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

rehfuess@ibe.med.uni-muenchen.de

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

Introduction to evidence-based public health

Evidence-basedmedicine (EBM)…

„…is the integrationof bestresearchevidence with clinicalexpertise and patient values.“

DavidSackett

“… 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)

“… 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)

An apple a day keeps the doctor away …

… 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

Wrongassumptionthatpublichealthinterventionscanonlydogood...

Publichealthinterventions• Canhavepositiveandnegativehealthconsequences• Affectlargepopulationgroups• Aresubjecttodifferentperceptionsbydifferentgroups• Canimpactdiverseaspectsoflifeandfreedomofchoice• Bindlimitedresources

Whytheneedforanevidence-basedapproach?

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

Examples fromINTEGRATE-HTA,CEBHA+and CPHE

Goal:

Developconceptsandmethodsforacomprehensive,patient–centred,andintegratedassessmentofcomplextechnologiesthatincludesandconsiders

• effectivenessandeconomic,sociocultural,ethical,andlegalissues,

• patientpreferencesandpatient-specificmoderatorsoftreatment,

• contextandimplementationissues

INTEGRATE-HTA(2012– 2015)

www.integrate-hta.org

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

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

Asystems perspective inrelation to designing andevaluating interventions

Population • Healthygeneralorat-riskpopulationIntervention • Population-levelintervention

• “Proactive”preventionthrougheducational,technologyorpolicyintervention

• Implementationinhousehold,communityorpolicysettings

Comparison • “Businessasusual”inseveralsectors

Outcome • Usuallyindirecteffectsonmultiplehealthoutcomesandothersocietalconsequences

• Usuallyimpactafterlagperiod

PICOas starting point

Rehfuess & Akl (2013)

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

Pfadenhauer et al, 2015; Rohwer et al, in press

Conceptualising interventions through logic models

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)

Synthesisingevidence

Rehfuess et al (2014)

©GIZ

Asystems perspective inrelation toimplementing evidence

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

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

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

Employing aresearch co-production approachinCEBHA+

• Stakeholdersareinvolvedthroughouttheresearchprocess

• Meansofensuringthat– Policy-relevantstudiesareconducted– Findingsareapplicableingivencontext– Findingsarerapidlyimplemented

• Caveat:Needfor careful evaluation of effectiveness

Using „pushand pull“strategies inCochrane PublicHealth Europe

Munichcommunicationproject

• Standardised summaryformatforsystematicreviews

• TestingwithpublichealthstakeholdersinGermany,AustriaandSwitzerland

• Startingpoint forlong-termengagementstrategy

Conclusions

„Data collection is not the solution – questionformulation and research design is.“

Jim McCambridge

Thank you