Introduction to

Evidence- Based Public Health

Agenda

Introductions

Overview of the session

 Introduction to Evidence- Based Public Health

2
 Overview

• EBM and EBPH

• Development of EBPH

• Steps in EBM and EBPH

• Evaluating and improving EBPH

• Summary

• Review of case presentation

 Case presentation

childhood malnutrition (under nutrition)

 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 malnutrition (under
nutrition) and requests your help.

• How do you proceed?

Rise of Evidence-Based Medicine

• First described in 1992

• A new Approach to teaching medicine

• A "revolution" in medical practice

 Definition of EBM

"The integration of best research evidence

with clinical expertise and patient
values."
 Factors Driving EBM

• Overwhelming size of the literature

• Inadequacy of textbooks

• Increased number of RCTs

• Available computerized databases

• Reproducible evidence strategies

Making the right health care decision
 To make the right EBHC decisions

We need:

Clear summary of all available evidences

Balanced (unbiased) reporting of evidence

Transparency

Up-to-date (current)
 Where does evidence come
from?
Various sources:
Scientific literature

Clinical observations

Laboratory results

Other sources
 Evidence from scientific literature
• Evidence from many research designs are
published

• The quality and strength of the evidence varies

across the research designs

 Some are more powerful than others in answering

research questions on the effectiveness of
interventions
 Research designs yielding different
level of evidence
A. Descriptive studies
• Correlational/ecological studies
• Cross-sectional/prevalence studies
B. Analytical studies
A. Observational
• Case control
• Cohort
B. Interventional
 Randomized control trails
 Clinical controlled trials

C. Systematic reviews
 Evidence Pyramid
Systematic Reviews &
Meta-analyses
[Perhaps also Meta-
RCTs syntheses of qualitative
studies?]
Cohort Studies

Case-Control Studies

Descriptive Studies,
Case Series & Reports

Ideas, Editorials, Opinions

Adapted from: The Medical Research Library of Brooklyn, http://servers.medlib.hscbklyn.edu/ebm/2100.htm

14
 Evidence from scientific literature

• Hence, not all research evidence is equal

 Different research designs produce diverse grade of

evidence

 There are hierarchical making of weight of evidences to

help answer an EBP question
 WHY EBP?
• Health research is growing
1948(4,700 scientific journal published)
1990 (100, 000)
22 million citations in Medline

• Old style database (e g Medline) not providing

information we need

• Gap between clinical practice and up-to-date

knowledge
 WHY EBP?
• Busy to search, find & integrate new
knowledge to improve practices

• Health care cost is increasing

• The slippery slope (additional challenge)

o Our knowledge of current best care may not be
good
o Performance deteriorates, too
 Why Evidence-Based Practice?
• So much information,
too little time
• Need high quality,
filtered information to
make informed decisions
• Value of scientific knowledge for
decision making
• Decisions should not be based only on
intuition, opinion or anecdotal information 18
 Lesson from history-ANC Visit schedule

• Since 1920s 14 routine ANC visits

• RCTs showed visit schedule can be reduced

without un pleasant effect
• NICE now recommends 10 visits for 1st
pregnancy and 7 for later pregnancies
 Steps of EBM/P
• Convert the need for information into an answerable
question

• Track down the best evidence

• Critically appraise that evidence

• Integrate the appraisal with one's clinical expertise

and the individual patient

• Evaluate
 Steps of EBM/P (5 “A”)
• Ask
• Acquire
• Appraise
• Apply
• Assess the outcome
 Critique of EBM

• De-emphasizes patient values

• Doesn't account for individual variation

• Devalues clinical judgment

• Leads to therapeutic nihilism
(doing nothing if there aren’t extensive randomized controlled trials
justifying an intervention)
Parachute use to prevent death and major trauma related to
gravitational challenge; systematic review of randomized
controlled trials.
Smith GC, Pell JP. BMJ 327:1459-1461; 2003.

NATURAL HISTORY OF
GRAVITATIONAL CHALLENGE:
If failure to use a parachute
resulted in 100% mortality, that
might be evidence of
effectiveness. However, survival
from falls of 33,000 feet have been
documented. Furthermore,
parachutes have been associated
with morbidity and mortality.
Therefore RCTs are needed to
determine the balance of risks and
benefits.
The Evidence-Based Movement
EBM → EBPH

How does public health

relate to medicine?

24
Public Health: Health of Populations

Medicine: Health of Individuals 25

 Public Health
• Focus on populations
• Prevention & health
promotion
• Environment & human
behavior interventions
• Diverse workforce, variable
education & certifications
• Social sciences integral;
clinical sciences peripheral
to education
• Observational studies: case
control & cohort studies
Medicine
• Focus on individuals
• Diagnosis & treatment
• Clinical interventions
• Well-established
profession, standardized
education & certification
• Clinical sciences integral;
social sciences less
emphasized
• Experimental studies with
control groups: RCTs.
26
10 Essential Services of Public Health

Public Health Functions Project, U.S. Dept. of Health and Human 27

Services
Evidence-Based Public Health
Besides evidence from research:
Best Evidence
• professional expertise &
knowledge from
Social values, Expertise,
• social, political,
Politics,
Research and economic
Knowledge
Economics
environment : regulatory
$ requirements, available resources
•Community’s values and
expectations
Decisions for Public Health Practice
•need to be taken into account
• Interventions
when deciding on a public health
program • Programs
• Policies 28
 Development of EBPH
• Jenicek (1997) published a review discussing
epidemiology, EBM, EBPH

• Epidemiology described as the foundation of

both EBM and EBPH

• EBPH unique in using complex interventions

with multiple community and societal issues
 Definition of EBPH

• "EBPH is 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
maintenance and improvement."

• Jenicek (1997)
 Definition of EBPH…

• "EBPH is 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 program
planning models."

Brownson (1999)
 Definition of EBPH…
• "The process of integrating
 science-based interventions with
 community preferences
to improve the health of populations."
 EBM and EBPH Parallels
• State the scientific question of interest

• Identify the relevant evidence

• Determine what information is needed to answer

the scientific question
• Determine the best course of action considering
the patient or population
• Evaluate process and outcome
 Steps of EBPH
• Develop an initial statement of the issue

• Search the scientific literature and organize

information
• Quantify the issue using sources of existing data

• Develop and prioritize program options; implement

interventions
• Evaluate the program or policy
 Steps in EBPH…

• In establishment of programs for health

promotion and Preventing disease, four
primary decision must commonly be made
1.should something be done?

2. what should be done?

3. how should it be done?

4. is it working or does it need to be modified?

Decision Type of Evidence
1. Should something
be done?
What is the burden of  Surveillance data (measuring
disease? morbidity, mortality, years of potential
life lost, incidence, prevalence)
 Survey data
 Vital statistics data
 Medical utilization data
 Cost data

What is the urgency?  Basic medical data ( e.g. does the

condition or risk factor progress
rapidly or have serious complications?
 Trend data
Is it a priority for the  Degree to which the problem is
community? understood( e g. Emerging issues
such as avian flu or environmental
hazards might merit more
attention than can be justified
based on current burden)

What is the perceived  Perceived interest or importance

need? based on surveys, focus groups, or
other information
2. What should be Type of Evidence
done?

What is the nature of •Information gathered from analysis or

the problem? conceptual and empirical information on
causes, natural course of the problem, and
possible points of intervention
What works? •Scientific evidence of effectiveness from
individual evaluation studies
•Systematic reviews of evaluation studies

What is acceptable to o Information about community members

the community understanding and approval of possible
intervention strategies from:
• Focus group discussion
• Key interviews
• Meetings
• Political process
What can be afforded ? • Information based on comparison of costs
and cost effectiveness and local assets

What is feasible? •Organizational assessment

3. How should it be Type of Evidence
done?
What steps are needed Documentation from previous implementation of
to implement this the specific intervention and other related
interventions.
intervention •Available polices, guidelines
•Best process information
•experience from others who have implemented
the intervention

•Documentation from previous implementation of

What barriers must be specific intervention and other related
overcome to implement interventions
this intervention •experience from others who have implemented
the intervention
•Focus groups
4. Is it working or does Type of Evidences
it need to be
modified?
Is it being implemented
well?
• Process measured from checklists,
interviews and other data collection tools,
program monitoring

What does the community Focus group

think? •Interview
•Less formal data collection
•Political process

Is it improving health risks or Achievement of behavior or health outcomes

outcomes? from evaluation and program monitoring
efforts
 The Future of Evidence-Based Public
Health

• How can we evaluate and improve EBPH in

practice?
 Improving EBPH in Practice

1. Quality of the Science Base

2. Community involvement

3. Effect on Public Health Outcomes

 1. Improving the Quality of the Science Base

• Moving beyond Randomized Clinical Trials

(RCTs)
RCTs are well suited for demonstrating efficacy of a clinical intervention.
They are less suitable for many public health interventions

• Transparent Reporting of Evaluations with Non-

randomized Designs

• Grading of Recommendations
 2. Improving Community Involvement

• "Public health institutions should provide

communities with the information they have that is
needed for decisions on policies or programs and
should obtain the community's consent for their
implementation."
 Informed Consent at the Community
Level

• Community-based participatory research

• Community advisory boards

 3. Improving EBPH Outcomes

• Difficult to assess: Issues of sample size,

contamination, blinding, long-term follow-up,
Ethical constraints of withholding evidence

• Patients do better in the "real world" when

provided with evidence-based therapy
 Summary

• EBM has transformed medicine

• EBM has fostered development of EBPH

• EBPH continues to evolve

• EBPH needs improvement in the quality of the

Science Base, Community involvement and
evaluating outcome.
 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 malnutrition (under
nutrition) and requests your help.

• How do you proceed?

Develop an Initial Statement of the Issue

• The prevalence of malnutrition in that kebele among

the 450 elementary school children in the community
is 35%.

• With the support of parents, school staff,

stakeholders and community-based organizations,
how can this malnutrition be reduced through
lifestyle interventions?
 Quantify the Issue
• The prevalence of malnutrition was determined
by a special survey.

• The rate of malnutrition was found to increase as

the age decreases.

• The rates were about equal in girls and boys.

 Search the Scientific Literature
• Medline search

• Publication on the issue, national and from

other similar countries

• Do rapid assessment and

• Organize the information

 Develop and Prioritize Program
Options
• Nutritional support program

• A community-based educational program

• School health education program (nutrition and

personal hygiene etc)
• Community based work group which continues
follow up of the interventions.
 Develop an Action Plan

• Develop an action plan on how to implement

interventions (SMART objective, activities, time
frame, follow up procedures)

• The program will be evaluated by all

stakeholders (e.g., children will be surveyed)