In 2017, the Policy, Location and Access in Community Environments (PLACE) Research Lab, School of Public Health, University of Alberta and Alberta Health Services (AHS) - Alberta Cancer Prevention Legacy Fund (ACPLF) collaborated to develop strategies to support cancer and chronic disease prevention in communities and workplaces. The goal of this project was to develop a set of evidence-based and contextually relevant strategies across seven focus areas (alcohol misuse, cancer screening, healthy eating, mental wellness, physical activity, tobacco use and ultraviolet exposure) that would help communities and workplaces foster supportive physical and social environments to reduce the risk of developing cancer and chronic disease. The strategies for these seven focus areas were developed in three phases described below.
Phase 1: Evidence search
The goal of Phase 1 was to gather high quality, current evidence regarding environmental and policy change strategies that support community and workplace action on cancer and chronic disease in the seven focus areas.
Evidence search method
Guidelines developed by the National Collaborating Centre for Methods and Tools (NCCMT) to support public health evidence searches were used.1 Figure 1 provides an overview of the six levels of evidence recommended by the NCCMT regarding purpose, level definition and areas to search within each level.
FIGURE 1. Overview of the NCCMT 6S Model with definitions1
Adapted from: National Collaborating Centre for Methods and Tools (NCCMT). Search pyramids. Hamilton (ON): NCCMT; 2013. Original figure.
The NCCMT recommends that evidence searches begin at the top of the pyramid (i.e., focus on the highest quality sources) and then work down through the pyramid to find additional evidence as necessary.1 Within public health, there is no evidence at the ‘systems’ level,1 so efforts were focused on the subsequent ‘summaries’ and ‘synopses of syntheses’ levels.
The search examined 20 databases, websites and search engines for ‘summaries’ and ‘synopses of syntheses’ related to the seven focus areas within community and workplace settings.
The search strategy focused across a variety of sources that spanned specific keyword searches through to database topic area searches (Table 1). Sources of evidence were limited to English language documents. The search emphasized evidence published during the past three years (i.e., 2014-2017) based on NCCMT recommendations for evidence-informed decision-making in public health. Evidence prior to 2014 was included and categorized separately (i.e., to capture established evidence that may not have changed in the intervening period) during the current phase of the project. Although the search was internationally inclusive, the documents revealed were primarily from Canada, the United States, the United Kingdom and Australia.
TABLE 1. Overview of search strategy
|SEARCH STRATEGY||SOURCE OF EVIDENCE|
|Hand-search of all guidelines available on website||Canadian Task Force on Preventive Health Care; CDC -- The 6|18 Initiative; Partnerships to Improve Community Health; Workplace Health Promotion; Cochrane Collaboration, Public Health|
General search using terms specific to each of the focus areas
|Cancer Care Ontario - Guidelines and Advice; CPAC Prevention Policy Directory; US Preventive Services Recommendations; National Guideline Clearinghouse; National Institute for Health and Care Excellence|
|Specific search using terms specific to each of the focus areas, plus some or all the following terms: (evidence OR evidence-informed OR evidence-based OR best practice OR guideline OR strategy OR policy OR intervention) AND (community OR workplace OR school OR work)||Trip Database; Google Search Engine|
|Selected pre-determined topic areas listed in drop-down menus or toggle buttons, one-by-one (topics were selected if they related to one or all the focus areas)||Health Evidence.ca; World Health Organization; Research-tested Intervention Programs; Healthy People 2020; Guide to Community Preventive Services; The Campbell Collaboration; Canadian Best Practices Portal; EPPI Centre|
Information extracted from each document included the year of publication (and year of any updates), title, URL, description of recommendations, search date and search number. The Appraisal of Guidelines for Research and Evaluation (AGREE) II tool (www.agreetrust.org/agree-ii/) was used to critically appraise the ‘summaries’ and the Critical Appraisal Skills Programme (CASP) tool (www.casp-uk.net/casp-tools-checklists) was used to assess ‘synopses of syntheses’. If the quality of the document was deemed low according to these tools, it was excluded.
Evidence documents reported on single or multiple strategies for each of the focus areas in the community and/or workplace setting. Relevant strategies were extracted from each document.
Upon review of the evidence, PLACE Research Lab and ACPLF identified a number of gaps in the evidence. The gaps were a symptom of the purposeful high level search strategy that was utilized. To addresses these gaps, ACPLF identified two topics for immediate rapid review: workplace mental health and community gardens. It is important to note that the workplace mental health rapid review included evidence from a systematic review level and community garden rapid review included evidence from primary research studies. Within the strategies outlined throughout the website, evidence derived from the rapid reviews are identified with a double asterisks (**).
Phase 2: Strategy development
A four-step approach (Figure 2) was used to develop a subset of strategies based on the evidence search results gathered in Phase 1.
FIGURE 2. Overview of strategy development steps
In Step 1, PLACE Research Lab research assistants summarized evidence collected during the Phase 1 evidence search into draft strategies for each focus area. Research assistants reviewed guideline development protocols to determine an approach to convert evidence into recommendations (Appendix A). The research assistants used elements of the protocols to inform the process by first reading through the entire evidence report and then summarizing evidence into key strategies that captured the breadth of the evidence identified.
In Step 2, a PLACE Research Lab associate reviewed the draft strategies. In this step, the primary evidence identified was also reviewed to ensure accuracy in strategy development.
In Step 3, the PLACE Research Lab team worked with an Alberta Policy Coalition for Chronic Disease Prevention (APCCP) policy analyst to conduct a final internal review. The APCCP is a provincial non-profit organization that represents a broad range of practitioners, policy-makers, researchers and community organizations who coordinate efforts, generate evidence and advocate for policy change to reduce chronic disease in Alberta (http://abpolicycoalitionforprevention.ca). Given this mandate, the APCCP policy analyst was an ideal resource to support strategy review. The APCCP policy analyst and PLACE Research Lab research associate worked together to refine strategies and ensure they were relevant to community and workplace contexts, while retaining a clear link to the original evidence.
In Step 4, APCCP member organizations (Appendix B), the AHS focus area teams (via ACPLF) and ACPLF community partners conducted a practice and policy review to ensure that strategies were applicable within the Alberta context.
Phase 3: Final strategy development
Following the strategy review completed by APCCP member organizations, AHS focus area teams and ACPLF, all suggested feedback and revisions were carefully reviewed by the PLACE Research Lab team and incorporated into final strategies for each focus area.
Appendix A: Guideline Development Protocol Examples
- BC Provincial Health Services Authority (BCPHSA). Healthy built environment linkages: a toolkit for design, planning, health. Vancouver (BC), BCPHSA; 2014. Available from: http://www.phsa.ca/Documents/linkagestoolkitrevisedoct16_2014_full.pdf.
- Briss PA, Zaza S, Pappaioanou M, et al. Developing an evidence-based guide to community preventive services: methods. Am J Prev Med. 2000;18(1 Suppl):35-43. Available from: https://www.ncbi.nlm.nih.gov/pubmed/10806978
- Canadian Task Force on Preventive Health Care (CTFPHC). Procedure manual. Edmonton (AB); CTFPHC; 2014. Available from: https://canadiantaskforce.ca/wp-content/uploads/2016/12/procedural-manual-en_2014_Archived.pdf.
- Guyatt GH, Oxman AD, Kunz R, et al. GRADE: going from evidence to recommendations. BMJ. 2008;336:1049-51. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2376019/
- Guyatt GH, Oxman AD, Kunz R, Vist GE, Falck-Ytter Y, Schünemann HJ. What is "quality of evidence" and why is it important to clinicians? BMJ. 2008;336(7651):995-8. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2364804/.
- Guyatt GH, Oxman AD, Vist GE, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008;336(7650):924. Available from: http://www.bmj.com/content/336/7650/924.full.
- Institute of Medicine (IOM) Committee on Standards for Developing Trustworthy Clinical Practice Guidelines. Clinical practice guidelines we can trust. Washington (DC); NASEM: 2011. Available from: https://www.ncbi.nlm.nih.gov/books/NBK209539/.
- National Institute for Health and Care Excellence (NICE). Developing NICE guidelines: The manual. London; NICE: 2014. Available from: https://www.nice.org.uk/media/default/about/what-we-do/our-programmes/developing-nice-guidelines-the-manual.pdf.
- National Institute for Health and Care Excellence (NICE). Health and social care directorate quality standards process guide. London; NICE: 2014. Available from: https://www.nice.org.uk/media/default/Standards-and-indicators/Quality-standards/Quality-standards-process-guide-April-2014.pdf.
- National Institute for Health and Care Excellence (NICE). Methods for the development of NICE public health guidance (third edition). London; NICE: 2012. Available from: https://www.nice.org.uk/process/pmg4/chapter/introduction.
- Olstad DL, Raine KD, Nykiforuk CIJ. Development of a report card on healthy food environments and nutrition for children in Canada. Prev Med. 2014;69:287-295. Available from: http://www.sciencedirect.com/science/article/pii/S0091743514003909.
- POWER UP!. Alberta's 2016 nutrition report card on food environments for children and youth. Edmonton (AB); POWER UP!: 2016. Available from: https://powerupforhealth.ca/albertas-2016-nutrition-report-card-on-food-environments-for-children-and-youth/.
- Schünemann H. Criteria for applying or using GRADE. 2016. Available from: http://www.gradeworkinggroup.org/docs/Criteria_for_using_GRADE_2016-04-05.pdf.
- U.S. Preventive Services Task Force (USPSTF). Procedure manual. Rockville (MD); USPSTF: 2015. Available from: https://www.uspreventiveservicestaskforce.org/Home/GetFileByID/2711.
- U.S. Preventive Services Task Force (USPSTF). Standards for guideline development. Rockville (MD); USPSTF: 2016. Available from: https://www.uspreventiveservicestaskforce.org/Page/Name/standards-for-guideline-development.
- World Health Organization (WHO). WHO handbook for guideline development. Geneva; WHO: 2012. Available from: http://apps.who.int/iris/bitstream/10665/75146/1/9789241548441_eng.pdf.
Appendix B: List of APCCP Member Organizations
- Action on Smoking and Health (ASH)
- Alberta Centre for Active Living (ACAL)
- Alberta Food Matters (AFM)
- Alberta Health Services (AHS)
- Alberta Public Health Association (APHA)
- Alberta Recreation and Parks Association (ARPA)
- Canadian Cancer Society (CCS), AB/NWT Division
- Centre for Health and Nutrition (CHN)
- Diabetes Canada
- Dietitians of Canada, Alberta and the Territories
- Ever Active Schools
- Heart and Stroke Foundation (HSF)
- Lung Association of Alberta and NWT
- Policy, Location and Access in Community Environments (PLACE) Research Lab
- Promoting Optimal Weights through Ecological Research (POWER) Lab
- Safe Healthy Active People Everywhere (SHAPE)
- Vivo for Healthier Generations
- National Collaborating Centre for Methods and Tools (NCCMT). Evidence-informed public health [Internet]. Hamilton (ON): NCCMT; [updated 2017 Nov; cited 2017 Nov 28]. Available from: http://www.nccmt.ca/professional-development/eiph.
- McLeroy KR, Bibeau D, Steckler A, Glanz K. An ecological perspective on health promotion programs. Health Educ Quarterly. 1988;15(4):351-377.
- Michie S, van Stralen MM, West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci. 2011;6(1):42. doi: 10.1186/1748-5908-6-42.
- Swinburn B, Egger G, Raza F. Dissecting obesogenic environments: the development and application of a framework for identifying and prioritizing environmental interventions for obesity. Prev Med. 1999;29:563-570.
- Brennan L, Castro S, Brownson RC, Claus J, Orleans CT. Accelerating evidence reviews and broadening evidence standards to identify effective, promising, and emerging policy and environmental strategies for prevention of childhood obesity. Annu Rev Public Health. 2011;32(1):199-223. doi: 10.1146/annurev-publhealth-031210-101206.