At this point in the process, the planning group has considered relevant data, defined the problem, and created a shared vision and goals for how to address the problem. The next step is to select interventions that can address the problem most effectively with available resources.
Module 4 discusses key concepts that will guide your coalition through the process of identifying and selecting appropriate evidence-based interventions to be implemented as part of your state plan. To follow the gardening analogy, this is the point at which you would identify and select seeds that will grow well in your garden, given the conditions in your area.
An Introduction to Public Health Planning
Learning the basics of gardening
Working Collaboratively with Partners, Pre-Planning and Launching the Planning Process with an Initial Meeting
Identifying what resources you have and what tools you need
Presenting the Data and Defining the Problem
Gathering information on weather and soil conditions in your area
Finding Solutions to the Problem
Finding the kinds of seeds that will grow well in the conditions in your area
Upon completion of this module, you should be able to:
It should take approximately 75 minutes to complete this module.
The next step in the state planning process is to identify and select appropriate interventions, which are backed by evidence demonstrating their effectiveness at addressing the problem at hand.
Evidence is information that indicates whether a belief or perception is true or valid.
Historically, the most highly valued evidence for the effectiveness of interventions has been based on randomized controlled clinical trials. While appropriate for determining the biological causes of disease or the effectiveness of a medication or vaccine, these types of studies are difficult to conduct outside of the medical clinic or laboratory.
As public health has moved toward exploring chronic diseases with complex multi-causal pathways and interventions that focus on policy, environment, systems, and behavior change, research approaches have expanded to include quasi-experimental designs, mixed methods, natural experiments, and repeated implementations over time across multiple sites and multiple populations.
The Knowledge to Action Framework demonstrates that there is a two-way flow of knowledge between researchers and practitioners. Evidence to support interventions is not generated exclusively by researchers and passively received by practitioners.
As research findings on effective interventions are disseminated, public health practitioners have launched their own implementations. Adaptations to interventions and the results of repeated implementations with new target populations provide additional evidence for the effectiveness of interventions. Dialogue between practitioners and researchers about these interventions creates a two-way flow of information.
To help demonstrate how this process works, the Centers for Disease Control and Prevention (CDC) developed the “Knowledge to Action Framework.” This framework graphically portrays the process by which evidence obtained through research (left side of diagram, in blue), is then translated into interventions through translation (middle of diagram, in red), and finally adopted in a widespread and sustainable manner through institutionalization (right side of diagram, in green). This diagram also shows how evidence gained through practice is fed back to stimulate additional research and the modification of interventions.
Knowledge to Action Framework
Download a PDF of the Knowledge to Action Framework with more information on each phase.
There are three main components of the Research Phase of the Knowledge to Action Framework, shown in blue in the diagram below.
Hover your mouse over each blue box for more information on the Research Phase.
After successful Effectiveness and Implementation Studies have occurred, if the intervention is deemed to be effective and worth translating into a widely-disseminated format, it will move into the Translation and Institutionalization Phases.
During Translation, research studies are turned into easy-to-replicate interventions suitable for a wide range of potential implementers and target audiences. There are five main components of the Translation Phase of the Knowledge to Action Framework, shown in red in the diagram below.
Hover your mouse over each Red box for more information on the Translation Phase.
There is one main component to the Institutionalization Phase, shown in green. Evaluation, in yellow, is critical to the entire process.
Hover your mouse over each Green box for more information on the Institutionalization Phase, and Yellow box for more information on Evaluation.
What about “Best Practices”?
“Best practice” is a term that is often used to describe interventions that have been tested in several different settings and have varying degrees of evidence behind them. Because it is an imprecise term, this course uses Research-Tested and Practice-Based Evidence instead.
As demonstrated through the Knowledge to Action Framework, both research and practice are critical in building up the body of evidence in support of an intervention. The evidence gathered through these two fields can be described as “research-tested” and “practice-based” evidence:
Research-Tested Evidence refers to evidence gathered through research studies or a series of studies. These results have typically been presented at a scientific meeting or have been reported in a peer-reviewed journal.
Practice-Based Evidence refers to evidence gathered about interventions that have been developed, implemented, and evaluated in practice but have not been tested in a research study. Once these “promising practices” are subjected to more rigorous research and/or program evaluation, they then become “research-tested.”Both types of evidence describe programs that are found to be effective with outcomes that are replicable and consistent over time.
Thought Provoker: Before clicking the link below, name an example of a theory that is commonly used in public health.
Evidence-based interventions are based in theory. A theory is a set of concepts that present a systematic view of how the relationships between particular factors produce certain results. A theory is applicable to all similar events or situations. A theory is also testable, in that new data collected should confirm or refute the theory. Theories give researchers and practitioners the concepts they need to examine health problems and to design and test interventions.
Click here for a brief overview of theories commonly used in health education and community health promotion, which you may encounter when researching evidence-based interventions.
Since no single theory alone explains how the entire range of individual, societal, and environmental factors affect health, public health researchers and practitioners frequently use models. Models are frameworks that draw on multiple theories to explain complex problems affected by many levels of factors. The model used most frequently in chronic disease prevention and control is the Socio-Ecological Model (as described in Module 1.) The model emphasizes the interaction between and the interdependence of factors across multiple levels.
The Socio-Ecological Model brings together theories that explain health and disease as the result of individual behavior with theories that explain health and disease as the result of social forces. To be the most effective, interventions should be planned that influence multiple levels of the Socio-Ecological Model.
Each level within the Socio-Ecological Model reflects the work of different social and behavioral disciplines, such as political science, sociology, anthropology, communications, organizational dynamics, and social psychology. Public health researchers and practitioners have been working to demonstrate how coordinated interventions at multiple levels have stronger, more long-lasting effects on health status of populations using inter-disciplinary concepts and methods. Advanced analytical approaches such as systems dynamic modeling have been developed to capture this complexity and predict how changes at different levels affect each other and produce changes in health outcomes.
Section I introduced evidence-based interventions and described how evidence gathered from both research and practice is used to inform them. This section also briefly explained the importance of theory and the Socio-Ecological Model in guiding evidence-based interventions.
Now, think about how these concepts apply to your state planning process. Watch the video below, in which the Connecticut DPCP Coordinator discusses evidence-based interventions, and then answer the questions that follow.
Click here for a worksheet to record your answers.
There are several reliable sources that planning group members can use to identify evidence-based interventions:
Each of these sources will be described in more detail in this section.
A systematic review is a review of published literature on a specific topic that uses a formal, unbiased process to identify relevant studies, assess the quality of these studies, and summarize the evidence presented in them. Systematic reviews may be done by individuals or by groups of experts working together as an expert panel. In some cases, an expert panel translates the results of the review process into recommendations for action regarding policy and practice guidelines. The group arrives at recommendations and conclusions, which are then documented along with their rationale in a widely disseminated panel report.
A finding of “insufficient evidence” does not mean that an intervention has been proven to be ineffective, but that there is not enough existing evidence for the reviewers to determine whether it was effective or not. Recommendations for or against these interventions can only come after further research is completed, analyzed, and published in the peer-reviewed literature.
Both the Guide to Clinical Preventive Services for Interventions in Clinical Settings and the Guide to Community Preventive Services (also known as The Community Guide) utilize systematic reviews to provide guidelines and recommendations about the effectiveness of tested interventions. Click here for more information about these critical resources.
While the Guides are very useful tools, they do come with some limitations. Not all health topics are included, because some have more published literature available than others. There is also lag time between when studies are conducted, published, and selected for systematic review, so the most up-to-date information may not be included. Because of these limitations, the recommendations in the Guides should be supplemented with other expert recommendations.
The National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) at the CDC and its various divisions have issued their own recommendations for evidence-based interventions.
For example, the Division of Diabetes Translation has identified three evidence-based, core interventions that have the greatest potential to achieve diabetes prevention and control program goals. These core interventions are:
NCCDPHP supports several programs focused on developing interventions at research universities, state health departments, and non-governmental organizations. These programs, including Prevention Research Centers (PRCs) and Racial and Ethnic Approaches to Community Health (REACH) programs, are important resources to use when identifying evidence-based interventions.
Click here to read more about these NCCDPHP projects and resources.
NCCDPHP has worked with many national-level organizations to develop interventions and to expand expertise on implementing and evaluating interventions through distance learning, conferences, and professional meetings. Some of these organizations include:
These organizations’ websites or publications can be a good source of information about interventions.
Colleges and universities within your state can also be useful resources, especially schools of public health and medicine. Faculty at these institutions may provide expert consultation on selecting, adapting, implementing, and evaluating evidence-based interventions.
Thought Provoker: What types of resources and experience can your partners contribute to the process of selecting interventions?
Key literature sources that publish peer-reviewed articles describing public health interventions include the publications of the Society for Public Health Education (SOPHE), Health Education and Behavior and Health Promotion Practice, and the on-line journal produced by NCCDPHP, Preventing Chronic Disease. The fields of nutrition, physical activity, diabetes education, and policy have journals that may contain relevant literature.
Coalition members representing a variety of professional fields are good resources to include in the intervention identification process.
It is also important to review previous and existing interventions implemented through state and local health departments, as well as by partners represented on state and community coalitions. The planning group members should develop their own set of criteria to review these interventions and describe a standard process of documenting these interventions and the assessments made.
Compare these interventions to what is recommended by the Community Guide, the research and programs developed by Prevention Research Centers, and guidance received from the CDC and other national institutions. Investigate what process and outcome data may have been collected and analyzed during implementation of these interventions – are these good examples of “practice-based evidence” even though they have not been reported in the scientific literature?
As you review previous and existing interventions, some criteria to consider are:
While the decision may be reached to discontinue some previous and existing interventions, others may prove to be worth continuing as is or with some adaptations to make them conform more closely to the recommendations discussed.
Section II described several sources of information regarding evidence-based interventions.
Now, think about how your planning group can utilize these sources in order to identify interventions that are suitable for your state. Watch the video below, in which the Connecticut and Minnesota DPCP Coordinators discuss sources of information regarding evidence-based interventions, and then answer the questions that follow. Click here for a worksheet to record your answers.
With all of the sources of information about evidence-based interventions that are available, how can your planning group narrow down and select interventions that will be most effective?
The information that you have already gathered about the problem, what causes and contributes to the problem, and what resources are available to you will inform your intervention selection. The overall compatibility between an intervention, the target population, and the implementing organization’s capacity to implement the intervention is referred to as “fit.”
Ultimately, the process of selecting interventions that “fit” comes down to balancing two criteria:
This section discusses the considerations that should be taken into account as your coalition develops criteria to select interventions, to ensure that the selected interventions fit your state’s circumstances.
The data that you have collected show the socioeconomic, demographic, and geographic characteristics of the populations with the highest rates of diabetes or chronic disease within your state. Data can illustrate which racial, ethnic, socioeconomic, and geographic subgroups are disparately affected by the problem.
When your planning group is examining interventions, you will need criteria to judge whether or not these interventions have been implemented with people who are similar to those in your target population. The target population for the intervention under consideration should be similar to yours in terms of:
You also will need criteria to judge whether or not the interventions you are considering have been implemented with people who have similar circumstances and available resources in the community (e.g. health care, self-management support, transportation, access to technology). You will need to consider the causes of the problem and the factors that contribute to the progression of disease in your target population. Interventions that have been implemented in similar circumstances and that have addressed similar contributing factors or missing resources will be a better fit than those that have not.During the process of reviewing the characteristics of your state’s target populations, you and your partners may decide that you need to implement different interventions that meet the needs of distinct target populations. You may also decide whether selected interventions will be focused on particular communities or geographic regions, or will be focused on certain populations across the state.
Consider: The Setting
When examining interventions, you also will need criteria to judge whether or not these interventions have been implemented in settings that are similar to the settings available in your state. The setting specified in the evidence-based intervention should match the settings available to you as much as possible. Some examples of intervention settings include:
Altering too much of the original intervention affects how well your intervention can achieve desired outcomes, but you may be able to transfer an intervention developed for one setting to a different setting if the age, health literacy, and socioeconomic status of the target populations are similar.
One of the most important characteristics to be considered when selecting interventions is their reach, or the extent to which the intended target population for the intervention is exposed to it. To estimate reach, compare the total number of persons that can receive or participate in an intervention to the total number of persons at risk for or already diagnosed with diabetes or other chronic diseases of interest in that particular group or community:
# in target population that can receive intervention
# in target population at risk for or having diabetes/other chronic diseases
Calculating this will give you an idea of what proportion of the population will be affected by the intervention. Interventions with greater reach are preferable, as they are more likely to reach a large enough proportion of the target population to create real change.
Closely related to reach is scalability, which refers to how easily an intervention can be widely or frequently implemented in order to gain a significant reach. Interventions that are easily implemented often, or that can be implemented for a large segment of the target population, are more scalable and will result in a greater reach. When thinking about scalability of potential interventions, the planning group should consider:
Some interventions are extremely effective but also are very expensive to implement, making wide scale implementation unlikely.
Policy, environmental, and systems change interventions inherently have a broad reach, because they can affect large populations at once, and they typically can be sustained over time with fewer resources. Communications and education interventions are important when first making environmental, policy, and systems changes, in order to increase awareness, change perceptions, and motivate the target population to take action.
A final issue to consider is sustainability, which refers to the ongoing availability of resources required to implement or expand selected interventions.
Interventions can be more sustainable if they are built into the systems or ongoing programming of a partner. For example, professional education on chronic disease can become part of the ongoing curriculum offered at an Area Health Education Center, an entity whose function it is to provide continuing education to health care professionals.
While it may not be possible to always develop a linked bundle, aim for interventions that affect at least two layers of the Socio-Ecological Model.
When identifying interventions, the planning group can think in terms of building a linked “bundle” or set of interventions that address multiple layers of the Socio-Ecological Model. Sets of interventions that work together across multiple levels of the model can produce stronger and longer-lasting effects than single interventions that address one level.
Interventions can be bundled that focus on the same health issue at different levels. For example, a change in policy can be linked to a communications campaign that educates members of the target population about the change. The different interventions can be implemented at the same time or sequentially, and some elements may need to be repeated on a regular basis in order to reach everyone in the target population.
An intervention must be matched to the ability and intent of the organization or agency that will be implementing it as much as it needs to be matched to the target audience that will be participating in it. Program “fit” with an organization is tied to a number of considerations, such as:
It is very important that the organization and agency be fully informed of what will be required to successfully implement the program.
When working with a set of interventions using the Socio-Ecological Model, a group of organizations may need to work together to implement the interventions at multiple levels. All organizations should be assessed for their capacity to implement.
Adaptation refers to the extent to which an intervention is changed or modified to make it more suitable for a target population or the implementing organization’s capacity. This could include changes, additions, deletions, or substitutions in the content or delivery methods of an intervention.
Adaptation can occur spontaneously or deliberately. Spontaneous adaptation occurs when delivering an intervention, during the interaction between a trainer or educator and participants. In other cases, adaptation occurs in a deliberate, planned fashion as a result of the intervention selection process.
Nearly every intervention is changed slightly to fit the target population and the circumstances surrounding implementation. The important challenge is to determine how much you can change and still have an evidence-based intervention.
Controlling the process of adaptation helps make sure that the program is implemented with fidelity. Fidelity means the intervention is implemented in form and in delivery as closely or as faithfully as possible to the way the program was intended to be delivered. The components of fidelity include adherence to:
To ensure fidelity of implementation when adapting an intervention, you must keep the key processes and core elements intact. The key processes are the required steps that are conducted during implementation that contribute to the intervention’s effectiveness, taken from the intervention’s methods section or implementation protocol. The core elements are the required components that represent the theory and internal logic of the intervention and are the most likely to produce the intervention’s effectiveness.
Click here to learn more about core elements.
Thought Provoker: What does your state do to ensure fidelity of implementation of your current interventions?
The core elements of the original intervention must remain the same in order to achieve results close to those achieved by the original developers of that intervention. There are several ways to make sure this happens.
First, prior to implementation, there should be a “train-the-trainer” phase, in which individuals selected to implement the intervention undergo a consistent training emphasizing that the intervention should remain as close to the original as possible. Second, all materials needed to implement the program should be provided, including standardized curriculum guides, implementation protocols, handouts, equipment or supplies, and reference materials. Finally, continuing to monitor and assess implementers’ performance over time will help to maintain the quality and fidelity of the implementation, as well as to capture any needed enhancements for successive implementations.
There are two main ways to identify what can and cannot be modified when adapting an intervention.
There also are general considerations regarding the target audience that should always prompt discussion about the need to adapt selected interventions. These factors include:
Click here to download a fact sheet that describes these factors in more detail.
Section III described the factors that must be considered when deciding what interventions to implement as part of your state plan. When selecting interventions consider:
Now, think about how these concepts apply to your state planning process. Watch the video below, in which state health department staff from Connecticut and Minnesota discuss the process of selecting evidence-based interventions, and then answer the questions that follow. Click here for a worksheet to record your answers.
The concepts covered in Module 4 apply directly to your efforts to organize meetings of the planning group to create and implement a state plan.
At this point in the planning process, the planning group will need to hold a meeting, followed by a series of follow-up meetings, in order to discuss evidence-based interventions and select the interventions that will be most effective in your state. Meetings of the entire planning group will alternate with independent meetings of smaller workgroups. There are four main actions to take during the meetings:
Module 4 described key concepts to guide the process of identifying and selecting the evidence-based interventions to include in your state plan.
You can download a PDF of helpful resources for more information about this topic.
Your next steps in the planning process are to create and implement your state plan.
Continue the course with Module 5: Implementation, Monitoring, and Evaluation.