Evidence-based public health policy and practice: promises and limits.
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Advisory Committees↗
Biomedical subjects
Ross C Brownson
Publications and source records attributed to Ross C Brownson.
Teaching evidence-based public health to public health practitioners.
PURPOSE: The purpose of the Evidence Based Public Health (EBPH) course is to train public health practitioners to utilize a comprehensive approach for program development and evaluation from a scientific perspective, including principles of scientific reasoning and systematic uses of data and information systems. The increasing technical sophistication of public health problems and approaches emphasizes the importance for an evidence-based approach to developing policy and interventions. METHODS: The training methods used highlight the linkages between data systems and program/policy initiatives. Participants learn to access and interpret existing data systems and methods of using data to impact specific policies or decision-makers. From 1992 through mid-2004 the EBPH course was offered a total of 20 times, in Missouri, nationally and internationally. In March 2002, the workshop was taped and pressed into a 16-CD set that public health workers can use as a self-teaching program in their own homes and offices. The group exercises from the classroom workshop have been adapted into individual self-guided applications, and background readings are included in the set. RESULTS: Compiled results of course evaluations indicate average ratings for course satisfaction ranging from 8.50 to 10.00 on a scale from 1 to 10. Satisfaction with course instructors ranged between 8.00 and 10.00 on the same scale. Ninety-four to ninety-six per cent of participants reported that they would use the course in their day-to-day work. Qualitative comments from participants at the time of and after the course show that the material is applied in a variety of ways. CONCLUSIONS: The EBPH course is making a valuable contribution in strengthening the application of scientific methods to public health practice. To expand the offerings of this training, a train-the-trainer component for the EBPH course is being developed, to be made available in 2005.
Curriculum↗
Intermediate term biochemical progression rates after radical prostatectomy and radiotherapy in patients with screen detected prostate cancer.
PURPOSE: We compared biochemical progression rates measured by increasing prostate specific antigen (PSA) levels using a standard definition of biochemical recurrence among patients with screen detected prostate cancer treated with radical prostatectomy (RP) or radiotherapy (RT). MATERIALS AND METHODS: A total of 1,939 patients diagnosed with clinically localized prostate cancer in a community based screening study from 1989 to 1998, followed through 2001, were treated with RP or RT and agreed to enroll in a followup study. This prospective cohort study (median followup 62 months, range 0.2 to 141) used adjusted Cox proportional hazards models to examine time to progression. Selection bias was addressed with propensity scores. Biochemical evidence of cancer progression was defined as PSA greater than 0.2 ng/ml in patients who underwent RP and 3 consecutive PSA increases as recommended by the American Society for Therapeutic Radiology and Oncology criteria for radiotherapy. RESULTS: Of the patients 17% had evidence of cancer progression. The percentage with progression-free survival at 5 and 9 years for RP was 84% and 76%, respectively, and for RT 80% and 70%, respectively. Cox proportional hazards models produced a hazard ratio of 1.63 (95% CI, 1.12, 2.38) for RT compared with RP, adjusting for clinical stage, Gleason grade, preoperative PSA, biopsy age, treatment year and propensity for treatment type. CONCLUSIONS: With intermediate term followup, patients treated with RT were more likely to have cancer progression than with RP adjusting for demographics, clinical factors, selection bias and treatment year.
Adult↗
A multilevel analysis of change in neighborhood walking activity in older adults.
The article reports on a multilevel analysis conducted to examine change in neighborhood walking activity over a 12-month period in a community-based sample of 28 neighborhoods of 303 older adults age 65 and over. The study employed a multilevel (residents nested within neighborhoods) and longitudinal (4 repeated measures over 1 year) design and a multilevel analysis of change and predictors of change in neighborhood walking activity. Results indicated a significant neighborhood effect, with neighborhood-level walking characterized by a downward trajectory over time. Inclusion of baseline variables using selected perceived neighborhood-level social- and physical-environment measures indicated that neighborhoods with safe walking environments and access to physical activity facilities had lower rates of decline in walking activity. The findings provide preliminary evidence of neighborhood-level change and predictors of change in walking activity in older adults. They also suggest the importance of analyzing change in physical activity in older adults from a multilevel or macrolevel framework.
Aged↗
Multilevel modelling of built environment characteristics related to neighbourhood walking activity in older adults.
OBJECTIVE: To examine the relation between built environment factors (representing several dimensions of urban form of neighbourhoods) and walking activity at both the neighbourhood level and the resident level, in an older adult sample. DESIGN, SETTING, PARTICIPANTS: A cross sectional, multilevel design with neighbourhoods as the primary sampling unit and senior residents as the secondary unit. Five hundred and seventy seven residents (mean age = 74 years, SD = 6.3 years) participated in the survey, which was conducted among 56 city defined neighbourhoods in Portland, Oregon, USA. Neighbourhood level variables were constructed using geographical information systems. Resident level variables consisted of a mix of self reports and geocoded data on the built environment. MAIN OUTCOME MEASURE: Self reported neighbourhood walking. MAIN RESULTS: A positive relation was found between built environment factors (density of places of employment, household density, green and open spaces for recreation, number of street intersections) and walking activity at the neighbourhood level. At the resident level, perceptions of safety for walking and number of nearby recreational facilities were positively related to high levels of walking activity. A significant interaction was observed between number of street intersections and perceptions of safety from traffic. CONCLUSIONS: Certain neighbourhood built environment characteristics related to urban form were positively associated with walking activity in the neighbourhoods of senior residents. Public health promotion of walking activity/urban mobility and the design of interventions need to consider the contribution of neighbourhood level built environment influences.
Aged↗
Declining rates of physical activity in the United States: what are the contributors?
This review describes current patterns and long-term trends (up to 50 years when possible) related to (a) physical activity, (b) employment and occupation, (c) travel behavior, (d) land use, and (e) related behaviors (e.g., television watching). On the basis of available data, the following trends were observed according to type of physical activity: relatively stable or slightly increasing levels of leisure-time physical activity, declining work-related activity, declining transportation activity, declining activity in the home, and increasing sedentary activity. These result in an overall trend of declining total physical activity. Large differences were noted in the rates of walking for transportation across metropolitan statistical areas. A strong linear increase existed in vehicle miles traveled per person over the past half century, coupled with a strong and consistent trend toward Americans living in suburbs. Although it is difficult to precisely quantify owing to the lack of long-term data, it is apparent that a combination of changes to the built environment and increases in the proportion of the population engaging in sedentary activities put the majority of the American population at high risk of physical inactivity.
Adolescent↗
Children's physical activity: using accelerometers to validate a parent proxy record.
INTRODUCTION: The purpose of this study was to validate a parent proxy record of children's physical activity with CSA Model 7164 accelerometers. METHODS: A parent proxy record was developed to record children's activity after school on weekdays and all day long on weekends for 7 d. Parents recorded both duration and intensity of activity (light, medium, hard and very hard). Children simultaneously wore a CSA-7164 accelerometer around their right hip, which served as the objective measurement against which the proxy record was validated. Sixty-five parent/child dyads participated in the study. RESULTS: The overall activity level of the children was low (<3 METs). Spearman-rho analyses indicated that the accelerometer and proxy record showed poor to fair agreement for the entire monitoring period, with parents consistently overreporting their child's activity levels. Correlation between the two instruments was highest at midday on weekends (0.383) and immediately after school on weekdays (0.267). CONCLUSION: Due to the low correlation between this proxy record and the accelerometer, the need still exists for a valid measurement of child physical activity that is both inexpensive and easy to employ in larger community-based interventions.
Child↗
Correlates of physical activity among pregnant women in the United States.
INTRODUCTION: Physical activity recommendations for pregnant and nonpregnant women have been issued, but little data exist to compare the extent that these women are meeting the recommendation levels. METHODS: A population-based, cross-sectional study using data from the 1994, 1996, 1998, and 2000 Behavioral Risk Factor Surveillance System evaluated the physical activity recommendations met by pregnant and nonpregnant women. The study population included women who were 18-44 yr of age. Random digit dialing, telephone surveys were used to assess all information. Pregnant and nonpregnant women were categorized into five mutually exclusive groups based upon their level of physical activity in the past month: vigorous activity (meeting guidelines) moderate activity (meeting guidelines), moderate or vigorous activity (not meeting guidelines), irregular activity, or no physical activity. RESULTS: Nonpregnant women were more likely than pregnant women to meet the vigorous or moderate physical activity recommendations. Walking was the most common activity among pregnant and nonpregnant women (52 and 45%, respectively). Pregnant women meeting the moderate or vigorous physical activity recommendations were more likely to be younger, nonhispanic white, more educated, not married, nonsmokers, and to have higher incomes. CONCLUSION: Many pregnant women do not appear to be meeting the physical activity recommendations. Healthcare providers should further encourage the promotion of physical activity during uncomplicated pregnancies.
Adolescent↗
Environmental correlates of physical activity among individuals with diabetes in the rural midwest.
OBJECTIVE: To determine the relationship between physical and social environment attributes and levels of physical activity in a population-based sample of diabetic individuals living in rural areas. RESEARCH DESIGN AND METHODS: Cross-sectional telephone survey data from rural communities of southeastern Missouri, Tennessee, and Arkansas were used. Logistic regression was used to calculate crude and adjusted prevalence odds ratios (PORs) and 95% CIs. RESULTS: A total of 278 (11%) individuals with diabetes were identified. Almost 37% of this group reported no leisure-time physical activity. Individuals with diabetes who reported regular physical activity were more likely to report better general health status, normal BMI, and no physical impairment. After adjustment, regular activity was positively associated with use of three or more facilities (POR 14.3, 95% CI 3.0-67.3) in the past 30 days, the availability of many nearby places to walk (2.3, 1.1-4.8), the availability of shoulders on streets (2.4, 1.3-4.5), often walking to nearby places (4.1, 2.0-8.3), and rating the community for physical activity as generally pleasant (2.3, 1.1-4.8). Additionally, the regular activity group was more likely to report their physician had helped make a plan to increase physical activity (2.8, 1.3-5.8) and followed up on their plan (2.2, 1.1-4.4). Social environment variables were not associated with physical activity after adjustment. CONCLUSIONS: Physical inactivity is a significant problem in rural diabetic populations. We have identified aspects of the social and physical environment that are positively associated with physical activity. Understanding the role of the environment may result in increased physical activity for individuals with diabetes.
Adult↗
A community-based approach to promoting walking in rural areas.
BACKGROUND: Ecologic models are often recommended to promote physical activity, yet sparse data exist on their effectiveness. DESIGN: A quasi-experimental design examined changes in walking behavior in six rural intervention communities in the Missouri "bootheel" region and in six comparison communities in Arkansas and Tennessee. SETTING/ PARTICIPANTS: The communities ranged in population from 2399 to 17,642; interventions focused on adults aged >/=18 years. INTERVENTION: Interventions were developed with community input and included individually tailored newsletters, interpersonal activities that stressed social support, and community-wide events such as walk-a-thons. MAIN OUTCOME MEASURES: Primary outcomes were rates of walking-trail use, total number of minutes walked in the past week, and total minutes walked for exercise. RESULTS: Among persons who used trails at baseline (16.9% of the total population), 32.1% reported increases in physical activity since they began using the trail. From community-wide samples, two subgroups indicated a positive net change in rates of 7-day total walking: people with high school degrees or less and people living in households with annual incomes of <==$20,000. However, no studied group showed a statistically significant net intervention effect. CONCLUSIONS: Although there was an increase in the rate of walking-trail use, a community-wide change in walking rates in rural communities was not documented. Results of this study should provide guidance for future projects.
Adolescent↗
Rationale for a consistent "powerhouse" approach to vegetable and fruit messages.
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Fruit↗
Perceptions of neighborhood environment for physical activity: is it "who you are" or "where you live"?
Lack of physical activity among American adults is a serious public health concern. Many factors influence activity levels, and most research has focused on either individual factors, such as race and income, or on characteristics of the physical environment, such as the availability of parks. Our study used a cross-sectional multilevel design to examine the influences of individual- and neighborhood-level characteristics on participant's perceptions of their neighborhood as an appropriate venue for physical activity. Study participants were 1,073 African American and white adults living in the St. Louis, Missouri, metropolitan area. Individual-level information was gathered from self-administered questionnaires; neighborhood-level data for these same individuals were obtained from the 2000 US Census. We found that both individual and neighborhood characteristics were significant predictors of how individuals perceived physical activity opportunities in their neighborhood, and that African Americans perceived their neighborhoods as less safe and less pleasant for physical activity than did whites, regardless of the racial composition of the neighborhood. We suggest that any evaluation of opportunities for physical activity within a neighborhood should include consideration of resident's perceptions of the safety and pleasantness of using them, and that the role of perceived and actual neighborhood conditions in explaining disparities in physical activity between African American and other populations should be examined further.
Adolescent↗
Developing and using the Guide to Community Preventive Services: lessons learned about evidence-based public health.
The Guide to Community Preventive Services (Community Guide) is being developed under the leadership of the independent, nonfederal Task Force on Community Preventive Services. The Task Force makes recommendations for the use of public health programs and policies based on scientific evidence about what practices have worked to improve health. The Community Guide thoroughly searches scientific literature for topic-relevant studies, evaluates their quality according to established criteria, and makes recommendations based on the overall strength of the body of evidence and the size and variability of reported effects. In addition, the Community Guide identifies promising interventions that have not been adequately researched, thus helping to inform the public health research agenda. The continuously updated and expanded body of recommendations and research agenda formulated by this rigorous process have been published on the Internet and in various publications since 1999 and constitute a highly valued and objective evidence-based resource for guiding current and future public health activities. More remains to be learned, however, on how best to disseminate Community Guide findings to key target audiences and encourage their use to inform practice, policy, and additional research.
Centers for Disease Control and Prevention, U.S.↗
Measuring the environment for friendliness toward physical activity: a comparison of the reliability of 3 questionnaires.
OBJECTIVES: We tested the reliability of 3 instruments that assessed social and physical environments. METHODS: We conducted a test-retest study among US adults (n = 289). We used telephone survey methods to measure suitableness of the perceived (vs objective) environment for recreational physical activity and nonmotorized transportation. RESULTS: Most questions in our surveys that attempted to measure specific characteristics of the built environment showed moderate to high reliability. Questions about the social environment showed lower reliability than those that assessed the physical environment. Certain blocks of questions appeared to be selectively more reliable for urban or rural respondents. CONCLUSIONS: Despite differences in content and in response formats, all 3 surveys showed evidence of reliability, and most items are now ready for use in research and in public health surveillance.
Adult↗
Improving dietary behavior in African Americans: the Parents As Teachers High 5, Low Fat Program.
BACKGROUND: The High 5, Low Fat Program (H5LF) for African American parents was developed in partnership with the Parents As Teachers program, and was designed to test a dietary intervention appropriate for national adoption. METHODS: H5LF used a group randomized, nested cohort design with 738 parents. Consistent with organizational goals and methods, parent educators delivered a dietary change program via personal visits, newsletters, and group meetings. Primary outcomes were reducing percentage calories from fat and increasing fruit and vegetable consumption among participating parents; intermediate aims included improving in nutrition-related skills and parental modeling of dietary behaviors. RESULTS: H5LF parents achieved a 0.53 increase in fruit and vegetable consumption (P = 0.03), and a higher proportion of H5LF parents reduced their intake to less than 30% calories from fat (chi(2) = 4.8, P < 0.03; -1.7% calories from fat, p = 0.07) and improved performance of dietary behaviors (F = 14.2, P = 0.004). Improvements in parental modeling were not statistically significant. CONCLUSIONS: H5LF is an effective intervention that is appropriate for national adoption by over 2000 Parents As Teachers sites with the potential to impact dietary intake of African American parents nationwide.
Adult↗
The role of repeat victimization in adolescent delinquent behaviors and recidivism.
PURPOSE: To report prevalence of adolescent victimization and delinquency recidivism as well as to assess the association between repeat victimization and delinquency recidivism in a large, population-based sample of high school seniors. METHODS: A nationally representative sample of the Monitoring the Future Project (about 17,000 high school seniors from 1996 to 1999) was analyzed as a pooled sample. The analysis was based on self-reported measures of ten different types of delinquent behaviors including violent and property offenses. Other measures included in the analysis are victimization and information about sociodemographic (e.g,. geographic region, parental education, number of parents in the home) and lifestyle (e.g., grade from average, truancy, work experience, religious commitment) characteristics. Pairwise and multivariate methods were used to examine the risk association between repeat victimization and delinquency recidivism. RESULTS: From 1996 to 1999, a downward trend was observed for most types of delinquent behaviors: recidivism among seniors except for hitting instructors/supervisors, damaging school property, and car theft. For the same study period, the prevalence of victimization recidivism was also on the decline except for injury with a weapon and physical threats. Repeat victimization was found to be significantly associated with delinquency recidivism. Other risk factors more frequently associated with delinquency recidivism included gender, race, drug use, poor school performance, truancy, risk-seeking, and conflicts with parents. CONCLUSIONS: The present study showed a significant association between repeat victimization and delinquent recidivism; it identified characteristics of adolescent at risk of repetitive delinquent behaviors, which could be used for planning intervention strategies.
Adolescent↗
Linking perceptions of the community to behavior: are protective social factors associated with physical activity?
Although the relationship of psychosocial factors to physical activity has been explored, there is increased interest in how perceptions of the community environment influence behavior. However, few methodological studies have incorporated perceptions of the social and community environment (protective social factors) or addressed key measurement issues. Computer-assisted telephone interviews were administered to a national sample of 1,818 U.S. adults. Unadjusted and multivariate-adjusted odds ratios were calculated to compare active and inactive participants by Protective Social Factors (PSF) scores and selected sociodemographics. Confirmatory factor analysis and reliability analysis suggested strong PSF scale psychometric properties (alpha = .92). After adjustment for potential confounders, a 10-point rise in the PSF score resulted in a 12% increased likelihood of meeting Centers for Disease Control and Prevention/American College of Sports Medicine recommendations. Additional analyses indicated that greater perceived PSFs were associated with meeting these recommendations among Whites but not among African Americans.
Adult↗
The epidemiology of walking for physical activity in the United States.
PURPOSE: The purpose of this paper was to describe the epidemiology of walking for physical activity among respondents to the U.S. Physical Activity Study. Correlates of walking among people who never walk for physical activity, those who walk regularly, and people who walk occasionally were compared. METHODS: Data on walking, personal and environmental correlates, and sociodemographics were collected via telephone using a modified random-digit-dialing technique on a national sample. Three categories were analyzed: Regular walkers were those who met public health recommendations by walking (5x wk-1 and 30 min at a time), occasional walkers were those who walked for physical activity but did not meet this recommendation, and never walkers were those who never walked for physical activity. Multiple logistic regression resulting in odds ratios (OR) and 95% confidence intervals were calculated. RESULTS: Thirty-four percent of this population were regular walkers, 45.6% occasional walkers, and 20.7% never walkers. Walkers reported using neighborhood streets, shopping malls, and parks for walking. Regular walkers had more self-confidence and more social support than occasional or never walkers. Occasional and never walkers reported time as a barrier more than regular walkers (OR 1.91 and 2.36). Never walkers were more likely (OR 3.25) to report feeling unhealthy and more likely (OR 4.43) to report lacking energy to exercise. CONCLUSION: Our results identify important information that can be used to help guide future interventions that promote walking as a form of physical activity. An ecological approach that combines individual (e.g., self-confidence), interpersonal (e.g., social support), and community aspects (e.g., improve streets for walking) may be the most beneficial.
Adolescent↗