Promoting Evidence-Based Public Health Policy: Can We Have Better Evidence And More Action?

ABSTRACT: Evidence-based approaches (those explicitly linked to the best available scientific evidence and reflecting community preferences and feasibility) are increasingly used to inform health policy decision making on the burden of a disease attributable to particular causes, interventions and policies that might work to confront those causes, and issues of community fit and feasibility. This paper introduces several tools for evidence-based public health: the health impact assessment, the systematic review, and a portfolio for assuring community fit and feasibility. Discussion of these tools serves as a springboard to consider how to better bring scientific evidence to bear on real-life health issues. [Health Affairs 25, no. 4 (2006): 969–978; 10.1377/hlthaff.25.4.969] M any improvements in the health of populations result from the introduction of evidence-informed policies or programs that affect the likelihood of acquiring a disease, the severity of the disease, the receipt of timely and effective care and treatment, and, for communicable diseases, the likelihood of disease transmission. Harnessing and constantly improving the available science in support of effective public health action reflects a centurieslong public health tradition. Examples include a very broad range of activities such as the introduction of childhood vaccination, environmental changes that improve workplace safety, fluoridation of community water supplies, and improved public health interventions to control the risk factors for heart disease and stroke.1 These and other successes in using the best available science to support community health are only part of the picture. Despite the billions of U.S. tax dollars Evidence-Based Policy HEALTH AFFAIRS ~ Vo l u m e 2 5, N u m b e r 4 969 DOI 10.1377/hlthaff.25.4.969 ©2006 Project HOPE–The People-to-People Health Foundation, Inc. Jonathan Fielding () is director of public health and health officer, Los Angeles County Department of Health Services; chair of the Task Force on Community Preventive Services; and a professor of health services and pediatrics, Schools of Public Health and Medicine, at the University of California, LosAngeles. Peter Briss is director of Community Guide, Division of Health Communication and Marketing Strategy, National Center for Health Marketing, at the Centers for Disease Control and Prevention in Atlanta, Georgia. spent on research and the more than a trillion spent on service delivery, movement of evidence-based interventions into communities and health systems is often slow.2 Making faster and better use of scientific information could increase the value of public investment and help ensure that policies designed to improve health have their desired effects. Accelerating the integration of scientific discoveries into routine public health practice and policy deserves priority attention.  Key questions for policymakers. Public and private decisionmakers on health issues must address a series of difficult questions when choosing programs and policies: What is the likely disease burden that might be prevented or reduced? Which programs and policy options are likely to result in meaningful improvements in health? How will the benefits be distributed among the affected groups? Which potential solutions are appropriate and feasible for a specific situation, considering (1) the fit between strategy and the community context, (2) political and technical feasibility, and (3) cost and cost-effectiveness? Public health science has the potential to inform these decisions but requires effort and investment at every stage, from production of primary studies to synthesis of results across studies and then to translation of research-tested findings into effective community action. For the health of the public to be protected and improved, it is critical that interventions be based on the best possible scientific evidence; that we continuously strive to improve and expand the scientific evidence base; and that we actively promote the use of the best-available, sciencetested programs and policies.  Working definition. For this paper we have adopted Neal Kohatsu’s definition of evidence-based public health: the process of integrating science-based interventions with community preferences to improve the health of populations.3 Lucy Rychetnik and colleagues, expanding on earlier work by Ross Brownson and colleagues, have identified three types of scientific evidence that can support evidence-based public health decisions.4 Type 1 evidence defines causes of disease and their magnitude, severity, and preventability and helps determine that “something should be done.” Type 2 evidence shows that specific interventions do or do not work to promote health and help inform decisions about “which interventions or policies should be done.” Type 3 evidence shows how and under what conditions interventions were implemented and how they were received, informing decisions about “how something should be done.” All of these types of evidence can come from a range of sources with differing levels of rigor and local relevance. A person’s hunch, an anecdotal observation, the expert opinion of a group, a formally designed and executed scientific study, or a group of studies all can constitute evidence. In general, however, scientific studies 970 July/Aug ust 2006 Evidence & Information “Making faster and better use of scientific information coul