The rates were about equal in girls and boys.  100 minutes/wk provided at school for physical activity, but only 40 minutes is guided by a teacher.

123 Search the Scientific Literature and Organize Information  Medline search  Cochrane Collaboration  Task Force on Community Preventive Services

Evidence-Based Practice for Public Health Project University of Massachusetts Medical School Task Force on Community Preventive Services  Insufficient evidence to recommend classroom-based health education to provide information on managing health risks.  Strongly recommended curricula and policies to increase the amount of moderate or vigorous activity, increase the amount of time in PE class, or the amount of time being active in PE.

125 Develop and Prioritize Program Options  A community-based work group develops a number of options to increase physical activity in school.  There are debates about losing time in the classroom and impact on test performance.

126 Develop an Action Plan

127 Develop an Action Plan  Agreement is reached on a pilot project for the next school year involving reducing the lunch hour and increasing time in physical education with an emphasis on activities that get all children to be active.  The program will be evaluated by all stakeholders (e.g., children will be surveyed)

128 Summary  EBM has transformed medicine  EBM has fostered development of EBPH  EBPH continues to evolve increased community engagement