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Chronic Disease Program Planning in Public Health: What's the Evidence

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Presented as part of a Canadian Institutes of Health funded Meetings, Planning & Dissemination grant (4 of 4 webinars). Recorded February 23, 2012.

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Chronic Disease Program Planning in Public Health: What's the Evidence

  1. 1. This webinar has been made possible with support from the Canadian Institutes of Health Research Welcome! Chronic Disease Program Planning:Discussing Review- Level Evidence You will be placed on hold until the webinar begins.The webinar will begin shortly, please remain on the line.
  2. 2. What’s the evidence? Booth, M., O’Brodovich, H., Finegood, D. (2004). Addressing childhood obesity: The evidence for action. Ottawa, ON: Canadian Institutes of Health Research, Institute of Nutrition, Metabolism and Diabetes. Shiell, A., Spilchak, P., Ladhani, N., Hawe, P., Lorenzetti, D. (2008). A systematic review of population health approaches to prevent type II diabetes: Report to the Public Health Agency of Canada. Calgary, AB: Population Health Intervention Research Centre (PHIRC). O’Brien, K., Nixon, S., Tynan, A.M., Glazier, R.H. (2010). Aerobic exercise interventions for adults living with HIV/AIDS. Cochrane Database of Systematic Reviews, Issue 8, Art. No.: CD001796. Farmer, A.P., Legare, F., Grimshaw, J., Harvey, E., McGowan, J.L., et al. (2008). Printed educational materials: Effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews, Issue 3, Art. No.: CD004398.
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  5. 5. This webinar has been made possible with support from the Canadian Institutes of Health Research Welcome! Chronic Disease Program Planning:Discussing Review- Level Evidence You will be placed on hold until the webinar begins.The webinar will begin shortly, please remain on the line.
  6. 6. The Health Evidence TeamMaureen Dobbins Kara DeCorby Daiva TirilisScientific Director Administrative Director Research CoordinatorTel: 905 525-9140 ext 22481 Tel: (905) 525-9140 ext. 20461 Tel: (905) 525-9140 ext. 20460E-mail: dobbinsm@mcmaster.ca E-mail: kdecorby@health-evidence.ca E-mail: dtirilis@health-evidence.caLori Greco Heather Husson Robyn Traynor Lyndsey McRaeKnowledge Broker Project Manager Research Coordinator Research Assistant
  7. 7. What is www.health-evidence.ca? Evidence inform Decision Making
  8. 8. Why use www.health-evidence.ca? 1. Saves you time 2. Relevant & current evidence 3. Transparent process 4. Supports for EIDM available 5. Easy to use
  9. 9. Meetings, Planning &Dissemination Project CIHR Funded MOP-238541
  10. 10. CIHR-Funded Reviews Booth, M., O’Brodovich, H., Finegood, D. (2004). Addressing childhood obesity: The evidence for action. Ottawa, ON: Canadian Institutes of Health Research, Institute of Nutrition, Metabolism and Diabetes. Shiell, A., Spilchak, P., Ladhani, N., Hawe, P., Lorenzetti, D. (2008). A systematic review of population health approaches to prevent type II diabetes: Report to the Public Health Agency of Canada. Calgary, AB: Population Health Intervention Research Centre (PHIRC). O’Brien, K., Nixon, S., Tynan, A.M., Glazier, R.H. (2010). Aerobic exercise interventions for adults living with HIV/AIDS. Cochrane Database of Systematic Reviews, Issue 8, Art. No.: CD001796. Farmer, A.P., Legare, F., Grimshaw, J., Harvey, E., McGowan, J.L., et al. (2008). Printed educational materials: Effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews, Issue 3, Art. No.: CD004398.
  11. 11. Evaluation Please check your email for the evaluation survey link after the webinar. It take 5 minutes to complete!If you’ve been watching with someone else and did not personally register for the webinar, please e-mail Jennifer McGugan at mcgugj@mcmaster.ca to be sent the survey.
  12. 12. Questions?
  13. 13. Summary Statement:Booth (2004)
  14. 14. Overall Considerations Considerations for Public Health Practice Conclusions from Health Evidence General ImplicationsInterventions that showed improvement in Public health should support:obesity outcomes promoted: • programs that focus on diet + exercise• consumption of a healthier diet plus • physical activity behavior change and dietary exercise (vs. diet only) change interventions for school children• increased physical activity in and out-of- • behavior modification with both diet and school physical activity strategies• healthier diet among school-aged children• behaviour modification strategies alongside Due to a current lack of evidence, public health strategies to improve diet and physical programs should not include: activity • a focus on specific elements of dietary interventionsEvidence is not conclusive enough to support: • dietary interventions for pre-school aged• dietary interventions children or minorities• dietary change interventions for preschool- • reinforcement after obesity treatment aged children or minorities • a focus on modifying factors including age,• reinforcement after obesity treatment setting, duration, or initial weight, as a way• modifying factors (age, duration, etc.) to modify obesity outcomes
  15. 15. Overall Considerations Considerations for Public Health Practice Conclusions from Health Evidence General ImplicationsNo impact on obesity outcomes were Due to a lack of effectiveness, public healthobserved for interventions on: should also avoid focus on:• dietary change • cardiovascular risk factor interventions to• cardiovascular risk factor reduction modify obesity outcomes• primary prevention programs for obesity • primary prevention programs for obesity• lifestyle exercise strategies • lifestyle exercise programs• parental involvement No current evidence to inform how publicNo review-level evidence was identified to health should address obesity treatment inaddress treatment of obesity in minority minority groups, and programs for these groupsgroups. should be evaluated and evaluations shared.
  16. 16. Interpreting the EvidencePrevention of obesity (6 SR including 34 studies + 6 narrativereviews; mostly low to moderate quality) What’s the evidence? Implications for practice & policyNo impact of obesity OR cardiovascular • Public health decision makers should notprevention interventions on adiposity rely on either obesity prevention or• Systematic review evidence (4 reviews for cardiovascular prevention programs for which citation analysis was possible): does decreasing adiposity, given the current not support obesity prevention programs evidence from both systematic and (i.e. several school-based) for the reduction narrative reviews. of adiposity. (7/26 studies identified a reduction in adiposity)• Systematic review evidence (1 review – 16 studies): Cardiovascular prevention programs were not effective in decreasing adiposity (7/77 showed a positive impact).• Narrative review evidence (6 reviews): insufficient evidence for obesity prevention as an adiposity reduction measure.
  17. 17. Interpreting the EvidenceDiet vs. Diet and Exercise (5 reviews) What’s the evidence? Implications for practice & policy• Exercise programs combined with a dietary • Public Health decision makers should intervention offered some improvement in promote diet and exercise together (as adiposity (6 of 10 studies); however the opposed to diet alone) for the secondary extent to which benefits are sustained in prevention of obesity, and evaluate whether long term is unclear) long-term benefits are realized.
  18. 18. Interpreting the EvidenceDietary Interventions (1 meta-analysis (17 studies) + 1 reviewof a single study) What’s the evidence? Implications for practice & policy• No impact of specific elements of dietary • Based on two SRs of fair quality, there is interventions on weight loss. insufficient evidence to recommend any specific elements of dietary interventions for obesity reduction.
  19. 19. Interpreting the EvidencePhysical Activity (PA) Behaviour Change (8 reviews) What’s the evidence? Implications for practice & policy• PA during school hours – high quality • Public health should promote PA behaviour review evidence (4 reviews) shows that change interventions to increase PA during school-based interventions are effective in school hours. Programs should be evaluated increasing PA during school hours. to determine whether PA outside school• PA outside school hours – there is some hours is increased. (mixed) evidence that school-based • Evaluations conducted by public health interventions increase PA outside school should ideally include long-term follow up hours. into adulthood.
  20. 20. Interpreting the EvidenceStrategies to promote dietary change (7 SR + 5 narrativereviews; analysis according to behaviour change model) What’s the evidence? Implications for practice & policy• Preschool children: 7/10 studies in 2 SRs • Public health should not rely on either offer mixed evidence that does not behavioural or knowledge-based conclusively support specific behavioural or approaches to improve preschool children’s knowledge-based strategies to change food- dietary behaviour. related behaviour (e.g. touch/smell/taste • Public health should use and evaluate new foods, modeling, repeated exposures) behaviourally-based approaches to improve• School-based: 42/59 studies in 6 reviews dietary behaviour in school-based programs. showed some improvement in dietary • Public health should evaluate efforts to behaviour that was more closely attributed improve dietary behaviour in minority to behaviourally-based approaches rather populations in order to contribute to the than knowledge-based approaches. evidence base available. Descriptions of strategies are not provided.• Minority Populations: 1 low-quality review offered no definitive conclusions that dietary interventions are effective.
  21. 21. Interpreting the EvidenceStrategies Lifestyle Exercise Strategies (3 reviews citing thesame 3 studies + 1 meta-analysis) What’s the evidence? Implications for practice & policy• Lifestyle exercise was distinct from other • Public Health decision makers should not exercise programs in that it (1) includes rely on lifestyle exercise to decrease activities of daily living, (2) includes caloric childhood obesity. However, public health expenditure in small increments throughout should consider other possible benefits to the day, and (3) no prescribed intensity. be derived from the promotion of lifestyle• No impact on childhood obesity compared exercise. to either no exercise or other exercise, based on the meta-analysis incorporating the widest range of evidence.
  22. 22. Interpreting the EvidenceParental Involvement (4 reviews (13 studies) + 1 meta-analysis) What’s the evidence? Implications for practice & policy• Parental involvement interventions varied, • Public health should not focus on parental with only one study directed solely at involvement strategies as a way to improve parents. A range of interventions were childhood obesity treatment. aimed at both children and parents to varying degrees. Intervention elements are not well described; but tend to be family- oriented and include homework assignments, and parents motivating their children.• No impact on childhood obesity treatment, even though there is good evidence in this topic area
  23. 23. Interpreting the EvidenceBehaviour Modification Strategies (2 reviews of 9 studies + 1meta-analysis) What’s the evidence? Implications for practice & policy• Little information provided regarding the • Behaviour modification strategies should be nature of behaviour modification strategies considered for use with dietary and physical used. activity interventions, and ideally with all• Improvement in obesity status when three strategies combined, in aiming to behaviour modification strategies were used improve obesity status. with dietary and physical activity strategies • Public health should not focus on self- in the short-term. Behaviour modification, control training as an additional strategy for dietary AND physical activity strategies reducing obesity in children. together demonstrated greater treatment effect than behaviour modification and either dietary or PA.• No impact of additional or “add-on” self- control training on obesity status.
  24. 24. Interpreting the EvidenceReinforcement (1 review) What’s the evidence? Implications for practice & policy• A single, small (15 subjects) study of fair • There is limited evidence at this time to quality in one review showed that periodic support the provision of reinforcement reinforcement after obesity treatment following obesity treatment programs enhanced weight loss
  25. 25. Interpreting the EvidenceFactors Influencing Obesity Prevention What’s the evidence? Implications for practice & policy• There is a very limited evidence examining • Based on evidence available at this time, the effect of setting, duration of treatment public health should not focus on modifying and initial weight status upon which to factors such as: setting, duration of assess the impact on obesity outcomes. treatment, age, and initial weight status to improve obesity outcomes. It is possible that relationships between these factors and obesity may exist; however, they are unclear at this time.
  26. 26. Overall Considerations Considerations for Public Health Practice Conclusions from Health Evidence General ImplicationsInterventions that showed improvement in Public health should support:obesity outcomes promoted: • programs that focus on diet + exercise• consumption of a healthier diet plus • physical activity behavior change and dietary exercise (vs. diet only) change interventions for school children• increased physical activity in and out-of- • behavior modification with both diet and school physical activity strategies• healthier diet among school-aged children• behaviour modification strategies alongside Due to a current lack of evidence, public health strategies to improve diet and physical programs should not include: activity • a focus on specific elements of dietary interventionsEvidence is not conclusive enough to support: • dietary interventions for pre-school aged• dietary interventions children or minorities• dietary change interventions for preschool- • reinforcement after obesity treatment aged children or minorities • a focus on modifying factors including age,• reinforcement after obesity treatment setting, duration, or initial weight, as a way• modifying factors (age, duration, etc.) to modify obesity outcomes
  27. 27. Overall Considerations Considerations for Public Health Practice Conclusions from Health Evidence General ImplicationsNo impact on obesity outcomes were Due to a lack of effectiveness, public healthobserved for interventions on: should also avoid focus on:• dietary change • cardiovascular risk factor interventions to• cardiovascular risk factor reduction modify obesity outcomes• primary prevention programs for obesity • primary prevention programs for obesity• lifestyle exercise strategies • lifestyle exercise programs• parental involvement No current evidence to inform how publicNo review-level evidence was identified to health should address obesity treatment inaddress treatment of obesity in minority minority groups, and programs for these groupsgroups. should be evaluated and evaluations shared.
  28. 28. Questions?
  29. 29. Summary Statement:Shiell (2008)
  30. 30. Overall Considerations Considerations for Public Health Practice Conclusions from Health Evidence General ImplicationsSchool-based interventions led to: The most current, rigorous evidence does not• no effects on physical activity, nutrition, BMI, support school-based interventions to reduce fruit and vegetable intake, energy from fat, Type II diabetes or its risk factors. Findings from total serum cholesterol, and VO2 Max less rigorous studies do support the use of (rigorous studies) school-based interventions.• improvements in triglycerides, physical activity, systolic and diastolic blood Community-based interventions are currently pressure, percentage body fat, smaller recommended for increasing physical activity. increase in BMI, and waist circumference among boys Worksite-based interventions are suggested for increasing smoking cessation rates.Community-based interventions led to:• increase in self-reported physical activity There is limited, good quality evidence. Results should be applied cautiously to public healthWorksite-based interventions led to: practice, and any associated public health• increase in smoking cessation rates programs need to evaluate the impact of these interventions.
  31. 31. Interpreting the EvidenceSchool-based interventions (5 RCTs of high quality, 6 quasi-experimental of moderate quality) What’s the evidence? Implications for practice & policyAmong studies of moderate methodological • Given evidence is mixed (rigorous studiesquality, a statistically significant impact was generally report no effect, lower qualityobserved on: studies report significant effects), school-• Triglycerides, blood pressure, percentage based interventions may not be an effective body fat, participation in rigorous physical public health strategy for reducing Type II activity, waist circumference, and(less of an diabetes and its risk factors. increase in BMI compared to usual care. • Given some interventions affect boys and• Some effects observed among girls only and girls differently, careful consideration of the others among boys only. different facilitators and barriers to physical activity among boys and girls is needed, ifAmong the most rigorous studies: these interventions are implemented.• No impact on physical activity, diet, total serum cholesterol,VO2 Max, or BMI.
  32. 32. Interpreting the EvidenceCommunity-based interventions (1 study; moderate quality) What’s the evidence? Implications for practice & policy• One studies of moderate methodological • Community-based interventions are quality, statistically significant impact was supported for increasing physical activity. observed on self-reported physical activity. Results should be interpreted cautiously as physical activity was measured through self- report, which may overestimate the true treatment effect. • These findings must be re-evaluated as more rigorous evidence emerges.
  33. 33. Interpreting the EvidenceWorksite-based interventions (1 study; moderate quality) What’s the evidence? Implications for practice & policy• One study of moderate methodological • Worksite-based interventions are quality found a statistically significant recommended for increasing smoking increase in smoking cessation rate (OR 1.38; cessation rates. 95% CI 1.05-1.81). • These findings must be re-evaluated as more rigorous evidence emerges.
  34. 34. Overall Considerations Considerations for Public Health Practice Conclusions from Health Evidence General ImplicationsSchool-based interventions led to: The most current, rigorous evidence does not• no effects on physical activity, nutrition, BMI, support school-based interventions to reduce fruit and vegetable intake, energy from fat, Type II diabetes or its risk factors. Findings from total serum cholesterol, and VO2 Max less rigorous studies do support the use of (rigorous studies) school-based interventions.• improvements in triglycerides, physical activity, systolic and diastolic blood Community-based interventions are currently pressure, percentage body fat, smaller recommended for increasing physical activity. increase in BMI, and waist circumference among boys Worksite-based interventions are suggested for increasing smoking cessation rates.Community-based interventions led to:• increase in self-reported physical activity There is limited, good quality evidence. Results should be applied cautiously to public healthWorksite-based interventions led to: practice, and any associated public health• increase in smoking cessation rates programs need to evaluate the impact of these interventions.
  35. 35. Questions?
  36. 36. Summary Statement:O’Brien (2010)
  37. 37. Overall Considerations Considerations for Public Health Practice Conclusions from Health Evidence General ImplicationsImmunologic/virologic The overall findings suggest that:• significant impact on CD4 count (interval • the promotion of aerobic exercise, while aerobic exercisers) resulting in improvements for a small• no impact: CD4 count, CD4%, and viral number of outcomes, does not positively load (all other types of exercise) impact most outcomes, and may not be anCardiopulmonary effective public health strategy for this• improvement in VO2 Max population.• no impact: max. heart rate or exercise time • various formats of aerobic exercise did notStrength positively and significantly impact• improvements in strength (exercisers) immunologic/virologic outcomes, mostWeight and Body composition cardiopulmonary outcomes, and strength• decrease in body fat (aerobic exercisers) measures• increased change in leg muscle (aerobic • given improvements on VO2 Max, percent exercise plus progressive resistive training) body fat, and depression in HIV patients,• no change in body weight, BMI, waist or hip promotion of exercise may be supported circumference, waist-to-hip ratio, fat mass If implemented, the impact of aerobic exercisePsychological promotion on this population should be• improvement in depression-dejection evaluated within the local context.
  38. 38. Interpreting the EvidenceImmunologic/Virologic Outcomes (14 RCTs) What’s the evidence? Implications for practice & policy• A statistically significant impact on CD4 • Generally the evidence does not support count was observed in the interval aerobic public health allocating resources to group compared to non-exercisers (69.58 promote aerobic exercise among HIV cell/mm3, 95% CI, 14.08 – 125.09, P=0.01) (2 populations for the purpose of improving studies). CD4 count, CD4%, or viral load.• No impact on change in CD4 count, CD4%, and viral load for all other combinations of exercise versus no exercise.
  39. 39. Interpreting the EvidenceCardiopulmonary (14 RCTs) What’s the evidence? Implications for practice & policy• A statistically significant improvement in • Exercise promotion is supported as a public VO2 Max was observed among aerobic health intervention among HIV populations exercisers vs. non-exercisers (2.63 if improvements in VO2 Max are of greatest Ml/kg/min, 95% CI, 1.19 – 4.07); constant interest. aerobic exercisers vs. non-exercisers (2.40 • However, improvements in maximum heart Ml/kg/min, 95% CI 0.82-3.99); heavy rate and exercise time should not be intensity vs. moderate intensity (4.30 expected. Ml/kg/min, 95% CI 0.67 – 7.98).• No impact on maximum heart rate or exercise time.
  40. 40. Interpreting the EvidenceStrength (6 RCTs) What’s the evidence? Implications for practice & policy• Meta-analysis not conducted due to • While meta-analysis was not possible, the variation in strength measures. 5 of 6 evidence suggests that exercise promotion individual studies reported statistically is supported to achieve improved strength significant improvements in strength among HIV populations. measures between exercisers and non- exercisers.
  41. 41. Interpreting the EvidenceWeight and Body Composition (9 RCTs) What’s the evidence? Implications for practice & policy• Statistically significant decrease in percent • While the majority of outcomes related to body fat (-1.12%, 95% CI -2.18 to -0.07), weight and body composition were not increase in change in leg muscle area impacted by aerobic exercise, improvement (4.79cm2, 95% CI 2.04 to 7.54). in percent body fat suggests promotion of• No impact on change in mean body weight, aerobic exercise among HIV populations waist circumference, hip circumference, may be an important public health strategy. waist-to-hip ratio, change in body mass index, change in fat mass.
  42. 42. Interpreting the EvidencePsychological (9 RCTs) What’s the evidence? Implications for practice & policy• Statistically significant improvement in • The evidence suggests the promotion of depression-dejection scale in exercisers vs. aerobic exercise among HIV populations for non-exercisers (7.68, 95% CI -13.47 to improving depression-dejection measure. -1.90).
  43. 43. Overall Considerations Considerations for Public Health Practice Conclusions from Health Evidence General ImplicationsImmunologic/virologic The overall findings suggest that:• significant impact on CD4 count (interval • the promotion of aerobic exercise, while aerobic exercisers) resulting in improvements for a small• no impact: CD4 count, CD4%, and viral number of outcomes, does not positively load (all other types of exercise) impact most outcomes, and may not be anCardiopulmonary effective public health strategy for this• improvement in VO2 Max population.• no impact: max. heart rate or exercise time • various formats of aerobic exercise did notStrength positively and significantly impact• improvements in strength (exercisers) immunologic/virologic outcomes, mostWeight and Body composition cardiopulmonary outcomes, and strength• decrease in body fat (aerobic exercisers) measures• increased change in leg muscle (aerobic • given improvements on VO2 Max, percent exercise plus progressive resistive training) body fat, and depression in HIV patients,• no change in body weight, BMI, waist or hip promotion of exercise may be supported circumference, waist-to-hip ratio, fat mass If implemented, the impact of aerobic exercisePsychological promotion on this population should be• improvement in depression-dejection evaluated within the local context.
  44. 44. Questions?
  45. 45. Summary Statement:Farmer(2008)
  46. 46. Overall Considerations Considerations for Public Health Practice Conclusions from Health Evidence General ImplicationsPrinted educational materials (PEMs) compared to Currently available evidence does notno intervention led to: support the use of PEMs by public health as• small negative change in patient outcomes, with a means to improve both professional the effects being of limited clinical significance practice and patient outcomes.• no improvement in professional practice outcomes Decision makers may consider including a single intervention (e.g. educational PEMs as part of a multi-facetedworkshops or outreach) resulted in: intervention, although this will require• a small change in some professional practice and rigorous evaluation. patient outcomes• non-significant changes in continuous outcomes Although there is currently insufficient evidence related to the circumstances andNo studies were found comparing PEMs as part of a contexts in which PEMs work best, futuremultifaceted intervention to other multifaceted projects re-explore this literature ininterventions. planning PEM campaigns.Unable to determine specific circumstances andcontexts in which PEMs are most effective.
  47. 47. Interpreting the EvidencePEMs compared to no intervention (4 cluster randomizedtrials, 3 RCTs, 10 interrupted time series (ITS) studies) What’s the evidence? Implications for practice & policy• Small deterioration of patient outcomes across • Public health decision makers should not 3 studies (median standard ES -0.004 to - consider PEMs to improve professional 0.20), with uncertain clinical significance. practice.• No impact on professional practice outcomes • Given the impact of PEMs on patient for categorical process outcomes (e.g. x-ray outcomes was minimal at best, PEMs may requests, prescribing and smoking cessation not be an optimal use of public health activities) and continuous process outcomes resources. (e.g. medication change, x-rays requests per practice).
  48. 48. Interpreting the EvidencePEMs as one component of any intervention compared to asingle intervention (1 RCT) What’s the evidence? Implications for practice & policy• A single RCT showed a small positive impact • When using PEMs as one component of a on professional practice outcomes (median larger intervention, public health decision absolute risk difference 0.5 in favour of makers should not invest heavily in PEMs PEMs), with the 2 other trials reporting non- to improve professional practice OR significant effects. patient outcomes. However, the• A single RCT showed a small positive impact currently-available evidence is limited. on categorical patient outcomes for smoking cessation (median standardized effect -0.2%).• No impact on continuous patient outcomes (e.g. screening, return to work, quit smoking).
  49. 49. Overall Considerations Considerations for Public Health Practice Conclusions from Health Evidence General ImplicationsPrinted educational materials (PEMs) compared to Currently available evidence does notno intervention led to: support the use of PEMs by public health as• small negative change in patient outcomes, with a means to improve both professional the effects being of limited clinical significance practice and patient outcomes.• no improvement in professional practice outcomes Decision makers may consider including a single intervention (e.g. educational PEMs as part of a multi-facetedworkshops or outreach) resulted in: intervention, although this will require• a small change in some professional practice and rigorous evaluation. patient outcomes• non-significant changes in continuous outcomes Although there is currently insufficient evidence related to the circumstances andNo studies were found comparing PEMs as part of a contexts in which PEMs work best, futuremultifaceted intervention to other multifaceted projects re-explore this literature ininterventions. planning PEM campaigns.Unable to determine specific circumstances andcontexts in which PEMs are most effective.
  50. 50. Questions?
  51. 51. Discussion ForumPlease continue to discuss this topic and other topics on our discussion forum. www.health-evidence.ca/forum/Login with your health-evidence username and password or register if you aren’t a member yet.Join us for a LIVE on Monday, February 27 at 1:00 pm EST to have your questions answered in real time!
  52. 52. Evaluation Please check your email for the evaluation link. It take 5 minutes to complete!If you’ve been watching with someone else and did not personally register for the webinar, please e-mail Jennifer McGugan at mcgugj@mcmaster.ca to be sent the survey. Thank you for your participation!

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