Using the Evidence-Base to Improve Local Public Health Practice.

Using the Evidence Base to Improve
Local Public Health Practice
Katie Duggan, MPH, MS, RD, Manager of
Special Projects, The Prevention Research
Center in St. Louis, St. Louis, MO
Dorothy Cilenti, DrPH, MPH, MSW, Assistant
Professor UNC Gillings School of Global
Public Health, Chapel Hill, NC
Moderator: Paul C. Erwin, MD, DrPH, University of
Evidence-Based Public Health
• The integration of science-based interventions
with community preferences to improve the
health of populations (Kohatsu ND, Am J Prev
Med. 2004)
• Relevance to PHAB Standard 10: “Contribute to
and apply the evidence base of public health”
• Relevance to Essential Service 10: “Evaluates the
development, implementation, and impact of
LPHS research efforts on public health practice.”
Evidence-Based Public Health
• What is it?
– Evidence-Based Practice
– Administrative Evidence-Based Practices
– Evidence-Based Decision Making
– Practice-Based Research
• How is it measured?
• Who is involved?
• What works?
Project LEAD
Katie Duggan, MPH, MS, RD, Manager of
Special Projects, The Prevention Research
Center in St. Louis, St. Louis, MO
 Robert Wood Johnson Foundation
 National Coordinating Center for PHSSR + University
of Kentucky in Lexington
 Project Team:
Katie Stamatakis, PhD MPH
Rodrigo Reis, PhD MSc
Carolyn Leep, MPH
Beth Dodson, PhD MPH
Katie Duggan, MPH MS RD
Paul Erwin, DrPH MD
Peg Allen, PhD MPH
Ross Brownson, PhD
Jenine Harris, PhD
Carson Smith, MPA
Robert Fields, BS
What are we trying to achieve?
- “Evidence-based public health is the process
of integrating science-based interventions
with community preferences to improve the
health of populations.”
Kohatsu, et al. Am J Prev Med 2004
But, more than only interventions…
from PHSSR, administrative EBPs
- Agency (health department)-level structures
and activities that are positively associated
with performance measures (e.g., achieving
core public health functions, carrying out
evidence-based interventions).
What is Project LEAD?
4 Aims:
1. Describe the evidence-base for local
EBPH in the United States (esp. A-EBPs)
2. Test the effectiveness of local-level EBPH
capacity building in 4 states
3. Describe a range of local models in EBPH
4. Translate and disseminate findings to
A few early findings for Aim 1
 Online survey was sent to 967 LHDs
 517 completed surveys were returned
(54% response rate)
 68% with top health official, 23% with
Preliminary Results, 5 EBP domains
Workforce development
QI (82%), EBDM (59%)
Staff participation (84%) hire w/ PH degree (36%)
Organizational climate and culture
Life long learning (71%), culture supports EBDM (42%)
Relationships and partnerships
Importance (92%), share resources (68%)
Financial processes
Multi funding sources (96%), QI resources (55%)
Preliminary Results
Patterns of A-EBPs and use of EBDM vary
significantly based on:
1. Population size served by the LHD
(strongest predictors after adjustment)
2. Governance structure (state governed)
3. Age group in the 50s
Use of resources
 26% of LHDs reported
systematic reviews as 1
of top 3 most
important resources
 33.5% were not
familiar with the
Community Guide
Most important resources
for decision making
• Funding guidance (57%)
• Guidance from state health agency (53%)
• Health Planning tools e.g., MAPP or Healthy
People (42%)
• Success stories or lessons learned from peers
How do LHDS learn about public
health findings?
Professional Associations (56%)
Seminars or workshops (52%)
Email alerts (34%)
Academic journals (31%)
Top Read Journals
1. American Journal of Public Health
2. Morbidity Mortality Weekly Report
3. Journal of Public Health Management
and Practice (12.4%)
4. Public Health Reports (10.5%)
Evidence-Based Interventions
 21% reported EBDM was packaged in a way
that is usable
 18% felt they are designed in a way to be
 25% agreed EBDM is easy to understand in
their agency
What encourages use of EBDM
in LHD’s?
• Trainings in EBDM (83%)
• High priority placed by Leadership (67%)
• Positive feedback or encouragement to use
EBDM (45%)
• A performance evaluation that considers the
use of EBDM (45%)
Factors Contributing to
Successful Implementation of
Evidence-Based Public Health
Practice: Findings from Case
Studies of Four Local Health
Dorothy Cilenti, DrPH, Ross C. Brownson,
PhD, Karl Umble, PhD, Paul Campbell Erwin,
MD, DrPH, Rosemary Summers DrPH
Funding: University of Kentucky National Coordinating
Center for Public Health Systems and Services Research
and the Robert Wood Johnson Foundation
Project team: The authors would like to recognize
Matthew Schnupp, MSPH, BSN, RN for his assistance
with the literature review and data collection activities.
Study participants: We would also like to thank the
local health departments and academic researchers
who were interviewed as part of this study.
Study Objectives
• To describe factors which contribute to
successful translation of science to practice in
public health agencies
Theoretical Framework
• Study utilized the Consolidated Framework for
Implementation Research (CFIR)* which integrates 19
models of innovation, dissemination and
implementation into five domains:
Intervention Characteristics
Outer Setting
Inner Setting
Individual Characteristics
Process of Implementation
*Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC.
Fostering implementation of health services research findings into
practice: A consolidated framework for advancing implementation
science. Implementation Science Aug 2009; 4 (50).
• Four health departments with special knowledge or
insight into the issue of interest were identified
through discussions with key informants from PBRNs,
PRCs, academic health departments, and the CDC.
• The research team conducted structured interviews
with key informants in the four health departments
and with four corresponding partners from academic
• Interviews were recorded and transcribed, and a
thematic analysis of codes was conducted using Atlas
Description of Case Study Sites
• County A: Home to large state university housing a
College of Medicine and a state-authority local public
health agency with 48 million budget and 640
positions serving a southeastern city with more than
1 million residents.
• County B: Home to a large state university housing a
College of Public Health and a local public health
agency employing 45 individuals in a Midwestern city
serving 240,000 residents. The agency has a 5 million
dollar budget comprised of 67% local funding.
Description of Case Study Sites
• City C: Home to a local public health agency employing 258
individuals serving 600,000 residents in a metropolitan area of
the Midwest. A large state university housing a School of
Medicine and Public Health is located in another city. The
agency has an annual budget of 26 million dollars, with 50% of
funding from local taxes.
• County D: Home to a local public health agency employing
134 individuals serving 300,000 residents in a medium-size
metropolitan area in the Northeast. A large private university
housing a School of Public Health is located in an urban city
approximately two hours from the health department. The
agency’s annual budget is approximately 36 million.
• Eight faculty members from academic
institutions and 14 public health executives
and senior leaders were interviewed across
the four sites. Several themes emerged that
were consistent with the CFIR.
• Outer setting:
– Health departments and academic partners were WIDELY
NETWORKED with external organizations such as NACCHO,
PBRNs, etc.
– Staff were given ample opportunities to assume BOUNDARYSPANNING ROLES including adjunct appointments; faculty also
assumed roles within health departments
– Academic departments made INVESTMENTS in faculty engaging
in practice-related activities
– Decisions to disseminate, adopt and implement EBP was directly
ADDITIONAL RESOURCES to meet those needs
– Implementation of EBP was also driven by EXTERNAL POLICIES
AND INCENTIVES, such as federal and state program mandates,
accreditation, etc.
• Inner Setting:
– Health departments established DEDICATED INTERNAL
UNITS to provide data support for programs, identify grant
opportunities, research evidence-based practices and
provide evaluation services.
– Health departments hired EMPLOYEES TRAINED IN
expertise to community-based organizations.
– Academic institutions funded FORMAL STRUCTURES
within their schools to facilitate communication and
collaborative work with local health departments
– Health departments identified FUNDING FOR STAFF
time for staff to pursue training.
• Process of Implementation:
– Health departments and academic partners
emphasized the important of ENGAGING
LEADERSHIP AND STAFF to implement evidencebased practice
– Successful implementation was typically
integrated with a QUALITY IMPROVEMENT
Seven Take-Aways:
1) Link the evidence-based practice to a visible, high-priority community
2) Maintain strong networks with professional organizations and peers
3) Leverage use of EBP through federal and state program mandates,
funding, and accreditation
4) Build strong political support for application of science-driven
5) Invest in dedicated resources and staff for research and data capacity
6) Establish strong communication channels between researchers and
practitioners and between agency staff and agency leaders
7) Identify funds for implementation of evidence-based policies and
Where to Go from Here
• Make use of theory and frameworks
• Develop measures to track health department
implementation of evidence-based practice
• Develop tracer conditions to measure and track over
time, such as specific organizational, structural,
financial, workforce and governance-related changes
• Conduct systems research to identify where
practitioners and researchers may make organizational
changes to create cultures that facilitate
implementation of evidence-based practice
Evidence-Based Public Health
• Do the themes from the case studies and
project LEAD resonate with you?
• Think about health depts. that stand out as
leaders in EBDM…..are there other
characteristics or factors that seem to help them
be high performers in this area?
– What has enabled you to utilize EBDM?
– What are the barriers to EBDM?
– How can we address these barriers?
• What do you currently see as the deficits in
– How can we address these deficits?
– What are your preferred methods for
– And thinking about a successful training
that you have been to, what would you say
made that training successful?
• What ONE next thing might you do in your
health agencies when you leave the
conference to move your agency along in
Using the Evidence Base to Improve
Local Public Health Practice
Katie Duggan, MPH, MS, RD, Manager of
Special Projects, The Prevention Research
Center in St. Louis, St. Louis, MO
Dorothy Cilenti, DrPH, MPH, MSW, Assistant
Professor UNC Gillings School of Global
Public Health, Chapel Hill, NC

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