Stakeholder Dialogue about Evidence-Based Practice

The Decision Making Process

A client’s or population’s characteristics, state, needs, values, and preferences should influence the decision-making process so that decision-making is shared and tailored to the client. Sometimes the treatment that a client wants is at odds with the practice best supported by research evidence.

If the decision-making process does not factor in these considerations, the chances of reaching a consensus are negatively impacted.

Decisions that put demands on communities or clients they do not have the resources for are not ideal.

Available resources, including practitioner training and expertise, must be taken into consideration.

Decisions about an optimal intervention need to take into account an individual's or community's resources. Relevant resources include practitioners who are trained to deliver an intervention and resources to pay for care.

Examples:

• Insurance status
• Grant funds
• Community/practice space for interventions
• Practitioner training and expertise

At the center of the model is decision making: the cognitive action that turns evidence into contextualized evidence-based practices. Decision making is placed in the center of the figure to emphasize that decision-making is at the center of evidence-based practice. Decision-making serves to integrate research evidence, client characteristics, and resource considerations to reach a decision about care options that are tailored to the target population and context.

Environmental and organizational factors create a cultural context that moderates the acceptability of an intervention, its feasibility, and the degree of adaptation needed for the intervention to fit the setting."

Context is important when making evidence-based decisions in all disciplines. Some disciplines—such as nursing, social work, and public health—place great emphasis on adapting evidence-based interventions to match the target context.

1. Westfall JM, Mold J, Fagnan L. Practice-based research—―blue highways‖ on the NIH roadmap. JAMA. 2007;297(4):403-406.
2. Krist AH, Woolf SH, Frazier CO, Johnson RE, Rothemich SF, Wilson DB, Devers KJ and Kerns JW. An Electronic Linkage System for Health Behavior Counseling: Effect on Delivery of the 5A's. Am J Prev Med 2008;35(5S):S350-S358.

The potential of practice -based research and practice-based research-networks (PBRNs) becomes clear, when one considers they can:

• Identify problems that arise in daily practice creating the gap between recommended care and actual care
• Demonstrate whether treatments with proven efficacy are truly effective and sustainable when provided in a real-world setting
• Maximize the number of clients benefiting from medical discovery by providing the ―laboratory‖ for testing system improvements in primary care

Practice-based research may be the best setting for:

• Studying the process of care and the way in which diseases and conditions are diagnosed, treated, and managed
• Measuring effectiveness
• Discovering new clinical questions
• Studying and addressing client readiness to change and adopt new treatments
• Encountering and managing client knowledge and preferences
• Exploring the interface between clients and their physicians to improve medical care

Examples

Background

Example - Background

In this example, researchers first concluded that a variety of factors was limiting the ability of clinicians to offer intensive counseling to clients with unhealthy behaviors, so they sought to institute a system that could increase referrals.

• Ability of clinicians to offer intensive counseling to clients with unhealthy behaviors is limited by a variety of factors
• Few clients (2%–5%) were referred to the community counseling resources
• System may be needed to increase referrals through an efficient collaborative partnership between community programs and clinicians

Methods

Example - Methods

Via an electronic linkage system, clients were offered nine months of free counseling for various issues and their reported experiences with the system were examined.

• An electronic linkage system was instituted to promote health behavior counseling and to automate client referrals to community counseling services
• Clients were offered nine months of free counseling for weight loss, smoking cessation, and problem drinking at a choice of venues
• Delivery of behavioral counseling and clients’ reported experiences with the linkage system were examined

Results

Example – Results

For five weeks, the linkage system was put into use and counseling and referrals occurred regardless of visit type. The results are summarized as follows.

For five weeks, the linkage system was put into use. Of the clients visiting the practices:

• 71% exhibited an unhealthy behavior
• Of the 71%, 10% were referred for intensive counseling from a community program—most often for weight loss

Counseling and referrals occurred regardless of visit type—wellness, acute, or chronic care. The linkage system was used more often for middle-aged adults and women and by more experienced clinicians.

Conclusions

Example - Conclusions

Intervention increased the rate at which clients were referred for intensive behavioral counseling.

Given the evidence that intensive counseling is more effective in promoting behavior change, implementing the linkage system was shown potentially to have substantial public health benefits.

Community-based research always asks a question—in this case, about how to best achieve evidence-based health promotion and provision of care in the communities where people live.

1. Office of Behavioral and Social Sciences Research, National Institutes of Health. "Translation." Last updated July 8, 2010. Retrieved from http://obssr.od.nih.gov/scientific_areas/translation/index.aspx
2. Ackerman RT & Marrero DG. Adapting the Diabetes Prevention Lifestyle Intervention for Delivery in the Community: The YMCA Model. The Diabetes Educator 2007;33:69-78.
3. Waldman, S & Terzic, A, Clinical and Translational Science: From Bench-Bedside to Global Village, CTS Journal, 3(5) 253—257.

T1 translation uses knowledge from the study of basic biological or behavioral sciences to inform the development and refinement of promising interventions.

T2 translation tests the effectiveness of interventions under conditions that are progressively more representative of the general population and usual practice settings.

The third translational phase (T3 or ―implementation‖) focuses on ensuring that effective interventions are routinely provided in day-to-day clinical care and public health practice. This requires studying and identifying ways to overcome motivational, capability and opportunity barriers.

T3 translation focuses on:

• Development of systematic reviews and practice guidelines
• Dissemination
• Health services research

Diabetes Prevention Program

Example - Diabetes Prevention Program (DPP)

The DPP was developed to reduce the development of diabetes in adults at risk of diabetes by adjusting their lifestyles. However, this intervention was designed for efficacy and not for sustainable delivery by community organizations.

The DPP:

• Was developed to achieve and maintain modest weight loss for overweight adults with impaired glucose tolerance
• Asked them to adopt a structured diet and physical activity in order to reduce the development of diabetes
• Was designed for efficacy and not for sustainable delivery by community organizations
• In order to become an effective real-world model, collaborated with community partners to balance the DPP design with elements that optimized effectiveness, minimized cost, and improved sustainability for capable community partners

Group-Organized YMCA Diabetes Prevention Program

Example - Group-Organized YMCA Diabetes Prevention Program (GO-YDPP)

The GO-YDPP model combined the lessons learned from the DPP intervention with modifications to enhance sustainability by the YMCA.

GO-YDPP kept the same goals and core beliefs, but required:

• Basic training of YMCA staff in diet, exercise, and behavior modification skills
• Emphasis on increasing participants’ self-esteem, empowerment, and social support.
• Flexible diet and physical activity interventions able to be tailored to be culturally sensitive and acceptable to community

Community-based research seeks to learn how to enhance access to and support the adoption of evidence-based strategies in clinical and community practice, and to institutionalize effective programs, products, and services to improve health.

Building on those precepts, community-based participatory research focuses on the process of collaboration during the research lifecycle

1. Israel BA, Schulz AJ, Parker EA and Becker AB. Review of Community-Based Research: Assessing Partnership Approaches to Improve Public Health. Annual Review of Public Health 2008;19:173-202.
2. Ying-Ying G, Bogart LM, Sipple-Asher BK, Uyeda K, Hawes-Dawson J, Olarita-Dhungana J, Ryan GW, and Schuster MA. Using community-based participatory research to identify potential interventions to overcome barriers to adolescents' healthy eating and physical activity. J Behav Med 2009;32:491-502.

Community-based participatory research, or CBPR, is built on a set of core principles:

• Recognizes community as a unit of identity
• Builds on strengths and resources within the community
• Facilitates collaborative, equitable partnership in all phases of the research
• Promotes co-learning and capacity building among all partners
• Integrates and achieves a balance between research and action for the mutual benefit of all partners
• Emphasizes local relevance of public health problems and ecological perspectives that recognize and attend to the multiple determinants of health and disease
• Involves systems development through a cyclical and an iterative process
• Disseminates findings and knowledge gained to all partners and involves all partners in the dissemination process
• Involves a long-term process and commitment

Engaging the Community

Abstract – Engaging the Community

A community-based participatory research approach was applied to explore barriers and facilitators of healthy eating and physical activity.

Focus groups were conducted with adolescents and parents, in addition to interviews with community members. The participants described ecological and psychosocial barriers, such as:

• Lack of accessible nutritious food
• Sedentary lifestyle
• Poor quality physical education
• Lack of nutrition knowledge

Research Findings

Abstract – Research Findings

Participants proposed interventions such as:

• Nutrition classes for families
• Addition of healthy school food options that appeal to students
• Non-competitive physical education activities
• Health education delivered by students

CBPR is a good way to learn about potential interventions that may be of interest and acceptable to community.

From the perspective of clinicians and researchers, which of the following may be potential barriers to involving clients in research?

―I would be interested in the clinic forming a partnership with you during this research project, but I have to know up front what kind of time commitment is involved. Is it months or years? How many hours per day? I already have a very overworked staff and I don’t want to burden them unnecessarily.

It might be helpful to get more buy-in from the staff if you can provide some kind of training support. Perhaps there are volunteers from the university willing to commit time to helping us out with our end of the research.Our budget is also limited here. Would we need more staff? What kind of equipment am I going to need to purchase? Also, will there be any financial incentives for the practice?

I’d like to set up a meeting with your staff and clearly spell out what the expectation would be of my clients and how they would benefit. I think the benefits are clear, but I just want us to be able to convey those messages to the clients uniformly.

―Hi, I’m Dr. Brenda Burkemper. I understand your clinic may have some patients that meet the needs of our latest research project. I work with University of Smithtown in the Medical Research department. Donna, one of your doctors, said that as lead clinician, you would be a great person to speak to about partnering on this project.

If you are interested, we’d like to spend some time here getting to know the lay of the land and speaking with some patients informally before taking samples and handing out surveys. I know your time is limited and valuable, but we’d also like to invite you and some of your staff to the university to see how we work. The university has a long history of extremely successful and influential programs intended to advance the scientific and medical communities, but we also need the type of insight that you can offer. We value the input of practitioners and communities, and make sure your voices are heard in our research process.

Also, we do have some budget to assist the clinic with purchasing new equipment for the research project which would then be yours to keep.