Who Develops Evidence-Based Recommendations?

Evidence-based recommendations may be developed by a range of groups, including the government, practitioner- oriented organizations, consumer-oriented organizations, organized healthcare systems, and even for-profit organiza- tions. Organizations developing evidence-based recommenda- tions, however, are expected to acknowledge their authorship and identify the individuals who participated in the process, as well as their potential conflicts of interest. In addition, regardless of the organization, the evidence-based recom- mendations should include a description of the process used to collect the data and make the recommendations.

For-profit organizations may make evidence-based recom- mendations. However, their obvious conflicts of interest often lead them to fund other groups to make recommendations. Thus, the funding source(s) supporting the development of evidence-based recommendations should also be acknowledged as part of the report.

One well-regarded model for the development of evidence- based recommendations is the task force model used by the United States Preventive Services Task Force of the Agency for Healthcare Research and Quality (AHRQ), as well as by the Task Force on Community Preventive Services of the Centers for Disease Control and Prevention (CDC).9, 10 The task force model aims to balance potential conflicts of interest and ensures a range of expertise by selecting a variety of experts, as well as community participants, based upon a public nomination process. Once the task force members are appointed, their recommendations are made by a vote of the task force and do not require approval by the government agency.

Thus, as a reader of evidence-based recommendations, it is important that you begin by looking at which group devel- oped the recommendations, whether they have disclosed their membership, including potential conflicts of interest, and the groups’ procedures for developing the recommendations.

Implementation: How Do We Get the Job Done? 35

they work. It also depends in part on our attitudes toward different types of interventions. In U.S. society, we prefer to rely on informational or educational strategies. These approaches preserve freedom of choice, which we value in public, as well as private, decisions. Use of mass media infor- mational strategies may be quite economical and efficient relative to the large number of individuals they reach though messages, but they often need to be tailored to different audi- ences. However, information is often ineffective in accom- plishing behavioral change—at least on its own.

Strategies based upon motivation, such as taxation and other incentives, may at times be more effective than information alone, though educational strategies are still critical to justify and reinforce motivational interventions. Motivational interventions should be carefully constructed and judiciously used, or they may result in what has been called victim blaming. For example, victim blaming in the case of cigarette smoking implies that we regard the conse- quences of smoking as the smokers’ own fault.

The use of obligation or legally required action can be quite effective if clear-cut behavior and relatively simple enforcement, such as restrictions on indoor public smoking, are used. These types of efforts may be regarded by some as a last resort, but others may see them as a key to effective use of other strategies. Obligation inevitably removes freedom of choice and if not effectively implemented with regard for individual rights, the strategy may undermine respect for the law. Enforcement may become invasive and expensive, thus obligation requires careful consideration before use as a strategy.

Understanding the advantages and disadvantages of each type of approach is key to deciphering many of the con- troversies we face in deciding how to implement programs to address public health problems; however, implementation is not the end of the evidence-based public health process.

EvAlUATIon: HoW Do WE EvAlUATE RESUlTS? Public health problems are rarely completely eliminated with one intervention—there are few magic bullets in this field. Therefore, it is important to evaluate whether an intervention or combination of interventions has been successful in reduc- ing the problem. It is also critical to measure how much of the problem has been eliminated by the intervention(s) and what is the nature of the problem that remains.

Traditionally, evaluation has asked before and after questions. For instance, studies of cigarette smoking between the mid-1960s, when cigarettes were first declared a cause of lung cancer, and the late 1990s demonstrated that there was nearly a 50% reduction in cigarette smoking in the United

occurrence of symptoms, but before irreversible disability. They aim to prevent irreversible consequences of the disease. In the cigarette smoking and lung cancer scenario, primary interventions aim to prevent cigarette smoking. Secondary interventions aim to reverse the course of disease by smoking cessation efforts or screening to detect early disease. Tertiary interventions diagnose and treat diseases caused by smoking in order to prevent permanent disability and death.

“Who” asks: At whom should we direct the interven- tion? Should it be directed at individuals one at a time as part of clinical care? Alternatively, should it be directed at groups of people, such as vulnerable populations, or should it be directed at everyone in a community or population?j

Finally, we need to ask: How should we implement interventions? There are three basic types of interventions when addressing the need for behavioral change. These interventions can be classified as information (education), motivation (incentives), and obligation (requirements).k

An information or education strategy aims to change behavior through individual encounters, group interactions, or the mass media. Motivation implies use of incentives for changing or maintaining behavior. It implies more than strong or enthusiastic encouragement—it implies tangible reward. Obligation relies on laws and regulations requir- ing specific behaviors. Table 2-4 illustrates how options for implementation for cigarette smoking might be organized using the “When-Who-How” approach. To better under- stand the “who” and “how” of the options for intervention when behavior change is needed, refer to Table 2-5, which outlines nine different options.

Deciding when, who, and how to intervene depends in large part upon the available options and the evidence that

j The CDC defines four levels of intervention: the individual, the relationship (for example, the family), the community, and society or the population as a whole. This framework has the advantage of separating immediate family interventions from community interventions. The group or at-risk group relationship used here may at times refer to the family unit or geographic communities. It may also refer to institutions or at-risk vulnerable groups within the community. The use of group or at-risk group relationship provides greater flexibility, allowing application to a wider range of situations. In addition, the three levels used here correlate with the measurements of relative risk, attributable risk percentage, and population attributable percentage, which are the fundamental epidemiological measurements applied to the magnitude of the impact of an intervention. k An additional option is innovation. Innovation implies a technical or engineering solution. The development of a safer cigarette might be an innovation. A distinct advantage of technical or engineering solutions is that they often require far less behavior change. Changing human behavior is frequently difficult. Nonetheless, it is an essential component of most, if not all, successful public health interventions. Certainly, that is the case with cigarette smoking.

CHAPTER 2 Evidence-Based Public Health36

maintenance. You can think of the “RE” factors as evaluating the potential of the intervention for those it is designed to include or reach as well as those it has the potential to reach in practice. It is important to recognize that interventions are often applied far beyond the groups for whom they have been designed or investigated. The “AIM” factors examine the acceptance of the intervention in clinical or public health practice in the short and long term. Table 2-6 defines the meaning of each of these components and illustrates how a new intervention for cigarette cessation might be evaluated using the RE-AIM framework.

Deciding the best combination of approaches to address a public health problem remains an important part of the judgment needed for the practice of public health. In general, multiple approaches are often needed to effectively address a complex problem like cigarette smoking. Population and high-risk group approaches, often used by public health professionals, and individual approaches, often used as part of health care, should be seen as complementary. Often using both types of interventions is more effective than either

States and that the rates of lung cancer were beginning to fall—at least among males. However, much of the problem still existed because the rates among adolescent males and females remained high and smoking among adults was preceded by smoking as adolescents nearly 90% of the time. Thus, an evaluation of the success of cigarette smoking interventions led to a new cycle of the process. It focused on how to address the issue of adolescent smoking and nicotine addiction among adults. Many of the interventions being used today grew out of this effort to cycle once again through the evidence-based public health process and look for a new understanding of the problem, its etiology, evidence-based recommendations, and options for implementation as illus- trated in Figure 2-3.

In recent years, this process of evaluation has been extended to attempt to address how well specific interven- tions work and are accepted in practice. A new framework, called the RE-AIM framework, is increasingly being used to evaluate these factors.12 RE-AIM is a mnemonic that stands for reach, effectiveness, adoption, implementation, and