Applying an Evidence-based Approach to Improve Community Health

1. 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

2. Presentation Objectives • 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

3. So what is evidence-based decision making? • 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

4. 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.

5. Q1: Should something be done about the problem? • 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

6. Magnitude of the Problem • Use descriptive statistics to describe the problem • Person • Place • Time • Use of a comparison group

7. Consequences of the Problem • 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

8. Community Perception • Determine if community: • Knows about the problem? • Sees it as a problem? • Strategies • Key informant interviews • Focus groups • Surveys

9. Before starting your data/research hunt… 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.

10. City of Manchester Department of Health and the Healthy Manchester Leadership Council COMMUNITY ASSESSMENT AND ACTION PLANS • 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 http://www.manchesternh.gov/CityGov/HLT/healthdatareports.html

11. Quantifying the Issue: Manchester Experience Babies Born to Manchester MothersAged 19 and Younger since 1985 (n=3071)

12. Manchester’s Adolescent Births:“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)

13. Developing an Issue Statement 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

14. Risk Factors for Adolescent Pregnancy AdolescentFamilyCommunity -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

15. Percentage of Manchester High School YouthEngaging in Sexual Intercourse By Grade Level, 2005 SOURCE: Manchester YRBSS, 2005

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

17. Who’s “Problem”Is 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.

18. Q2: What should be done about the problem? • What effective interventions exist to address the problem? • What intervention(s) will work in my community?

19. Finding What Works • 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

20. Evidence “Life Course” QUANTITATIVE SYSTEMATIC REVIEW (META-ANALYSIS) INCREASING STRENGTH INDIVIDUAL STUDIES GUIDELINES QUALITATIVE SYSTEMATIC REVIEW NARRATIVE For more information about reviews, go to http://www.publichealthsolutions.org/researchreviews.html

21. Evidence Sources • E-Roadmap to Evidence-Based Public Health Practice Website • One-stop shopping to evidence websites www.publichealthsolutions.org

22. Guide to Community Preventive Services

25. Insert slide of NLM webpage – refer people to resource sheet for how to search medline.

26. Beyond Evidence Websites & Literature Databases • Reputable efforts focusing on the problem • American Academy of Pediatrics (www.aap.org) • Action for Healthy Kids (http://www.actionforhealthykids.org/) • National Coalition for Promoting Physical Activity (http://www.ncppa.org/) • Conferences • On-line trainings & list-serves • National, state, and local experts • Suggested search strategy • www.publichealthsolutions.org/step-by-step.html

27. Selecting Interventions Intervention Decision Matrix Acknowledgement: by: C.J. Fowler and A.L. Dannenberg, 1995. Revised in 1998, 2000, and 2003.

29. Manchester Case Study • 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

30. 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

31. Manchester Experience…Finding Evidence for What Works.. • 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

32. 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

33. 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.

34. Q3: How should it be done? • What steps are needed to implement the intervention(s)? • What barriers must be overcome (or opportunities taken) to implement it/them?

35. Action Planning • Create action plan to implement selected intervention • Components • Goals • Objectives • Activities/Strategies • Timeline • Resources • Accountability • Evaluation Measures

36. Use of Logic Models for Action Planning Learn about Logic Models: http://www.ecnh.unh.edu/logicmodels.ppt

37. Logic models are useful to: • Explain how your project will achieve goals • Map resources & activities to include in action plan • Develop evaluation measures to attach to action plan

38. Identify Implementation Barriers & Opportunities SWOT Analysis Positive Negative Internal External

39. Environmental Scan Questions • 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.

40. Comprehensive School Health Education • “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

41. Comprehensive School Health Education • 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

42. Adolescent PregnancyPrevention Media Campaign • Contracted with High Point Communications to develop messages and media campaign • Implemented the “Not Me, Not Now” abstinence campaign www.notmenotnow.org • Television, movie screen and radio advertisements • Press conferences • Community presentations

43. Enhanced Adolescent Health Services • Added one primary care clinic session to Teen Health Clinic operations, including access to reproductive health services www.childhealthservices.org/id22.htm • More than 400 clients added per year as a result • Increased enrollment in NH Health Kids (90% of clients are uninsured)

44. Coordinated Services for Pregnant/Parenting Adolescents • 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

45. Q4: How will I know it is working? • Is the intervention being implemented well? • Is the intervention improving health outcomes? • What does the community think about the intervention?

46. Is intervention being implemented well? • 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 http://www.ecnh.unh.edu/Evaluation.ppt

47. Is the intervention improving health outcomes? • 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 http://www.ecnh.unh.edu/Evaluation.ppt

48. Linking Evaluation to Planning PERFORMANCE OUTCOME Process, Formative Accountability Impact/Intermediate & Outcome Structure

49. Addressing the Causality Question • 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

50. Addressing the Causality Question • Use evidence-based practices • Evaluation design method • Use mix of measures • Performance & outcome • Qualitative & quantitative • Monitoring community context