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Linking Science and Practice: Toward a System for Enabling Communities to Adopt Best Practices for Chronic Disease Prevention
Roy Cameron, Mari Alice Jolin, Rosemary Walker, Nicky McDermott and Myrna Gough Health Promot Pract 2001 2: 35 DOI: 10.1177/152483990100200109 The online version of this article can be found at: http://hpp.sagepub.com/content/2/1/35

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In this article, the development of a system for collecting and assessing best community-based health promotion practices for dissemination is described. The key system components are (a) a protocol for identifying meritorious practices, (b) criteria for assessing those practices, and (c) an assessment procedure. A key informant process was used to identify interventions, and interviews were conducted to acquire detailed information on them. Categories of criteria pertaining to (a) effectiveness, (b) plausibility, and (c) practicality were developed for assessing practices. Application of the criteria led to selected practices being designated as best, promising, or to be tracked.

Linking Science and Practice: Toward a System for Enabling Communities to Adopt Best Practices for Chronic Disease Prevention
Roy Cameron, PhD Mari Alice Jolin, BA Rosemary Walker, MSc Nicky McDermott, MSc Myrna Gough, BA, RN

here has recently been an increasing number of calls for evidence-based programming in the health promotion literature (Glanz, 1996; Holman, 1996; King, Hawe, & Wise, 1996; Nutbeam, 1996; Oldenburg, Hardcastle, & French, 1996; Speller, Learmonth, & Harrison, 1997; Ziglio, 1997). There is growing recognition that linkages need to be made so that health promotion researchers and practitioners are able to work effectively together to reduce the burden of chronic diseases. The acknowledged gap between science and practice is attributed to a number of barriers, including (a) problems in program development (e.g., research projects of little practical relevance and emphasis on innovative programs at the expense of effectiveness trials; King et al., 1996; Nutbeam, 1996), (b) a lack of consensus on methods for
Authors Note: This project was supported by the Ontario Ministry of Health and Long-Term Care. The authors gratefully acknowledge the contributions of Suzanne Carrell, Charles Clayton, Josie DAvernas, Ena deJong, Nancy Dubois, Geoff Dunkley, Irving Rootman, and Janette Smith.
Health Promotion Practice / January 2001 / Vol. 2, No. 1, 35-42 2001 Sage Publications, Inc.

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measuring the effectiveness of health promotion programs (Speller et al., 1997; Ziglio, 1997), and (c) failures of dissemination (e.g., premature dissemination of programs of unknown effectiveness and lack of knowledge of dissemination strategies; King et al., 1996; Oldenburg et al., 1996). It has been proposed that many of these barriers could be overcome through the introduction of a connecting system to facilitate knowledge transfer between researchers and practitioners (Holman, 1996; Orlandi, Landers, Weston, & Haley, 1990). Such a connecting system would collect input from many research organizations (both academic and public health), synthesize findings, and communicate usable information to practitioners. For example, community practitioners need to make decisions about which programs to adopt or develop. Their decision-making processes would be enhanced if they had available a menu of activities that represented the most promising approaches developed around the world. The current project was designed to create and test a first generation prototype system of this type in the province of Ontario. The need for the system was triggered by growing interest in community-based approaches to chronic disease prevention (Green & Krueter, 2000). This interest stems from the knowledge that the majority of North American adults have at least one modifiable risk factor for chronic disease (e.g., Health Canada, 1995; Heart and Stroke Foundation of Canada, 2000), and traditional methods for defining risk may underestimate the extent to which these risk factors contribute to the burden of illness and premature death (Rose, 1992). Although there is substantial investment in community-based interventions, there is currently no mechanism in place to ensure that effective interventions are widely disseminated. This dissemination is critical to ensure the efficiency as well as the effectiveness of public health practice. In the absence of systematic dissemination, there is a tendency to reinvent the wheel, using scarce resources for development rather than adaptation and implementation. What is required is a system analogous to the system that is used for supporting evidence-based practice in preventive clinical medicine, which involves a partnership between the Canadian Task Force on the Periodic Health Examination and the U.S. Preventive Services Task Force. These groups review evidence pertaining to the efficacy and effectiveness of specific clinical maneuvers. Evidence is distilled and published, and recommendations for practice are disseminated (Canadian

Task Force on the Periodic Health Examination, 1994; U.S. Preventive Services Task Force, 1996). A system to support community, as opposed to clinical, intervention requires a different approach to identifying promising approaches and evaluating evidence (Tones, 1997). Health promotion programs are multifaceted and complex, and they take a population-based approach rather than targeting individuals. Such a system appears to be emerging in the form of the Guide to Community Preventive Services (Truman et al., 2000); this has the potential to be a landmark development in public health practice. When this project was undertaken, it was urgent that a system (to guide growing provincial investment) be developed for evaluating and disseminating information about community-based chronic disease prevention practices. The Ontario Ministry of Health and Long-Term Care funds and supports the Ontario Health Promotion Resource Centre to provide technical assistance for health promotion and chronic disease prevention activities across the province. A component of this system is the Heart Health Resource Centre (HHRC), whose mandate is to support the Ontario Heart Health Programs 37 community-based projects. The HHRC led the development of the system described here to help them identify best practices (Tones, 1997). A variety of approaches to best practice in health promotion are described in the literature. Kahan, Goodstadt, and Rajkumar (1999) suggested six directions a best practice approach might take: a principles approach, a guidelines approach, a service standard approach, an outcomes approach, a tell me what to do approach, and a what works approach. Nutbeam (1996) made the point that best practice involves systematically applying lessons learned in research to practice. He suggested that decision making take into account both the best available evidence concerning effectiveness and its application in real-life circumstances. Speller et al. (1997) emphasized the development of quality assurance standards. The project described below was initiated at a grassroots level to support best practices in heart health in Ontario. Given mounting government investment and the absence of a formal (national or international) system to support best practices, we set out to create a system that would meet the need as well as possible. The system was developed with the full knowledge that it would be imperfect but with the hope that it would become a prototype that would help stimulate creative and critical thinking.

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The approach used in this study is related most closely to that of Nutbeam (1996) and to the what works approach described by Kahan et al. (1999). We were searching for best practices in the domain of intervention programs, policies, and protocols that had been implemented as part of population-based community health promotion programs. We limited the search during this pilot phase to practices that addressed multiple risk factors (i.e., at least two of physical activity, nutrition, and tobacco use reduction). Single risk factor practices addressing nutrition or physical activity were considered only if the practice was contextualized within heart health or was part of a package of interventions that address heart health (practices addressing tobacco use reduction as a single risk factor were not sought because this is within the mandate of other organizations in Ontario). The evaluation of a practice was considered not to be part of the practice but rather to be a tool whose results would inform the assessment process. This article provides a brief overview of the prototype system developed for identifying, assessing, and disseminating community-based heart health programs. The emphasis in the project was on the development of the system, and this (not the specific programs identified) is the focus of the current article. THE SYSTEM The system involves three key components: (a) a protocol for identifying practices worthy of consideration, (b) a set of criteria for assessing practices, and (c) a procedure for assessing practices against criteria. Protocol for Identifying Practices A two-stage key informant process was used to identify interventions for consideration. First, members of a small group of widely known key international experts were asked to identify practices they considered to be outstanding. In the second stage, program contacts were invited to share the details of a selection of the nominated practices. The first stage involved contacting 41 opinion leaders in Canada, the United States, Australia, and Europe and asking them to nominate (a) practices they believe to be so valuable that all potential adopters should be aware of them, and (b) other individuals we should contact about programs they perceive to be outstanding. The experts were provided a set of guidelines for the nomination of best practices that encouraged them to

consider a range of (a) practice types (i.e., programs, processes, or organizational structures), (b) approaches (i.e., education, environmental support, or policy), (c) channels (e.g., schools, homes, health care settings, etc.), and (d) indications of effectiveness (e.g., evidence through rigorous evaluation to meritorious design that shows great promise). Twenty-eight heart health experts (a 68% response rate) nominated 61 distinct practices. In the second stage, telephone interviews were conducted with individuals familiar with the practical details of the practices selected for follow-up (due to the limited scope of the project and the priority of the primary funder, only those programs that addressed more than one cardiovascular disease risk factor concurrently were included). Telephone interviews were requested for 37 practices, and 36 interviews were conducted (a 98% response rate). The interview questions focused on purpose and rationale, target groups, settings, content of programs/main activities, program supports (partnerships and resource needs), and evaluation. Supporting materials and documentation were also obtained. The interviews with the program contacts and the provision of additional materials were designed to ensure that adequate information could be disseminated to practitioners to enable them to replicate the practices. The Criteria Previous criteria used to evaluate public health and clinical practice were reviewed (Abt Associates of Canada, 1996; Canadian Task Force on the Periodic Health Examination, 1994; Finnegan, Murray, Kurth, & McCarthy, 1989; Health Canada, 1996; Lefebvre, Lasater, Carleton, & Peterson, 1987; RBJ Health Management Associates, 1995). A small provincial advisory committee of key stakeholders in heart health helped develop three categories of criteria pertaining to (a) effectiveness, (b) plausibility, and (c) practicality. Effectiveness criteria (Figure 1) pertain to scientific evidence of efficacy or effectiveness. Both outcome and impact data are reflected in the list of effectiveness criteria. Although randomized controlled trials are the gold standard for clinical interventions, they are less appropriate and/or practical for evaluating health promotion interventions (Glanz, 1996; Macdonald, Veen, & Tones, 1996; Speller et al., 1997; Tones, 1997; Ziglio, 1997). In recognition of this, practices evaluated using well-designed quasi-experimental trials (no randomization) and other qualitative and quantitative method-

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FIGURE 1 Effectiveness Criteria

ologies were included for consideration as best practices. Plausibility criteria (Figure 2) were applied to practices for which there was either no evaluation or minimal evaluation. Plausibility criteria are designed to assess the extent to which an intervention incorporates (a) formative evaluation, pilot testing, and process evaluation (to debug and ensure implementability); (b) clear behavioral objectives and the use of appropriate behavioral principles (to ensure that it is conceptually sound and takes advantage of scientifically established principles for inducing change); and (c) sensitivity to issues of concern to adopters (to ensure that broader community concerns are addressed; see process attributes, Figure 2). A practice rated as plausible is one for which there is reason to expect that if an evaluation is completed, it will yield positive results. Practicality criteria (Figure 3) were designed to assess the extent to which the intervention was afford-

able, available, and compatible with provincial practices and policies. Protocol for Assessing Practices Against Criteria Three individuals (the principal investigators and the coordinator of the Ontario HHRC) applied the assessment criteria. Each one independently assessed the practices. Ratings in major areas (i.e., effectiveness, plausibility, and practicality) were compared, and there was good interrater agreement (not formally assessed). When there were discrepancies among raters, consensus was achieved through discussion. A decision flowchart (Figure 4) was used to sort practices into three categories: (a) best practices, (b) promising practices, and (c) practices to be tracked. Five programs were identified as best practices. All demonstrated statistically significant results for at least some program goals. These programs have been disseminated to community practitioners in Ontario by the

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FIGURE 2 Plausibility Criteria

HHRC. It was assumed that issues of fit (setting, transferability, generalization, etc.) would have to be assessed by potential adapters at the community level. Promising practices are those that, although plausible and practical, have not been evaluated rigorously. Four projects fell into this category. It would be desirable to put resources into evaluating these practices because positive results seem likely, but the practices developers do not plan rigorous evaluations. If the evaluations are positive, these practices could be moved to the best practice category. Seven practices were assigned to the tracking category. These included projects for which either (a) evaluations had been conducted, but results were not yet available; or (b) program materials were not yet available for dissemination. The plan is to follow and disseminate these projects given both positive evaluation results and availability.

DISSEMINATION Each best and promising practice was systematically documented in a dissemination format by the HHRC. The summary format, originally developed to disseminate the most promising interventions from the Ontario Heart Health Action Demonstration Project (HHRC, 1997), is user friendly and extensive. Summaries include the following information:
Contacts Abstract Rationale (needs/problems/gaps, process/description, justification/theory) Details of the intervention (goals and objectives, audiences, risk factor(s), activities and/or implementation steps, channel/settings, approach) Resource needs (staff time, other costs) Outputs (outputs, materials) Results (evaluation, recommendations/insights)

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FIGURE 3 Practicality Criteria

Fit with other interventions Generalizability Sustainability Sources of information used for this summary (articles, materials)

Each summary is six to eight pages long, allowing for sufficient detail for potential implementers to decide whether the practice is likely to meet their needs. The summaries will be posted on the HHRCs web site (http://www.hhrc.net/). A best practice resource directory, which included all the summaries of the selected best and promising practices, was developed. This was disseminated to the heart health coordinator in each of the 37 public health units in Ontario for insertion into a preexisting best practice binder. The HHRC houses a complete copy of resource materials for each best practice for reference purposes. The HHRC is tracking uptake of the practices by collecting data on requests for further information about the practices and on implementation of the practices as part of community heart health programs. The HHRC provides technical assistance to communities across the province and plays a proactive role in stimulating use of best practices.

REFLECTIONS The health of the population depends on effective practices being in place. If poor practices become entrenched, they may be difficult to supplant. Investment in the development and evaluation of interventions will only be translated into improvements in population health if best practices are identified and brought to the attention of potential adopters in a systematic and effective manner. Nutbeam (1996) indicates that there is to date a lack of true dialogue between researchers and practitioners where the information flows both ways, with researchers responding to calls from practitioners that research be more relevant to practice. Journal reporting is often not practice oriented (Health Promotion Practice is a notable exception); publication lag time, reluctance to allow prepublication release of information, and the lack of detailed information on interventions usual in journal articles all decrease timely availability to and uptake by practitioners. Practitioners in turn need to hone skills in the critical appraisal of evidence, in planning, and in the evaluation of program effects, to make informed decisions about adoption and to carry out and assess the effectiveness of their implementation. Holman

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FIGURE 4 Decision-Making Flowchart for the Assessment of Heart Health Practices

(1996) suggests that the effective communication of health promotion research knowledge, such as effective practices, is an issue of social marketing and as such warrants its own behavioral science research agenda. Although a system for strategic widespread dissemination of effective practices is essential to improving the delivery of community-based health promotion, it is important to note that the assumption cannot be made that resources and protocols that have worked in one context will necessarily work in another (Best, Thomson, Santi, Smith, & Brown, 1988; Green & Kreuter, 1999). Community practitioners need to understand

how to work with core principles to achieve results that improve community health. At the same time, they need tools to work with, and it is costly for communities to spend time and energy reinventing practices similar to those already available. The prototype system that has been described is intended to address the issue of assessing existing interventions that communities might consider for adoption or adaptation as part of a careful, comprehensive community initiative. A mechanism to support evidence-based practice should be developed at a national or (preferably) international level to ensure both efficiency and credibility.

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The prototype system that has been described here is in need of refinement. The hope is that this work will provoke critical discussion and help build the momentum to create an effective system for supporting evidence-based practices in public health and community-based health promotion initiatives. There is a pressing need for such a system (as evidenced by Ontarios investment in the undertaking reported here) given growing investment in community-based interventions to improve population health. REFERENCES
Abt Associates of Canada. (1996). Review of the demonstration programs: Sustainability and dissemination project (Criteria for the Ontario Heart Health Demonstration Programs from a report to the Ontario Ministry of Health). Unpublished manuscript. Best, J. A., Thomson, S. J., Santi, S. M., Smith, E. A., & Brown, K. S. (1988). Preventing cigarette smoking among school children. Annual Review of Public Health, 9, 161-201. Canadian Task Force on the Periodic Health Examination. (1994). The Canadian guide to clinical preventive health care. Ottawa: Health Canada, Minister of Supply and Services to Canada. Finnegan, J. R., Murray, D. M., Kurth, C., & McCarthy, P. (1989). Measuring and tracking education program implementation: The Minnesota Heart Health Program experience. Health Education Quarterly, 16, 77-90. Glanz, K. (1996). Achieving best practice in health promotion: Future directions. Health Promotion Journal of Australia, 6, 25-28. Green, L. W., & Kreuter, M. W. (1999). Health promotion planning: An educational and environmental approach (3rd ed.). Mountain View, CA: Mayfield. Green, L. W., & Kreuter, M. W. (2000). Commentary on the emerging guide to community preventive services from a health promotion perspective Community health promotion: Applying the science of evaluation to the initial sprint of a marathon. American Journal of Preventive Medicine, 18(1), 7-9. Health Canada. (1995). Canadians and heart health: Reducing the risk. Ottawa, Canada: Author. Health Canada. (1996). Office of Tobacco Reduction Programs guidelines for selection of best practice models (Guidelines developed for committee use). Ottawa, Canada: Author. Heart and Stroke Foundation of Canada. (2000). The changing face of heart disease and stroke in Canada. Ottawa, Canada: Author. Heart Health Resource Centre. (1997). What worked for us: A catalogue of interventions from Ontarios heart health demonstration sites & two healthy lifestyle sites. Toronto, Canada: Heart Health Resource Centre. Holman, D. J. (1996). Creating partnerships, building systems: Improving interactions between research and practice. Health Promotion Journal of Australia, 6, 21-24. Kahan, B., Goodstadt, M., & Rajkumar, E. (1999). Best practices in health promotion: A scan of needs and capacities in Ontario. Toronto, Canada: Centre for Health Promotion, University of Toronto. King, L., Hawe, P., & Wise, M. (1996). Dissemination in health promotion in Australia. Health Promotion Journal of Australia, 6, 4-8. Lefebvre, R. C., Lasater, T. M., Carleton, R. A., & Peterson, G. (1987). Theory and delivery of health programming in the community: The Pawtucket Heart Health Program. Preventative Medicine, 16, 80-95.

Macdonald, G., Veen, C., & Tones, K. (1996). Evidence for success in health promotion: Suggestion for improvement. Health Education Research, 11, 367-376. Nutbeam, D. (1996). Achieving best practice in health promotion: Improving the fit between research and practice. Health Education Research, 11, 317-326. Oldenburg, B., Hardcastle, D., & French, M. (1996). How does research contribute to evidence-based practice in health promotion? Health Promotion Journal of Australia, 6, 15-20. Orlandi, M. A., Landers, C., Weston, R., & Haley, N. (1990). Diffusion of health promotion innovations. In K. Glanz, F. M. Lewis, & B. K. Rimer (Eds.), Health behavior and health education: Theory, research and practice (pp. 288-313). San Francisco: Jossey-Bass. RBJ Health Management Associates. (1995). The heart health action program: Final evaluation report. Toronto, Canada: Heart Health Resource Centre. Rose, G. (1992). The strategy of preventive medicine. New York: Oxford University Press. Speller, V., Learmonth, A., & Harrison, D. (1997). The search for evidence of effective health promotion. British Medical Journal, 315, 361-363. Tones, K. (1997). Beyond the randomized controlled trial: A case for judicial review [Editorial]. Health Education Research, 12, i-iv. Truman, B. I., Smith-Akin, C. K., Hinman, A. R., Gibbie, K. M., Brownson, R., Novick, L. F., Lawrence, R. S., Pappaioanou, M., Fielding, J., Evans, C. A., Guerra, F. A., Vogel-Taylor, M., Mahan, C. S., Fullilove, M., Zaza, S., & The Task Force on Community Preventive Services. (2000). Developing the guide to community preventive servicesOverview and rationale. American Journal of Preventive Medicine, 18(1S), 18-26. U.S. Preventive Services Task Force. (1996). Guide to clinical preventive service (2nd ed.). Alexandria, VA: International Medical Publishing. Ziglio, E. (1997). How to move toward evidence-based health promotion interventions. Promotion Education, 4, 29-33.

Roy Cameron, PhD, is a professor in the Department of Health Studies and Gerontology, University of Waterloo, and Director of the Canadian Cancer Society/National Cancer Institute of Canadas Centre for Behavioural Research and Program Evaluation, located at the University of Waterloo. Mari Alice Jolin, BA, is a project manager for the Health Behaviour Research Group, Department of Health Studies at the University of Waterloo. Rosemary Walker, MSc, is a research assistant professor in the Department of Health Studies at the University of Waterloo, where she is affiliated with the departments Health Behaviour Research Group. Nicky McDermott, MSc, is manager of the Heart Health Resource Centre (HHRC), Toronto, Ontario. The Heart Health Resource Centre provides consultation and technical support to communities as part of the Ontario Heart Health Program. Myrna Gough, BA, RN, is the manager of Provincial and Community Programs in the Community and Health Promotion Branch of the Ontario Ministry of Health. Her responsibilities include the Ontario Heart Health Program.

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