Leslea Peirson

Building capacity for evidence informed decision making in public health: a case study of organizational change

BackgroundCore competencies for public health in Canada require proficiency in evidence informed decision making (EIDM). However, decision makers often lack access to information, many workers lack knowledge and skills to conduct systematic literature reviews, and public health settings typically lack infrastructure to support EIDM activities. This research was conducted to explore and describe critical factors and dynamics in the early implementation of one public health units strategic initiative to develop capacity to make EIDM standard practice.MethodsThis qualitative case study was conducted in one public health unit in Ontario, Canada between 2008 and 2010. In-depth information was gathered from two sets of semi-structured interviews and focus groups (n = 27) with 70 members of the health unit, and through a review of 137 documents. Thematic analysis was used to code the key informant and document data.ResultsThe critical factors and dynamics for building EIDM capacity at an organizational level included: clear vision and strong leadership, workforce and skills development, ability to access research (library services), fiscal investments, acquisition and development of technological resources, a knowledge management strategy, effective communication, a receptive organizational culture, and a focus on change management.ConclusionWith leadership, planning, commitment and substantial investments, a public health department has made significant progress, within the first two years of a 10-year initiative, towards achieving its goal of becoming an evidence informed decision making organization.

Exploring the function and effectiveness of knowledge brokers as facilitators of knowledge translation in health-related settings: a systematic review and thematic analysis

BackgroundKnowledge brokers (KBs) work collaboratively with key stakeholders to facilitate the transfer and exchange of information in a given context. Currently, there is a perceived lack of evidence about the effectiveness of knowledge brokering and the factors that influence its success as a knowledge translation (KT) mechanism. Thus, the goal of this review was to systematically gather evidence regarding the nature of knowledge brokering in health-related settings and determine if KBs effectively contributed to KT in these settings.MethodsA systematic review was conducted using a search strategy designed by a health research librarian. Eight electronic databases (MEDLINE, Embase, PsycINFO, CINAHL, ERIC, Scopus, SocINDEX, and Health Business Elite) and relevant grey literature sources were searched using English language restrictions. Two reviewers independently screened the abstracts, reviewed full-text articles, extracted data, and performed quality assessments. Analysis included a confirmatory thematic approach. To be included, studies must have occurred in a health-related setting, reported on an actual application of knowledge brokering, and be available in English.ResultsIn total, 7935 records were located. Following removal of duplicates, 6936 abstracts were screened and 240 full-text articles were reviewed. Ultimately, 29 articles, representing 22 unique studies, were included in the thematic analysis. Qualitative (n = 18), quantitative (n = 1), and mixed methods (n = 6) designs were represented in addition to grey literature sources (n = 4). Findings indicated that KBs performed a diverse range of tasks across multiple health-related settings; results supported the KB role as a ‘knowledge manager’, ‘linkage agent’, and ‘capacity builder’. Our systematic review explored outcome data from a subset of studies (n = 8) for evidence of changes in knowledge, skills, and policies or practices related to knowledge brokering. Two studies met standards for acceptable methodological rigour; thus, findings were inconclusive regarding KB effectiveness.ConclusionsAs knowledge managers, linkage agents, and capacity builders, KBs performed many and varied tasks to transfer and exchange information across health-related stakeholders, settings, and sectors. How effectively they fulfilled their role in facilitating KT processes is unclear; further rigourous research is required to answer this question and discern the potential impact of KBs on education, practice, and policy.

An Ecological Process Model of Systems Change

In June 2007 the American Journal of Community Psychology published a special issue focused on theories, methods and interventions for systems change which included calls from the editors and authors for theoretical advancement in this field. We propose a conceptual model of systems change that integrates familiar and fundamental community psychology principles (succession, interdependence, cycling of resources, adaptation) and accentuates a process orientation. To situate our framework we offer a definition of systems change and a brief review of the ecological perspective and principles. The Ecological Process Model of Systems Change is depicted, described and applied to a case example of policy driven systems level change in publicly funded social programs. We conclude by identifying salient implications for thinking and action which flow from the Model.

Prevention of overweight and obesity in children and youth: a systematic review and meta-analysis

BACKGROUND One-third of Canadian children are overweight or obese. This problem carries considerable concern for negative impacts on current and future health. Promoting healthy growth and development is critical. This review synthesized evidence on the effectiveness of behavioural interventions for preventing overweight and obesity in children and adolescents. METHODS We updated the search of a previous Cochrane review. Five databases were searched up to August 2013. Randomized trials of primary care-relevant behavioural (diet, exercise and lifestyle) interventions for preventing overweight and obesity in healthy normal- or mixed-weight children or youth aged 0-18 years were included if 12-week postbaseline data were provided for body mass index (BMI), BMI z-score, or prevalence of overweight or obesity. Any study reporting harms was included. Meta-analyses were performed if possible. Features of interventions showing significant benefits were examined. RESULTS Ninety studies were included, all with mixed-weight populations. Compared with controls, interventions showed a small but significant effect on BMI and BMI z-score (standardized mean difference -0.07, 95% confidence interval [CI] -0.10 to -0.03, I (2) = 74%), a reduction in BMI (mean difference -0.09 kg/m(2), 95% CI -0.16 to -0.03, I (2) = 76%) and a reduced prevalence of overweight and obesity (risk ratio [RR]; RRintervention - RRcontrol 0.94, 95% CI 0.89 to 0.99, I (2) = 0%; number needed to treat 51, 95% CI 29 to 289). Little evidence was available on harms. There was variability across efficacious interventions, although many of the interventions were short-term, involved school-aged children and were delivered in educational settings. INTERPRETATION Behavioural prevention interventions are associated with small improvements in weight outcomes in mixed-weight populations of children and adolescents. No intervention strategy consistently produced benefits. REGISTRATION PROSPERO no. CRD42012002754.

The Registry of Knowledge Translation Methods and Tools: a resource to support evidence-informed public health

ObjectivesThis paper examines the development of a globally accessible online Registry of Knowledge Translation Methods and Tools to support evidence-informed public health.MethodsA search strategy, screening and data extraction tools, and writing template were developed to find, assess, and summarize relevant methods and tools. An interactive website and searchable database were designed to house the registry. Formative evaluation was undertaken to inform refinements.ResultsOver 43,000 citations were screened; almost 700 were full-text reviewed, 140 of which were included. By November 2012, 133 summaries were available. Between January 1 and November 30, 2012 over 32,945 visitors from more than 190 countries accessed the registry. Results from 286 surveys and 19 interviews indicated the registry is valued and useful, but would benefit from a more intuitive indexing system and refinements to the summaries. User stories and promotional activities help expand the reach and uptake of knowledge translation methods and tools in public health contexts.ConclusionsThe National Collaborating Centre for Methods and Tools’ Registry of Methods and Tools is a unique and practical resource for public health decision makers worldwide.

Interventions for prevention and treatment of tobacco smoking in school-aged children and adolescents: A systematic review and meta-analysis

OBJECTIVES To determine the effectiveness of primary health care relevant interventions to prevent and treat tobacco smoking in school-aged children and adolescents. METHODS This systematic review considered studies included in a prior review. We adapted and updated the search to April 2015. Titles, abstracts and full-text articles were reviewed in duplicate; data extraction and quality assessments were performed by one reviewer and verified by another. Meta-analyses and pre-specified sub-group analyses were performed when possible. PROSPERO #CRD42015019051. RESULTS After screening 2118 records, we included nine randomized controlled trials. The mostly moderate quality evidence suggested targeted behavioral interventions can prevent smoking and assist with cessation. Meta-analysis showed intervention participants were 18% less likely to report having initiated smoking at the end of intervention relative to controls (Risk Ratio 0.82; 95% confidence interval 0.72, 0.94); the absolute effect is 1.92% for smoking initiation, Number Needed to Treat is 52 (95% confidence interval 33, 161). For cessation, meta-analysis showed intervention participants were 34% more likely to report having quit smoking at the end of intervention relative to controls (Risk Ratio 1.34; 95% confidence interval 1.05, 1.69); the absolute effect is 7.98% for cessation, Number Needed to Treat is 13 (95% confidence interval 6, 77). Treatment harms were not mentioned in the literature and no data were available to assess long-term effectiveness. CONCLUSION Primary care relevant behavioral interventions improve smoking outcomes for children and youth. The evidence on key components is limited by heterogeneity in methodology and intervention strategy. Future trials should target tailored prevention or treatment approaches, establish uniform definition and measurement of smoking, isolate optimal intervention components, and include long-term follow-up.

Screening for lung cancer: A systematic review and meta-analysis.

OBJECTIVES To examine evidence on benefits and harms of screening average to high-risk adults for lung cancer using chest radiology (CXR), sputum cytology (SC) and low-dose computed tomography (LDCT). METHODS This systematic review was conducted to provide up to date evidence for Canadian Task Force on Preventive Health Care (CTFPHC) lung cancer screening guidelines. Four databases were searched to March 31, 2015 along with utilizing a previous Cochrane review search. Randomized trials reporting benefits were included; any design was included for harms. Meta-analyses were performed if possible. PROSPERO #CRD42014009984. RESULTS Thirty-four studies were included. For lung cancer mortality there was no benefit of CXR screening, with or without SC. Pooled results from three small trials comparing LDCT to usual care found no significant benefits for lung cancer mortality. One large high quality trial showed statistically significant reductions of 20% in lung cancer mortality over a follow-up of 6.5years, for LDCT compared with CXR. LDCT screening was associated with: overdiagnosis of 10.99-25.83%; 11.18 deaths and 52.03 patients with major complications per 1000 undergoing invasive follow-up procedures; median estimate for false positives of 25.53% for baseline/once-only screening and 23.28% for multiple rounds; and 9.74 and 5.28 individuals per 1000 screened, with benign conditions underwent minor and major invasive follow-up procedures. CONCLUSION The evidence does not support CXR screening with or without sputum cytology for lung cancer. High quality evidence showed that in selected high-risk individuals, LDCT screening significantly reduced lung cancer mortality and all-cause mortality. However, for its implementation at a population level, the current evidence warrants the development of standardized practices for screening with LDCT and follow-up invasive testing to maximize accuracy and reduce potential associated harms.

Supporting collaborative use of the diabetes population risk tool (DPoRT) in health-related practice: a multiple case study research protocol

BackgroundHealth policy makers have stated that diabetes prevention is a priority; however, the type, intensity, and target of interventions or policy changes that will achieve the greatest impact remains uncertain. In response to this uncertainty, the Diabetes Population Risk Tool (DPoRT) was developed and validated to estimate future diabetes risk based on routinely collected population data. To facilitate use of DPoRT, we partnered with regional and provincial health-related decision makers in Ontario and Manitoba, Canada. Primary objectives include: i) evaluate the effectiveness of partnerships between the research team and DPoRT users; ii) explore strategies that facilitate uptake and overcome barriers to DPoRT use; and iii) implement and evaluate the knowledge translation approach.MethodsThis protocol reflects an integrated knowledge translation (IKT) approach and corresponds to the action phase of the Knowledge-to-Action (KtoA) framework. Our IKT approach includes: employing a knowledge brokering team to facilitate relationships with DPoRT users (objective 1); tailored training for DPoRT users; assessment of barriers and facilitators to DPoRT use; and customized dissemination strategies to present DPoRT outputs to decision maker audiences (objective 2). Finally, a utilization-focused evaluation will assess the effectiveness and impact of the proposed KtoA process for DPoRT application (objective 3). This research design utilizes a multiple case study approach. Units of analyses consist of two public health units, one provincial health organization, and one provincial knowledge dissemination team whereby we will connect with multiple regional health authorities. Evaluation will be based on analysis of both quantitative and qualitative data collected from passive (e.g., observer notes) and active (e.g., surveys and interviews) methods.DiscussionDPoRT offers an innovative way to make routinely collected population health data practical and meaningful for diabetes prevention planning and decision making. Importantly, we will evaluate the utility of the KtoA cycle for a novel purpose – the application of a tool. Additionally, we will evaluate this approach in multiple diverse settings, thus considering contextual factors. This research will offer insights into how knowledge translation strategies can support the use of population-based risk assessment tools to promote informed decision making in health-related settings.

Screening for Type 2 Diabetes in Adults: An Updated Systematic Review

Background: This review was conducted to determine the clinical benefit and potential harms of screening for type 2 diabetes mellitus (T2DM) in asymptomatic adults. Methods: The search strategy from the 2008 US Preventive Services Task Forces framework on type 2 diabetes screening was updated. MEDLINE ® and the Cochrane Database of Systematic Reviews were searched from 2007 to 2012 for systematic reviews, randomized controlled trials and modeling studies. Study quality was assessed using the GRADE System and a standardized review process. Results: Previous results showing benefit of screening among those with high blood pressure were confirmed. No new or old trials were found regarding the effect of screening for T2DM on mortality, cardiovascular mortality and diabetes related complication outcomes. An observational study demonstrated a modest benefit in mortality in an initial cohort invited for T2DM screening (1990-1992), (HR 0.79; 95% CI 0.63, 1.00), but was not replicated in the second cohort invited for screening (2000-2003). Modeling studies reported that population based screening in high-risk individuals (age and hypertension as risk factors) might increase quality adjusted life years and was cost-effective if screening began at age 45 and every three to five years thereafter. Two new randomized controlled trials noted that screening was associated with higher levels of short-term anxiety and worry, but had limited overall psychological impact. Interpretation: This review found no controlled studies of the effectiveness of screening for T2DM, and one observational study demonstrating a modest benefit on mortality. Evidence for the harms associated with screening showed minimal clinical significance. Differences between current and previous evidence can be attributed to the current methodology that integrates the GRADE approach. Recommendations for screening reflect the best available evidence and include screening individuals at high risk for T2DM every 3-5 years with an A1C test, and individuals at very high risk annually with an A1C test.

Navigating knowledge to action: a conceptual map for facilitating translation of population health risk planning tools into practice.

A population health risk tool was created that estimates future diabetes risk and provides outputs that can inform practical and meaningful diabetes prevention strategies and support local decision making and planning. A project was designed to inform and understand knowledge translation and application of this novel tool in multiple health‐related settings. Lacking published studies in this area, the authors conceived a conceptual map to guide the project that integrates and adapts elements from several planned action theories. This paper describes the rationale and basis for constructing the Population Health Planning Knowledge‐to‐Action Model and elaborates on the 2 connected structures of the framework: the Tool Creation Path and the Action Cycle. Although created for an express purpose, this model has the potential to inform application of other tools. This work demonstrates how a research team can adapt and integrate existing frameworks to better align with novel real‐world knowledge translation issues. Furthermore, the integration of a population risk tool to support health decision making highlights the interaction between continuing education and knowledge translation.