Evidence-based public health: a systems perspective and ... · domain of health protection, disease...
Transcript of Evidence-based public health: a systems perspective and ... · domain of health protection, disease...
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Evidence-based public health:a systems perspective and its implications for generating and implementing evidence
UNC Chapel Hill, 12 April 2016
Eva Rehfuess BA MA(Oxon) PhDLudwig-Maximilians-University, Munich, Germany
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Overview
• Introduction to evidence-based public health• Examples from INTEGRATE-HTA,CEBHA+and CPHE• Asystems perspective inrelation to designing and
evaluating interventions• Asystems perspective inrelation to implementing
evidence• Conclusions
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Introduction to evidence-based public health
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Evidence-basedmedicine (EBM)…
„…is the integrationof bestresearchevidence with clinicalexpertise and patient values.“
DavidSackett
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“… 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 protection, disease prevention, health maintenance and improvement (health promotion).”
Jenicek (1997)
“… is the development, implementation and evaluation of effective programmes and policies in public health through application of principles of scientific reasoning, including systematic uses of data and information systems and appropriate use of programme planning models.”
Brownson (1999, 2003)
“… is the process of integrating science-based interventions with community preferences to improve the health of populations.”
Kohatsu (2004)
Evidence-basedpublichealth(EBPH)…(1)
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“… integrates the best available evidence with the knowledge and considered judgements from stakeholders and experts to improve health and protect the population from infectious and environmental hazards.”
ECDC (2011)
“… intends to improve health at population level through scientifically established decisions. To do so, available knowledge of medical, economic, ethical, socio-cultural and legal aspects of diseases and interventions is assessed in a systematic, transparent and goal-oriented way and integrated with the decision-making process. All steps –from defining the problem to the implementation of interventions and programmes – must be made explicit and transparent.”
Gerhardus et al (2010)
Evidence-basedpublichealth(EBPH)…(2)
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An apple a day keeps the doctor away …
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… one or five a day?(effectiveness)
… what about apple allergies? (adverse effects)
… are apples better than oranges? (comparison)
… do people like apples? (acceptability)
… do we have enough apples? (feasibility)
… what if the guy in the grocery store is attractive? (preferences)
Adapted from Manfred Wildner
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Wrongassumptionthatpublichealthinterventionscanonlydogood...
Publichealthinterventions• Canhavepositiveandnegativehealthconsequences• Affectlargepopulationgroups• Aresubjecttodifferentperceptionsbydifferentgroups• Canimpactdiverseaspectsoflifeandfreedomofchoice• Bindlimitedresources
Whytheneedforanevidence-basedapproach?
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Basisofanevidence-basedapproach
• Evidence hierarchy for effectiveness evidence– Intervention study designs (e.g. RCTs, (quasi-)experimental)– Observational study designs (e.g. cohort, case-control)
• Need to be systematic and transparent:systematic reviews, evidence grading, guidelines– Avoid ad hoc selection of information– Make uncertainties in knowledge explicit– Select effective programmes and policies
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Examples fromINTEGRATE-HTA,CEBHA+and CPHE
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Goal:
Developconceptsandmethodsforacomprehensive,patient–centred,andintegratedassessmentofcomplextechnologiesthatincludesandconsiders
• effectivenessandeconomic,sociocultural,ethical,andlegalissues,
• patientpreferencesandpatient-specificmoderatorsoftreatment,
• contextandimplementationissues
INTEGRATE-HTA(2012– 2015)
www.integrate-hta.org
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Collaboration for Evidence-Based Healthcare andPublicHealth inAfrica (CEBHA+)(2016– 2020)
Makerere University (Africancoordinator) Uganda
University of Rwanda Rwanda
Stellenbosch University South Africa
Cochrane SouthAfrica South Africa
Universityof Malawi Malawi
AddisAbaba University Ethiopia
Chronic Disease InitiativeinAfrica -
LMU(Germancoordinator) Germany
Cochrane Germany Germany
Goal:Buildlong-termcapacityandinfrastructureforevidence-basedhealthcareandpublichealthinsub-SaharanAfrica
www.cebha.org
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Cochrane Austria(CA) and Departmentfor Evidence-basedMedicine and ClinicalEpidemiology,Danube UniversityKrems
CochraneSwitzerland(CochraneCH)comprisingInstituteofSocialandPreventiveMedicine,LausanneUniversityHospitalandEpidemiology,Biostatistics&PreventionInstitute,UniversityofZurich
HealthSciencesBremen(HSB)comprisingInstituteforPublicHealthandNursingResearch,UniversityofBremenandLeibnizInstituteforPreventionResearchandEpidemiologyBIPS,Bremen
InstituteforMedicalInformatics,Biometryand Epidemiology,Ludwig-Maximilians-University,Munich (LMU)
Cochrane PublicHealth Europe(CPHE)(2015- )
http://ph.cochrane.org/cochrane-public-health-europe
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Asystems perspective inrelation to designing andevaluating interventions
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Population • Healthygeneralorat-riskpopulationIntervention • Population-levelintervention
• “Proactive”preventionthrougheducational,technologyorpolicyintervention
• Implementationinhousehold,communityorpolicysettings
Comparison • “Businessasusual”inseveralsectors
Outcome • Usuallyindirecteffectsonmultiplehealthoutcomesandothersocietalconsequences
• Usuallyimpactafterlagperiod
PICOas starting point
Rehfuess & Akl (2013)
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INTERVENTION• Theory• Components• Execution
OUTCOME• Health• Non-health
POPULATION• Biological,social• Organisational
Embeddingthe PICOwithin asystem
COMPARISON• Business as usual
CONTEXT• Geographical• Epidemiological• Socio-cultural• Socio-economic• Ethical• Legal• Political
SYSTEM• Multiple interactions• Feedbackmechanisms• Phasechanges• Emergent properties
IMPLEMENTATION• Organisation/structure• Financing• Policy
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Pfadenhauer et al, 2015; Rohwer et al, in press
Conceptualising interventions through logic models
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Choosing study designs for evaluation
• Interventionstudies– RCTsand cluster RCTs– Rangeof „neglected“designs
• Interrupted timeseries• Controlled before-afterstudies• Naturalexperimentstudies
• Mixed-method approaches– Process evaluation– Qualitativeresearch
• Modelling–Dynamicsystemsmodelling
Craig et al (2012); Gerhardus et al (2015)
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Synthesisingevidence
Rehfuess et al (2014)
©GIZ
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Asystems perspective inrelation toimplementing evidence
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A. Sequential, dissemination-based model of EBPH
Evidence production and synthesis Evidence dissemination Policy-making
C. Research co-production model of EBPH
Policy-making
Evidence production and synthesis
B. Political theory-informed model of EBPH
Evidence production and synthesis
Policy-making
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Primaryresearch
Evidencesynthesis
Policyandpractice
Individual,institutionalandsystemcapacity
building
South-SouthandNorth-Southnetworking
Primaryresearch,evidence synthesis andpolicy-and-practice within the research and health system
CEBHA+ research and implementation framework
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Developing evidence-based and stakeholder-informedresearch priorities
Three-step CEBHA+approach:• onlinesurveyandface-to-face
consultations• evidencemaps• developmentofstudyprotocols
Evidencemapping1. Developing aframework2. Formulating aquestion3. Defining inclusion criteria4. Conducting searches5. Selecting studies6. Extracting data7. Presenting results
Rehfuess et al (2016)©FrodeForland
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Employing aresearch co-production approachinCEBHA+
• Stakeholdersareinvolvedthroughouttheresearchprocess
• Meansofensuringthat– Policy-relevantstudiesareconducted– Findingsareapplicableingivencontext– Findingsarerapidlyimplemented
• Caveat:Needfor careful evaluation of effectiveness
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Using „pushand pull“strategies inCochrane PublicHealth Europe
Munichcommunicationproject
• Standardised summaryformatforsystematicreviews
• TestingwithpublichealthstakeholdersinGermany,AustriaandSwitzerland
• Startingpoint forlong-termengagementstrategy
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Conclusions
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„Data collection is not the solution – questionformulation and research design is.“
Jim McCambridge
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Thank you