The ability to understand and incorporate evidence into practice is a public health core competency in Ontario (1), Canada (2), the United States (3), and elsewhere (4) and is considered a key component of public health training (5). Nonetheless, it remains difficult to achieve and is inadequately supported by existing tools and processes (6).

Several approaches have been used to facilitate use of evidence, such as organizational diagnostic tools (7), measures of knowledge exchange outcomes (8), online tool kits and guides (9,10), and critically appraised evidence collections such as the Guide to Community Preventive Services (www.thecommunityguide.org) in the United States, and Health-evidence.ca (www.health-evidence.ca) and the Canadian Best Practices Portal in Health Promotion and Chronic Disease Prevention (http://cbpp-pcpe.phac-aspc.gc.ca/) in Canada.

Despite these supports, community-based practitioners face multiple challenges using evidence. For example, relevant evidence may not be available or readily accessible; skills, time and resources may be lacking; and organizational infrastructure may not facilitate knowledge exchange (11,12). Adapting interventions to the local context (11,13) remains a challenge despite the use of adaptation guidelines (14,15), and very few practical, context-sensitive evaluations are available in the published literature (16). As a result, there is a need to look at broader definitions of evidence, including evaluations, prior experience, and stakeholder opinion (17).

Toward Evidence-Informed Practice (TEIP) is a set of tools developed at the Ontario Public Health Association to facilitate the use of relevant evidence in community-based health promotion and chronic disease prevention. TEIP tools recognize the high level of engagement required among researchers, decision makers, and local stakeholders, as well as the need to build supports and overcome organizational barriers to facilitate the use of evidence.

A Program Assessment Tool has been developed to identify strengths and areas for improvement in the planning and implementation of local chronic disease prevention programs (18). A review of 22 community-level program assessments showed that most interventions were not informed by relevant theory and research. Practitioners expressed the need for a step-by-step resource that would assist them in identifying and using evidence for program planning. The result was the Program Evidence Tool.

The Program Evidence Tool consists of a set of guidelines and worksheets that provide step-by-step support in identifying and applying relevant sources of evidence to strengthen local chronic disease prevention programming. The tool aims to balance scientific rigor with the needs and challenges of evidence use at the local level. Existing models of evidence use (6,10,19–24) were reviewed, and an advisory committee consisting of public health practitioners and knowledge-exchange researchers was formed.

The Program Evidence Tool (available upon request from the authors) consists of 5 steps: 1) define evidence question, 2) develop search strategy, 3) collect and synthesize evidence, 4) interpret and adapt evidence, and 5) implement and evaluate.

In 2008, the Program Evidence Tool was used to conduct 12 evidence searches by local community partnerships affiliated with 4 small to midsize regional public health departments. None were formally connected to academic institutions, and access to literature was limited to abstracts via PubMed, public-access journals, and online resources. One of the 4 organizations had support from an in-house librarian. Examples of initiatives for applying the tool included the following: a workplace wellness program, a school-based heart-health program, an initiative to link public health and municipal planners for the purpose of building healthy communities, and a nutrition education and cooking program for low-income women with young children.

The paragraphs below describe an example of using the Program Evidence Tool at a small, mainly rural public health department. The program selected for the evidence search was an initiative to provide a slow cooker and cooking classes featuring inexpensive slow-cooker recipes to low-income women with young children. The program was embraced by a public health nurse who wanted to address a need she saw in her community. A dietitian participated in the nutrition education aspect of the program. Health department management objected to the high cost of the program and wanted to discontinue it.

The evidence question originally proposed was “Is the use of slow cookers in a nutrition education and cooking class an effective way to improve the nutrition of low-income families with young children?” Working through Step 1, it became apparent that the focus of the original question was too narrow, and, after much discussion, the team realized they needed to address the broader issue of food security. The evidence question evolved to “What approaches are effective in building food security among low-income families with young children?” During the evidence search, the team found the most practical evidence in the gray literature. This literature included position papers on the effectiveness of community food security initiatives by Dietitians of Canada, publications from several health units that have been leaders in addressing local food security issues, and reports from the provincial and federal governments.

The content advisor selected by the team was a public health practitioner recognized as a leader in addressing food security in Ontario. She provided many useful sources of evidence and shared her experience of shifting the culture of her health department toward active engagement in local food security issues.

To obtain input from informed colleagues, a listserv request for information was disseminated across Ontario. Several useful responses detailed local experiences and reference lists. Because of inadequate local capacity, a researcher was hired to assist with completing the evidence collection worksheet and the evidence synthesis worksheet and with facilitating the evidence forum.

Participants at the evidence forum included the program manager, public health nurse, dietitian, content expert, consultant, and a representative from the Ontario Public Health Association. The group worked through seemingly contradictory evidence on whether community access to food security programs should be universal or targeted at the more marginalized subpopulations, opting for universal food delivery and targeted social support.

A major shift occurred in the group’s work when participants realized their organizational culture was part of the problem. The more they learned about food security through the evidence, the more they recognized the need for an organizational education initiative. They envisioned a 3-year plan, beginning with inviting guest speakers to educate their organization about food security. In the medium term, they planned to modify their programming to empower clients to become involved in program planning and to develop peer leaders. In the longer term, they planned to reach out to local social service agencies on joint community food security initiatives.

Use of the Program Evidence Tool transformed the vision of the participants and led to an ambitious plan to change the culture of their organization. Gray literature, content advisors, and informed colleagues were the most useful sources of evidence in this case. Management was impressed by the quality of the evidence collected and began to see links between the goals of community food security and requirements within the new Ontario Public Health Standards (1) to address the needs of people living in poverty.

Using the Program Evidence Tool presented some challenges to the public health practitioners involved in the 4 health departments that tested the tools. Finding time to complete the steps was difficult because this work had to be completed in addition to handling a full workload of regular activities. Some groups spent several weeks settling on a final evidence question. Challenges were also in identifying and organizing the evidence. Much support was needed to do these tasks, mostly from a consultant or graduate student.

Organizational and contextual challenges were also evident. For example, community partnerships were challenged by insufficient time, limited organizational capacity and resources, and varied support from upper management in implementing evidence-informed recommendations. To overcome these challenges support for capacity building from the TEIP facilitator was provided. Strategies, such as train-the-trainer workshops, were developed subsequent to the pilot-testing phase, to address the identified need to build local capacity.

Public health practitioners using the Program Evidence Tool reported many benefits. These benefits were felt at the individual and program/organizational levels. At the individual level, reported outcomes included an increase in individual capacity development, especially as it pertained to knowledge and skills enhancement for the use of evidence. Users felt more competent in using research evidence and learned innovative approaches to health promotion and public health program planning. In addition, participants felt they gained awareness of and access to existing resources to support their work in public health. They recognized the benefit of connecting with a content expert and gained confidence in developing such a relationship.

At the program/organization level, many benefits for program planning and implementation were identified. Overall, participants felt they received increased support, especially from their managers, either in the expansion or in the continuation of their programs. Practitioners indicated that the Program Evidence Tool provided a way to review and systematically assess relevant evidence in their area of interest, which resulted in improved decision making and program planning.

Chronic disease prevention programs are influenced by various social, political, and structural factors. Evidence is needed that is not only valid and robust but also contextual and practical (16,26). The Program Evidence Tool supports use of a wide range of evidence sources, including randomized studies, needs assessments, local evaluations, and stakeholder opinion. Providing a tool through which varied sources of evidence can be considered allows for multiple viewpoints and empowers practitioners to make informed decisions about the programs they deliver.

Once the appropriate evidence has been identified, the next step is how to apply it in making informed decisions in public health practice. The quality of the evidence found must be considered, assumptions must be made explicit, and the decision-making process must be transparent (10). In the pilot test, users found that the Program Evidence Tool offered a capacity-building process to guide the selection and interpretation of evidence and promote an interactive process to enable “sense making” and appropriate use of evidence. The dialogue that resulted from the evidence forum was neither straightforward nor simplistic. Groups had to make decisions amid conflicting evidence, too much evidence, or not enough evidence. Much of the program-planning decisions could not be made on evidence alone, but rather on evidence combined with the knowledge and expertise of all stakeholders involved, promoting a 3-way dialogue between health promoters, researchers, and community stakeholders.

Public health practitioners must be skilled in identifying and applying relevant evidence to community-based programs to have a positive impact on the health of populations. The Program Evidence Tool provides a practical set of guidelines and worksheets to achieve this goal. The tool captures a wide range of evidence that is pertinent to practitioners. Use of the Tool facilitates an opportunity to debate and reflect on available evidence and contributes to program development that is supported and inspired by different forms of evidence and multiple viewpoints. The process acknowledges the expertise and experience of local chronic disease prevention practitioners in making decisions to improve their programs and the health of their communities.