Bridging the Gap: Utilizing Evidence Based Approaches in Public Health Practice

State: AZ Type: Promising Practice Year: 2014

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With a goal of increasing the number of evidence based approaches being utilized by the department, the Maricopa County Office of Performance Improvement created a searchable inventory of public health practices that are classified by a variety of indicator types including a recommendation level of recommended, promising practice, insufficient evidence, or not recommended.

To provide public health staff easy access to this information and promote use in strategic planning, program improvement, quality assurance, and evaluation design, a user-friendly web portal and associated training materials (see supplemental materials) were created. Designed as an information hub and tracking tool, the online Evidence Based Approaches (EBA) Guide database is accessible by all MCDPH employees with Maricopa County network access with requests from community partners being processed through the use of an information request form on departmental and community oriented websites (see supplemental materials). Furthermore, a built-in tracking system allows for monitoring the quantity and types of evidence based approaches being implemented by MCDPH programs and collaboration groups.

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Maricopa County Department of Public Health
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Bridging the Gap: Utilizing Evidence Based Approaches in Public Health Practice
Serving a diverse central Arizona community of more than four million, the Maricopa County Department of Public Health (MCDPH) is the third largest local public health jurisdiction in the United States covering a geographical region roughly the size of Massachusetts. Over 400 employees provide a wide range of public health services to Maricopa County residents.Understanding and implementing evidence based practices, strategies, policies, interventions, and programs is important to maximize efficiency, increase capacity, and sustain innovation in public health practice. While scientific evidence and expert recommendations regarding public health practices are available from a variety of reputable sources, time and resources do not always allow individual program staff to conduct thorough reviews of current literature. With a goal of increasing the number of evidence based approaches being utilized by the department, the Maricopa County Office of Performance Improvement created a searchable inventory of public health practices that are classified by a variety of indicator types including a recommendation level of recommended, promising practice, insufficient evidence, or not recommended. To provide public health staff easy access to this information and promote use in strategic planning, program improvement, quality assurance, and evaluation design, a user-friendly web portal and associated training materials (see supplemental materials) were created. Designed as an information hub and tracking tool, the online Evidence Based Approaches (EBA) Guide database is accessible by all MCDPH employees with Maricopa County network access with requests from community partners being processed through the use of an information request form on departmental and community oriented websites (see supplemental materials). Furthermore, a built-in tracking system allows for monitoring the quantity and types of evidence based approaches being implemented by MCDPH programs and collaboration groups.
At a 2011 estimated population of more than four million, Maricopa County is the third largest local public health jurisdiction in the United States. Its population continues to mushroom, having grown by more than 30% since the 2000 census. Within 10 years, it is anticipated that the population will exceed five million.Maricopa County is ethnically and culturally diverse, home to more than 1.2 million Hispanics (31% of all residents), 180,000 African Americans, 120,000 Asian Americans, and 90,000 Native Americans. Non-Hispanic whites constitute 57% of the total population. Spread out over 9,200 square miles (the approximate size of the state of Massachusetts), Maricopa County is a mix of urban and rural areas, including 27 cities and towns, as well as the whole or parts of five sovereign American Indian reservations. Effectively serving the public health needs of this large population requires innovation, capacity building, and a high level of efficiency through implementing or adapting evidence based approaches and promising practices. Furthermore, today’s public health landscape holds high expectations for impacting not just knowledge, attitudes, and behaviors, but linking interventions to actual changes in health outcomes. In an environment frequently characterized by limited funding, competitive grant processes often emphasize the importance of utilizing evidence based approaches (EBA) to maximize efficiency, demonstrate effectiveness and link proposed program interventions to desired health outcomes. Maricopa County Department of Public Health (MCDPH) aims to increase the number of evidence-based programs and policies employed by the department. To help reach this goal, the Office of Performance Improvement began an extensive inventory of hundreds of strategies and their corresponding scientific reviews. By providing brief descriptions and active hyper-links to data from a wide array of sources, the Evidence Based Approaches Guide provides a single access point for public health practitioners to quickly find evidence based recommendations. To increase the accessibility of this information, a web based portal for the EBA Guide creates a user friendly interface and promotes increased utilization of evidence based approaches, creates reports, and establishes tools for tracking EBA utilization by MCDPH programs and partner collaboration groups. Any MCDPH staff with a network user account is now be able to easily access and use this important information. The Maricopa County Office of Performance Improvement also processes requests for data sets from the EBA Guide for community partners making this information available to other agencies. In total the information in the EBA Guide is available to more than 500 professionals working in the public health system. The EBA Guide includes evidence based practices, policies, strategies, and interventions classified by a number of indicator types. Brief descriptions of approaches are categorized by Primary Targeted Outcome Area, Type of Strategy, Location Type, Target Audience, and a Recommendation level matrix. Recognized agencies or organizations that conduct rigorous reviews of the existing literature and make available comprehensive information to public health practitioners and health-related fields is the primary consideration when assessing a potential evidence-based approach. Trusted agencies such as the Community Preventative Services Task Force, Healthy People 2020 and the Cochrane Collaboration have high standards of excellence, seek expert opinions from those in public health-related fields, and conduct rigorous meta-analytic reviews. Published data from these sources meet MCDPH’s expectations of excellence and are included in the EBA Guide if the content is applicable to the scope of work at MCDPH. Targeted outcome areas relating to the CDC Winnable Battles of global immunization; HIV in the U.S.; motor vehicle injuries; nutrition, physical activity, and obesity; Mother-to-Child Transmission of HIV and Syphilis; Teen Pregnancy; and Tobacco are included.Approaches appearing in the EBA Guide are hyper-linked to original sources and content is reviewed and updated regularly by MCDPH staff. While every effort is made to ensure accuracy of the content provided, the EBA Guide should only be considered a general resource. All information comes from external sources and should be reviewed by the user to ensure that information from the Guide accurately reflects the original data source. In this way, this innovative tool is positioned to bridge the gap from original data sources and expert review to implementation in the field by public health system practitioners, who may not otherwise have the staff time, analytic skills or organizational capacity to systematically review the wide breadth of scientific evidence and expert recommendations available.
Global Immunization|HIV in the U.S.|Motor Vehicle Injuries|Nutrition, Physical Activity, and Obesity|Mother-to-Child Transmission of HIV and Syphilis
he primary goal of this practice is to increase the number of evidence-based programs and policies employed by the department. Advancing the science-base of chosen strategies also supports the department’s Public Health Accreditation application. Specific objectives for this practice include: establishment of unique criteria used to assess a variety of source information, creating a user friendly web interface, establishing a maintenance protocol, training MCDPH staff and community partners on using the EBA Guide, and linking MCDPH program and collaboration group initiatives to evidence based approaches.In building the structure and classification criteria of the EBA Guide, Maricopa County Office of Performance Improvement staff discussed with representatives at the Centers for Disease Control and Prevention, The Community Preventive Services Task Force, and the Prevention Institute, the best way to classify and organize the evidence-based literature. Because there is no single definition of what constitutes a gold-standard, “evidence-based practice,” defining those actions which show some potential for positive health effects, but may be lacking extensive supporting data can be challenging. Therefore, a list of criteria and definitions unique to this Guide was developed. A “Recommended” approach is defined as a practice with positive effects that has been rigorously examined and reviewed using strong scientific methods, and replicated across multiple settings. “Promising Practice” is defined as a practice with generally positive effects that has been examined or reviewed using strong scientific methods or program evaluation but may not have been replicated across multiple settings. Furthermore, practices with inconclusive effects or a lack of scientific data or examination are deemed as “Insufficient Evidence” and practices that have been demonstrated as having no effect, being potentially harmful or having negative effects are defined as “Not Recommended” in the MCDPH Evidence Based Approaches Guide. Approaches are also categorized by the ultimate outcome area that the original source identifies, the sector or location of the intervention or practice, the method by which the approach intends to impact a health outcome, and the specific group of people in which the approach intends to affect an impact either as a primary target audience or an intermediary target population. To increase the accessibility and usability of the EBA Guide, MCDPH worked with a web designer to create a web based portal for accessing the EBA Guide. This custom designed database includes a user-friendly matrix of approaches that can be filtered by classification criteria or searched by keyword. Site administration tools, report functions that can be exported to Excel, as well as guidelines and definitions are included. This online version of the EBA Guide went live in August 2013 and is accessible by all MCDPH employees on the Maricopa County network. Since the body of scientific evidence and quality literature review is constantly changing, regular review of the EBA Guide content, sources, source links, and classifications is necessary. A maintenance protocol outlining basic, advanced, and expert level maintenance tasks and associated procedures was completed in October 2013. Mechanisms in the site administration controls of the EBA Guide online database facilitate these processes. The MCDPH Offices of Performance Improvement and Epidemiology work with student interns to perform regular maintenance and content review as well as add additional sources as they become available. Although the content in the EBA Guide had been made available to MCDPH programs and partners in an excel document prior to the development of the online database portal, it was not extensively used due to accessibility limitations and navigability challenges. In order to increase awareness and use of the online version, training materials were developed in September 2013. MCDPH Staff trainings have been conducted with department management teams with additional staff trainings scheduled through January of 2014. It is anticipated that by March 2014, more than 150 MCDPH staff will have been trained on utilizing the EBA Guide online database. Additionally, in a September 2013 meeting of the Health Improvement Partnership of Maricopa County (HIPMC), a description of the EBA Guide and other technical assistance services provided by MCDPH was presented to 45 community partners. A partner request form and response protocol for processing community partner requests for information from the EBA Guide has also been established and distributed through departmental and community websites (see MaricopaHealthMatters.org).In addition to providing information and original source links for practices, policies, programs, and interventions related to public health practice, the EBA Guide database will also serve as a tracking tool linking the evidence based approaches currently being implemented to MCDPH programs and collaboration groups. During MCDPH’s annual strategic planning cycle, program initiatives and objectives are carefully reviewed by the Office of Performance Improvement to identify the evidence based approaches currently utilized by MCDPH programs and community partner collaboration initiatives. The approach description, categorization information, and original source hyper-link are then cross-referenced to each MCDPH program or collaboration group in the EBA Guide database. A report output option allows database users to see the number and description of evidence based approaches currently being utilized by each MCDPH program, office, division, or collaboration group. Start-up costs associated with this project are estimated to be approximately $47,000. Included in this figure is $22,054 for database development and $1,819 which funded three temporary employees who were trained and conducted the first round of content and link verification after the online database was completed. An additional $23,000 is the estimated cost for the initial MCDPH staff time investment of approximately 1,000 hours at $23 per hour. Ongoing costs for staff time to maintain this database are expected to range between $5,000 and $10,000 annually. In-kind contributions of labor through unpaid student internships will also contribute to the ongoing maintenance of the EBA database.
The primary goal of this practice is to increase the number of evidence-based programs and policies employed by the department and secondarily in the community. Specific objectives for this practice include: establishment of unique criteria used to assess a variety of source information, creating a user friendly web interface, establishing a maintenance protocol, training MCDPH staff and community partners on using the EBA Guide, and linking MCDPH program and collaboration group initiatives to evidence based approaches. While MCDPH is still in the process of mapping programs and initiatives to evidence based approaches and additional trainings will be held in the coming months, all of the other objectives stated above have already been achieved. Additionally, MCDPH plans to collect periodic user feedback with individuals who access the online database to obtain useful information on ease of use, applicability of information, and methods of utilization. Since the approaches outlined in the EBA Guide focus on specific practices, policies, strategies, and interventions examined through scientific research, there is a wide range of opportunity for interpreting and applying this information. Users of the Guide may consult the information to assist in strategic planning, program improvement, quality assurance, and evaluation design. Some examples of how the EBA Guide has already been used by MCDPH programs and partners are included below.In June 2012, MCDPH convened stakeholders as part of a community health improvement planning process. These stakeholders developed strategic priorities to impact five identified health indicators. By using a version of the EBA Guide that had been pre-sorted to show relevant outcome areas by strategy type and location, stakeholders were able to easily identify specific evidence based approaches to implement. During 2013, the Maricopa County Office of Public Health Policy consulted with a local employer on developing a comprehensive written wellness policy for employees. By using the EBA Guide to create a list of evidence based recommendations, they delivered a high quality product with a very small investment of staff time. In 2011, the Maricopa County Office of Tobacco and Chronic Disease Prevention used the EBA Guide to demonstrate that the objectives and interventions included in their grant aligned with scientific recommendations for tobacco control. In 2010, the Maricopa County Office of Health Promotion and Education decided to end a program that provided car seat education alone as the evidence demonstrates that this type of education is not sufficiently effective when it is delivered alone and not in conjunction with car seat provisions.  Evaluation3 
While the body of scientific research and expert analysis providing evidence based recommendations for public health practice has long been accessible from reputable sources such as The Community Guide, Cochrane Review and the Centers for Disease Control among others, the EBA Guide and database tools created by MCDPH are positioned to bridge the gap between this evidence base and public health practice. By providing a centralized system to easily filter, search, and access original source reviews and information, MCDPH program staff and community partners can readily access a wide breadth of quality scientific information with a minimal investment of time and effort.Since the body of scientific evidence and quality literature review is constantly changing, regular review of the EBA Guide content, sources, source links, and classifications is necessary. In order to sustain this tool as a resource that provides active links to up to date scientific recommendations, mechanisms were built into the site administration controls of the online database to facilitate regular review, modifications, additions, verifications and tracking. Database users granted administrative access can add, edit, and delete records; modify or de-activate categorization variables; link evidence based approaches to MCDPH programs and collaboration groups as well as access information on verification dates and site usage. An Evidence Based Approaches Guide database maintenance protocol has been established that outlines maintenance tasks as well as roles in adding new approaches, obtaining user feedback, mapping approaches being used and training new users and maintenance staff. These tasks are divided into three skill levels: basic, advanced, and expert. Basic skill level tasks include verifying links and database content, identifying updated sources to be reviewed, compiling feedback survey information and customizing reports for distribution to partners and programs. Tasks that require a more thorough understanding of the database and an advanced skill level include reviewing suspected duplications/contradictions between sources, extracting new approaches from new sources, linking evidence based approaches to current MCDPH programs and partner initiatives, and training new users on utilizing the EBA database. Expert level tasks include training staff or interns to basic or advanced level maintenance tasks, reviewing new approaches extracted by others and reviewing or revising categorization criteria. MCDPH staff in the Offices of Performance Improvement and Epidemiology will act as the database experts and trainers with student interns being assigned database maintenance activities appropriate to their individual skill level. Because utilizing evidence based approaches is a crucial strategy for any area of public health practice, student interns from a variety of academic disciplines will become an essential piece in sustaining this tool.
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