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Best Practices In Chronic Disease Prevention



I Introduction



Health promotion and chronic disease prevention are incredibly complex, involving the determinants of health, overlapping risk factors, and people's lifestyle choices. There are no simple answers about what works and certainly no one size fits all solution. Yet chronic disease is the leading cause of preventable death, illness, and disability. Consequently, with the aging population the occurrence of chronic disease will only increase. It is imperative that we use our limited resources -- human, financial, and material -- to adopt interventions that have been shown to be effective.



This was the basis for undertaking the projects collectively known as best practices in chronic disease prevention.



This article describes the projects, the process that was used to identify practices, the assessment criteria, the review process, and the intentions for dissemination.


II The Projects and Principle Investigators



The Heart Health Resource Centre (HHRC) has provided leadership in the identification, documentation, and dissemination of best practices since the mid-1990s.



In 1996, the HHRC contracted Dr. Roy Cameron at the Health Behaviour Research Group (HBR) at the University of Waterloo to lead the first international scan of best practices in heart health. Our initial foray into the field of identifying community-based best practices included developing the process and criteria for identifying the recommended interventions. The first project employed an international key-informant scan as the method of identifying qualifying practices and three-level review criteria assessing effectiveness, plausibility, and practicality. The best and promising practices were summarized in a document and hard copies were disseminated to practitioners involved in community-based heart health programming. International Best Practices in Heart Health I and II are available on the HHRC website (http://www.hhrc.net).



In 2002-03, the HHRC again contracted the HBR, with Dr. Rhona Hanning as the principal investigator (PI), to lead a second best practices review. The Best Practices in Cardiovascular Health Promotion and Stroke Prevention project was designed to identify best practices based in community, schools or worksite settings as well as practices specifically addressing hypertension. This review not only updated the initial review but also included a literature review to complement the scan process and identify published interventions.



In 2003, the HHRC again contracted HBR, with Dr. Rhona Hanning and Dr. Steve Manske as co-PIs, to identify best practices in the prevention of type II diabetes. The two-pronged methodology, combining a literature review and nominated international key informant scan, was again used. This project also included a thorough process evaluation of the methodology and the creation of a web-based, searchable database of the best and promising practices.



A similar set of parameters were established for each of these projects and interventions had to demonstrate the following characteristics to be considered for inclusion:

* Be a community-based population health approach

* Focus on primary prevention

* Be adoptable in the Ontario and Canadian context

* Have sufficient information available to provide adequate information for review

* Have a multi-risk factor approach addressing two or more of following: physical inactivity, tobacco use, and poor nutrition; for the stroke prevention project hypertension was also included as risk factor; for the diabetes project the practices were grouped into six categories: Aboriginal, African-American, Women, Community, Schools, and Worksites.



The practices identified as best and promising are intended to increase the capacity of those working in the area of chronic disease prevention by providing details about relevant, recommended interventions that can be adapted and adopted in the Ontario and Canadian context.



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III The Process



Step 1: Establishing a Project Advisory Committee



A committee representing researchers, government, practitioners, and disseminators was established to guide all aspects of the projects. Each of the three projects had a distinct advisory dommittee. The role of the advisory committee remained consistent between the three projects and was predominantly to revise and refine the review criteria and nominate key informants for the international scan.



Step 2: Literature review



The literature search was conducted through relevant databases (e.g., PubMed, ERIC, Pyschinfo, Web of Science) and a manual search of English-language journals for a period of five years prior to the project. The literature search yield thousands of records that were scanned by two independent reviewers and relevant titles were selected for further consideration. Selected abstracts were read by two independent reviewers and the appropriate papers chosen for retrieval and through assessment.



Step 3: International Nominated Practices Scan



Building on the format developed by Cameron et al. (2001), a two-staged key informant process, called a scan, was used to identify potential best practices. First, the advisory committee brainstorms a list of international contacts involved with community-based, chronic disease prevention programs. These initial key informants are contacted and asked to nominate programs they think are worthy of a best practices label and to suggest other individuals who may be aware of appropriate interventions. In the second phase contacts of the nominated practices are contaced and asked to complete a survey and to send detailed documentation on their project.



On average, over 100 international key contacts were identified who in turn nominated over 150 interventions for consideration. The nominated practices were scanned for eligibility and inappropriate interventions were discarded (e.g. ,those addressing only one risk factor). In the second phase of the scan, an 80% response rate was achieved for the stroke prevention and setting-specific heart health scan and a 88% response rate was achieved for the diabetes prevention scan. A total of four contacts by a combination of emails and phone were made to each key contact.



Step 4: Review criteria



The practices were reviewed according to two levels of criteria: Effectiveness (or strength of evidence) and Plausibility (or evaluation and program content attributes).



The effectiveness criteria relate to the scientific evaluation of the intervention and consider study design, selection bias, treatment of confounders, etc. Interventions with well-designed evaluations showing positive outcomes and a strong to moderate strength of evidence are designated as best practices. For the two recent projects, the criteria established by PHRED were adopted.



Interventions were also assessed according to the Plausibility criteria. This was especially important for practices with insufficient evidence or no evaluation data. This criterion considers the potential of an intervention being effective based on its evaluation attributes (formative and process evaluation) and its content attributes (grounded in behavior change principles with behavioral objectives). When an intervention is judged to have a strong or moderate plausibility it is designed as a "Promising" practice.



Criteria worksheets were developed to facilitate the reviews.



Step 5: Review Process



The qualifying interventions from the literature review and the international nominated scan were reviewed by two to four independent reviewers who had been oriented to the criteria and review ratings. Reviewers included academics, researchers, public health managers, project managers and graduate students. One reviewer of each team had previous experience with best practice reviews. Where review scores differed for a particular intervention, meetings were used to achieve a consensus score and associated intervention rating (e.g., best, promising, to be tracked, weak).



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IV Results



From the final reports submitted by HBR, the process described above identified a total of 120 practices:

* Stroke Prevention -- Best 6, Promising 17

* Workplace setting -- Best 3, Promising 8

* School setting -- Best 6, Promising 12

* Diabetes Prevention -- Best 12, Promising 56

* Total -- Best 27, Promising 93



The methodology described in this article is currently undergoing a comprehensive evaluation by Dr. Brian Rush. The results will refine and improve the process and inform future best practice projects. The evaluation is scheduled for completion by March 31, 2005.



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V Dissemination of Best Practices



In 2004, the HHRC contracted Nancy Dubois and Tricia Wilkerson (of DuBFit Associates) to conduct a literature review and focus groups to develop a model for disseminating identified best practices to practitioners. Their work identified the roles of the knowledge developers, knowledge brokers, and knowledge adopters and this was used to create an evidence-based dissemination model. A proposal to implement this Dissemination Framework to disseminate the best practices to practitioners involved in chronic disease prevention has been submitted and is under review by a potential funder.



Regardless of whether funds are secured to implement the evidence-based dissemination protocol, a searchable database containing all the above-identified best and promising practices is being created and should be available online (http://www.hhrc.net) by the end of this fiscal year.



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VI Insights and Reflections



There continues to be development and debate in the area of best/better practices in the health promotion and chronic disease prevention field, as evidenced by the fact there is no one common definition or accepted set of guidelines. It is hoped that this project will further the movement and will contribute to the discussions in this area. Certainly a common understanding of best/better practices in the field would better support all involved.



The project advisory committee (PAC) worked well for each of the best practices projects. Care must be taken to ensure advisory committees are representative of researchers, intended adopters, and relevant stakeholders. A total of four meetings, during strategic times of the project, informed the project and efficiently used the time of the committee representatives.



Traditionally, literature reviews have been used to capture and identify best practices relevant to community practitioners. This methodology, employing both a literature review and an international nominated scan process, demonstrated that the two techniques identified different interventions (Hanning et al., 2003). In conclusion, both approaches may be needed to identify relevant community-based practices.



A comprehensive process to identify and document best practices requires substantial time. The two most recent best practices scans, Stroke Prevention and Prevention of Diabetes Type II, have now spanned into their third year and are still in process. If undertaking a well-designed process, worthy itself of a 'best practice' designation, allow a minimum of 2 years per each project. Given that the best practices are not time sensitive the project results will be relevant to practitioners with a reasonable time lag between identification and dissemination.



Overall, it is hoped that these Best Practices in Chronic Disease Prevention projects will improve the ability of practitioners in community-based programming to make informed decisions in selecting interventions that have been shown to be effective.



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V References



Cameron R, Jolin MA, Walker R et al. Linking science and practice: toward a system for enabling community to adopt best practices for chronic disease prevention. Health Promotion Practice 2001;2:35-42.



Hanning R, May H, Skinner K et al. Identifying Best Practices in Cardiovascular Health Promotion in Schools: Comparison of Systematic Literature Review versus Nominated Practices Scan. Oral presentation: Second Conference of the International Society for Behavioral Nutrition and Physical Activity, 2003



R. Hanning, D. Royall, et al. Best Multi-Risk Factor Practices in the Primary Prevention of Stroke (Report by HRG submitted to HHRC), 2003



R. Hanning, S. Manske, et al. International Best Practices in Type II Diabetes Prevention (Report by HRG submitted to HHRC), 2004