The document outlines the steps involved in evidence-informed public health decision making. It discusses defining a focused question, efficiently searching for relevant research evidence such as from systematic reviews, critically appraising the research methods, interpreting the results and adapting the information to the local context, deciding whether and how to implement changes, and evaluating the effectiveness of changes made. The goal is to integrate the best available research evidence with local factors to inform public health policies and practices.

1. Evidence-informed public health decisions made easier: Take it one step at a time TOPHC, Toronto, ON April 7, 2011

2. Objectives 1. To understand the process of evidence-informed decision making in public health. 2. To clearly frame an answerable question. 3. To know where to find high quality relevant research. 4. To practice integrating the research evidence with other important factors that contribute to public health decisions. 5. To plan for implementation and evaluation

3. Purpose Describe the steps involved in evidence-informed public health, and apply this process to a practice scenario relevant to public health

4. Who are we? One of six National Collaborating Centres for Public Health created by the Government of Canada to renew and strengthen public health.

5. Aims of the National Collaborating Centres Increase awareness of new and existing knowledge. Identify and help address public health priorities. Collaborate with established public health networks. Identify gaps in knowledge and relevant applied research.

6. NCC Aboriginal Health Prince George, BC NCC Environmental Health Vancouver, BC NCC Infectious Diseases Winnipeg, MB NCC Determinants of Health Antigonish, NS NCC Methods and Tools Hamilton, ON NCC Healthy Public Policy Montreal and Quebec City, PQ

7. Methods and tools for what?sharing what works in public health

8. NCCMT products and services DialoguePH Public Health+ Workshops Online learning modules Webcasts Webinars Searchable Registry of Methods and Tools Online Health Program Planner sharing what worksin public health

9. Health Evidence Registry of systematic review evidence Capacity building & knowledge translation Research evaluating KT strategies

10. Health-Evidence.ca database 2100+ reviews Comprehensive & transparent process Quality appraised Evidence-summaries (86 well-done reviews)

11. Health Evidence – engagement 40, 000 visitors annually (~110/day) 5,000 registered users Tailoring options Feedback and user queries Knowledge brokers HE-CBPP simultaneous searches Social media strategy in development YouTube Twitter

14. Evidence Transfer Gap

15. Evidence of Gap in Acute and Primary Care Consistent evidence of failure to translate research findings into clinical practice 30-40% patients do not get treatments of proven effectiveness 20-25% patients get care that is not needed or potentially harmful Schuster, McGlynn, Brook (1998). Milbank Memorial Quarterly Grol R (2001). Med Care

17. existing public health resources

19. What is Evidence-Informed Public Health? … the process of distilling and disseminating the best available evidence from research, context and experience, and using that evidence to inform and improve public health policy and practice.

20. What is Evidence-Informed Public Health? Put simply, it means finding, using and sharing what works in public health.

21. Why implement Evidence-Informed Public Health? Effectively transfer knowledge from both quantitative and qualitative research into practice and policy. Efficiently use limited health care resources.

22. Why implement Evidence-Informed Public Health? Create programs and actions that are both effective and appropriate for our communities and target populations. Improve client satisfaction. Strengthen public health in Canada.

23. Why implement Evidence-Informed Public Health? Do what works … and don’t do what does not work!

24. Barriers to Evidence-Informed Public Health Lack of time Difficulty accessing research Lack of skills or confidence with critically appraising evidence Difficulty interpreting results Challenges with applying research findings to local context and setting Insufficient power or support to make a change Environment/organizational culture (Keifer et al.,2005; Retsas, 2000; Thomas et al., 2004)

25. Stages in the process of Evidence-Informed Public Health

26. Stages in the process of Evidence-Informed Public Health Clearly define the question or problem

27. Scenario You are a public health nurse working on a team that focuses on healthy living and physical activity. Despite walking being free and relatively safe, a recent survey of adults in the community indicated few people were walking regularly or engaging in any exercise. In a team meeting, you discuss whether a community-wide strategy should be implemented to promote walking and increase physical activity among sedentary adults. You are unsure which intervention would be most effective, and whether specific subgroups should be targeted (vs. a broader approach). Your supervisor has asked you to identify the best available research about the effectiveness of interventions to promote walking, and share with the team.

28. Define the question P opulation I ntervention C omparison O utcome (T) ime

29. Stages in the process of Evidence-Informed Public Health Efficiently search for research evidence

30. Searching Start here with a question 6S Pyramid (DiCenso et al., 2009; Haynes et al. 2005; Robeson et al., 2010)

31. 6S pyramid of pre-processed research evidence (DiCenso et al., 2009; Haynes et al. 2005; Robeson et al., 2010)

32. Searching Start here with a question (program* OR intervention*) AND (walking) 0 174 3 18 329 Google Scholar 103,000 Google 38,200,000 (DiCenso et al., 2009; Haynes et al. 2005; Robeson et al., 2010)

33. health-evidence.ca Online registry of reviews evaluating effectiveness of public health interventions. Provides quality rating for every review Summary statements are available for some high quality reviews and include: PICO and main findings of the study Methodological strengths and weaknesses Implications for policy/practice

38. What is a systematic review? A rigorous summary of all primary research evidence relevant to a focused question. Evidence is consolidated through a systematic process to avoid possible sources bias at various stages in the review process. (Haynes, 2007)

39. Define the question Steps of a Systematic Overview Review of reference lists of articles Systematic manual search of key journals Computerized databases Consultation with experts Search of personal files Identify studies Review for relevance Not Relevant Reject Relevant Evaluate methodological quality Extract data Analyze data Draw conclusions

40. What is a meta-analysis? A method for combining the results of several independent studies that measure the same outcomes so that an overall summary statistic can be calculated. (Dawson-Saunders & Trapp, 1994)

41. Royal S, Kendrick D, Coleman T. Non-legislative interventions for the promotion of cycle helmet wearing by children. Cochrane Database of Systematic Reviews 2005, Issue 2

42. Richardson, C.R., Newton, T.L., Abraham, J.J., Sen, A., Jimbo, M., Swartz, A.M.(2008). A meta-analysis of pedometer-based walking interventions and weight loss. Annals of Family Medicine, 6(1), 69-77.

43. Narrative summary vs. Meta-analysis Clinical heterogeneity Multiple outcomes Availability of data * Review authors need to justify the method they choose

44. Is the summary statement useful? What is the “actionable message”?

45. What if you do not find an answer in health-evidence.ca?

46. http://www.guideline.gov/

47. http://www.ncbi.nlm.nih.gov/pubmed/

49. Public Health+

50. www.nccmt.ca

51. http://cbpp-pcpe.phac-aspc.gc.ca/

52. Stages in the process of Evidence-Informed Public Health Critically and efficiently appraise the research methods

54. Practice appraisal Refer to NCCMT’s online learning modules for additional practice: http://www.nccmt.ca/modules/index-eng.html Week long critical appraisal course at McMaster

55. Stages in the process of Evidence-Informed Public Health Interpret information; understand how to prioritize conflicting results

56. Stages in the process of Evidence-Informed Public Health Adapt the information to the local community

58. Stages in the process of Evidence-Informed Public Health Decide whether (and plan how) to implement the change in practice or policy

59. Implementation Situational assessment Identify barriers and facilitators in the organization, the people, and the change you are trying to make. Identify key people. Obtain approval from appropriate leadership. Create a project timeline. (Dobbins et al. 2005; Fineout-Overholt & Johnston, 2006)

60. Implementation Toolkit http://www.rnao.org/Page.asp?PageID=924&ContentID=823 Related resources: DiCenso A et al. A toolkit to facilitate the implementation of clinical practice guidelines in healthcare settings. Hospital Quarterly 2002;5(3):55-60. Dobbins M et al. Changing Nursing Practice: Evaluating the Usefulness of a Best-Practice Guideline Implementation Toolkit. Nursing Leadership 2005;18(1):34-45.

61. Implementation What is the message? To whom (audience)? By whom (messenger)? How (transfer method)? With what expected impact (evaluation)? (Institute of Work & Health with J. Lavis, 2006. www.iwh.on.ca)

63. Education

64. Academic detailing/outreach visits

65. Audit and feedback

66. Opinion leaders

67. Knowledge broker

68. Champions

69. Reminders: prompts; patient reminds staff

70. Interactive educational meetings/workshops

72. Stages in the process of Evidence-Informed Public Health Assess the effectiveness of the change in practice or policy

73. Evaluation How will you know if people are using the evidence? Have they changed their practice? Does it make any difference to patients? Decide on indicators (structure, process, outcome) Gather baseline data

74. Stages in the process of Evidence-Informed Public Health

75. Stages in the process of Evidence-Informed Public Health

76. Stages in the process of Evidence-Informed Public Health

77. Stages in the process of Evidence-Informed Public Health

78. Stages in the process of Evidence-Informed Public Health

79. Stages in the process of Evidence-Informed Public Health

80. Stages in the process of Evidence-Informed Public Health

81. Stages in the process of Evidence-Informed Public Health

82. Step ‘0’Reflecting on areas of uncertainty Examine practice critically. Acknowledge uncertainty in your practice. Formulate a focused clinical questions through the process of reflective practice. Will contribute to professional practice requirements. (Johnston & Fineout-Overholt, 2005; Witmer & Cullum, 1999)

83. Road ahead Individual skills Organizational capacity, leadership resources and culture

84. How can I continue to develop the skills needed for EIPH? On-line learning modules http://www.nccmt.ca/modules/index-eng.html Dialogue PH On-line support and discussion EIDM workshops offered by Health Evidence or NCCMT

85. NCCMT future directions Renewed website Upcoming conferences with networking opportunities: CHNC, CPHA, New modules Web casts Digital stories..share yours with us! Discussion forums linked to CHNETworks

86. HE future directions More summary statements are on the way! Plans to disseminate Continuing work with public health units Improving health-evidence.ca (watch for our survey!)

87. Feedback Your input is needed to determine whether this workshop was effective in meeting your learning needs. Please take a minute to complete the evaluation form in your packages and provide your comments or suggestions.

88. Contact Info Jackie Muresan, RN, MSc Knowledge Broker National Collaborating Centre for Methods and Tools (NCCMT) McMaster University 905-525-9140, x 20453 jmures@mcmaster.ca Donna Ciliska, RN, PhD Professor and Scientific Director 905-525-9140, x 22529 ciliska@mcmaster.ca Kara DeCorby, MSc Research Coordinator Health Evidence McMaster University 905-525-9140, ext. 20461 kdecorby@health-evidence.ca