Transcript No Slide Title

How can the Community Guide be
Used to Inform and Support State
Policy?
Randy Elder, PhD1
Shawna L. Mercer, MSc, PhD1
David Sleet, PhD2
Krista Cole, MPH3
Jim Nichols, PhD4
1 The
Guide to Community Preventive Services (Community Guide), CDC;
2 National Center for Injury Prevention and Control, CDC; 3 Contractor,
McKing Consulting; 4 Contractor, Formerly with the National Highway Traffic
Safety Administration
Key Starting Points and Outline

Community Guide processes are grounded in trying
to meet the needs of user audiences:
 Prioritizing
topics, reviews
 Review teams with real-world experience and expertise
 What questions are asked
 Data search, collection, analysis, interpretation,
dissemination

This will be demonstrated by:
 Walking
through the full range of Guide processes—
from the earliest stages of considering a review through
to its successful translation of research into policy,
using the example of alcohol-impaired driving laws
 Identifying lessons learned
 Discussing our experiences with other policy-related
Community Guide reviews
“In order to advocate effectively for lifesaving
legislation, advocates must have clear and
compelling scientific evidence to provide a basis for
policy change. The combination of scientific
research and advocacy efforts is key to success at
the federal level, in state legislatures, and in
communities across the nation…We weave
research findings into every piece of our advocacy
efforts.”

Millie Webb, Mothers Against Drunk Driving

“The research community was generating evidence
on drinking and driving long before changes
occurred in public policy…Data alone were not
sufficient to bring about major changes in policies
affecting individual behavior. Success is
attributable to a wide range of participants,
including legislative, enforcement, judicial, public
health, medical, and public organizations and
advocates.”

Patricia Waller, PhD, Former Director,
U Michigan Transportation Research Institute,
UNC Highway Safety Research Center
The Public Health Challenge
Impact of Alcohol-impaired Driving

A third of all traffic deaths

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2008: 11,773 people killed
Every day, 32 people in US die
in a motor vehicle crash
involving an alcohol-impaired
driver
~300,000 injuries each year
2000: $51 billion annual costs
of alcohol-related crashes
One in 10 Americans will be involved in an alcoholrelated crash in their lifetime
Blood Alcohol Concentration

Blood alcohol concentration (BAC):
A measure of the amount of alcohol in a person's
bloodstream

State laws specify BAC levels in grams of alcohol
per 100 milliliters of blood
Often abbreviated as g/dL

Having a BAC of 0.08% means:
A person has 8 parts alcohol per 10,000 parts blood in
the body

BAC levels can be detected by breath, blood, or
urine tests
Alcohol Consumed in 2 Hours to
Reach .08 BAC
(12-oz. beers)

170 lb man
= 5 beers

120 lb woman
= 3 beers
At .08 BAC, a person is 11 times more likely to
be involved in a crash than someone who has
had nothing to drink
BAC Dose-Response Fatal Crash Risk
by Age
Crash risks even at low BAC levels.
Attempts to Address the Challenge
What is a .08% BAC Law?

Specifies that it is illegal per se to operate a vehicle
with a BAC of >0.08 g/dL

Replace older laws that set BAC limit of 0.10 g/dL
Status in 1997
.08
.10
.08
16 states with .08
(1983-1997)
32 States with .10
Policy Development

In 1998, the Clinton administration endorsed a bill
that would have:
Required states to enact and enforce .08 BAC laws or
face sanctions (diversion of highway construction funds
to safety programs)
 Required .08 per se BAC laws to receive basic grants


Both requirements were removed and replaced
with:

An incentive grant program to encourage states to enact
.08 per se laws
Evidence of Effectiveness in 1998-1999

Only 4 published studies had examined
effectiveness of BAC laws in 5 states

National Highway Traffic Safety Administration
(NHTSA) characterized the studies as conclusively
establishing that .08 BAC was effective, but the
studies had limitations

In April 1999, 3 new studies were released
The 1999 Conclusion
This influential
1999 US General
Accounting Office
report suggested
that the evidence
about 0.08% BAC
was inconclusive
GAO Report
"Overall, the evidence does not conclusively
establish that .08-BAC laws, by themselves,
result in reductions in the number and severity
of alcohol-related crashes."
The Alcohol Beverage Institute director of
public relations John Doyle heralds the
GAO's conclusions as "ending the scientific
debate over .08."
GAO Report
"Overall, the evidence does not conclusively
establish that .08-BAC laws, by themselves, result in
reductions in the number and severity of alcoholrelated crashes."
2008
Enhancing the Likelihood of Policy
Action
Motor Vehicle-Related Injury
Prevention and the Community Guide

At the same time:

The Community Guide was undergoing its
first review topic prioritization process

Extensive input from intended user
audiences

The Task Force identified motor vehiclerelated injury prevention as high priority

The Community Guide and the Division of
Unintentional Injury Prevention (DUIP) at
CDC initiated a series of systematic
reviews of the effectiveness of
interventions to reduce motor vehiclerelated injuries
Critical to the Community Guide’s
Ability to Inform and Support Policy:

The equal weight that it places on ensuring the
quality of:

Its analytic systematic review methods

Its group processes

Participation and collaboration
from intended users throughout
all components of its work
Community Guide Group Processes
By actively engaging those who are expected to be
the users and beneficiaries of the research in both
the conduct and dissemination of the systematic
review, it is more likely that the review findings and
recommendations will be relevant to their needs and
used by them
Intended Users Participation: Are we…

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

Prioritizing the right topics and interventions for
review?
Asking the right questions?
Staying true to the important questions over the
course of the review?
Appropriately considering context, other issues of
applicability to different settings, populations?
Thinking proactively about interpretability, relevance,
usefulness, use?
Planning for and undertaking dissemination and
translation into action from the outset?
The Motor Vehicle Coordination Team

Subject Matter Experts
DUIP, CDC
 NHTSA


Systematic Review
Methodologists

Community Guide, CDC
The Motor Vehicle Consultation Team

Federal Agencies



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Centers for Disease Control
and Prevention
National Highway Traffic
Safety Administration
Health Resources Services
Administration
Substance Abuse and Mental
Health Services
Administration
National Institute for Alcohol
Abuse and Alcoholism, NIH
Indian Health Service

Professional and NonGovernmental Organizations





National SAFE KIDS Campaign
Insurance Institute for Highway
Safety
National Safety Council
National Public Service
Research Institute
Other SMEs from:


State, County, City
Departments of Health
Academic institutions
(Mothers Against Drunk Driving;
MADD)
Critical to the Community Guide’s
Ability to Inform and Support Policy:

The equal weight that it places on ensuring the
quality of:

Its analytic systematic review methods

Its group processes

Participation and collaboration
from intended users throughout
all components of its work
The CG Seeks to Answer Key
Questions about Interventions

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

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Do they work?
How well?
For whom?
To what circumstances are
they applicable?
What do they cost?
Do they provide value?
Are there barriers to their use?
Are there any harms?
Are there any unanticipated outcomes?
Community Guide Review Process

Convene review teams
Coordination team
 Consultation team


Develop a conceptual framework

Develop prioritized list of interventions

Use a Delphi process

Develop: clear research questions,
intervention definitions, models of
how interventions are presumed
to work (Lump/split decisions)

Search for evidence
Community Guide Review Process

Abstract, critically evaluate all available studies

Synthesize the evidence
Qualitatively
 Quantitatively:


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
Calculate effect sizes
Assess harms, benefits, applicability
Task Force draws conclusions, makes
recommendations

With input from Official Liaisons, Team, etc.

Disseminate the findings

Support translation of findings into action
In General, a Conclusion About
Effectiveness Requires….
A Body of
Evidence
+
A Demonstration of
Effectiveness
•Number of studies
•Quality of studies
•Study limitations
•Suitability of study
design
Consistency
of Effect
“Most” studies
demonstrated an
effect in the
direction of the
intervention
+
Sufficient Magnitude
of Effect
The effect demonstrated
across the body of evidence
is “meaningful”
Percent Change in Alcohol-related Motor Vehicle
Fatalities Attributable to .08% BAC Laws, by State
16 states
VA
VT
UT
OR
NC
NM
NH
ME
KS
FL
CA
-50
-40
-30
-20
-10
0
10
20
30
40
50
Percent Change in Fatalities
Median percent change: -7%; interquartile interval: -15%, -4%
Task Force Recommendation, 2000
The Task Force on Community Preventive
Services recommends 0.08% BAC laws based on
strong evidence of their effectiveness in
reducing alcohol-related motor vehicle crash
fatalities
After the Recommendation…

CDC:

Intensive communication efforts with all important
partners, stakeholders


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Facilitated by NHTSA
Congressional Hearings on 2001 Transportation
legislation while the review was on way to
publication
Consultation Team members and partners:
Got the results of the Community Guide review and Task
Force recommendations into the hands of legislators
 Their third party dissemination fostered public support
throughout the nation

The Impact

Policy Impact
Both the House and Senate approved the Transportation
Appropriations bill that included sanctions for states
without a 0.08 BAC law, as a result of testimony including
the Community Guide evidence
 Bill was signed into law by President Clinton on October
23, 2000
 Before enactment of bill, only 19 states had passed 0.08
BAC laws
 By July 12, 2004, all states had enacted laws


Resulting Health Impact

With laws in all states: save 500 lives per year
Nine Lessons Learned for How the
Community Guide can Successfully
Inform and Support Policy
a) Lessons from the .08 BAC Experience
b) Additional Experiences with Other Community
Guide Reviews
Lesson #1 for Translating Research
to Policy: The Importance of…

The salience of and compelling relationships
between the health problem, policy intervention, and
health outcomes
Problem and solution easily understood by policymakers
 Intervention:

Addresses an important health problem
 Can play a key role in its reduction


Ultimate intended outcome:
Measured in the studies
 Could be extrapolated to broad (e.g., nation-wide)
implementation

Lesson #2 for Translating Research
to Policy: The Importance of…

The use of systematic review methods to synthesize
the full body of evidence
Large number of studies re .08 BAC laws provided stronger
evidentiary basis
 Systematic review methods:

Helped control for differential threats to validity across the
studies
 Showed whether there is consistency of effect across studies
 Synthesis of the findings provided the foundation for a
stronger, more defensible policy recommendations

Lesson #3 for Translating Research
to Policy: The Importance of…

The use of a recognized, credible, impartial process
for assessing the evidence
Reviews were staffed by CDC, which has a reputation for
scientific integrity
 Community Guide was known to:

Employ rigorous, standardized, transparent processes
 Use strong scientific methods

Lesson #4 for Translating Research
to Policy: The Importance of…

The development of evidence-based policy
recommendations by an independent, impartial body

Community Guide scientific findings were accompanied by
actionable, evidence-based policy recommendations made
by a Task Force known to be:
Reputable
 Impartial
 Non-federal
 Independent
 Generalist

Lesson #5 for Translating Research
to Policy: The Importance of…

The ability to capitalize on readiness and teachable
moments

Coordination Team and DUIP recognized the need to:

Develop and maintain readiness/”prime the pump”
• Undertook activities over years to increase awareness,
document evidence, identify policy actions

Capitalize on a teachable moment/briefly opening policy
window
• Partners took prompt action when legislation was being debated
• Matched messages to the appropriate “stage of change”
• Provided information right before the legislative vote—perhaps
before opponents had time to cast doubt
Lesson #6 for Translating Research
to Policy: The Importance of…

The active participation of key partners and intended
users throughout all stages of the process

Helped to ensure:
Relevance to real world issues
 Early understanding and buy-in
 Readiness of dissemination channels and supports


Team members:
Strove to collaborate effectively, communicate well, rise
above turf issues, build consensus, be outcomes-oriented
 Nurtured relationships with partners so their extended
networks were ready to disseminate, so their constituents, in
turn, were informed when policy makers faced decisions

Lesson #7 for Translating Research
to Policy: The Importance of…

The use of personalized channels, targeted formats,
and compelling graphics to disseminate the evidence
All communications were brief but referred to both the
scientific findings and the recommendations
 Developed a compelling graphic that clearly demonstrated
how the data supported the conclusion
 Dissemination focused on:

Who would have the most credibility with each audience
 What would be most helpful for each audience
 Use of personal connections

Lesson #8 for Translating Research
to Policy: The Importance of…

The capacity to involve multiple stakeholders in
encouraging uptake and adherence

Stakeholders at multiple levels could act meaningfully to
support policy action:
Federal policy makers: budgetary sanctions
 Public health, traffic safety groups, advocates (including
MADD) worked to support state laws
 Public health, police, traffic safety professionals, advocates
(including MADD) worked at local levels to encourage
adherence

Lesson #9 for Translating Research
to Policy: The Importance of…

The attention paid to addressing sustainability
Ongoing personal commitment of several influential
“champions”
 Continue to look for opportunities to feature Community
Guide systematic review findings and Task Force
recommendations


Including in training for federal and state employees (NHTSA)
Continued surveillance to maintain current data,
demonstrate outcome
 Updates of Community Guide reviews can re-engage
influential partners

Comments, Questions,
Discussion?
For More Information
Shawna Mercer, MSc, PhD
Director
The Community Guide
[email protected]
Randy Elder, PhD
Scientific Director for Systematic Reviews
The Community Guide
[email protected]
www.thecommunityguide.org
The findings and conclusions in this presentation are those of the
presenters and do not necessarily represent the views of CDC.