Evidence – Based Public Health

Evidence
When we hear word evidence most of us
conjure up the mental picture of courtroom,
with opposing lawyers presenting their
evidence, or of law enforcement personnel
sifting through a crime scene for evidence
to be used in judical proceedings
 Evidence
so central to our notion of justice
is equally central
to public health
This is because it should inform all of our
judgments about:
- what interventions to implement,
- in what populations,
- when
- and how determine both positive and
negative effects of those interventions
 In public health there are four
principal user groups for
evidence

• Public health practitioners

• Policy makers
• Key stakeholders
• Researchers on population health issues
Public health practitioners with executive and
managerial responsibilities want to know what
is the evidence for alternative strategies, be
they policies, programs, or other activities.
The fundamental question is:

What are the most important

things I can do to improve the
public’s health ?
 The first prerequisite
• Population-based data
• Covering health status
• Health risks
• Health problems for the overall population
• Demographic subsegments
• Population’s attitudes
• Beliefs about various major health problems
 The second prerequisite
• Data on potential interventions
• What are they?
• What do we know about each?
• What is their individual and conjoint
effectiveness in improving health in the
populations we are serving?
This marriage of information can
lead to a rational prioritization of
opportunities, constrained only by
resources and feasibility
More often public health practitioners
have more narrow set of options.
Still the practitioner has the opportunity,
even the obligation, to survey the
evidence carefully for alternative ways to
achieve the desired health goals.
Those on the front lines share the
responsibility of seeking evidence on
how they can be most effective and
efficient
Policy makers at local, regional,
state, national and international
levels
• They are faced macrolevel decisions on
how to allocate on how to allocate the
public resources for which they have been
elected stewards.
• This group has the additional responsibility
of making policies on controversial public
issues.
 For instance............
• Under what conditions should gun
ownership be allowed?
• How much tax should be levied on
cigarettes and how should these tax
revenues be used?
• Should needle exchange programs be legal
for intravenous drug addict?
 For instance......
• Should treatment be the required alternative
for perpetrators of nonviolent offences who
commited crimes while abusing alcohol or
other drugs ?
Good politicians want to know the evidence
for the effects of options they are being
asked to consider or may want to propose.
 Key stakeholders
• This group includes the public, especially
those who vote , as well as interest groups
formed to support or oppose specific
policies, such as legality of abortion, if the
community water supply should be
fluoridated or if the adults must be issued
handgun licenses if they pass background
checks
 While ideology fuels passion on
these issues, evidence can temper
views or suggest a feasible range
for compromise among opposing
views
 Researchers on population health issues,
they evaluate the impact of specific
policies or programs
• They develop and use evidence to explore research
hypotheses.
• Some of them are interested in the methods used to
determine the quality and implications of research
on population-based interventions.
• They frequently ask: was the study design
appropriate ?
• What are the criteria for determining the adequacy
of the study methods?
Public health has successfully
addressedmany challenges, yet nearly
every success story is a two-edged
sword.
Programs and policies have been
implemented and in some cases positive
results have been reported.
Are there ways to take the lessons
learned and apply them to other issues
and settings?
 Examples..........
• Over the past century, it has become clear
that primary care physicians are in a
position not only to treat disease but also to
provide screening tests and counseling that
will help prevent many diseases.Despite
new evidence-based guidelines for clinical
preventive services, many patients are not
receiving scientifically proven interventions
 Examples………
• State-based programs to reduce tobacco use
have demonstrated progress in California,
Massachusetts, Florida and elsewhere, yet
many states and communities are not
implementing comprehensive evidence-
based interventions to control tobacco use
 Examples………
• Obesity is on sharp rise among children in
several countries. While we must focus on
healthy eating and increasing activity, it
remains unclear which interventions will be
most effective in preventing obesity among
children
 Examples………
• There are large health disparities /among racial-
ethnic groups, across socioeconomic gradients/ in
the United States and many other countries.
Although some promising behavioral interventions
have been shown to address these disparities, new
approaches are needed that include a focus on the
“upstream” causes such as income inequality,
poor housing, racism, and lack of social cohesion.
 As noted over a decade ago by the Institute Of
Medicine there are multiple reasons for
inefficiency and ineffectiveness of many public
health efforts. There are at least three ways in
which a public health program or policy may
not reach stated goals for success
• Choosing an intervention approach whose
effectiveness is not established in scientific
literature
• Selecting a potentially effective program or policy
yet achieving only week, incomplete
implementation or “reach” thereby failing to attain
objectives
• Conducting an inadequate or incorrect evaluation
that results in lack of generalizable knowledge on
effectiveness of program or policy
 Clinical knowledge
Patient preferences
Experience,skills,gus, flair

BEST EVIDENCE

CLINICAL DECISION
Characteristic EBM EB-PH
Quality of Experimental Observational and
evidence studies quasi
experimental
studies
Volume of Larger Smaller
evidence
Time frome Shorter Longer
intervention to
outcome
Professional More formal with Less formal, no
training certification standard
and/or licensing certification
Decision making Individual team
 Five essential steps
• Convert information needs into answerable
questions
• Track down, with maximum efficiency, the
best evidence with which to answer them
/from the clinical examination, the
diagnostic laboratory, the published
literature or other sources/
 Five essential steps
• Critically appraise that evidence
performance for its validity /closeness to the
truth/ and usefulness /clinical applicability/
• Apply the results of this appraisal in clinical
practice
• Evaluate performance
NEW PERSPECTIVES FOR
PUBLIC HEALTH
AREAS FOR PUBLIC HEALTH
ACTION
• Health promotion, education, information
and training,
• Health data and indicators, monitoring and
surveillance of diseases\
• Cancer
• Drugs
• AIDS and other communicable diseases