Evidence-Based Public Health Finding and Appraising Relevant by kzgpwtxtim


									Evidence-Based Public Health:
    Finding and Appraising
     Relevant Resources

     Medical Library Association
    Continuing Education Course
           April 27, 2006

• Understand the characteristics of
  evidence-based public health
• Be informed about the variety of resources
• Know how to respond to typical questions
  posed by public health workers and what
  resources are available to provide info
• Identify types of evidence and methods for
  appraising the public health literature
• What is Evidence-Based Public Health
• Why is EBPH important?
• What is the difference between public
  health practice & medical practice?
• What can be used as evidence for making
  informed public health decisions?

Injury Prevention

                 Definition of
         Evidence-Based Public Health

     “the conscientious, explicit, and judicious
     use of current best evidence in making
     decisions about the care of communities
     and populations in the domain of health
     protection, disease prevention, health
     maintenance and improvement.”

Jenicek M. Epidemiology, evidenced-based medicine, and evidence-based public health. J Epidemiol. Dec
     Evidence-Based Practice

• Requires integrating practitioner expertise
  with the best evidence from systematic
  research. [someone must be doing
• Involves finding and selecting resources
  that are credible, relevant, and applicable
  to practice. [how unique is your
                   Process of
             Evidence-Based Practice
1. Define the problem: convert information
   needs into focused questions.
2. Find the best evidence from the literature.
3. Critically appraise the evidence for validity
   and relevance.
4. Apply the evidence to practice.
5. Evaluate the results.
  Adopted from:
  Sackett DL, Rosenberg WM. The need for evidence-based medicine. J R Soc Med. Nov 1995;88(11):620-
  624.                                                                                                      7
  Sibbald WJ. Some opinions on the future of evidence-based medicine. Crit Care Clin. 1998;14(3):549-558.
  Why Evidence-Based Practice?
• So much information,
  too little time
• Need high quality,
  filtered information to
  make informed decisions
• Value of scientific knowledge for
  decision making
• Decisions should not be based only on
  intuition, opinion or anecdotal information   8
 Evidence for Public Health Practice
       and Policy Decisions
             • “I make a lot of decisions
               about how money is going
               to be spent, and I would like
               to always be able to back it
               up and say that this is
               proven, or evidence-based.”
 Politicians need evidence to
  make decisions about public
  health programs.
From Public Health Professionals:
  “Some things have simply always been
  done a certain way – are common practice,
  but there is really no research to back it up.”

  “Politics always overlays decision-making
  on everything that is not evidence-based in
  the public health world. Everything we do is
  imbued with political priorities and funding
          Quotes on this and previous page from
       MA DOH, Bureau of Communicable Dis Control
The Evidence-Based Movement
       EBM → EBPH

   How does public health
    relate to medicine?

Public Health: Health of Populations

   Medicine: Health of Individuals     12
   Public Health                         Medicine
• Focus on populations           • Focus on individuals
• Prevention & health            • Diagnosis & treatment
• Environment & human            • Clinical interventions
  behavior interventions
                                 • Well-established
• Diverse workforce, variable      profession, standardized
  education & certifications       education & certification
• Social sciences integral;      • Clinical sciences integral;
  clinical sciences peripheral     social sciences less
  to education                     emphasized
• Observational studies: case    • Experimental studies with
  control & cohort studies         control groups: RCTs.     13
Public Health                      Medicine

Interaction of Public Health & Medicine:
• Medicine/Public Health Initiative
• AAMC-CDC Cooperative Agreement (pop health)
• Collaboration on emerging health threats
  – Bioterrorism (anthrax, 2001)
  – Emerging infections (SARS,2003)
  – Surveillance Technology: ability to quickly
    exchange information electronically
• Managed care: What can we afford?               14
10 Essential Services of Public Health

 Public Health Functions Project, U.S. Dept. of Health and Human Services   15
Evidence-Based Public Health

                  Best Evidence
 Social values,         from         Expertise,
                      Research       Knowledge


Decisions for Public Health Practice
                   • Interventions
                     • Programs
                      • Policies                  16
   Sources of Public Health Evidence
• Journal literature        • Surveillance data
• Books                     • Newsletters
• Conference                • Teleconferences &
  proceedings &               webcasts
  abstracts                 • Alert systems
• Dissertations & theses    • Email discussion lists
• Unpublished scientific    • Internet sources
  papers                    • Expert knowledge &
• Government reports          opinion
• Policy statements, laws
  & regulations
                Evidence Pyramid

                                                                             Applicable to
                                                                             environmental health,
                                                                             food safety, vaccine
                                                                             development, etc…

From: The Medical Research Library of Brooklyn, http://servers.medlib.hscbklyn.edu/ebm/2100.htm      18
                             Evidence Pyramid
                                                                  Systematic Reviews &
                                                                  [Perhaps also Meta-
                                                RCTs              syntheses of qualitative
                                          Cohort Studies

                                     Case-Control Studies

                                    Descriptive Studies,
                                   Case Series & Reports

                                 Ideas, Editorials, Opinions

Adapted from: The Medical Research Library of Brooklyn, http://servers.medlib.hscbklyn.edu/ebm/2100.htm
                                         Evidence Matrix
                                  Survey      Case-               Quasi-         Non
Research            Qualitative   Cross-      control   Cohort    Experimental   Experimental          Systematic
Question            Research      Sectional   Studies   Studies   Studies        Evaluations    RCTs   Reviews

Process of
Service Delivery






Satisfaction with
the Service

Petticrew M, Roberts H. Journal of Epidemiology and Community Health, 2003
  The Project’s Website


   CDC/ATPM Qualitative Study
Investigation of Information Needs of
    Public Health Professionals
             Nancy La Pelle, PhD
        Roger L. Luckmann, MD, MPH
         E. Hatheway Simpson, MPH
             Elaine R. Martin, DA

Identifying Strategies to Improve Access to
Credible and Relevant Information for Public
 Health Professionals: A Qualitative Study
          Evidence-Based Practice for Public Health Project
             University of Massachusetts Medical School       22
Findings from Study of Public Health
   Workforce Information Needs
 There are many relevant websites to
  search: need for one portal access.
 Bombarded with unfiltered, irrelevant
  information: need filtered searches.
 Too little information on legislation and
  policy change and newly identified
  health threats.

          Evidence-Based Practice for Public Health Project
             University of Massachusetts Medical School       23
           Findings Continued
 Need information from areas beyond
  biomedical domains.
 Need access to systematic reviews and
  summary information.
 Need access to full-text journal articles,
  government reports (grey literature), and
  conference proceedings.
 Need for training in accessing evidence-
  based resources.

           Evidence-Based Practice for Public Health Project
              University of Massachusetts Medical School       24
     Models of Information:
Sources of evidence-based knowledge

1. Reports of Original Research
2. Summaries, Critiques and
3. Systematic Reviews, Meta-Analyses,
   and Evidence-Based Guidelines
4. Knowledge Bases

1. Reports of Original Research
•   Journal articles
•   Book chapters
•   Reports (government & other sources)
•   Newsletter articles
•   Conference proceedings and abstracts
•   Dissertations from Schools of Public Health
•   Bibliographic databases that cite the above
•   Filtered searches of bibliographic databases
Original Research Article: Am J Public Health

  2. Summaries, Critiques and
• Summaries of original studies
• Critiques of original studies
• Expert commentary and
  recommendations based on original
• Structured abstracts of individual
  research articles

3. Systematic Reviews, Meta-Analyses,
    and Evidence-Based Guidelines
• Systematic reviews with explicit criteria
• Meta-analyses of data from original
• Evidence-based guidelines based on
  original studies, systematic reviews, and
• NB: Not all guidelines are EB; some are
  expert opinion/consensus
Link from Guide to Community Preventive Services: American Journal of Preventive Medicine
             4. Knowledge Bases
• Searchable online textbooks with up-to-
  date information
• Collections of multiple online resources
  –   Journal articles
  –   E-textbook chapters
  –   Guidelines
  –   Recommendations
  –   Patient handouts
  –   Images
  –   Data (prevalence, incidence, costs, charges, etc..)
  –   Multiple databases with integrated searching

   What are the Knowledge
  Domains of Public Health?

• The field of public health is very
  broad and diverse
• There are multiple disciplines
  (knowledge domains) within the field
  of public health

          Public Health is Multidisciplinary

•   Epidemiologists              • Mental Health Workers
•   Statisticians                • Substance Abuse
•   Environmental Engineers        Counselors
•   Animal Control Officers      • Doctors
•   Sanitarians                  • Nurses
•   Food Scientists              • Teachers
•   Industrial Hygienists        • Disaster Relief Workers
•   Health Care Administrators   • Nutritionists
•   Health Economists            • Lab Technicians
•   Politicians                  • Librarians
•   Social Workers               • Communication
                                 • Security & Enforcement /
                                   Health Police           37
    Defining Public Health
•   Public health accreditation criteria
•   Public health associations
•   Government health agencies
•   National health objectives
•   Public health occupational categories
•   Public health literature
•   Public health subject headings from the
    National Library of Medicine

          Identified Knowledge Domains
                   Public Health
•   General Public Health             •   Public Health Nursing
•   Epidemiology                      •   Disaster Control &
•   Biostatistics                         Emergency Services
•   Vital Statistics & Surveillance   •   Communicable Diseases
•   Environmental Health              •   HIV/AIDS
•   Occupational Health               •   Nutrition
•   Health Services Administration    •   Chronic Diseases
•   Social & Behavioral Sciences      •   Public Health Laboratory
•   Health Promotion & Education
•   Community Health
                                      •   Public Health Informatics
•   Maternal & Child Health
                                      •   Global Health

Define the public health problem

 Convert the information needs
    into focused questions
Forming a Searchable
Public Health Question
  P - Population
  I - Intervention
  C - Comparison
  O - Outcome
Search and find the best evidence

 Critically appraise the evidence
    for validity and relevance
Sample Search Pathway
 1.   Evidence-Based Guidelines
 2.   Systematic Reviews
 3.   Pre-formulated Searches
 4.   Best and Model Practices
 5.   Bibliographic Databases
 6.   Public Health Journals
 7.   Health Data and Statistics
 8.   Legislation and Policy
 9.   Government Reports           43
     EBPPH Project Web Site:

Evidence-Based Resources for
    Public Health Practice
 1.   Evidence-Based Guidelines
 2.   Systematic Reviews
 3.   Pre-formulated Searches
 4.   Best & Model Practices
 5.   Public Health Bibliographic Databases
 6.   Public Health Journals

      Public Health
Bibliographic Databases
• CDC Information Center
• Public health librarians
• Abstracting and indexing services for
  key public health journals
• Journals and newsletters
• E-mail discussion lists
• Public health websites
• Public health subject experts
        Public Health
  Bibliographic Databases
– Access free or by subscription only?
– Who produced the database?
– What topics are covered?
– What kinds of materials are indexed?

     Sources Used to Identify
      Public Health Journals

1. CDC Information Center
2. Healthy People 2010 Information
   Access Project
3. Core Public Health Journal Project
4. ISI’s Journal Citation Reports
5. Public health subject experts

   Continuing the Pathway:
Evidence-Based Resources for
    Public Health Practice
   7. Health Data and Statistics
   8. Legislation and Policy
   9. Government Reports

Public Heath Web Portal: http://PHPartners.org
Public Health Web Portal:

EBPH Critical Appraisal and
   Database Searching

Brainstorming – “Best Practices”

              EBPH Searching
• Findings from attendees of 2004 EBPH course
  at MLA:
  –   MEDLINE – every six months (12)
  –   Cochrane – never (3) < 6 mon (2) >6 mon (7)
  –   ERIC – never (1) < 6 mon (7) > 6 mon (4)
  –   NCJRS - never (9) < 6 mon (3) > 6 mon (0)
  –   TOXNET - never (3) < 6 mon (6) > 6 mon (3)
  –   PIE - never (11) < 6 mon (1) > 6 mon (0)
  –   AGELINE - never (3) < 6 mon (8) > 6 mon (1)
  –   POPLINE - never (5) < 6 mon (4) > 6 mon (2)
  –   AGRICOLA - never (3) < 6 mon (6) > 6 mon (3)
   Forming a searchable public
         health question
• The PICO framework used in evidence-based
  medicine can also be used to create a
  searchable question in public health.

• P Patient, population, problem
• I Intervention (program or treatment or
  screening test or exposure or prognostic
• C Comparison (if any)
• O Outcome
              PICO Exercise
• You coordinate social activities for a few of the
  city’s senior centers. The latest Behavioral Risk
  Factor Surveillance System (BRFSS) survey
  showed that seniors in your state are not
  participating in regular exercise or many other
  health promotion behaviors. You’ve heard that
  physical activities for older adults can have a
  host of benefits, but there aren’t many resources
  with which to build a program. You must find
  literature supporting the effect of exercise in
  reducing injuries or decreasing risk of chronic
  disease in the elderly. Increasing client
  satisfaction and social engagement are
  secondary goals.
    Searchable Foreground ?
• Using the PICO to create a searchable
  question along the lines of the following:

• In the Patient Population with this
  Problem, does the Intervention more
  than the Comparison (if any) result in the

      Issues in PH Searching
• Access
  – Free versus paid
  – Functionality
• Vocabulary
  – The language of public health
  – Built-in or external thesauri
• Levels of Available Evidence
• Keeping Up
           Critical Appraisal
• Does this item address the question? [Are
  the population and intervention similar
  enough to be useful]
• Is this item quality evidence?

• Always better to appraise full-text
• Realistically, most make the first cut by
  appraising the abstract (or executive
        MEDLINE / PubMed
• Access (free): http://www.pubmed.gov
• Also available through multiple vendors
• Coverage: 1950 – present (moving
  backwards as well) ; journal and
  newsletter literature
• 4300+ journals in biomedical science,
  nursing, allied health, psychology, etc..

    MEDLINE Sample Search
• Are needle exchange programs effective for
  reducing HIV transmission in intravenous drug
  users? What are the characteristics of
  successful programs.

• MeSH
  – Needle-Exchange Programs
  – HIV Infections/transmission or
    /prevention & control
              MEDLINE Results
• Clinical Queries – Systematic Reviews
   – Evaluating effectiveness of syringe exchange programmes:
     current issues and future prospects. Soc Sci Med. 2000 Dec.
• Combine subject terms with cohort studies
   – Continued transmission of hepatitis B and C viruses, but no
     transmission of human immunodeficiency virus among
     intravenous drug users participating in a syringe/needle
     exchange program. Scand J Infect Dis. 2000
   – High rates of HIV infection among injection drug users
     participating in needle exchange programs in Montreal: results of
     a cohort study. Am J Epidemiol. 1997 Dec [debated]
   – Effectiveness of needle-exchange programmes for prevention of
     HIV infection. Lancet. 1997 Jun 21
• Other studies use statistical modeling; program
  evaluation; qualitative research – interviews.
• Are they interested in other intermediate outcomes such
  as risk reduction?
            Cochrane Library
• Access to Cochrane Database of Systematic
  – http://www.thecochranelibrary.com (Free to search
    and get abstract; pay for full-text review
  – Also indexed in PubMed and available for purchase
    through OVID
• Coverage:
  – Brings together a number of regularly updated (every
    3 months) evidence-based medicine databases,
    some available free at

     Cochrane Search Sample
• Is pneumococcal vaccination effective in
  reducing the number of ear infections in
  children? Is it worthwhile to promote it for
  otherwise healthy children in your
• Search Terms (Keywords or MeSH)
  – Pneumococcal Vaccines
  – Otitis Media /prevention & control
  – Age group (children) – since this is a small database
    you might be willing to leave out the age group and
    just browse.
           Cochrane Results
• Straetemans M, Sanders EA, et al.
  Pneumococcal vaccines for preventing
  otitis media. Cochrane Database Syst
  Rev. 2002;(2):CD001480.
• Document Delivery:
  – If you do not have full-text access to this
    database, you can order the full-text of a
    Cochrane review through the Cochrane
    website for a fee.
   ERIC (Educational Resources
       Information Center)
• Access (free)
  – http://www.eric.ed.gov/
  – Also available through multiple vendors
• Coverage:
  – The database contains more than 1 million
    abstracts of education-related documents and
    journal articles from 1966 onwards.
  – Linked full-text to grey literature (reports,
    documents, etc…)
            ERIC Search Sample
• The school health program at your health
  department and the board of education are
  interested in making sure that kids with asthma are
  appropriately treated while at school. What are
  issues about access to a child’s school health
  records that need to be addressed in your plan to
  develop electronic school health records?
• Search terms (ERIC descriptors or identifiers)
   –   Browse or search the Thesaurus of ERIC Descriptors at
   –   http://www.ericfacility.net/extra/pub/thessearch.cfm
   –   Confidential Records
   –   School Health Services
   –   Student Records
                    ERIC Results
• School Health Services and Educational Records:
  Conflicts in the Law. Gelfman, Mary H. B.;Schwab,
  Nadine C. West's Education Law Reporter v64 n2 p319-
  28 Jan 31 1991
• A Computerized School Health Records System:
  Problems and Prospects Pitkin, Olive;Rosner, Lester J.
  Journal of School Health v41 n5 p258-261 May 1971

• Document Delivery
   – ERIC Document Retrieval Service – direct ordering or through
     OCLC. Libraries and research institutions can offer their patrons
     access to full-text copies of ERIC documents online through

National Criminal Justice Reference
   Service Abstracts & Full-Text
• Access (free)
  – Also available through multiple vendors
• Coverage
  – National Criminal Justice Reference Service
    Abstracts Database contains summaries of more than
    180,000 criminal justice publications from 1970 to the
    present. The Full-Text Virtual Library contains 7,000+
    full-text publications.

            NCJRS Search Sample
•   Your maternal, child and reproductive health program has been invited to
    review the case management of pregnant inmates at a state correctional
    facility. You are looking for current practices with pregnant inmates to
    compare with best practices for prenatal care in the community health
    center environment.

•   Search Terms
     – National Criminal Justice Thesaurus – You can browse or search it at
       the Advanced Thesaurus Search Screen
     –   Pregnant inmates
     –   Pregnant offenders
     –   Pregnant women
     –   Use above as keywords
     –   Prenatal care

                  NCJRS Results
• Pregnant Girls and Moms in Detention. Justice Policy
  Journal: Analyzing Criminal and Juvenile Justice Issues
  and Policies Volume:1 Issue:2 Dated:Spring 2003
  Pages:3 to 20
• Nine Months to Life - The Law and the Pregnant Inmate.
  Journal of Family Law Volume:20 Issue:3 Dated:(1981-
  1982) Pages:523-543
   – [note that this does not have the subject headings above
     assigned, but comes up in a keyword search on pregnant
• Document delivery
   – Paper reproductions of older NCJRS publications and agency
     final reports are available for a fee. The Sale field of the abstract
     will indicate "Paper Reproduction Sales.” Many recent
     documents published by sponsoring agencies can be ordered in
     hard copy from the Online Store on the NCJRS Web site.
• Access (free) http://toxnet.nlm.nih.gov/
  – Some of the databases are available from vendors
• Coverage
  – Database descriptions at http://toxnet.nlm.nih.gov/cgi-
  – Search all at once or multi-database search includes
     • Hazardous Substances Data Bank (HSDB), Integrated Risk
       Information System (IRIS), Chemical Carcinogenesis
       Research Information (CCRIS), and Genetic Toxicology

        TOXNET Search Sample
• Your city has a large and thriving rat population. In
  the past, the city has used anticoagulant rodenticides
  but they don’t seem to be working as well as they
  had been. There has been some discussion that the
  rats may be resistant to warfarin or other
  components of the rodenticides. You want to find
  out whether this is prevalent and what other
  rodenticides might work on these resistant rats.

• Search Terms
• (Rodenticides OR anticoagulants OR warfarin) AND rats
  AND resistan*

Search Results from TOXNET
• Current literature comes from PubMed with the
  TOXLINE [sb]
• These are older results from TOXNET Special
   – Warfarin-resistant rats. Greaves JH JR
     Agriculture (London); 77(3): 107-10 1970
   – Anticoagulant resistance in Norway rats...in
     U.S. cities. Bowerman AM ; Brooks J ;
     Jackson WB ; Kaukeinen DE. Pest Contr.;
     41(4): 55, 57, 58, 60-64, 81; 1973 ; (REF:15)
     [HAPAB]                                         73
 Mental Health Policy Information
• Access (free)
• Coverage:
  – Over 5,000 documents related to mental
    health, substance abuse, and disability policy
  – Most linked to full-text reports online
  – No new content being added due to loss of

        PIE Search Sample
• What are the characteristics of successful
  programs on managing adolescents with
  dual diagnosis (co-occurring substance
  abuse and mental health problems).
• Search Terms
  – Dual diagnosis
  – Adolescents

               PIE Results
• Improving Policy and Practice for Adolescent
  Girls with Co-occurring Disorders.
  Prescott,Laura. National GAINS Center for
  People with Co-occurring Disorders in the
  Justice System, 1998.

• Specialist Mental Health Services for Children
  and Youth - A Report of a Review of Recent and
  Planned Changes - New Zealand Mental Health
  Commission, 2001 [FT]

• Access (free)
  – Also available through multiple vendors
• Coverage:
  – Updated regularly and includes material from
    1978 on, with selected coverage of the years
    1966-1977. The database covers English-
    language literature from many countries.
  – Over 60,000 abstracts and content
    summaries of current literature on aging.
     AGELINE Search Sample
• You coordinate social activities for a few of the
  city’s senior centers. The latest Behavioral Risk
  Factor Surveillance System (BRFSS) survey
  showed that seniors in your state are not
  participating in regular exercise or many other
  health promotion behaviors. You’ve heard that
  physical activities for older adults can have a
  host of benefits, but there aren’t many resources
  with which to build a program. You must find
  literature supporting the effect of exercise in
  reducing injuries or decreasing risk of chronic
  disease in the elderly. Increasing client
  satisfaction and social engagement are
  secondary goals.                                    78
     AGELINE Search Terms
• Search Terms (Thesaurus of Aging
  – Physical activity OR exercise
  – Community centers
  – Search specific age groups or cohorts using
    subject terms (See AGELINE help)
  – Personal satisfaction OR Cost benefit analysis
    OR economics OR falls OR program
             AGELINE Results
• Development and evaluation of "Aging Well and
  Healthily": a health-education and exercise program for
  community-living older adults. Hopman-Rock, Marijke;
  Westhoff, Marja H. Journal of Aging and Physical
  Activity Vol. 10 No. 4 (Oct 2002) 364-381

• National blueprint, increasing physical activity among
  adults age 50 and older. AARP; American College of
  Sports Medicine; American Geriatrics Society; Centers
  for Disease Control and Prevention (U.S.); National
  Institute on Aging; Robert Wood Johnson Foundation,
  Princeton, NJ (Mar 2001)

• Access (free)
  – Also available through multiple vendors
• Coverage
  – 300,000+ citations to scientific articles,
    reports, books, and unpublished reports in
    population, family planning, & related issues.
  – References as old as 1837, but mostly 1950
    to present
    POPLINE Search Sample
• Your STD clinic is seeing more STDs in
  pregnant teens. The hypothesis is that
  since they are already pregnant, they do
  not feel the need to use protection. You
  want to find out what strategies for STD
  prevention in pregnant teens are effective.

         POPLINE Vocabulary and
• User's Guide to POPLINE Keywords
• http://db.jhuccp.org/popinform/tools/kweng.pdf
• Browse or search or prepared searches [MeSH and
   –   Pregnancy
   –   Adolescents
   –   Sexually Transmitted Diseases
   –   Pregnant Adolescents
• [use & for AND, slash for OR ; use browse feature to
  select multiple terms which will be combined with
  slashes by default – you will have to change to &]
   – pregnancy & stds & adolescents
• Limits (peer-reviewed journal articles)

    POPLINE Sample Results
• Crosby RA; DiClemente RJ; Wingood GM; Rose
  E; Lang D. Correlates of continued risky sex
  among pregnant African American teens.
  Implications for STD prevention. Sexually
  Transmitted Diseases. 2003 Jan;30(1):57-63.
• Oh MK; Cloud GA; Baker SL; Pass MA;
  Mulchahey K; Pass RF. Chlamydial infection and
  sexual behavior in young pregnant teenagers.
• Access (free) http://agricola.nal.usda.gov/
   – Also available through multiple vendors
• Coverage
   – AGRICOLA (AGRICultural OnLine Access) is a bibliographic
     database of citations to the agricultural literature created by the
     National Agricultural Library (NAL) and its cooperators.
     Database covers materials in all formats, including printed works
     from the 15th century. The records describe publications and
     resources encompassing all aspects of agriculture and allied
     disciplines, including food and human nutrition.
   – You may search the National Agricultural Library Catalog and
     Journals Database at the same time.

   AGRICOLA Search Sample
• How does fear of foodborne illness play into
  food handling education and practice?
• Search Terms
• NAL Agricultural Thesaurus
• Library of Congress Subject Headings
  – Food safety education (or education as a broader
  – Foodborne illness or special illnesses
• Limits: language, date, type of item
        AGRICOLA Results
• Serving up safety. Fitzgerald, P.L.
  School foodservice & nutrition. Sept 2002.
  v. 56 (8) 28-32.
• Use of the health belief model to
  examine older adults' food-handling
  behaviors. Hanson, J.A., Benedict, J.A.
  Journal of nutrition education and
  behavior. Mar/Apr 2002. v. 34 (suppl.1)

Questions or Comments?


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