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Applying an Evidence-based Approach to Improve Community Health. Holly Tutko, MS, Univ. of NH Anna Thomas, MPH, Manchester Health Dept. April 2006 Training Provided by Empowering Communities Project. Presentation Objectives.

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Applying an evidence based approach to improve community health l.jpg

Applying an Evidence-based Approach to Improve Community Health

Holly Tutko, MS, Univ. of NH

Anna Thomas, MPH, Manchester Health Dept.

April 2006

Training Provided by Empowering Communities Project

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Presentation Objectives Health

  • At the end of this training, participants will have increased awareness about how to:

    • Define a community health issue

    • Locate proven interventions

    • Determine intervention(s) best suited for your community

    • Develop an action plan to implement the intervention(s)

    • Conceptualize major “building blocks” of an evaluation plan

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So what is evidence-based decision making? Health

  • Evidence: data or information

  • Evidence-based decision making (EBDM)

    • Using data/information to make a conclusion or judgment

  • Examples of EBDM in community health improvement

    • Using data to identify community health priorities

    • Consulting literature to see what research says works

    • Modifying programs/policies based on evaluation data

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Evidence-Based Decision Making is… Answering 4 Key Questions

  • Should something be done about the problem?

  • What should be done about the problem?

  • How should it be done?

  • How will I know it is working?

Acknowledgement: Stephanie Zaza (2005). What is Evidence-based Decision Making? APHA Presentation.

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Q1: Should something be done about the problem? Questions

  • Quantify the issue from the perspective of those making the decision

  • They want to know…

    • Magnitude of the problem

    • Consequences of the problem

    • Community perception of the problem

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Magnitude of the Problem Questions

  • Use descriptive statistics to describe the problem

    • Person

    • Place

    • Time

  • Use of a comparison group

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Consequences of the Problem Questions

  • Search literature to understand:

    • Causal pathway (risk/protective factors)

    • Consequences of doing nothing

      • Health, economic, social

  • Use local data to model problem prognosis

    • Risk/protective factors getting better, worse, or staying the same

    • Community-specific consequences computed

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Community Perception Questions

  • Determine if community:

    • Knows about the problem?

    • Sees it as a problem?

  • Strategies

    • Key informant interviews

    • Focus groups

    • Surveys

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Before starting your data/research hunt… Questions

Write an Issue Statement

  • Significance of the issue using data

    • Statewide rates of obesity among children are increasing.

  • Hypothesis being considered

    • Is obesity a problem for children in our community?

    • What is the prevalence of risk and protective factors associated with childhood obesity in our community?

    • What are the consequences of childhood obesity?

    • Does the community believe that childhood obesity is a problem?

  • Potential interventions

    • Do nothing

    • Examine effective strategies to reduce risk factors and increase protective factors to reduce obesity rates

  • Potential outcomes/measures

    • Trends in obesity incidence & prevalence rates (overall & high risk)

    • % of community children participating in school physical education programs

    • Projected future rates of childhood obesity

    • Focus groups findings on community perceptions about childhood obesity.

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City of Manchester Department of Health and the Healthy Manchester Leadership Council


  • Public Health Report Cards, 1996

  • The City of Manchester, NH Comprehensive HIV Prevention Plan, 1996

  • Greater Manchester Community Needs Assessment 1997

  • Taking a Tough Look at Adolescent Pregnancy Prevention, 1998

  • The Oral Health Status of the City of Manchester, NH: Actions Speak Louder Than Words, 1999

  • Preventing Childhood Lead Poisoning in Manchester, NH: Recommendations for the Community, 2002

  • Improving Childhood Immunization Levels in the City of Manchester, NH: Recommendations for the Community, 2003

  • Public Health Report Cards, 2005

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Quantifying the Issue: Manchester Experience Manchester Leadership Council

Babies Born to Manchester MothersAged 19 and Younger since 1985 (n=3071)

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Manchester’s Adolescent Births: Manchester Leadership Council“The Tip of the Iceberg”

130 Births Annually to Manchester Mothers Age 19 and Younger(1999-2003 Vital Statistics, NHDHHS)

13,757 Manchester youth age 10-19 either currentlysexually active or soon will be (2000 U.S. Census)

14,333 Manchester youth age 9 and younger - future “at risk” and the cohort for whom Healthy People 2010 Objectiveswill be measured (2000 U.S. Census)

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Developing an Issue Statement Manchester Leadership Council

Data Description: In Manchester, approximately 160 babies are born to adolescent moms (15-19 years) each year. When compared to the state and Nashua, Manchester’s adolescent moms are younger (< 17 years). (1988-1992 Vital Stats)

Issue under review: Is adolescent pregnancy a priority issue Manchester should address?

Potential interventions: Comprehensive school health education, home visiting, others, nothing??

Potential Outcomes: 1) % of Manchester adolescents who report being sexually active 2) % of repeat births to adolescent moms

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Risk Factors for Adolescent Pregnancy Manchester Leadership Council


-Age at first date -Poverty -High unemployment

-Substance abuse -Parent ed. level -Marginalized community

-Sexually abused -Single parent -Poverty

-Low academic household

performance -Mom/Sister an

adolescent mom

-Lack of parent support

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Percentage of Manchester High School Youth Manchester Leadership CouncilEngaging in Sexual Intercourse By Grade Level, 2005

SOURCE: Manchester YRBSS, 2005

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Estimated Cost Savings for Manchester Taxpayers from a 20% Adolescent Birth Reduction Over the Next 5 Years


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Who’s “Problem” Adolescent Birth Reduction Over the Next 5 YearsIs This Anyway?

  • There was an overall lack of community awareness about adolescent pregnancy as a COMMUNITY issue or responsibility.

  • Only anecdotal reports from adolescent health care providers and school staff.

  • There was also a disconnect between whether or not primary, secondary or tertiary prevention was needed.

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Q2: What should be done about the problem? Adolescent Birth Reduction Over the Next 5 Years

  • What effective interventions exist to address the problem?

  • What intervention(s) will work in my community?

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Finding What Works Adolescent Birth Reduction Over the Next 5 Years

  • Start w/searching for already completed reviews

  • Clearly define target population and contributing factors

    • Children 5-14 yrs or adults 18-30 yrs?

    • Lack of exercise, poor nutrition, both?

  • Develop a list of key words

  • Insufficient evidence

  • Multi-pronged interventions

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Evidence “Life Course” Adolescent Birth Reduction Over the Next 5 Years











For more information about reviews, go to

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Evidence Sources Adolescent Birth Reduction Over the Next 5 Years

  • E-Roadmap to Evidence-Based Public Health Practice Website

  • One-stop shopping to evidence websites

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Guide to Community Preventive Services Adolescent Birth Reduction Over the Next 5 Years

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Beyond Evidence Websites & Literature Databases sheet for how to search medline.

  • Reputable efforts focusing on the problem

    • American Academy of Pediatrics (

    • Action for Healthy Kids (

    • National Coalition for Promoting Physical Activity (

  • Conferences

  • On-line trainings & list-serves

  • National, state, and local experts

  • Suggested search strategy


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Selecting Interventions sheet for how to search medline.

Intervention Decision Matrix

Acknowledgement: by: C.J. Fowler and A.L. Dannenberg, 1995. Revised in 1998, 2000, and 2003.

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Manchester Case Study sheet for how to search medline.

  • Used HMLC leadership to guide the process

  • Held two community conferences

  • Formed MAPPS subcommittee to prioritize interventions

  • Secured grant dollars for media campaign, home visiting program, increased access to adolescent health care and the implementation of comprehensive school health education

  • Secondary interventions ensued

  • The MHD is continuing to monitor trends

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Reducing Adolescent Pregnancy in Manchester: Determining What is KnownThrough the Literature

Programs/Policies to Reduce Adolescent Pregnancy

  • Mentoring / Career Guidance

  • Homework Assistance and Tutoring

  • Comprehensive Health Education

  • Sports & Fine Arts Programs

  • Primary Care Provider

  • Mental Health (increase resiliency)

  • Building and Supporting Strong Families

  • Home Visits & Adolescent Parent Support

  • Case Management

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Manchester Experience…Finding Evidence for What Works.. What is Known

  • NH Adolescent Health Task Force Report

    • Based on US Dept. of Health and Human Services National Strategy to Prevention Teen Pregnancy

    • “Success by 19”: Adolescent Pregnancy Prevention Model

      • Developed by K. Dunn and J. Underhill

      • Integrated all interventions demonstrated effective in the literature

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Manchester Adolescent Pregnancy Prevention Subcommittee (MAPPS)

  • Review of health education curriculum in Manchester schools

  • Improved access to adolescent health services

  • Enhanced and well coordinated services for pregnant and parenting teens

  • Creation of an on-going media campaign focused on adolescent pregnancy prevention

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Manchester Adolescent Pregnancy Prevention Subcommittee (cont.)

  • Development of a peer education program

  • Improved access to high quality pre-school education

  • Enhanced services for high-risk youth

  • Improved out reach to out-of-school youth

  • Enhanced after school and summer program options

  • Design of meaningful data reporting and evaluation tools.

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Q3: How should it be done? (cont.)

  • What steps are needed to implement the intervention(s)?

  • What barriers must be overcome (or opportunities taken) to implement it/them?

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Action Planning (cont.)

  • Create action plan to implement selected intervention

  • Components

    • Goals

    • Objectives

    • Activities/Strategies

    • Timeline

    • Resources

    • Accountability

    • Evaluation Measures

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Use of Logic Models for Action Planning (cont.)

Learn about Logic Models:

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Logic models are useful to: (cont.)

  • Explain how your project will achieve goals

  • Map resources & activities to include in action plan

  • Develop evaluation measures to attach to action plan

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Identify Implementation Barriers & Opportunities (cont.)

SWOT Analysis





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Environmental Scan Questions (cont.)

  • Internal Assessment

    • Is the issue relevant to the mission & values of the org?

    • What, if anything, are we already doing to address the issue?

    • Does the org. have the desire & ability to address the issue?

    • If so, how high is the priority?

    • Who is interested in the org?

  • External Assessment

    • Will the community accept & support addressing the issue?

    • Are there govt. regulations or other legal factors affecting the issue?

    • Have the views of important stakeholders been taken into account?

    • Are there external groups addressing the issue now (or in the past)? Successful or not successful?

Source: Adapted from Timmreck, TA. Planning, Program Development, and Evaluation. A Handbook for Health Promotion, Aging, & Health Services.

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Comprehensive School Health Education (cont.)

  • “Clear evidence has shown that comprehensive school health education in schools is effective in reducing risk behaviors among youth, which account for most of the health problems among young people that will follow them into adulthood if not prevented or solved.”

  • “Such education is also cost effective: for every $1 spent on tobacco, drug, alcohol and sexuality education, $14 are saved in avoided health care costs.”

    - CDC Strategic Plan, 2000

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Comprehensive School Health Education (cont.)

  • Hired a Certified Health Educator to research models and work closely with the school administration, the School Board and community partners

  • The Michigan model was adopted and implemented in 2002

  • The Manchester School District hired 16 health educators as part of this implementation

  • Middle and high school curriculum to be finalized this year

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Adolescent Pregnancy (cont.)Prevention Media Campaign

  • Contracted with High Point Communications to develop messages and media campaign

  • Implemented the “Not Me, Not Now” abstinence campaign

  • Television, movie screen and radio advertisements

  • Press conferences

  • Community presentations

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Enhanced Adolescent Health Services (cont.)

  • Added one primary care clinic session to Teen Health Clinic operations, including access to reproductive health services

  • More than 400 clients added per year as a result

  • Increased enrollment in NH Health Kids (90% of clients are uninsured)

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Coordinated Services for Pregnant/Parenting Adolescents (cont.)

  • Collaboratively-supported home visiting program designed to meet the specific needs of adolescent moms

  • Includes “Parents As Teachers” curriculum, smoking cessation services, family planning and maternal depression services

  • Enrolled 25 adolescent moms per year

  • Offers new mother’s support group

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Q4: How will I know it is working? (cont.)

  • Is the intervention being implemented well?

  • Is the intervention improving health outcomes?

  • What does the community think about the intervention?

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Is intervention being implemented well? (cont.)

  • Performance Measures:

    • Is the intervention being delivered as intended?

    • What aspects of the intervention are working well or poorly?

    • What can be done now to improve the intervention?

Acknowledgement: “Introduction to Evaluation presentation by Mike Stoto at

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Is the intervention improving health outcomes? (cont.)

  • Outcome Measures

    • For whom?

    • Under what conditions?

    • Were the benefits worth the cost?

    • What intervention components were most effective?

Acknowledgement: “Introduction to Evaluation presentation by Mike Stoto at

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Linking Evaluation to Planning (cont.)



Process, Formative Accountability

Impact/Intermediate & Outcome


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Addressing the Causality Question (cont.)

  • Theory of Change Approach

    • Intervention based on a specific, plausible theory of change

    • Intervention activities/steps implemented as planned

    • Short, mid, and long-term evaluation measures follow patterns expected

    • Contextual shifts are monitored

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Addressing the Causality Question (cont.)

  • Use evidence-based practices

  • Evaluation design method

  • Use mix of measures

    • Performance & outcome

    • Qualitative & quantitative

  • Monitoring community context

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What does the (cont.)community think??

  • How are you communicating results back to key audiences?

  • What is their feedback/insight on results?

  • Importance

    • Future program support

    • Understand results

    • Good will

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City of Manchester (cont.)Teen Birth Rates, 1993-2000

Healthy Manchester Leadership Council Program Initiation


Reduce births to adolescents aged 17 or younger by 40%.

Reduce births to adolescents aged 19 or younger by 33%.

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2005 Public Health Report Cards (cont.)

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Summary (cont.)

  • Applying an evidence-based approach is a multi-step process examining:

    • Should something be done about the problem?

    • What should be done about the problem?

    • How should it be done?

    • How will I know it is working?

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Sources (cont.)

  • Brownson, R. et al. Evidence-based Public Health Practice. Oxford University Press, 2003.

  • Durch, J. S., Bailey, L. A., & Stoto, M. A. (Eds.). (1997). Improving Health in the Community: A Role for Performance Monitoring. Washington DC: National Academy Press.

  • Evidence-Based Decision Making in Public Health: A How To Training Manual

  • E-Roadmap to Evidence-based Public Health Practice (

  • Zaza, Stephanie (2005). What is Evidence-based Decision Making? APHA Presentation.

  • Stoto, Michael. “Introduction to Evaluation presentation at

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Contact Information (cont.)

Holly Tutko, MS

Clinical Asst Professor

Univ. of NH

Ph: (603) 862-1128

Email: [email protected]


Anna Thomas, MPH

Community Epidemiologist

Manchester Health Dept.

Ph: (603) 624-6466 x341

Email: [email protected]