Sources of Support for Studies That Inform Recommendations of the Community Preventive Services Task Force.

OBJECTIVES: The Community Preventive Services Task Force (CPSTF) makes evidence-based recommendations about preventive services, programs, and policies in community settings to improve public health. CPSTF recommendations are based on systematic evidence reviews. This study examined the sponsors (ie, sources of financial, material, or intellectual support) for publications included in systematic reviews used by the CPSTF to make recommendations during a 9-year period. METHODS: We examined systematic evidence reviews (effectiveness reviews and economic reviews) for CPSTF findings issued from January 1, 2010, through December 31, 2018. We assessed study publications used in these reviews for sources of support; we classified sources as government, nonprofit, industry, or no identified support. We also identified country of origin for each sponsor and the most frequently mentioned sponsors. RESULTS: The CPSTF issued findings based on 144 systematic reviews (106 effectiveness reviews and 38 economic reviews). These reviews included 3846 publications: 3363 publications in effectiveness reviews and 483 publications in economic reviews. Government agencies supported 57.1% (n = 1919) of publications in effectiveness reviews and 59.2% (n = 286) in economic reviews. More than 1500 study sponsors from 36 countries provided support. The National Institutes of Health was the leading sponsor for effectiveness reviews (21.3%; 718 of 3363) and economic reviews (16.2%; 78 of 480), followed by the Centers for Disease Control and Prevention (7.0%; 234 of 3363 effectiveness reviews and 14.8%; 71 of 480 economic reviews). CONCLUSIONS: The evidence base used by the CPSTF was supported by an array of sponsors, with government agencies providing the most support. Study findings highlight the need for sponsorship transparency and the role of government as a leading supporter of studies that underpin CPSTF recommendations for improving public health.

Economics of Multicomponent Interventions to Increase Breast, Cervical, and Colorectal Cancer Screening: A Community Guide Systematic Review.

CONTEXT: The Community Preventive Services Task Force recently recommended multicomponent interventions to increase breast, cervical, and colorectal cancer screening based on strong evidence of effectiveness. This systematic review examines the economic evidence to guide decisions on the implementation of these interventions. EVIDENCE ACQUISITION: A systematic literature search for economic evidence was performed from January 2004 to January 2018. All monetary values were reported in 2016 US dollars, and the analysis was completed in 2018. EVIDENCE SYNTHESIS: Fifty-three studies were included in the body of evidence from a literature search yield of 8,568 total articles. For multicomponent interventions to increase breast cancer screening, the median intervention cost per participant was $26.69 (interquartile interval [IQI]=$3.25, $113.72), and the median incremental cost per additional woman screened was $147.64 (IQI=$32.92, $924.98). For cervical cancer screening, the median costs per participant and per additional woman screened were $159.80 (IQI=$117.62, $214.73) and $159.49 (IQI=$64.74, $331.46), respectively. Two studies reported incremental cost per quality-adjusted life year gained of $748 and $33,433. For colorectal cancer screening, the median costs per participant and per additional person screened were $36.63 (IQI=$7.70, $139.23) and $582.44 (IQI=$91.10, $1,452.12), respectively. Two studies indicated a decline in incremental cost per quality-adjusted life year gained of $1,651 and $3,817. CONCLUSIONS: Multicomponent interventions to increase cervical and colorectal cancer screening were cost effective based on a very conservative threshold. Additionally, multicomponent interventions for colorectal cancer screening demonstrated net cost savings. Cost effectiveness for multicomponent interventions to increase breast cancer screening could not be determined owing to the lack of studies reporting incremental cost per quality-adjusted life year gained. Future studies estimating this outcome could assist implementers with decision making.

Community Guide Cardiovascular Disease Economic Reviews: Tailoring Methods to Ensure Utility of Findings.

The Community Preventive Services Task Force recommended five interventions for cardiovascular disease prevention between 2012 and 2015. Systematic economic reviews of these interventions faced challenges that made it difficult to generate meaningful policy and programmatic conclusions. This paper describes the methods used to assess, synthesize, and evaluate the economic evidence to generate reliable and useful economic conclusions and address the comparability of economic findings across interventions. Specifically, steps were taken to assess completeness of data and identify the components and drivers of cost and benefit. Except for the intervention cost of self-measured blood pressure monitoring intervention, either alone or with patient support, all cost and benefit estimates were standardized as per patient per year. When possible, intermediate outcomes were converted to quality-adjusted life year. Differences within and between interventions were considered to generate economic conclusions and inform their comparability. The literature search period varied among interventions. This analysis was completed in 2016. Although team-based care, self-measured blood pressure monitoring with patient support, and self-measured blood pressure monitoring within team-based care were found to be cost effective, their cost-effectiveness estimates were not comparable because of differences in the intervention characteristics. Lack of enough data or incomplete information made it difficult to reach an overall economic finding for the other interventions. The Community Guide methods discussed here may help others conducting systematic economic reviews of public health interventions to respond to challenges with the synthesis of evidence and provide useful findings for public health decision makers.

Economics of mass media health campaigns with health-related product distribution: a community guide systematic review.

CONTEXT: The objective of this systematic review was to determine the costs, benefits, and overall economic value of communication campaigns that included mass media and distribution of specified health-related products at reduced price or free of charge. EVIDENCE ACQUISITION: Economic evaluation studies from a literature search from January 1980 to December 2009 were screened and abstracted following systematic economic review methods developed by The Community Guide. Data were analyzed in 2011. EVIDENCE SYNTHESIS: The economic evidence was grouped and assessed by type of product distributed and health risk addressed. A total of 15 evaluation studies were included in the economic review, involving campaigns promoting the use of child car seats or booster seats, pedometers, condoms, recreational safety helmets, and nicotine replacement therapy. CONCLUSIONS: Economic merits of the intervention could not be determined for health communication campaigns associated with use of recreational helmets, child car seats, and pedometers, primarily because available economic information and analyses were incomplete. There is some evidence that campaigns with free condom distribution to promote safer sex practices were cost-effective among high-risk populations and the cost per quit achieved in campaigns promoting tobacco cessation with nicotine replacement therapy products may translate to a cost per quality-adjusted life-year less than $50,000. Many interventions were publicly funded trials or programs, and the failure to properly evaluate their economic cost and benefit is a serious gap in the science and practice of public health.

Effectiveness of interventions to increase screening for breast, cervical, and colorectal cancers: nine updated systematic reviews for the guide to community preventive services.

CONTEXT: Screening reduces mortality from breast, cervical, and colorectal cancers. The Guide to Community Preventive Services previously conducted systematic reviews on the effectiveness of 11 interventions to increase screening for these cancers. This article presents results of updated systematic reviews for nine of these interventions. EVIDENCE ACQUISITION: Five databases were searched for studies published during January 2004-October 2008. Studies had to (1) be a primary investigation of one or more intervention category; (2) be conducted in a country with a high-income economy; (3) provide information on at least one cancer screening outcome of interest; and (4) include screening use prior to intervention implementation or a concurrent group unexposed to the intervention category of interest. Forty-five studies were included in the reviews. EVIDENCE SYNTHESIS: Recommendations were added for one-on-one education to increase screening with fecal occult blood testing (FOBT) and group education to increase mammography screening. Strength of evidence for client reminder interventions to increase FOBT screening was upgraded from sufficient to strong. Previous findings and recommendations for reducing out-of-pocket costs (breast cancer screening); provider assessment and feedback (breast, cervical, and FOBT screening); one-on-one education and client reminders (breast and cervical cancer screening); and reducing structural barriers (breast cancer and FOBT screening) were reaffirmed or unchanged. Evidence remains insufficient to determine effectiveness for the remaining screening tests and intervention categories. CONCLUSIONS: Findings indicate new and reaffirmed interventions effective in promoting recommended cancer screening, including colorectal cancer screening. Findings can be used in community and healthcare settings to promote recommended care. Important research gaps also are described.

Methods for conducting community guide systematic reviews of evidence on effectiveness and economic efficiency of group-based behavioral interventions to prevent adolescent pregnancy, human immunodeficiency virus, and other sexually transmitted infections: comprehensive risk reduction and abstinence education.

This paper describes methods used to conduct systematic reviews and meta-analyses and economic reviews of group-based behavioral interventions for adolescents to prevent pregnancy, HIV, and other sexually transmitted infections. The steps described include developing a conceptual approach, defining the interventions, identifying outcome and moderator variables, searching the literature, abstracting the data, and analyzing the results. In addition, identification of potential harms and benefits, applicability of results, barriers to implementation, and research gaps are described.

Scientific evidence and policy change: lowering the legal blood alcohol limit for drivers to 0.08% in the USA.

The United States (US) Centers for Disease Control and Prevention (CDC), and key partners conducted a systematic review of the effectiveness of 0.08% blood alcohol concentration (BAC) laws on alcohol-related traffic mortality. Review findings of strong evidence of effectiveness were presented by partners during US Congressional hearings contributing to the passage of a bill requiring states to lower the legal BAC limit to 0.08% (80 mg of alcohol/100 ml of blood) or lose a portion of their federal highway funds. The bill was signed into law, making 0.08 the new national standard. Extensive and targeted dissemination of the evidence and recommendations to key stakeholders and partners built support for policy change at the state level.

Translating evidence into policy: lessons learned from the case of lowering the legal blood alcohol limit for drivers.

This case study examines the translation of evidence on the effectiveness of laws to reduce the blood alcohol concentration (BAC) of drivers into policy. It was reconstructed through discussions among individuals involved in the processes as well as a review of documentation and feedback on oral presentations. The Centers for Disease Control and Prevention collaborated extensively with federal and non-federal partners and stakeholders in conducting a rigorous systematic review, using the processes of the Guide to Community Preventive Services to evaluate the body of empirical evidence on 0.08% BAC laws. The timely dissemination of the findings and related policy recommendations-made by the independent Task Force on Community Preventive Services-to Congress very likely contributed to the inclusion of strong incentives to States to adopt 0.08 BAC laws by October 2003. Subsequent dissemination to partners and stakeholders informed decision-making about support for state legislative and policy action. This case study suggests the value of: clearly outlining the relationships between health problems, interventions and outcomes; systematically assessing and synthesizing the evidence; using a credible group and rigorous process to assess the evidence; having an impartial body make specific policy recommendations on the basis of the evidence; being ready to capitalize in briefly opening policy windows; engaging key partners and stakeholders throughout the production and dissemination of the evidence and recommendations; undertaking personalized, targeted and compelling dissemination of the evidence and recommendations; involving multiple stakeholders in encouraging uptake and adherence of policy recommendations; and addressing sustainability. These lessons learned may help others working to translate evidence into policy.

The scientific basis for law as a public health tool.

Systematic reviews are generating valuable scientific knowledge about the impact of public health laws, but this knowledge is not readily accessible to policy makers. We identified 65 systematic reviews of studies on the effectiveness of 52 public health laws: 27 of those laws were found effective, 23 had insufficient evidence to judge effectiveness, 1 was harmful, and 1 was found to be ineffective. This is a valuable, scientific foundation-that uses the highest relevant standard of evidence-for the role of law as a public health tool. Additional primary studies and systematic reviews are needed to address significant gaps in knowledge about the laws' public health impact, as are energetic, sustained initiatives to make the findings available to public policy makers.

The value and challenges of participatory research: strengthening its practice.

The increasing use of participatory research (PR) approaches to address pressing public health issues reflects PR's potential for bridging gaps between research and practice, addressing social and environmental justice and enabling people to gain control over determinants of their health. Our critical review of the PR literature culminates in the development of an integrative practice framework that features five essential domains and provides a structured process for developing and maintaining PR partnerships, designing and implementing PR efforts, and evaluating the intermediate and long-term outcomes of descriptive, etiological, and intervention PR studies. We review the empirical and nonempirical literature in the context of this practice framework to distill the key challenges and added value of PR. Advances to the practice of PR over the next decade will require establishing the effectiveness of PR in achieving health outcomes and linking PR practices, processes, and core elements to health outcomes.

The public health infrastructure and our nation's health.

Threats to Americans' health-including chronic disease, emerging infectious disease, and bioterrorism-are present and growing, and the public health system is responsible for addressing these challenges. Public health systems in the United States are built on an infrastructure of workforce, information systems, and organizational capacity; in each of these areas, however, serious deficits have been well documented. Here we draw on two 2003 Institute of Medicine reports and present evidence for current threats and the weakness of our public health infrastructure. We describe major initiatives to systematically assess, invest in, rebuild, and evaluate workforce competency, information systems, and organizational capacity through public policy making, practical initiatives, and practice-oriented research. These initiatives are based on applied science and a shared federal-state approach to public accountability. We conclude that a newly strengthened public health infrastructure must be sustained in the future through a balancing of the values inherent in the federal system.

Participatory research and evaluation: from best practices for all states to achievable practices within each state in the context of the Master Settlement Agreement.

Because the Centers for Disease Control and Prevention (CDC) already assisted state tobacco control initiatives, many state health departments turned to CDC for guidance on how to use Master Settlement Agreement monies. This article describes how CDC funded participatory research to establish local evidence and provided technical assistance for participatory program evaluation. The article (a) presents a telephone interview study of principal investigators (PIs) to determine how CDC could best facilitate participatory research and (b) identifies factors CDC considered to devise evaluation technical assistance that reflected local context. The interview study identified 8 areas where PIs needed CDC's support to undertake participatory research: continuity, timeliness, flexibility, clear and explicit expectations, appropriate and instructive accountability, creation of a vision for participatory research, tailored technical assistance, and enhancement of partner collaboration and support. These findings are being used to inform CDC's research funding. Meanwhile, user-driven technical assistance for participatory evaluation is being accessed by many states.

Possible lessons from the tobacco experience for obesity control.

Although obesity is increasing to epidemic proportions in many developed countries, some of these same countries are reporting substantial reductions in tobacco use. Unlike tobacco, food and physical activity are essential to life. Yet similar psychological, social, and environmental factors as well as advertising pressures influence the usage patterns of all 3. These similarities suggest that there may be commonalities between factors involved in controlling obesity and tobacco. This review, therefore, seeks to draw lessons from the tobacco experience for the organization of more successful obesity control. Smoking cessation counseling by physicians has been found to be one of the most clinically effective and cost-effective of all disease prevention interventions. When used alone, however, it cannot decrease the cultural acceptability of tobacco and the pressures and cues to smoke. Research and evaluation have shown the key elements of tobacco control to be (1) clinical intervention and management, (2) educational strategies, (3) regulatory efforts, (4) economic approaches, and (5) the combination of all of these into comprehensive programs that address multiple facets of the environment simultaneously. For each element, we present the evidence outlining its importance for tobacco control, discuss its application to date in obesity control, and suggest areas for further research. Viewing all of the elements involved and recognizing their synergistic effects draws researchers and practitioners back from an exclusive concentration on their particular setting to consider how they might seek to influence other settings in which individuals and populations must negotiate desired changes in nutrition and physical activity.