Using practice-based evidence from the field to adapt evidence-based practices in guiding interventions in health promotion and public health has gained some traction in recent years. Although there are multiple sources of practice-based evidence, three—participatory research and Practice-Based Research Networks, systematic reviews and systems science—comprise the most promising potential candidates for collecting and analyzing organized evidence that demonstrates relevance, applicability or generalizability, and effectiveness. This paper argues for generating more diversity and complementarity in the methods and sources of evidence for epidemiology, public health and health promotion, if we are to improve population health and eliminate health disparities

Allegrante, John P.

Green, Lawrence W.

Columbia University Academic Commons

2. Katz DL, Meller S. Can we say what diet is best for health?AnnuRev Public Health. 2014;35:83-103.3. Glickman D, Mozaffarian D. Our food is killing toomany of us. 2019. Accessed September 01, 2020. https://www.nytimes.com/2019/08/26/opinion/food-nutrition-health-care.html4. Katz DL, Karlsen MC, Chung M, et al. Hierarchies of evidenceapplied to lifestyle Medicine (HEALM): introduction of a strength-of-evidence approach based on a methodological systematicreview. BMC Med Res Methodol. 2019;19(1):178. doi:10.1186/s12874-019-0811-z5. Pearl J. The Book of Why. BASIC Books; 2020.Practice-Based Evidence and the Need for More DiverseMethods and Sources in Epidemiology, Public Healthand Health PromotionLawrence W. Green, DrPH, ScD(Hon)1 and John P. Allegrante, PhD2IntroductionUnderstanding the varied applicability of evidence across popula-tions and settings, and its uses and limitations to help profession-als and communities advance the goals of health promotion and publichealth, received increased attention throughout the first decade of thiscentury.1,2 Much of the attention had previously centered on settingand enforcing adherence to ‘‘evidence-based practice reporting’’ stan-dards (e.g., GRADEworkinggroup.org) in research publications, andthen screening publications for their adherence to these standards insystematic reviews that then could be used to guide policy and prac-tice. Although iron-clad evidence about the causal links between riskfactors and disease or interventions and outcomes may still be elusivein many areas of research on human population health, the publichealth community has made considerable progress in closing the gapbetween certainty and uncertainty by marshalling evidence alongdimensions of relevance, generalizability and effectiveness from awide range of sources. These included greater attention to practice-based experience and community trials as sources of evidence ratherthan depending so exclusively on evidence generated from highlycontrolled, investigator-initiated experimental trials. The editors ofthe 2019 issue of the Annual Review of Public Health sought in com-missioning a series of reviews to close that gap in the evidence base.3Although there are multiple sources of practice-based evidence, 3sources in particular—participatory research and Practice-BasedResearch Networks (PBRNs), systems science, and systematicreviews—are the most promising candidates for collecting and ana-lyzing systematically organized evidence from practice experience.Below, we briefly describe these sources of evidence and summarizesome of the advantages and disadvantages of each.Participatory Research and Practice-BasedResearch NetworksBased on over 3 decades of experience in community-based partici-patory research (CBPR), health promotion has sought to lead the wayfor medicine and health services research in adopting a more patient-provider participatory approach to understanding how public healthcare can be best improved. Donald Berwick notes, however, that med-icine and health services research had already adapted and applied thebusiness model of continuous quality improvement. This was to pro-vide practice-based evidence of what works in real time, under realmedical circumstances, and with real employees and patients. Thus,continuous quality improvement, Berwick said, has been one of med-icine’s best applications of participatory research and evaluation inresponse to the growing concern that academic medical research andevidence-based medicine were failing to translate its research fully topractice.4Primary care researchers and practitioners extended the participa-tory approach from institutional settings and solo practices to multiplepractices with their organization of PBRNs.5 Organized under theauspices of the federal Agency for Healthcare Research and Quality(AHRQ), PBRNs comprise groups of primary care clinicians workingtogether to answer community-based health care questions and thenusing the answers to translate research findings into practice(pbrn.ahrq.gov/). Through PBRNs, primary care practitioners havebeen able to power their evaluation studies of practices with sufficientnumbers of practices and diversity of settings, as well as a broad arrayof practitioners and patients, and thus increase the external validity,generalizability and translational potential of their results. They werealso able increasingly to collaborate with public health in respondingto the growing demand from communities for research studies thatcould link clinical with community-based participatory research6 andresearchers other than solely medical, including epidemiologists andbehavioral scientists.Health promotion programs and schools of public health, mean-while, were facing growing criticism as their research gravitated to anincreasingly downstream, individualistic focus on behavior, such assmoking behavior and specific disease risk factors such as high bloodpressure and obesity, rather than toward changes in policy, systems,and populations. In lieu of continuous quality improvement and theadvent of PBRNs, schools of public health sought with federal legis-lation and the backing of a National Academy of Sciences study7 torespond to the suggestion that if we wanted more evidence-based1 Department of Epidemiology & Biostatistics, School of Medicine, University ofCalifornia at San Francisco, CA, USA2 Departments of Health and Behavior Studies (Teachers College) andSociomedical Sciences (Mailman School of Public Health), ColumbiaUniversity, New York, NY, USACorresponding Author:Lawrence W. Green, Department of Epidemiology & Biostatistics, Universityof California at San Francisco, CA, USA.Email: lwgreen@comcast.net946 American Journal of Health Promotion 34(8)practice, we would need more practice-based evidence.7-9 The relativepaucity of research funding available from CDC and the growingdependence on NIH funding made the increased reductionism associ-ated with randomized clinical trials necessary to meet the NIH researchdemands for internal validity over external validity and application. Toremain competitive in the ever competitive marketplace of federalresearch funding, their grant applications had to demonstrate more pre-cision and adherence to basic science criteria than to applied implemen-tation science and relevance to diverse populations.8 Moreover,assessing the impact of research conducted through the CDC networkof Prevention Research Centers (PRCs) to identify public health prob-lems and to develop, test and evaluate public health interventions thatcan be applied widely, particularly in underserved communities(cdc.gov/prc/index.htm), has proved problematic; an analysis of peer-reviewed publications generated by PRCs has been of limited value dueto a variety reasons, including, according to Franks et al., omissionsfrom ISI’s databases and because citation benchmarks for preventionresearch have not been established or adequately codified.10Systematic ReviewsAn important and perhaps more promising source of practice-basedevidence is emerging from systematic reviews, especially in clinicalhealth care but increasingly in a broader range of health promotion andpublic health settings. Systematic reviews seek to identify, evaluateand summarize the findings of all relevant individual studies that havebeen conducted on a particular issue over time.11 Coupled with meta-analysis, systematic reviews can also illuminate the cumulative effec-tiveness of interventions. For example, in the case of interventionsdesigned to improve a particular health condition, reviews that includea meta-analysis can help to adjudicate the question of effectivenessbased on effect sizes reported over multiple published studies. Suchreviews thus ultimately make the available evidence more accessibleto clinicians and practitioners, as well as decision makers.Given the scope, complexity and rapidly evolving nature of theevidence base in medicine, most clinicians and public health profes-sionals cannot possibly know all the literature, nor can they always bein a position to locate original articles, critically evaluate them, ormarshal the evidence they need to pursue the correct course of treat-ment. Thus, systematic reviews and clinical practice guidelines maybe the only source of available evidence.11 In recent years, theCochrane Collaboration (Cochrane.org/) and its library has becomethe largest repository of the best global evidence-based knowledgethat can inform clinical medical practice and decision-making, includ-ing the evidence from practice-based experience.Systems ScienceSome attempts by the public health community have sought to invokesystems science as an approach by which to make its research moreaccurately reflect the complexity of practice and program interactions.Systems science is concerned with how public health practitioners canunderstand and act effectively within complex systems and has beencharacterized as an analytic approach that can accommodate nonlinearrelationships, bidirectional feedback loops, and time-delayedeffects.12,13 One recent example of a systems-oriented frameworkdesigned to improve the use of a wide variety of evidence sourcesto address population-wide obesity problems can be found in theL.E.A.D. (Locate the evidence, Evaluate the evidence, Assemble theevidence, and inform Decisions) framework, which was developed byan expert consensus committee convened by the National Academy ofMedicine. The framework has been applied specifically to the problemof obesity but is broadly applicable to other complex, community-wide health problems.14With such a broad purview, however, the very notion of systemsscience itself has often raised puzzling questions about its scope,depth, and potential value for health promotion and public health.Thus, although it has been increasingly pursued, the widespread com-prehension of the complex visual maps of multiple connections amongcauses and effects reported in published applications of systems sci-ence has been disappointing. If community engagement and partici-pation in decision making is to be a criterion of success, systemstheory and its graphic representation of swirling cause-and-effectinteractions is unlikely to be the leading tool at the interface of scien-tists and the public.1ConclusionGood, high-quality evidence from a practice-based source has becomeincreasingly necessary to support implementation of relevant, general-izable and effective health promotion and public health practice.15 Thepromising candidates for the best and most reliable sources of suchpractice-based evidence presented here are starting points, not anexhaustive list. Other valuable practice-based evidence can come froma variety of sources, including journalistic and ethnographic accounts ofpublic health efforts, photovoice descriptions and depictions, and otherless systematic, but not necessarily less valid or valuable, observationsmade and reported by practitioners themselves. However, the 3 sourcesof evidence we have described here have been found trustworthy amongmost in both the scientific and practitioner communities. Without suchevidence, programs are likely to miss their mark or, worse, do harm tothe targets of public health intervention. In short, and as we have arguedelsewhere, ‘‘If we want more evidence-based practice, we need morepractice-based evidence’’1 as the source of our knowledge, along withmore attention to external validity of the results.15References1. Green LW. Public health asks of systems science: to advance ourevidence-based practice, can you help us get more practice-basedevidence? Am J Public Health. 2006;96(3):406-409.2. Green LW, Ottoson JM. From efficacy to effectiveness to com-munity and back: evidence-based practice vs practice-based evi-dence. In: Green L, Hiss R, Glasgow R, et al. (eds.) From ClinicalTrials to Community: The Science of Translating Diabetes andObesity Research. Bethesda: National Institutes of Health; 2004:15-18.3. Aiello AE, Green LW. Introduction to the symposium: causalinference and public health. Ann Rev Public Health. 2019;40:1-7.4. Berwick DM. Broadening the view of evidence-based medicine.Qual Saf Health Care. 2005;14(5):315-316.5. Green LA, Hickner J. A short history of primary care practice-based research networks: from concept to essential researchlaboratories. J Am Board Fam Med. 2006;19(1):1-10.6. Minkler M, Wallerstein N. Community-Based ParticipatoryResearch for Health. Jossey-Bass; 2003:410-418.7. Green LW, Glasgow R. Evaluating the relevance, generalization,and applicability of research: issues in external validation andtranslation methodology. Eval Health Prof. 2006;29(1):126-153.8. Stoto MA, Green LW, Bailey LA. Linking Research and PublicHealth Practice: A Review of CDC’s Program of Centers forResearch and Demonstration of Health Promotion and DiseasePrevention. National Academy Press; 1997.How Humans Know 9479. Green LW, Mercer SL. Participatory research: can public healthresearchers and agencies reconcile the push from funding bodiesand the pull from communities?Am J Public Health. 2001;91(12):1926-1929.10. Franks AL, Simoes EJ, Singh R, Sajor Gray B. Assessing preven-tion research impact: a bibliometric analysis. Am J Prev Med.2006; 30(3):211-216.11. Gopalakrishnan S, Ganeshkumar P. Systematic reviews and meta-analysis: understanding the best evidence in primary healthcare. JFamily Med Prim Care. 2013;2(1):9-14.12. Livingood W, Allegrante JP, Airhihenbuwa CO, et al. Appliedsocial and behavioral science to address complex health prob-lems. Am J Prev Med. 2011;41(5):525-531.13. Mabry PL, Milstein B, Abraido-Lanza A, Livingood WC, Alle-grante JP. Opening a window on systems science research inhealth promotion and public health. Health Educ Behav. 2013;40(Suppl 1):5S-8S.14. Chatterji M, Green LW, Kumanyika SLEAD. A framework forevidence gathering and use for the prevention of obesity and othercomplex public health problems. Health Educ Behav. 2014;41(1):85-99.15. Green LW, Nasser M. Furthering dissemination and implementa-tion research: the need for more attention to external validity(chapter 15). In: Brownson R, Colditz G, Parker E, (eds.) Disse-mination and Implementation Research: Translating Science toPractice. 2nd ed. Oxford University Press; 2018:305-326.Observational Epidemiology, Lifestyle, and Health:The Paradigm of the Mediterranean DietMiguel A. Martı́nez-González, MD, PhD1 and Antonia Trichopoulou, MD, PhD2IntroductionIn the context of the unprecedented Covid-19 pandemic, major riskfactors for its severity include cardiometabolic conditions, espe-cially obesity, cardiovascular disease and diabetes.1,2 These are amen-able to preventive interventions through population changes in dietaryhabits. The Mediterranean diet (MedDiet) can represent the idealmodel for this preventative effort. In fact, this dietary model hasattracted considerable interest in the last 3 decades because of itspotential advantages in the prevention of cardiometabolic condi-tions.3-7The term MedDiet is usually defined as the dietary pattern found inthe olive-growing areas of the Mediterranean region during the early1960s characterized by:*High olive oil consumption*High consumption of legumes*High consumption of unrefined cereals*High consumption of fruits and nuts*High consumption of vegetables*Moderate to high consumption of fish*Moderate to low consumption of dairy products, mostly ascheese and yogurts*Low consumption of meat and meat products*Moderate wine consumption.3,4,8The yearly number of medical publications on the MedDiet hassubstantially increased since 1990 (Table 1). Observational studies,particularly, large longitudinal nutritional epidemiological studies5-7,9have been instrumental to achieve sound evidence-based recommen-dations of utmost interest in public health. This is important since mostof the scientific articles published are observational epidemiologicalstudies.In a hallmark study conducted in Greece and published in 2003,5the definition of the MedDiet was operationally defined with an apriori 10-point score, subsequently referred to as the MediterraneanDiet Score (MDS). A value of 0 or 1 was assigned to each of 9indicated elements with the use of the sex-specific medians as thecut-off points. For beneficial components (vegetables, legumes, fruitsand nuts, cereal, and fish), persons whose consumption was below themedian were assigned a value of 0, and a value of 1 otherwise. Forelements presumed to be detrimental (meat and dairy products), per-sons whose consumption was below the median were assigned a valueof 1, and a value of 0 otherwise. A value of 1 was given to menconsuming from 10 g to less than 50 g of alcohol per day and towomen consuming from 5 g to 25 g. For lipid intake, the ratio ofmonounsaturates to saturates (MUFA/SFA ratio) was calculated.Those above the sex-specific median in the MUFA/SFA ratio weregiven 1 point. Thus, the MDS ranged from 0 (minimal adherence tothe traditional Mediterranean diet) to 9 (maximal adherence). In alarge sample of the general Greek population,5 and in elderly partici-pants of the EPIC study,6 after adjusting for potential confounders, theMedDiet was inversely associated with total mortality, cardiovascularmortality and cancer mortality.The SUN Study is a Spanish dynamic cohort of university gradu-ates.9,10 It began in 1999 and as of September 2020, it included 23,000participants.After adjusting for potential confounders, an inverse associationwas found between better conformity with the traditional MedDiet andall-cause mortality, fatal and non-fatal major cardiovascular disease(CVD), type 2 diabetes, weight gain, metabolic syndrome, depression,cognitive decline, and nephrolithiasis. An inverse dose-response rela-tionship was found for many of these associations.101 Department of Preventive Medicine and Public Health, IdisNA, University ofNavarra, Pamplona, Spain and CIBEROBN, Instituto de Salud Carlos III,Madrid, Spain2 Hellenic Health Foundation, Athens, GreeceCorresponding Author:Miguel A. Martinez-Gonzalez, Departamento de Medicina Preventiva y SaludPública, Facultad de Medicina, Irunlarrea 1, 31080 Pamplona, Spain.Email: mamartinez@unav.es948 American Journal of Health Promotion 34(8)

Practice-Based Evidence and the Need for More Diverse Methods and Sources in Epidemiology, Public Health and Health Promotion

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Practice-Based Evidence and the Need for More Diverse Methods and Sources in Epidemiology, Public Health and Health Promotion

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