Putting the 'public' back in public health research

Don Nutbeam
2018 Public Health Research & Practice  
Previous studies of what gets funded and what gets published in public health reveal that the great majority of public health research is descriptive and observational. 1 This is research that helps us to understand the nature and causes of health and ill health in populations, often making optimal use of available epidemiological and social data. This work is important and is the foundation on which modern public health has been built over the past 150 years. It allows us to observe and
more » ... observe and understand change over time, and variations between groups in key measures of health in populations. It has enabled us to examine potential causal relationships between environmental, behavioural and social variables, and subsequent health outcomes. This research, in turn, helps to identify and develop potential responses to current and emerging public health challenges. Far fewer published papers -generally about 15% of all papers -report on the evaluation of public health interventions. 1,2,3 Of these, most are efficacy and implementation trials (translation stage 2-3); very few are studies that examine how changing public health practice leads to changes in health in populations (including policy and impact research; translation stage 4). 1 It is not hard to understand why the number is so low. Improving public health is a complex process. A comprehensive program might consist of multiple interventions working synergistically to achieve several outcomes -think of all the different fiscal, regulatory, health service and public education interventions that were required to reduce smoking rates in the population. Reducing an integrated set of interventions to the component parts for the purposes of evaluation almost invariably results in an irretrievable loss of the 'whole', providing good answers to the wrong question. Evaluation designs have to be tailored to suit the nature of the intervention and the context into which programs are introduced. Because of their multifaceted nature and dependence on context, most public health interventions require adaptations during implementation. Our evaluation designs and methods need to accommodate this. Evaluating public health interventions is messy and time-consuming. It involves human subjects and real-world environments, both of which are difficult to 'control' and measure. The word 'evaluation' has at its core the concept of 'value'. Values are contested. Scientists, health practitioners, politicians and the wider community may all have different views on what represents value from public investment in research. Currently, most research grant funding systems, especially in health and medicine, favour narrowly
doi:10.17061/phrp2821808 pmid:29925080 fatcat:27hayxi6xne2fjvo54fs43xg44