LAndersonAssessmentMtg0905

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Science-Technology

Published on January 12, 2009

Author: aSGuest10215

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Slide 1: Annual Conference on Assessment Initiative Seattle, WA September 22, 2005 Laurie M. Anderson, PhD, MPH Centers for Disease Control & Prevention Task Force on Community Preventive Services : Task Force on Community Preventive Services Independent Task Force Goal - to provide a comprehensive set of evidence-based recommendations on the effectiveness and feasibility of health promotion & disease prevention interventions in community settings Why Systematic Reviews for Evidence Synthesis in the Guide to Community Preventive Services? : Why Systematic Reviews for Evidence Synthesis in the Guide to Community Preventive Services? Explosive growth of scientific information too much to keep up with contradictory results The body of intervention literature can be quite large, inconsistent, and uneven in quality Systematic reviews for research synthesis : Systematic reviews for research synthesis Combine many studies with different methods and results Look for consistencies in set of findings More robust than single study May pinpoint why studies differ Shows what is effective and why Task Force Priority Topics : Task Force Priority Topics Steps in Conducting a Review : Steps in Conducting a Review Multidisciplinary team of experts Develop conceptual framework Prioritize intervention topics State precise purpose of the review Search for and retrieve evidence Rate quality of evidence Summarize evidence Translate into a recommendation Evidence Of …. : Evidence Of …. Program effectiveness Feasibility of implementation Acceptability to the population Unanticipated harms (or benefits) Cost-effectiveness Slide 8: Consumer Demand Household resources Nutrition knowledge Cultural practices Psychosocial characteristics Taste and preferences Advertising and marketing Logic Framework: Nutrition and Community Health Modifiable Determinants Food Supply Factors Agriculture policy Nutrition policy Science and technology Food production, processing, storage and distribution Food fortification Food safety Environmental Factors Food Availability & Price Neighborhoods Schools Worksites Homes Local, state & national food assistance programs POPULATION FOOD INTAKE Food Consumption Patterns (e.g. fruits, vegetables) Intake of Nutrients and Food Components: Vitamins Minerals Fiber Fats Other food constituents Dietary supplements Alcohol Energy balance Life Stage Requirements Pregnancy Lactation Childhood Adolescence Adulthood Older Adulthood Intermediate Outcomes Community Health Outcomes Physiologic Indicators: Growth Adipose tissue Musculoskeletal Gastrointestinal Metabolic Cardiovascular Reproductive Immunological Neurological Genetics, Co-morbidities Morbidity Mortality Measures of Health & Fitness Quality of Life Physical Activity Patterns I N T E R V E N T I O N S Slide 9: Priority Ranked Topics for Nutrition Food & beverage availability in schools. Comprehensive community approaches to increase fruit & vegetable intake. Food and beverage advertising to children. Food & beverage availability, price, portion size, and labeling in restaurants. Slide 10: Food choice and nutrition education in food assistance programs. Nutrition and weight management counseling in healthcare settings. Breast-feeding. Product labeling in grocery stores, restaurants and vending machines. Food & beverage availability and price in worksites. Use of dietary supplements across the lifespan. Slide 11: Question: Do multi-component, school-based interventions improve nutrition-related behaviors and nutritional status of children and adolescents. Nutrition Topic for Systematic Review Slide 12: Definition:  School-based nutrition interventions implemented in K-12th grades to promote healthy nutritional attitudes, knowledge and behavior, including eating and physical activity. The interventions are multi-component and may target food policy, environmental factors and/or nutrition education. Interventions may be directed at school administrators, food service staff, teachers or parents or delivered by special program instructors directly to students. Slide 13:  Environmental support for healthy choices Nutrition & health messages Promotion of self-awareness, self-efficacy Multi-component School-based Nutrition Interventions Physiologic Indicators Normal growth & development Fitness Health status School achievement School policy Behaviors Dietary intake Physical activity Knowledge Nutritional needsFood content Attitudes Self-care Body image Abilities Self-assessment Behavioral change skills Media literacy Study Outcomes Literature Search Results : Literature Search Results 1980–2003, publications, dissertations, government reports, US & non-US 1500 abstracts, ~150 papers, 76 studies Dual abstraction completed on 76 studies 13 studies did not meet inclusion criteria 14 studies excluded due to limitations in quality 6 studies excluded due to least suitable design 45 reports of 41 studies Slide 15: Intervention Combinations 4 studies reported policy change Study Characteristics : Study Characteristics Intervention Duration n Percent < 3 months 14 27% 4 to 9 months 10 22% 10 to 24 months 10 22% 25 to 36 months 9 21% 60 months 2 4% Not reported 2 4% Total 45 Follow-up Period for Outcome Evaluation : Follow-up Period for Outcome Evaluation n Percent Immediate 24 55% 1 month 7 16% 2-3 months 3 7% 6-12 months 6 13% 24 months 3 7% 48 months 1 2% Not reported 1 2% Total 45 Slide 18: Behavioral Outcomes Intake of fruit and vegetables Intake of fat Intake of saturated fat Slide 19:  Environmental support for healthy choices Nutrition & health messages Promotion of self-awareness, self-efficacy Multi-component School-based Nutrition Interventions Physiologic 17 Indicators body size & composition growth fitness Health status 13 blood pressure cholesterol general health School Achievement 0 attendance participation performance social behavior School Policy Behaviors dietary intake 39 physical activity 13 Knowledge 22 nutritional needs food content Attitudes 13 self-care body image Abilities 5 self-assessment behavioral change skills media literacy STUDIES REPORTING OUTCOMES Difference in Fruit & VegetableServings per day (I-C) 9 studies : Difference in Fruit & VegetableServings per day (I-C) 9 studies -1.5 1.0 .5 0 .5 1.0 1.5 Favors Control Favors Treatment Difference in % kcal from Fat (I-C) : Difference in % kcal from Fat (I-C) -4 -3 -2 -1 0 1 2 3 4 Favors Treatment Favors Control Difference in % kcal from Saturated Fat (I-C)6 studies : Difference in % kcal from Saturated Fat (I-C)6 studies -3 -2 -1 0 1 2 3 Favors Treatment Favors Control Difference in % kcal from Saturated Fat (I-C)RCTs : Difference in % kcal from Saturated Fat (I-C)RCTs -1.5 -1.0 -.5 0 .5 1.0 1.5 Favors Treatment Favors Control Meaningful Effects : Meaningful Effects Is there an effect? Is the effect real? Findings are based on self-report of dietary intake Reporting bias may account for some of the effect, possibly rendering small effects negligible Physiologic & Health Effects : Physiologic & Health Effects BMI (n=11) Boys -2.7% Girls -0.3% Overall 0% Skinfold thickness (n=8) Boys 4.3% Girls -5.4% Overall 0% Systolic B/P (n=10) Overall 0.3% Serum cholesterol (n=11) Overall -3% Median Effect Size % ? I - % ? C School Review Conclusions : School Review Conclusions Number of studies: Sufficient Magnitude of reported effect was small Fruit & vegetable servings per day: +0.24 Saturated fat as % kcal: –0.71 % point Consistent? Yes Biased? Likely Task Force Recommendation : Task Force Recommendation The Task Force found insufficient evidence to determine whether multicomponent school-based nutrition interventions are effective in increasing fruit and vegetable intake and decreasing fat and saturated fat intake among school-age children. Evidence was limited because bias due to self-report of dietary intake could not be ruled out. Guide to Community Preventive ServicesPhysical Activity Reviews : Guide to Community Preventive ServicesPhysical Activity Reviews Informational Approaches : Informational Approaches Community-wide campaigns Large-scale, high intensity, high visibility Use of TV, radio, newspaper, information sites Multi-component, multi-site ‘Combined Package’ Recommended Informational Approaches : Informational Approaches Single Component Mass Media Knowledge, attitudes, and beliefs, behavior Paid advertisements and donated promotion TV, radio, newspapers, billboards Insufficient evidence of effectiveness. Informational Approaches : Informational Approaches “Point-of-decision” prompts Motivational signs placed by elevators and escalators Encourage stair use for health/weight control Single component Recommended School-based Approaches : School-based Approaches Modified Physical Education Modified curricula and policies Studies designed to modify the amount of physical activity during PE Lifetime activities and games Recommended Insufficient Evidence : Insufficient Evidence Health education TV/video game turn off College health education Behavioral & Social Approaches : Behavioral & Social Approaches Individually Adapted Health Behavior Change Goal setting and self-monitoring Building social support Behavioral reinforcement Structured problem solving Relapse prevention Recommended Behavioral & Social Approaches : Behavioral & Social Approaches Social Support in Community Contexts Creating, strengthening, and maintaining social networks Use of ‘buddy’ systems Contracting Walking groups Recommended Family-based social support Insufficient Evidence Environmental & Policy Approaches : Environmental & Policy Approaches Creation or Enhanced Access to Places for Physical Activity Built environment - trails and/or facilities access Reducing barriers - safety, affordability Site-specific programs Recommended Environmental & Policy Approaches : Environmental & Policy Approaches Street-scale Urban Design and Land Use that Supports Physical Activity in Small Geographic Areas - generally limited to a few blocks Improved lighting Ease and safety of street crossing Sidewalk continuity Presence of traffic calming structures Making aesthetic enhancements Recommended Environmental & Policy Approaches : Environmental & Policy Approaches Transportation policies and practices that encourage and facilitate walking and bicycling for transportation Policy measures such as roadway design standards Expanding public transportation services Subsidizing public transportation Providing bicycle lanes and racks Increasing the cost of parking Insufficient evidence Task Force RecommendationStatement : Task Force RecommendationStatement Recommend For (Strong or Sufficient Evidence) Recommend Against (Strong or Sufficient Evidence) Insufficient Evidence Lack of Persuasive Evidence : Lack of Persuasive Evidence Interventions that either produce no effect or produce harm should not be used Lack of evidence does not mean that interventions don’t work Interventions for which evidence is insufficient should be more thoroughly researched Slide 41: Evidence-based Public Health Practice has Promise & Limits Fewer Systematic Reviews in Public Health than for Clinical Practice : Fewer Systematic Reviews in Public Health than for Clinical Practice US Community Guide 175 reviews Cochrane Health Promotion and Public Health Field identified 142 reviews 105 protocols Cochrane Library – 2170 reviews Evidence-Based Medicine and Evidence-Based Public Health : Evidence-Based Medicine and Evidence-Based Public Health Lesson Learned:Body of evidence uneven across topics : Lesson Learned:Body of evidence uneven across topics Over 175 Community Guide reviews - 50% resulted in “insufficient evidence” Why? some program effectiveness questions are easier to answer some outcomes are easier to evaluate new or emerging health issues sociopolitical processes shape the research agenda Lesson Learned:Even where evidence does exist : Lesson Learned:Even where evidence does exist Program effectiveness questions must be revisited periodically: - shifting environmental conditions - shifting population behaviors Evidence gaps inevitably exist for: - some variation in program design - some subpopulation Evidence-Based Practice: What Evidentiary Criteria ? : Evidence-Based Practice: What Evidentiary Criteria ? Seeking a Balance: Systematic reviews provide a powerful tool for decision- making Decisions often must be made with incomplete empirical evidence of program effectiveness Using All Available Knowledge : Using All Available Knowledge Recognize how scientific evidence contributes to the larger realm of knowledge for decision-making Using All Available Knowledge : Using All Available Knowledge Evidence-based Public Health Practicea Long-Term View : Evidence-based Public Health Practicea Long-Term View Evidence-based approach a continuous process a long-term investment never complete evaluating innovations Systematic reviews promise transparent and explicit process robust where evidence exists likelihood for intervention success accountability for research investment The Community Guide is one of severalefforts to improve public healthto synthesis of researchand translation knowledgeinto action : The Community Guide is one of severalefforts to improve public healthto synthesis of researchand translation knowledgeinto action www.TheCommunityGuide.org

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