The History & Future of. The History & Future of Prevention Research: Achieving Dissemination Success. Prevention Research Centers Annual Program

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1 The History & Future of The History & Future of Prevention Research: Achieving Dissemination Success Presented in part at the 20 th Anniversary Celebration of the University of Texas PRC Houston, February 1, 2007 and as the Keynote at the Prevention Research Centers Annual Program Meeting Atlanta, March 13, 2007 Lawrence W. Green Lawrence W. Green University of California at San Francisco University of California at San Francisco

2 Four Century Milestones in Prevention Research Dissemination Captain Lancaster s s 1601 experiment experiment on scurvy James Lind s s 1747 replication replication on scurvy John Snow s s 1854 mapping of cholera and recommendation to the Broad Street Board of Guardian s s to remove the pump handle The great public health successes of 20 th Century The first 10 years of the PRC program The second 10 years of the PRC program

3 What is this public health achievement of the 20th Century? What is the evaluation method to judge this an achievement? 5,000 4,000 3,000 2,000 1,

4 Adult Per Capita Cigarette Consumption and Major Historical Events United States, ,000 4,000 3,000 2,000 1,000 0 End of WW II (Social norms) WW II Great Depression (Economics) 1st World Conference on Smoking and Health 1st Surgeon General s Report 1st Smoking- Cancer Concern Fairness Doctrine Messages on TV and Radio Nonsmokers Rights Movement Begins Broadcast Ad Ban 1st Great American Smokeou Nicotine Medications Available Over the Counter Federal Cigarette Tax Doubles Master Settlement Agreement Surgeon General s Report on Environmental Tobacco Smoke Source: USDA; 1986 Surgeon General's Report. MMWR Number of Cigarettes

5 3 Conceptualizations of the Gap 3 Conceptualizations of the Gap Between Knowledge & Practice Practitioners need to implement the lessons of research by translating them into practice. Research and practice are entirely separate disciplines and each must develop their own answers to their own problems Research and practice have complementary perspectives and skills that need to be used together to address the real need, collaborative knowledge production. V Van De Ven A, Johnson P. Knowledge for theory and practice. Academy of a Management Review. 2006;31(4).

6 Illustration of the Problem: Illustration of the Problem: Canadian Cancer Society RFP for a Review to Answer 4 Questions Are group counseling programs for smoking cessation effective? If so, what is the optimal content of the sessions? What is the optimum number and frequency of sessions that should be offered? What are the characteristics of the most effective facilitators?

7 University of Waterloo Results* University of Waterloo Results* A comprehensive literature review of over 40 years of published and unpublished studies Deficiencies in purpose, design and reporting Research could answer only the first of 4 questions: that group programs for smoking cessation are effective. *Manske SR, Miller S, Moyer C, Phaneuf MR, Cameron RC. Best practice in groupbased smoking cessation: Results of a literature review. AJHP 18:409-23, 2004.

8 Issues for Evidence-Based Practice and Getting Research to Practice Setting research & evaluation priorities Making research findings actionable, usable, relevant (to whom?) Translating research to local circumstances, cultures, and personnel Making practice more evidence-based Making evidence more practice-based

9 Priority-Setting for Health Research* Basic Research Applied Research & Development Population Clinical Trials Clinical Investigations CDC & PRCs Surveillance Community & Statewide Effectiveness Trials PBRNs, CQI AHRQ CIHR, CHSRF PR & Program Evaluation Demonstration & Education Research NIH MRC Knowledge Acquisition Knowledge Validation Molecular Dissemination Implementation Knowledge Transfer Knowledge Translation *Adapted from Green LW, Popovich T, et al. Report of the CDC Futures Workgroup on The Development and Positioning of CDC s Research Agenda. Atlanta, CDC, 2004.

10 Issues for Evidence-Based Practice and Translating Research to Practice Setting research priorities Making research findings actionable, usable, relevant within settings (3 ways) Translating research from outside to local circumstances, cultures, personnel Making practice more evidence-based Making evidence more practice-based

11 1. A Business Marketing Approach 1. A Business Marketing Approach Wholesale Distribution Partners Retail Distribution Partners Service Providers Consumers Maibach EW, Van Duyn MAS, Bloodgood B. A marketing perspective on disseminating evidencebased approaches to disease prevention and health promotion. Prev Chronic Dis [serial online] 2006 Jul. Available from: URL:

12 2. Training Experimenting Practitioners Can t t turn the MPH degree into a PhD Can turn an MPH into a questioning practitioner: Skeptical about the external validity of most research and research syntheses Willing to adapt and engage Can turn curious, questioning, adapting practitioners into experimenting practitioners, esp with DrPH & PRC links

13 3. Some Benefits of Participatory 3. Some Benefits of Participatory Research in Practice-Based Evidence Results are relevant to interests, circumstances, and needs of those who would apply them Results are more immediately actionable in local situations for people and/or practitioners Generalizable findings more credible to people, practitioners and policy makers elsewhere because they were generated in partnership with people like themselves Helps to reframe issues from health behavior of individuals to encompass system and structural issues. Green LW, Mercer SL. Am J Public Health Dec

14 Definition and Standards of Definition and Standards of Participatory Research for Health* Systematic investigation Actively involving people in a co-learning process For the purpose of action conducive to health** --not just involving people more intensively as subjects of research or evaluation *Green, George, Daniel, et al., Participatory Research Ottawa: Royal Society of Canada,

15 Participatory Research in Participatory Research in its Various Incarnations -Action Research -Participatory Action Research (PAR) -Participative Research -Policy Policy-oriented oriented Action Research -Collaborative Inquiry -Participatory Rural Appraisal (PRA) -Dialectical Research -Conscientizing Research -Emancipatory Research -Social Reconnaissance -Participatory Learning Research Empowerment Evaluation Participatory Research

16 Layers of Collaboration in Participatory Research Basic & applied > Traditionally defined researchers Action research > PAR in practice > PAR on health needs of Practitioners, Service providers patients, families > PAR on other needs > Patients, Families, Public *Green et al., Participatory Research Ottawa: Royal Society of Canada,

17 The Lenses of Scientists, Health The Lenses of Scientists, Health Professionals and Lay People Subjective Indicators of Health Professional, Scientific Layperson Objective Indicators of Health

18 Closing the Gaps Between Population & Scientists Perception of Needs, and Policy Makers Assessments People s perceived needs, priorities A Actual needs Resources, feasibilities, policy *Green & Kreuter, Health Program Planning: An Educational and Ecological Approach, 4th ed., New York: McGraw-Hill, 2005.

19 Reconciling Perceived Needs, Reconciling Perceived Needs, Actual Needs, & Resources People s perceived needs, priorities Actual needs Health Education Action Participatory Research Resources, feasibilities, policy Community organization & capacity development

20 Issues for Evidence-Based Practice and Translating Research to Practice Setting research priorities Making research findings actionable, usable, relevant: participatory research Translating research to local circumstances: External validity & fidelity fidelity vs adaptation Making practice more evidence-based Making evidence more practice-based

21 Building Policy and Practice from Building Policy and Practice from Evidence + Theory Not starting with theory and looking for problems on which to test them, but starting with problems and looking for theories to help us solve them* Evidence generalizes to other circumstances, settings, & populations in the form of either replication or theory Replication is limited by the infinite number of context-population combinations "In theory, theory and practice are the same thing. In practice they're not.. -Jan L.A. van de Snepscheut All models are wrong. Some are useful --Box *Green LW. Public health asks of systems science Amer J Public Health 96, March See also: Gielen & Sleet, Epid Reviews 25, 2003; Gielen, Sleet & DiClemente (Eds.). Injury & Violence Prevention. San Francisco: Jossey-Bass, 2006.

22 Problems Perceived by Practitioners Problems Perceived by Practitioners in Translating Research from RCTs* An accessibility gap Do I have the same resources as the experimenters? A credibility gap How different is their situation of practice from mine? An expectation gap Is it really necessary and realistic for me to strive for such lofty goals in my practice? *Lancaster B. Closing the gap between research and practice. Health Educ Q. 1992; 19:

23 Fidelity Fidelity vs Adaptation Researchers test an intervention for its efficacy Rigorous test qualifies the study for official lists of evidence evidence-based practices and guidelines Practitioners try to incorporate it into their programs Poor fit produces failure of program Practitioners are blamed for not implementing with fidelity fidelity Now buy the producers training program

24 Issues for Evidence-Based Practice and Translating Research to Practice Setting research priorities Making research findings actionable, usable, relevant: participatory research Translating outside research to local circumstances Making practice more evidence-based Making evidence more practice-based

25 The Pipeline of Research to Practice Practice Research Priorities for Funding Peer Review of Grants Publication Priorities & Peer Review Academic Promotion & Tenure Review Research Synthesis Guidelines for Evidence - Based Practice Evidence -Based Medicine Movement Funding, Con - sumer Demand, Population Need, Local Practice Circumstances, Professional Discretion Credibility & Fit of the Evidence Green LW, Glasgow RE, Atkins D. Getting Evidence from Science to Practice: Slips Twixt Cup and Lip. Submitted.

26 The Reductionist, Internal Validity Drift of Health Sciences Evidence Evidence-based medicine movement taken to scale in public health The peer review preferences for experimental control and certainty of causation The publishing preferences for RCTs and positive results The limitations of print space driving out richer description of interventions, protocols, procedural lessons, subgroup variations But there is a more natural type of public health evidence that has greater influence on program planning, practice & policy

27 Change in Per Capita Cigarette Consumption Change in Per Capita Cigarette Consumption California & Massachusetts vs Other 48 States, Percent Reduction -25 Other 48 States California Massachusetts

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29 Efficacy vs. Effectiveness: Efficacy.. The tested impact of an intervention under highly controlled circumstances. Effectiveness.. The tested impact of an intervention under more normal circumstances (relatively less controlled, real-time, typical typical setting, population, and conditions). Broad Program Evaluation. The tested impact of a blended set of interventions on larger systems and populations. Natural Experiments with minimal control, maximum variability.

30 The Trade-offs Efficacy. Maximizes internal validity,, i.e., the degree to which one can conclude with confidence that the intervention caused the result. Effectiveness. Maximizes external validity,* i.e., the degree to which one can generalize from the test to other times, places, or populations. Program Evaluation. Maximizes reality testing in particular settings, & with the combination of interventions required for public health effect. * Green & Glasgow, Evaluation & the Health Professions, Mar

31 Issues for Evidence-Based Practice and Translating Research to Practice Setting research priorities Making research findings actionable, usable, relevant in Canada: Participatory Research Translating research to local circumstances in Atlantic provinces Making practice more evidence-based Making evidence more practice-based

32 Mediating and Moderating Variables Intervention or Program Mediator Outcome Variable(s) Mediator Moderators Moderators Green & Kreuter, Health Program Planning: An Educational and Ecological Approach. 4th ed. New York: McGraw-Hill, Green & Glasgow, E&HP, 2006.

33 The Bridge (not the Pipeline) from Research to Practice If we want more evidence-based practice, we need more practice-based evidence. The importance of practitioners and other end-users in shaping the research questions. Practitioners and their organizations represent the structural links (and barriers) to addressing the important health issues. Engage them. *Green, L.W. From research to best practices in other settings and populations. Am J Health Behavior 25: , April-May Full text:

34 Aligning Evidence with (and deriving it from) Practice: Matching, Mapping, Pooling and Patching Matching ecological levels of a system or community with evidence of efficacy for interventions at those levels Mapping theory to the causal chain to fill gaps in the evidence for effectiveness of interventions Pooling experience to blend interventions to fill gaps in evidence for the effectiveness of programs in similar situations Patching pooled interventions with indigenous wisdom and professional judgment about plausible interventions to fill gaps in the program for the specific population *Green & Kreuter, Health Program Planning: An Educational and Ecological Approach. 4th ed. NY: McGraw-Hill, 2005, Chapter 5. Green & Glasgow, 2006.

35 Uses of Evidence in Population- Based Planning-Research Models A. Evidence from surveillance and participatory research 1. Assess Needs & Capacities of Population B. Evidence from Etiologic Research + Theory 4. Evaluate Program Reconsider X in this context 2. Assess Causes (X) & Resources D. Program Evidence 3. Design & Implement Program C. Evidence from RCTs and Natural Experiments *Green & Kreuter, Health Program Planning: An Educational and Ecological Approach. 4th ed. NY: McGraw-Hill, 2005, Chapter 5. Green & Glasgow, 2006.