PSEP Meeting – October 16th, 2012
The Brownson Model: Evidence-based Public Health from Concept to Application in MCH
Barbara Gabella, MSPH – Epidemiology, Planning, and Evaluation
Mandy Bakulski, RD – Maternal Wellness Unit Manager
OBJECTIVES Concept: the Brownson Model of EBPH
Describe each step
Application: addressing pregnancy-related depression Handouts:
Concise statement Logic model Excerpt of Action Plan
WHAT AND WHY?EVIDENCE-BASED PUBLIC HEALTH (EBPH)
EBPH: A systematic method to identify, prioritize, implement, and evaluate public health strategies
Applies scientific method to practice
An approach, not a bar
Why use an EBPH approach? Informed decision making accountable to funders
Higher likelihood of successful implementation
Greater impact on the population
Reduction in costs or leverage funding
CONTEXT
A pilot “portfolio” project for the MCH priority:
pregnancy-related depression
BROWNSON MODELBrownson, RC; Fielding JE; Maylahn CM. Ann. Rev. Public Health 2009.30:189
Logic Model
Timeline
May-Sep 2011:Steps 1-3
Aug-Sep 2011:Lit review
Oct-Nov 2011:Logic model
Nov 2011:Prioritization
Nov-Dec 2011:Action plan
TIMELINEMay 9, 2011 Overview training on each step of the 7-step model
May – Dec Meeting twice a month w/ Maternal Wellness Team• Work together through each step, assign homework
May-Sep Step 1 Community assessmentStep 2 Quantifying issues Step 3 Concise statement
August - Sept Step 4 Literature review (training 8/9/2011)
October-Nov Logic Model development (trainings 9/28 & 9/29/11)
November Step 5 Prioritization (SurveyMonkey end of Nov)
Nov - Dec Step 6 Action planning: work plan w/ SMART objectives (trainings 11/21 & 11/29/11)
January 31, 2012
Goal: State MCH logic models & action plans for each priority
Pregnancy-related depression
PREGNANCY-RELATED DEPRESSION
Colorado MCH Priority State Performance Measure
Improve screening, referral, and support for pregnancy- related depression.
Percent of mothers reporting that a doctor, nurse, or other health care worker talked with them about what to do if they felt depressed during pregnancy or after delivery.
2010 PRAMS = 75.1%
PRAMS: Pregnancy Risk Assessment Monitoring System
STEP 1: COMMUNITY ASSESSMENT
Define the health issue according to the needs and assets of the population or community of interest
• Population characteristics, needs, values, and preferences
• Resources, including practitioner expertise
• Environmental and organizational context
STEP 1: COMMUNITY ASSESSMENT
Defined pregnancy-related depression: During pregnancy or postpartum, including after a
pregnancy loss
Persists beyond early postpartum up to one year after birth
Pregnancy-related depression
STEP 1: COMMUNITY ASSESSMENT (CONT.)
Recorded Structured Input at Key Stakeholder Meetings
MCH Roundtables (Sept 2010) Capacity Issues; Local vs. State Role
Maternal Wellness Summit (Aug 2011) Target Audience; Assets; Threats;
Opportunities; Gaps; additional Concerns
Pregnancy-related depression
STEP 2: QUANTIFY THE ISSUE
Measure behaviors, risk factors and disease frequency in a defined population and time frame
STEP 2: QUANTIFY THE ISSUE
In Colorado, 11% of women experience postpartum depressive symptoms.
15% among women who did not indicate that they were married
21% among African-American women
Pregnancy-related depression
(Colorado Department of Public Health And Environment, Health Statistics Section, Pregnancy Risk Assessment Monitoring System, 2009-2010)
STEP 3: DEVELOP A CONCISE STATEMENT
OF THE ISSUE
Purpose: To build support for the issue and focus the literature review
Includes: Health condition or risk factor considered
Population affected
Size and scope of the problem
Prevention opportunities
Potential stakeholders
Often describes gap between the current status of a program and the desired goal.
STEP 3: CONCISE ISSUESTATEMENT
Public Health Issue
Programmatic Issue
Program & Policy Options
Pregnancy-related depression
STEP 4 WHAT WE KNOW (LIT REVIEW)
Determine what strategies work to address the issue(s) identified in Steps 1-3
Objective, systematic search and summarization of previous research
Classify or rate the level of evidence
WHAT IS “EVIDENCE?”Scientific literature in systematic reviews
Scientific literature in one or more journal articles
Public health surveillance data
Program evaluations
Qualitative data
Community members
Other stakeholders
Media/marketing data
Word of mouth
Personal experience
Objective
Subjective
Figure 2 in Brownson RC, et al. Evidence-Based Public Health. Annu. Rev. Public Health 2009: 30
STEP 4: LEVELS OF EVIDENCE
Click icon to add picture
Level Established byEvidence-based or proven
Peer review via systematic or narrative review Community Guide, Cochrane Review, Campbell
Effective or likely effective
Peer review Scientific research in individual journal articles
Promising Written program evaluation without formal peer reviewGrounded in a theory of change
Emerging Ongoing work, practice-based summaries or evaluation works in progress
Brownson, RC; Fielding JE; Maylahn CM. Ann. Rev. Public Health 2009.30:180
STEP 4 – LIT REVIEW
What is and is not effective in increasing early identification of pregnancy-related depression?
Focus of the literature search:
Policy
Systems-building
Population-based services aimed at prevention or early identification
Pregnancy-related depression
STEP 4 – RATING THE LITERATUREPregnancy-related depression
STEP 5: PRIORITIZATION
Select:
1. Team – include partners, stakeholders
2. Criteria
3. Tools
Assemble & share information from Steps 1-4
STEP 5: PRIORITIZATION
Advisory group of internal and external experts and stakeholders prioritized 5 potential strategies:
Improve insurance coverage Enhance referral network Develop statewide training to support
providers Raise public awareness Explore self-administered options
Pregnancy-related depression
STEP 5: PRIORITIZATION
Rated 6 criteria from “little” to “great” for each strategy:
Promise (likelihood to lower rates)
Capacity to implement
Lasting impact
Political feasibility
Return on investment
Appropriateness for state public health
Pregnancy-related depression
STEPS 6 & 7: ACTION PLAN, EVALUATION
Logic Model Step 6: Action Plan Step 7: Evaluation Plan
Purpose Describes relationships between investments
[inputs], strategies, and results [outcomes]
If / then relationships
Detailed activities to accomplish SMART
objectives or how to operationalize
strategies & achieve outcomes
To answer specific questions to improve programs or inform
future programming:-Process
-Outcome
Duration 7-10 years 3 years Variable
Length Brief (~1 pg) Moderate (~5pgs) Long (~10pgs)
Who Reads Many Some Less
MCH / MIT Template
Yes Yes Stay tuned…
LOGIC MODELS
Whirlwind tour
Overarching Goal ~ other programs can contribute to reaching it
Impact = long-term accomplishments
Short term Outcomes = What will be different in 1-3 years?• Informs the SMART objectives in your 3-year action plan
Medium-term Outcomes = What will be different in 4-6 years? Most likely include performance measures
Outputs = Strategies & Participants (in the change that influences the outcomes)
Inputs = staff & skills, funding, previous work? Be specific.
LOGIC MODEL TO CRAFT ACTION PLAN
Logic Model Action PlanGoal, Mid- & Long-term Outcomes
Program goals
Short-term Outcomes Objectives (SMART)Output: Strategies Strategies broken down into
Milestones (or “Key Activities”)
Output: Participation Target Population--- Team member responsible--- TimelineInputs ---Evaluation Focus ‘Criteria for Success’ & ‘As
Measured By’
DETAILED EXAMPLES
Logic Model Handout
Action Plan Handout
“PORTFOLIO” OF LIVING DOCUMENTS
To sustain capacity ~ tools, templates, and resulting documents:
1. Community assessment report
2. Summary data figures and tables & data analysis plan
3. Concise issue statement
4. Evidence ratings of strategies & relevant articles
5. List of prioritized interventions or policies
6. Logic model, work plan with SMART objectives
7. Evaluation plan
What are some of the challenges and barriers
to using an EBPH approach?
BARRIERS AND CHALLENGES
Additional work on top of our existing commitments
Some of this work was very new
Not a lot of peer-reviewed research
Timeline for pulling together action plan was tight
Some items in action plan depended on other partners – have to be willing to adjust if their priorities change
What are your session takeaways?
What are your next steps in applying EBPH?
RESOURCESCourse, articles, and textbook by Ross C. Brownson, PhD et al. at Washington
University in St. Louis http://prcstl.wustl.edu/EBPH/Pages/Evidence-BasedPublicHealthCourse.aspx
Colorado School of Public Health, Center for Health Practice http://publichealthpractice.org/
Mobilizing for Action through Planning and Partnerships http://www.naccho.org/topics/infrastructure/mapp/
Brownson RC, Gurney JG, Land GH. Evidence-based decision making in public health. J Public Health Manag Pract 1999;5:86 –97Brownson RC, Fielding JF, Maylahn CM. Evidence-Based Public Health. Annu. Rev. Public Health 2009; 30: 175-201.Jacobs JA, Jones E, Gabella BA, Spring B, Brownson RC. Tools for Implementing an Evidence-Based Approach in Public Health Practice. Prev Chronic Dis 2012;9:110324. DOI: http://dx.doi.org/10.5888/pcd9.110324
ACKNOWLEDGEMENTS
Team from MCH: Linda Archer, MSN, RNMandy Bakulski, RD
Julie Davis, RNRebecca Heck, MPHFlora Martinez, MPH
Technical team developed tools & trainings: Renee Calanan, PhD ~ chronic disease epidemiologistBarbara Gabella, MSPH ~ supervising epidemiologist
Julie Graves, PhD (ABD) ~ evaluatorIndira Gujral, PhD ~ senior epidemiologist
Ashley Juhl, MSPH ~ epidemiologistKristin McDermott, MA ~ supervising evaluator
Kerry Thomson, MPH ~ senior evaluator
Dr. Ross Brownson and the Prevention Research Center in St. Louis