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Assessing the extent to which public health research findings can be causally interpreted continues to be a critical endeavor. In this symposium, we invited several researchers to review issues related to causal inference in social epidemiology and environmental science and to discuss the importance of external validity in public health. Together, this set of articles provides an integral overview of the strengths and limitations of applying causal inference frameworks and related approaches to a variety of public health problems, for both internal and external validity.

BACKGROUND: Women aged 50–70 should receive breast, cervical (until age 65), and colorectal cancer (CRC) screening; men aged 50–70 should receive CRC screening and should discuss prostate cancer screening (PSA). PreView, an interactive, individually tailored Video Doctor Plus Provider Alert Intervention, adresses all cancers for which average risk 50–70-year-old individuals are due for screening or screening discussion. METHODS: We conducted a randomized controlled trial in 6 clinical sites. Participants were randomized to PreView or a video about healthy lifestyle. Intervention group participants completed PreView before their appointment and their clinicians received a “Provider Alert.” Primary outcomes were receipt of mammography, Pap tests (with or without HPV testing), CRC screening (FIT in last year or colonoscopy in last 10 years), and PSA screening discussion. Additional outcomes included breast, cervical, and CRC screening discussion. RESULTS: A total of 508 individuals participated, 257 in the control group and 251 in the intervention group. Screening rates were relatively high at baseline. Compared with baseline screening rates, there was no significant increase in mammography or Pap smear screening, and a nonsignificant increase (18% vs 12%) in CRC screening. Intervention participants reported a higher rate of PSA discussion than did control participants (58% vs 36%: P < 0.01). Similar increases were seen in discussions about mammography, cervical cancer, and CRC screening. CONCLUSION: In clinics with relatively high overall screening rates at baseline, PreView did not result in significant increases in breast, cervical, or CRC screening. PreView led to an increase in PSA screening discussion. Clinician-patient discussion of all cancer screenings significantly increased, suggesting that interventions like PreView may be most useful when discussion of the pros and cons of screening is recommended and/or with patients reluctant to undergo screening. Future research should investigate PreView’s impact on those who are hesitant or reluctant to undergo screening. TRIAL REGISTRATION: ClinicalTrials.gov: NCT02264782 ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-019-05438-0) contains supplementary material, which is available to authorized users.

Timely implementation of principles of evidence-based public health (EBPH) is critical for bridging the gap between discovery of new knowledge and its application. Public health organizations need sufficient capacity (the availability of resources, structures, and workforce to plan, deliver, and evaluate the preventive dose of an evidence-based intervention) to move science to practice. We review principles of EBPH, the importance of capacity building to advance evidence-based approaches, promising approaches for capacity building, and future areas for research and practice. Although there is general agreement among practitioners and scientists on the importance of EBPH, there is less clarity on the definition of evidence, how to find it, and how, when, and where to use it. Capacity for EBPH is needed among both individuals and organizations. Capacity can be strengthened via training, use of tools, technical assistance, assessment and feedback, peer networking, and incentives. Modest investments in EBPH capacity building will foster more effective public health practice.

Thirty years after expressing concerns about the translation and communication of science to the public and to policy makers, this reflection finds that the same issues face public health education perhaps even more urgently today with the advent of politicians who actively dispute science, and a public that has voted in support of their campaign promises to repeal and replace laws that provided health care and protection from global warming.

Two contrasting reviews (authored by Abrams et al. and Glantz & Bareham) in this volume have reached opposing conclusions on the effects of electronic cigarettes in a debate that is dividing the scientific and professional communities that have devoted careers to controlling the manufacture, advertising, sale, and use of combustible cigarettes. The research on the types, degree, and extent of harm from e-cigarettes is far from complete and, together with trends in teenage smoking and vaping, has raised new questions and prospects about the potential benefits that the new electronic products offer smokers of combustible cigarettes in quitting or at least cutting back on the known risks associated with the traditional forms of smoking. The rapidly morphing forms, constituents, promotions, and uses of the electronic varieties of the new nicotine delivery products (in this case electronic cigarettes) make research on their biological and behavioral effects moving targets. The two sides of this argument have produced a global divide on policy strategies.

Author(s): Moreno, Gala D; Schmidt, Laura A; Ritchie, Lorrene D; McCulloch, Charles E; Cabana, Michael D; Brindis, Claire D; Green, Lawrence W; Altman, Emily A; Patel, Anisha I | Abstract: IntroductionPromoting water consumption among children in schools is a promising intervention to reduce sugar-sweetened beverage (SSB) intake and achieve healthful weight. To date, no studies in the United States have examined how a school-based water access and promotion intervention affects students' beverage and food intake both in and out of school and weight gain over time. The Water First trial is intended to evaluate these interventions.MethodsInformed by the PRECEDE-PROCEED model and Social Cognitive Theory, the Water First intervention includes: 1) installation of lead-free water stations in cafeterias, physical activity spaces, and high-traffic common areas in lower-income public elementary schools, 2) provision of cups/reusable water bottles for students, and 3) a 6-month healthy beverage education campaign. A five year-long cluster randomized controlled trial of 26 low-income public elementary schools in the San Francisco Bay Area is examining how Water First impacts students' consumption of water, caloric intake from foods and beverages, and BMI z-score and overweight/obesity prevalence, from baseline to 7nmonths and 15nmonths after the start of the study. Intervention impact on outcomes will be examined using a difference-in-differences approach with mixed-effects regression accounting for the clustering of students in schools and classrooms.DiscussionThis paper describes the rationale, study design, and protocol for the Water First study. If the intervention is effective, findings will inform best practices for implementing school water policies, as well as the development of more expansive policies and programs to promote and improve access to drinking water in schools.

Vaccinations have been shown repeatedly to be extremely safe with low incidence of complications. Given the rarity, these adverse events, they must be reported and examined cautiously. This case report illustrates the first case of an adult presenting with Wells syndrome that developed soon after vaccination with the thiomersal, a common preservative, containing influenza vaccine. Wells syndrome, also known as eosinophilic cellulitis, is an uncommon dermatologic condition of unknown etiology. Lesions in patients with Wells syndrome (eosinophilic cellulitis) progress over a few days to become large indurated plaques with associated edema and erythema. Although the etiology of Wells syndrome remains unknown, certain precipitants have been described in the literature, including but not limited to parasitic infections, contact dermatitis, Churg-Strauss disease and various medications. This article describes a possible sensitivity to thiomersal, as well as describes other cases that have reported a similar sensitivity secondary to receiving thiomersal-containing vaccines.

This reflection is on a health education professional’s rotation from professor in a school of public health to a government position and back parallels that of Professor Howard Koh’s journey to Assistant Secretary of Health, one level higher in the same federal bureaucracy. We both acknowledge the steep learning curve and some bureaucratic hassles and mazes that can attend government service, but similarly conclude that “. . . it was worth it.” In this personalized case, I weigh some of the specific learning experiences and challenges I faced while in the government against the needs of the field of health promotion for more such revolving-door experiences among academic public health professionals. From my argument that to get more evidence-based practice we need more practice-based evidence, I conclude that more experience in practice among those returning to academia will render their teaching and research more relevant to the needs for evidence in policy and practice.

Efforts to change policies and the environments in which people live, work, and play have gained increasing attention over the past several decades. Yet health promotion frameworks that illustrate the complex processes that produce health-enhancing structural changes are limited. Building on the experiences of health educators, community activists, and community-based researchers described in this supplement and elsewhere, as well as several political, social, and behavioral science theories, we propose a new framework to organize our thinking about producing policy, environmental, and other structural changes. We build on the social ecological model, a framework widely employed in public health research and practice, by turning it inside out, placing health-related and other social policies and environments at the center, and conceptualizing the ways in which individuals, their social networks, and organized groups produce a community context that fosters healthy policy and environmental development. We conclude by describing how health promotion practitioners and researchers can foster structural change by (1) conveying the health and social relevance of policy and environmental change initiatives, (2) building partnerships to support them, and (3) promoting more equitable distributions of the resources necessary for people to meet their daily needs, control their lives, and freely participate in the public sphere.

Context Health communication campaigns including mass media and health-related product distribution have been used to reduce mortality and morbidity through behavior change. The intervention is defined as having two core components reflecting two social marketing principles: (1) promoting behavior change through multiple communication channels, one being mass media, and (2) distributing a free or reduced-price product that facilitates adoption and maintenance of healthy behavior change, sustains cessation of harmful behaviors, or protects against behavior-related disease or injury. Evidence acquisition Using methods previously developed for the Community Guide, a systematic review (search period, January 1980–December 2009) was conducted to evaluate the effectiveness of health communication campaigns that use multiple channels, including mass media, and distribute health-related products. The primary outcome of interest was use of distributed health-related products. Evidence synthesis Twenty-two studies that met Community Guide quality criteria were analyzed in 2010. Most studies showed favorable behavior change effects on health-related product use (a median increase of 8.4 percentage points). By product category, median increases in desired behaviors ranged from 4.0 percentage points for condom promotion and distribution campaigns to 10.0 percentage points for smoking-cessation campaigns. Conclusions Health communication campaigns that combine mass media and other communication channels with distribution of free or reduced-price health-related products are effective in improving healthy behaviors. This intervention is expected to be applicable across U.S. demographic groups, with appropriate population targeting. The ability to draw more specific conclusions about other important social marketing practices is constrained by limited reporting of intervention components and characteristics.

The usual remedy suggested for bridging the science-to-practice gap is to improve the efficiency of disseminating the evidence-based practices to practitioners. This reflection on the gap takes the position that it is the relevance and fit of the evidence with the majority of practices that limit its applicability and application in health promotion and related behavioural, community and population-level interventions where variations in context, values and norms make uniform interventions inappropriate. To make the evidence more relevant and actionable to practice settings and populations will require reforms at many points in the research-to-practice pipeline. These points in the pipeline are described and remedies for them suggested.

Editors’ Note: We invited a sample of AJPM’s Editorial Board, supplement guest editors, and longtime colleagues and contributors to share their experiences and impressions of the impact of AJPM on their respective domains. We were particularly fond of Ken Powell’s analogy to being “tenders of the planted seed”—as planters, weeders, and harvesters—watching and nurturing the growth of AJPM, and have elected to lead with his commentary. In the mid-1940s my brothers and I helped our father tend our victory garden. We were suburbanites and our small garden shared a vacant lot with the concrete foundation of a home abandoned in mid-construction during the Depression. We helped plant, weed, and harvest the crops. I especially liked the tall stalks of sweet corn that grew taller than I was. Many years later, in the mid-1990s, I met a couple of other gardeners: Kevin Patrick and Doug Scutchfield visited the Centers for Disease Control (now the Centers for Disease Control and Prevention) to discuss their plans as the editors of the American Journal of Preventive Medicine. I was working in a Branch that was trying to understand the public health importance of regular physical activity, and they had the foresight to know we were planting some seeds in an important new area. I’m not sure that I had even heard of AJPM before their visit. A few years later, while the field of physical activity and public health continued to grow, I shifted my focus to violence and injury prevention. Once again, the team of Patrick and Scutchfield recognized the importance of this topic to the field of preventive medicine. By the turn of the century my work had shifted from the national to the state level. I tried to keep up with the literature by reading or scanning articles as I rode the subway to and from work. The Georgia Division of Public Health had no access to a library so I circulated my personal copy of the American Journal of Preventive Medicine to my team in the Chronic Disease and Injury Epidemiology Section because it contained by far the most articles of interest and practical application for us. Isn’t it interesting to watch things grow. Gardens, journals, and the fields of public health and preventive medicine.

Background Increasingly, funders expect that public health researchers will include policy contributions as outcomes. Lack of agreement as to what constitutes a policy contribution of research provides little conceptual or implementation guidance to researchers who lack policy training, as well as to evaluators called on to assess "good" policy contribution. Purpose This study applies a previously developed policy framework to explore potential policy contributions from research conducted by 20 principal investigators of Salud America! , the Robert Wood Johnson Foundation's (RWJF) Research Network to Prevent Obesity Among Latino Children. Methods The literature-driven "Policy Contribution Spectra" served as the conceptual framework to jointly develop 20 cases of potential policy contribution. Data collection included document reviews and interviews. Data analysis included within- and cross-case analyses, member checking, data triangulation, and expert reviews. Results Plotting all 20 projects on the Policy Contribution Spectra showed projects have the potential to contribute to policy across intervention types (e.g., needs assessment or applied research); levels (e.g., local or state); timing (e.g., before or after policy enactment); and outcomes (e.g., process action or health benefits). Potential policy contributions on the Spectra framework were shown as multidirectional; multilayered (e.g., simultaneous state and local action); and multidimensional (e.g., multiple strategies aimed at multiple stakeholders). Conclusions The Policy Contribution Spectra adds a useful policy lens to existing public health practice by enabling researchers, funders, advocates, and evaluators to visualize, reframe, discuss, and communicate with policymakers and the public to resolve important public health issues.

The misuse of alcohol, tobacco, and illicit drugs by youth and young adults is a major public health challenge across nations and the world. This chapter reviews the extensive international research concerning the use of public policy approaches to reducing these problems associated with the use and misuse of alcohol, tobacco, and illicit drugs. In general, wide differences arise in public policies both in the type of research undertaken and the practical application of policy approaches to reduce harm. For illegal drugs and for alcohol, research concerning public health effects has been associated with policies addressing specific control mechanisms, whereas many public health policy approaches for tobacco harm prevention have been multifaceted. Overall, the cumulative international evidence offers public health policy approaches with demonstrated potential to reduce harm from and use of alcohol, tobacco, and illicit drugs and can have specific effects for adolescents and young adults.

Over-reliance on decontextualized, standardized implementation of efficacy evidence has contributed to slow integration of evidence-based interventions into health policy and practice. This article describes an “evidence integration triangle” (EIT) to guide translation, implementation, prevention efforts, comparative effectiveness research, funding, and policymaking. The EIT emphasizes interactions among three related components needed for effective evidence implementation: (1) practical evidence-based interventions; (2) pragmatic, longitudinal measures of progress; and (3) participatory implementation processes. At the center of the EIT is active engagement of key stakeholders and scientific evidence and attention to the context in which a program is implemented. The EIT model is a straightforward framework to guide practice, research, and policy toward greater effectiveness and is designed to be applicable across multiple levels—from individual-focused and patient–provider interventions, to health systems and policy-level change initiatives.

CONTEXT: Participatory research (PR) is the co-construction of research through partnerships between researchers and people affected by and/or responsible for action on the issues under study. Evaluating the benefits of PR is challenging for a number of reasons: the research topics, methods, and study designs are heterogeneous; the extent of collaborative involvement may vary over the duration of a project and from one project to the next; and partnership activities may generate a complex array of both short- and long-term outcomes. METHODS: Our review team consisted of a collaboration among researchers and decision makers in public health, research funding, ethics review, and community-engaged scholarship. We identified, selected, and appraised a large-variety sample of primary studies describing PR partnerships, and in each stage, two team members independently reviewed and coded the literature. We used key realist review concepts (middle-range theory, demi-regularity, and context-mechanism-outcome configurations [CMO]) to analyze and synthesize the data, using the PR partnership as the main unit of analysis. FINDINGS: From 7,167 abstracts and 591 full-text papers, we distilled for synthesis a final sample of twenty-three PR partnerships described in 276 publications. The link between process and outcome in these partnerships was best explained using the middle-range theory of partnership synergy, which demonstrates how PR can (1) ensure culturally and logistically appropriate research, (2) enhance recruitment capacity, (3) generate professional capacity and competence in stakeholder groups, (4) result in productive conflicts followed by useful negotiation, (5) increase the quality of outputs and outcomes over time, (6) increase the sustainability of project goals beyond funded time frames and during gaps in external funding, and (7) create system changes and new unanticipated projects and activities. Negative examples illustrated why these outcomes were not a guaranteed product of PR partnerships but were contingent on key aspects of context. CONCLUSIONS: We used a realist approach to embrace the heterogeneity and complexity of the PR literature. This theory-driven synthesis identified mechanisms by which PR may add value to the research process. Using the middle-range theory of partnership synergy, our review confirmed findings from previous PR reviews, documented and explained some negative outcomes, and generated new insights into the benefits of PR regarding conflicts and negotiation between stakeholders, program sustainability and advancement, unanticipated project activity, and the generation of systemic change.

The promise of widespread implementation of efficacious interventions across the cancer continuum into routine practice and policy has yet to be realized. Multilevel influences, such as communities and families surrounding patients or health-care policies and organizations surrounding provider teams, may determine whether effective interventions are successfully implemented. Greater recognition of the importance of these influences in advancing (or hindering) the impact of single-level interventions has motivated the design and testing of multilevel interventions designed to address them. However, implementing research evidence from single- or multilevel interventions into sustainable routine practice and policy presents substantive challenges. Furthermore, relatively few multilevel interventions have been conducted along the cancer care continuum, and fewer still have been implemented, disseminated, or sustained in practice. The purpose of this chapter is, therefore, to illustrate and examine the concepts underlying the implementation and spread of multilevel interventions into routine practice and policy. We accomplish this goal by using a series of cancer and noncancer examples that have been successfully implemented and, in some cases, spread widely. Key concepts across these examples include the importance of phased implementation, recognizing the need for pilot testing, explicit engagement of key stakeholders within and between each intervention level; visible and consistent leadership and organizational support, including financial and human resources; better understanding of the policy context, fiscal climate, and incentives underlying implementation; explication of handoffs from researchers to accountable individuals within and across levels; ample integration of multilevel theories guiding implementation and evaluation; and strategies for long-term monitoring and sustainability.

Type 2 diabetes imposes a large and growing burden on the public's health. This burden, combined with the growing evidence for primary prevention from randomized controlled trials of structured lifestyle programs leads to recommendations to include caloric reduction, increased physical activity and specific assistance to patients in problem solving to achieve modest weight loss as well as pharmacotherapy. These recommendations demand exploration of new ways to implement such primary prevention strategies through more integrated community organization, medical practice and policy. The US experience with control of tobacco use and high blood pressure offers valuable lessons for policy, such as taxation on products, and for practice in a variety of settings, such as coordination of referrals for lifestyle supports. We acknowledge also some notable exceptions to their generalizability. This paper presents possible actions proposed by an expert panel, summarized in Table 1 as recommendations for immediate action, strategic action and research. The collaboration of primary care and public health systems will be required to make many of these recommendations a reality. This paper also provides information on the progress made in recent years by the Division of Diabetes Translation at the US Centers for Disease Control and Prevention (CDC) to implement or facilitate such integration of primary care and public health for primary prevention.

Community interventions are complex social processes that need to move beyond single interventions and outcomes at individual levels of short-term change. A scientific paradigm is emerging that supports collaborative, multilevel, culturally situated community interventions aimed at creating sustainable community-level impact. This paradigm is rooted in a deep history of ecological and collaborative thinking across public health, psychology, anthropology, and other fields of social science. The new paradigm makes a number of primary assertions that affect conceptualization of health issues, intervention design, and intervention evaluation. To elaborate the paradigm and advance the science of community intervention, we offer suggestions for promoting a scientific agenda, developing collaborations among professionals and communities, and examining the culture of science.

Background The FLU–FOBT Program is an intervention in which nurses provide home fecal occult blood tests (FOBTs) to eligible patients during annual influenza vaccination (FLU) campaigns. The effectiveness of the FLU–FOBT Program when implemented during primary care visits has not been extensively studied. Purpose The effectiveness of the FLU–FOBT Program was tested as adapted for use during primary care visits in community clinics serving multiethnic patients with low baseline colorectal cancer (CRC) screening rates. Design Randomized clinical trial. During intervention weeks, nurses routinely initiated the offering of FOBT to eligible patients who were given FLU (FLU–FOBT group). During control weeks, nurses provided FOBT with FLU only when ordered by the primary care clinician during usual care (FLU-only group). Setting/participants The study was conducted in six community clinics in San Francisco. Participants were patients aged 50–75 years who received FLU during primary care visits during an 18-week intervention beginning on September 28, 2009. Main outcome measures The primary outcome was the change in CRC screening rates in the FLU–FOBT group compared to the FLU-only group at the end of the study period, on March 30, 2010. Multivariate logistic regression analysis was used to determine predictors of becoming up-to-date with CRC screening. Results Data were analyzed in 2010. A total of 695 participants received FLU on FLU–FOBT dates, and 677 received FLU on FLU-only dates. The CRC screening rate increased from 32.5% to 45.5% (+13.0 percentage points) in the FLU–FOBT group, and from 31.3% to 35.6% (+4.3 percentage points) in the FLU-only group (p=0.018 for change difference). For those due for CRC screening, the OR for completing CRC screening by the end of the measurement period was 2.22 (95% CI=1.24, 3.95) for the FLU–FOBT group compared to the FLU-only group. Conclusions FLU–FOBT Program participants were twice as likely to complete CRC screening as those receiving usual care. The FLU–FOBT Program is a practical strategy to increase CRC screening in community clinics. Trial registration # NCT01211379

U.S. childhood obesity has reached epidemic proportions, with one third of children overweight or obese. Latino children have some of the highest obesity rates, a concern because they are part of the youngest and fastest-growing U.S. minority group. Unfortunately, scarce research data on Latinos hinders the development and implementation of evidence-based, culturally appropriate childhood obesity interventions. In response, the Salud America! network conducted a national Delphi survey among researchers and stakeholders to identify research priorities to address Latino childhood obesity and compare differences by occupation and race or ethnicity. The resulting first-ever National Latino Childhood Obesity Research Agenda provides a framework to stimulate research and collaboration among investigators, providers, and communities, and inform policy makers about the epidemic’s seriousness and specific needs for priority funding. The agenda ranks family as the main ecological level to prevent Latino childhood obesity—followed by community, school, society, and individual—and ranks top research priorities in each level.

Legislators and their scientific beneficiaries express growing concerns that the fruits of their investment in health research are not reaching the public, policy makers, and practitioners with evidence-based practices. Practitioners and the public lament the lack of relevance and fit of evidence that reaches them and barriers to their implementation of it. Much has been written about this gap in medicine, much less in public health. We review the concepts that have guided or misguided public health in their attempts to bridge science and practice through dissemination and implementation. Beginning with diffusion theory, which inspired much of public health's work on dissemination, we compare diffusion, dissemination, and implementation with related notions that have served other fields in bridging science and practice. Finally, we suggest ways to blend diffusion with other theory and evidence in guiding a more decentralized approach to dissemination and implementation in public health, including changes in the ways we produce the science itself.

The Robert Wood Johnson Foundation requested this utilization-focused evaluation of its Active Living Research (ALR) program. This evaluation reports on the trajectory of influence of past and future ALR outcomes on field-building and policy contributions as well as on possible users of completed and disseminated ALR products.In 2006 and 2007, key-informant interviews were conducted with 136 representatives of first-line potential users of ALR research products, including state physical activity and nutrition program coordinators, policymakers, scientists, and funders. Literature reviews, bibliometric analyses, and document reviews served to describe the context for ALR's work and the ways it could enhance its utility for field building and policymaking.The contributions of ALR to the emerging transdisciplinary field included leadership in the development of measurement tools, epidemiologic studies, implementation research, the translation of research to practice, and the communication of learned lessons to diverse audiences. ALR's contributions to policy discussions were found across a spectrum of policy-development phases that included describing the problem, raising awareness of alternative strategies for increasing physical activity, convening nontraditional partners, and evaluating policy implementation.Policy-relevant research can make contributions to policymakers' thinking but almost never causes a change by itself. Five years after the original authorization of ALR, there is ample evidence of its recognition as a resource by key players, its field-building influence, and its contributions to policy discussions. All these bear promise for a broader contribution to obesity prevention. Recommendations for increasing ALR's impact on policy and practice are offered.

Background Understanding the process by which research is translated into practice is limited. This study sought to examine how interventions change during implementation. Methods Data were collected from July 2005 to September 2007. A real-time and cross-case comparison was conducted, examining ten interventions designed to improve health promotion in primary care practices in practice-based research networks. An iterative group process was used to analyze qualitative data (survey data, interviews, site visits, and project diary entries made by grantees approximately every 2 weeks) and to identify intervention adaptations reported during implementation. Results All interventions required changes as they were integrated into practice. Modifications differed by project and by practice, and were often unanticipated. Three broad categories of changes were identified and include modifications undertaken to accommodate practices' and patients' circumstances as well as personnel costs. In addition, research teams played a crucial role in fostering intervention uptake through their use of personal influence and by providing motivation, retraining, and instrumental assistance to practices. These efforts by the research teams, although rarely considered an essential component of the intervention, were an active ingredient in successful implementation and translation. Conclusions Changes are common when interventions are implemented into practice settings. The translation of evidence into practice will be improved when research design and reporting standards are modified to help quality-improvement teams understand both these adaptations and the effort required to implement interventions in practice.

The usual search for explanations and solutions for the research-practice gap tends to analyze ways to communicate evidence-based practice guidelines to practitioners more efficiently and effectively from the end of a scientific pipeline. This examination of the pipeline looks upstream for ways in which the research itself is rendered increasingly irrelevant to the circumstances of practice by the process of vetting the research before it can qualify for inclusion in systematic reviews and the practice guidelines derived from them. It suggests a 'fallacy of the pipeline' implicit in one-way conceptualizations of translation, dissemination and delivery of research to practitioners. Secondly, it identifies a 'fallacy of the empty vessel' implicit in the assumptions underlying common characterizations of the practitioner as a recipient of evidence-based guidelines. Remedies are proposed that put emphasis on participatory approaches and more practice-based production of the research and more attention to external validity in the peer review, funding, publication and systematic reviews of research in producing evidence-based guidelines.

Over the past several months some researchers and health organizations have proclaimed circumcision to be a compelling and important new HIV tool. A recent commentary claims that circumcision is “at least as good as the HIV vaccine we have been waiting for praying for and hoping to see in our lifetimes”. Thousands of African men now line up to get circumcised in the mistaken belief that it will save them from HIV as some developing nations -lacking even rudimentary medical care and clean drinking water -rush to implement mass circumcision programs with encouragement and millions of pledged dollars from the US government. In addition there are calls for implementing mass neonatal circumcision. The push to institute mass circumcision in Africa following the three randomized clinical trials (RCTs) conducted in Africa is based on an incomplete evaluation of real-world preventive effects over the long-term -effects that may be quite different outside the research setting and circumstances with their access to resources sanitary standards and intensive counseling. Moreover proposals for mass circumcision lack a thorough and objective consideration of costs in relation to hoped-for benefits. No field-test has been performed to evaluate the effectiveness complications personnel requirements costs and practicality of proposed approaches in real-life conditions. These are the classic distinctions between efficacy and effectiveness trials and between internal validity and external validity. Campaigns to promote safe-sex behaviors have been shown to accomplish a high rate of infection reduction without the surgical risks and complications of circumcision and at a much lower cost. For the health community to rush to recommend a program based on incomplete evidence is both premature and ill-advised. It misleads the public by promoting false hope from uncertain conclusions and might ultimately aggravate the problem by altering people’s behavioral patterns and exposing them and their partners to new or expanded risks. Given these problems circumcision of adults and especially of children by coercion or by false hope raises human rights concerns.

The purchase of packaged software has brought new opportunities and challenges to the development of information systems. An important question for packaged software consumers is how a software package will support, change or inhibit practices. To address this question, our paper focuses on the decisions made by a team developing four different software prototypes, with increasingly relaxed constraints on data content and structure. Each prototype significantly enlarged the number of health promotion planners that could be supported by the software. Consistent with the literature, the software designers balanced specificity (constraint) and generality (opening) in the software to incorporate a desire to serve a broad audience, and a need to be relevant to various sub-groups within this audience. Given a detailed knowledge of the software artefact, including the data content and structural choices made by designers, we hope to enable software consumers to question IT artefacts and their spokespeople, so they can make active and informed choices about software generality and specificity. We also suggest that this questioning process is shared across both customised and packaged software, and that the inscription of technology by designers may be either deterministic and detailed, or emergent and general. The implications for packaged software research and practice are considered.

Background Community-Based Participatory Research (CBPR) is an approach in which researchers and community stakeholders form equitable partnerships to tackle issues related to community health improvement and knowledge production. Our 2012 realist review of CBPR outcomes reported long-term effects that were touched upon but not fully explained in the retained literature. To further explore such effects, interviews were conducted with academic and community partners of partnerships retained in the review. Realist methodology was used to increase the understanding of what supports partnership synergy in successful long-term CBPR partnerships, and to further document how equitable partnerships can result in numerous benefits including the sustainability of relationships, research and solutions. Methods Building on our previous realist review of CBPR, we contacted the authors of longitudinal studies of academic-community partnerships retained in the review. Twenty-four participants (community members and researchers) from 11 partnerships were interviewed. Realist logic of analysis was used, involving middle-range theory, context-mechanism-outcome configuration (CMOcs) and the concept of the ‘ripple effect’. Results The analysis supports the central importance of developing and strengthening partnership synergy through trust. The ripple effect concept in conjunction with CMOcs showed that a sense of trust amongst CBPR members was a prominent mechanism leading to partnership sustainability. This in turn resulted in population-level outcomes including: (a) sustaining collaborative efforts toward health improvement; (b) generating spin-off projects; and (c) achieving systemic transformations. Conclusion These results add to other studies on improving the science of CBPR in partnerships with a high level of power-sharing and co-governance. Our results suggest sustaining CBPR and achieving unanticipated benefits likely depend on trust-related mechanisms and a continuing commitment to power-sharing. These findings have implications for building successful CBPR partnerships to address challenging public health problems and the complex assessment of outcomes. Electronic supplementary material The online version of this article (doi:10.1186/s12889-015-1949-1) contains supplementary material, which is available to authorized users.

Community intervention trials in high-income countries. This chapter summarizes results of combined mass media and community organizing methods used and evaluated during the past 40 years to achieve chronic disease prevention through changes in behaviour and risk factors. These studies are examples of experimental epidemiology and community-based participatory research, using cost-effective health promotion methods. The chapter also reviews earlier experiences in public screening, immunization, family planning, HIV/AIDS, and tobacco control, which provided useful theory and methods on which the later trials built. Major advances in theory development and intervention methods occurred in the 1970s from two pioneering community intervention projects on cardiovascular disease prevention from Stanford (USA) and Finland. These projects, followed in the 1980s and beyond in North America, Europe, Australia, and elsewhere, added many major lessons in both theory and practice. These lessons, considered ‘operational imperatives’, are: economic, social normative (or ‘denormalization’), informed electorate, public health, surveillance, comprehensiveness, formative, ecological, and logical sequencing of needs and action. Therefore, these recent decades of applying ‘total community’ health promotion in developed countries achieved considerable change at reasonable cost. Such communities were changed greatly through organizing and education; changes requiring advocacy, activism, partnership building, leadership, and regulations. This results in community transformation, creating ‘community efficacy’, a composite of enhanced self-efficacy of the community’s residents and leaders. Such transformed communities, as models, allow leverage in disseminating methods, including regulatory tactics. Such dissemination can lead to national changes analogous to those of the recent decade’s tobacco control successes.

Efforts at reducing tobacco use in the United States and Canada over the last half century have been amazingly successful. This article examines those efforts in order to identify policies, programs, and practices found useful in tobacco control that might be usefully disseminated to world populations to improve rates of physical activity. Tobacco-control activities began with efforts to influence the individual smoker through public education and counter-advertising. Increasing awareness of the addictive properties of tobacco, industry efforts to manipulate those properties, and to target youth with aggressive advertising, fueled public outrage that supported additional policy changes to include community interventions, legal actions, and restraints against the tobacco industry. The article first examines ways to view the process of transferring knowledge from one enterprise (reducing tobacco consumption) to another (increasing physical activity). Several theories of knowledge generalization and dissemination are explored: transfer, knowledge utilization, application, diffusion, and implementation. The second section identifies the dissemination of tobacco control by means of brief health behavior-change interventions for smoking cessation that have been successfully integrated into primary clinical care. The question of whether similar strategies can be successfully disseminated to increase physical activity is examined in detail. The article then moves on to look at the success of arguably the most successful program in the world at achieving a reduction in tobacco control-the State of California. Finally, we compare and contrast some of the lessons as they have played out in another national context-Canada. In the concluding section, some lessons are identified that we believe may be successfully utilized in societal attempts to increase physical activity in world populations.

Because the Centers for Disease Control and Prevention (CDC) already assisted state tobacco control initiatives, many state health departments turned to CDC for guid-ance on how to use Master Settlement Agreement mon-ies. This article describes how CDC funded participa-tory research to establish local evidence and provided technical assistance for participatory program evalua-tion. 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: con-tinuity, timeliness, flexibility, clear and explicit expec-tations, appropriate and instructive accountability, creation of a vision for participatory research, tailored technical assistance, and enhancement of partner col-laboration and support. These findings are being used to inform CDC’s research funding. Meanwhile, userdriven technical assistance for participatory evaluation is being accessed by many states.

Introduction. Although there is general agreement about the complex interplay among individual-, family-, organizational-, and community-level factors as they influence health outcomes, there is still a gap between health promotion research and practice. The authors suggest that a disjuncture exists between the multiple theories and models of health promotion and the practitioner's need for a more unified set of guidelines for comprehensive planning of programs. Therefore, we put forward in this paper an idea toward closing the gap between research and practice, a case for developing an overarching framework—with several health promotion models that could integrate existing theories—and applying it to comprehensive health promotion strategy. An Integrative Framework. We outline a theoretical foundation for future health promotion research and practice that integrates four models: the social ecology; the Life Course Health Development; the Predisposing, Reinforcing, and Enabling Constructs in Educational/Environmental Diagnosis and Evaluation–Policy, Regulatory and Organizational Constructs in Educational and Environmental Development; and the community partnering models. The first three models are well developed and complementary. There is little consensus on the latter model, community partnering. However, we suggest that such a model is a vital part of an overall framework, and we present an approach to reconciling theoretical tensions among researchers and practitioners involved in community health promotion. Integrating the Models: The Need for Systems Theory and Thinking. Systems theory has been relatively ignored both by the health promotion field and, more generally, by the health services. We make a case for greater use of systems theory in the development of an overall framework, both to improve integration and to incorporate key concepts from the diverse systems literatures of other disciplines. Vision for Healthy Communities. (1) Researchers and practitioners understand the complex interplay among individual-, family-, organizational-, and community-level factors as they influence population health; (2) health promotion researchers and practitioners collaborate effectively with others in the community to create integrated strategies that work as a system to address a wide array of health-related factors; (3) The Healthy People Objectives for the Nation includes balanced indicators to reflect health promotion realities and research-measures effects on all levels; (4) the gap between community health promotion “best practices” guidelines and the way things work in the everyday world of health promotion practice has been substantially closed. Conclusions and Recommendations. We suggest critical next steps toward closing the gap between health promotion research and practice: investing in networks that promote, support, and sustain ongoing dialogue and sharing of experience; finding common ground in an approach to community partnering; and gaining consensus on the proposed integrating framework.

Background and Purpose— Carotid endarterectomy is an effective method for preventing strokes if patients do not suffer adverse perioperative outcomes. The purpose of this study was to identify preoperative patient risk factors for adverse outcomes (death or nonfatal stroke) after carotid endarterectomy through the use of a large population-based registry from Ontario, Canada. Methods— Medical records of all 6038 patients who underwent carotid endarterectomy in Ontario between January 1, 1994, and December 31, 1997, were abstracted from 34 hospitals. Patient characteristics (demographic data, past medical history, neurological symptoms, comorbidities, radiological findings) and 30-day postoperative death or stroke rates were analyzed with logistic regression analysis. Results— The overall 30-day death or stroke rate after surgery was 6.0%. A history of transient ischemic attack or stroke (odds ratio [OR], 1.75; 95% confidence interval [CI], 1.39 to 2.20), atrial fibrillation (OR, 1.89; 95% CI, 1.29 to 2.76), contralateral carotid occlusion (OR, 1.72; 95% C.I., 1.25 to 2.38), congestive heart failure (OR, 1.80; 95% CI, 1.15 to 2.81), and diabetes (OR, 1.28; 95% CI, 1.01 to 1.63) were significant independent predictors for 30-day death or stroke. These 5 factors were combined into a simple risk score that can be used to stratify patients into different risk groups for complications after surgery. Conclusions— Several patient characteristics predict the development of stroke and death after carotid endarterectomy. These characteristics may help clinicians in patient counseling and contribute to studies “benchmarking” the outcomes of carotid surgery in the community setting.

Objective To develop a theoretical framework of youth empowerment in the context of a participatory community health promotion intervention, a longitudinal qualitative study was conducted. Methods Individual and group interviews, documents, and observations were analyzed using the constant comparative method and theoretical sampling. Results Practitioners created an environment conducive to adolescents' taking responsibility for their quality-of-life issues by welcoming and enabling youth. Power was transferred to youth as responsibility for voicing, decision making, and action. This led to positive changes in youth development and their social integration into community. Conclusion Empowerment emerged as a transactional partnering process between adults and youth.

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.

Ever the optimists (if not positivists), we continue to look to research to vindicate community health strategies in relation to chronic diseases, complex lifestyle changes and social problems, as they were vindicated in earlier decades against communicable diseases. If we had vaccines to deliver against chronic diseases and substance abuse behaviors, perhaps this hopefulness would be justified. The paper by Hallfors et al. in this issue of the AJPM describes an evaluation of the “Fighting Back” substance abuse initiative supported by the Robert Wood Johnson (RWJ) Foundation. They examined the extent to which coalitions attained selected substance abuse goals in 12 “Fighting Back” communities on which they tracked a variety of indicators through much of the 1990s. They employed a prospective design with multiple comparison communities for each coalition community, quantitative and qualitative methods, and thousands of interviews and observations. Despite all these strengths, lending credibility to the authors’ conclusions, some conceptual and methodologic limitations raise the usual doubts that follow randomized and otherwise controlled community trials, especially when they attempt to isolate one component of complex interventions as a causal explanation for success or failure. Other commentaries and analyses have grappled with the methodologic limitations and pitfalls of such research for purposes of studying community-wide interventions or interventions in communities evaluated at the community level. Some have called specifically into question the limitations of “traditional scientific methodology. . .to capture the outcomes of these complex collaborative organizations” called community coalitions. Others have addressed the problem of unrealistic expectations of community strategies in the short term. Our commentary will address some of the conceptual and procedural issues in understanding community coalitions, best practices, and their evaluation in communities. These are not entirely independent of methodological issues of evaluation, but we believe that we must know what we are attempting to measure and evaluate before we can make strategic and scientific decisions on how best to do so. We will comment, then, on two aspects of the evaluation: (1) the complexity-of-interventions issue in evaluating Fighting Back and the isolation of community coalitions as the common starting point in what became widely varied programs across the communities, and (2) the inflated expectations that follow from isolating community coalitions as the independent variable.

This paper presents the evaluation of a participatory research process used in a community-based heart health project, the British Columbia Heart Health Demonstration Project. The project utilized both a population heart health approach and a community mobilization model for taking action on heart health. A participatory evaluation plan was selected to: allow for participation in decision-making, incorporate the community perspective, enhance utilization of data, increase skills and capacities at the community level and enhance the responsiveness of the project team to emerging issues. Six elements common to participatory research were synthesized from the literature and rating scales were developed. Project participants across three project levels (investigative team, community project management committee members, community and provincial project coordinators) were asked to rate each of the elements and then explain their ratings during a focus group interview. Ratings were averaged and plotted on a 'sextagram' to illustrate the extent of participation in the research project. Patterns and themes that emerged from the transcripts and fieldnotes, regarding issues that influenced each rating, were categorized according to the framework of participatory research. Ratings and descriptions of participation on each element varied across project levels. The ratings of participation for the elements of sustainability and resource mobilization were uniformly low reflecting the large dependence on external funds. Participants involved at the community level perceived a greater level of participation in the identification of need and definition of goals and activities. Critical issues identified were related to the predominance of the external funding source, the imposition of funding agency guidelines on the communities, the amount of guidance by experts and the data collection methods. The analysis highlighted the responsiveness of the project to feedback over time and increases in the capacity of communities over time. Critical issues in the evaluation of participation were: differentiating stakeholder participation in program activities from research activities, variations in the meaning of community and participation among interviewees, the complexity of evaluating the extent of participation in a multi-level project and the evolution of participation over a 5 year time span. A definitive conclusion about the level of participation was elusive, however, the methodology afforded a contextual understanding of the assessments of participation and of participation itself and provides a foundation for evaluating and improving future participatory research initiatives.

The researchers used grounded theory methodology to study the implementation of a school-based alcohol and drug prevention project in secondary schools in British Columbia, Canada. Preventionworkers (PWs) were responsible for working with school and community personnel in a collaborative process to develop, implement, and evaluate prevention strategies in the school using an adaptation of the Precede-Proceed Model for health promotion planning. Before they could begin to do this, PWs had to establish their credibility in the school. Once accepted, the focus of the PWs’workwas to reconcile the goals, values, and philosophy of the project with those of the school. In doing so, PWs encountered many practical dilemmas. The challenges in resolving these dilemmas are presented, and the implications for policy and practice are discussed.

Objectives This paper investigates changes in the psychosocial and physical work conditions of the sawmill industry in British Columbia, Canada, over the past 35 years. Methods Shifts in work conditions were examined within the context of historical changes in sawmill labor demography and job taxonomy as the industry was both downsized and restructured, largely in response to an economic recession in the early 1980s. Results and conclusions Downsizing eliminated approximately 60% of the work force and 1/4 of sawmill job titles. Although all the job categories in restructured sawmills showed increased levels of control, the gradient in control across job categories was steeper in 1997 than in 1965; this change may have important health implications particularly for the unskilled workers in the restructured mills.