|Year : 2015 | Volume
| Issue : 2 | Page : 131-135
Evidence-based public health: Barriers and facilitators to the transfer of knowledge into practice
Kapil Kumar Singh
Consultant, National Urban Health Mission, Department of Health and Family Welfare, Ministry of Health and Family Welfare, Government of India, Nirman Bhawan, New Delhi, India
|Date of Web Publication||25-May-2015|
Kapil Kumar Singh
Consultant, National Urban Health Mission, Department of Health and Family Welfare, Ministry of Health and Family Welfare, Government of India, Room No. 408-A, Nirman Bhawan, New Delhi-110011
Source of Support: None, Conflict of Interest: None
| Abstract|| |
This paper underscores some of the barriers and facilitators in the practice of evidence-based public health (EBPH). A large body of evidence-based interventions (EBIs) exists, which has been generated through highly robust systematic reviews. These EBIs have been widely disseminated and promoted by public health researchers and the World Health Organization (WHO) as effective public health interventions against various preventable/treatable diseases. The inability of many low- and middle-income countries to contextually adapt and effectively implement evidence-informed interventions (EBIs) has been identified as a major obstacle to progress in achieving Millennium Development Goals (MDGs). Hence, it is imperative to identify and understand the factors that are detrimental to the successful transfer of evidence into policy as well as practice. This paper discusses how factors such as political, contextual, and organizational factors; nature of evidence; and community participation influence the practice of EBPH.
Keywords: Disease prevention, evidence-based intervention (EBI), evidence-based public health (EBPH), knowledge transfer
|How to cite this article:|
Singh KK. Evidence-based public health: Barriers and facilitators to the transfer of knowledge into practice. Indian J Public Health 2015;59:131-5
|How to cite this URL:|
Singh KK. Evidence-based public health: Barriers and facilitators to the transfer of knowledge into practice. Indian J Public Health [serial online] 2015 [cited 2019 Nov 16];59:131-5. Available from: http://www.ijph.in/text.asp?2015/59/2/131/157534
| Introduction|| |
In South Asia and Sub-Saharan Africa, around 14,000 people die every day due to preventable and/or treatable diseases that more or less have been eliminated in high-income countries through public health interventions.  The effectiveness of those interventions has been systematically reviewed and well documented, and they are available for use in low-and middle-income countries. Generally, these evidence-based interventions (EBIs) are either not articulated into policies or not practiced as intended.  The transfer of evidence into policy and/or practice is hindered by various barriers, and this issue has been identified as a major challenge to the practice of evidence-based public health (EBPH). 
| What Is EBPH?|| |
EBPH has been defined by Jenicek as 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 (health promotion)." 
Commonly, there are three types of evidence (types 1, 2, and 3) for public health practice.  Type 1 evidence defines the determinants of the diseases and the preventability of risk factors and diseases.  It underscores the need to do something about a particular risk factor or disease. Type 2 evidence relates the relative effectiveness of specific interventions and, hence, suggests a specific strategy for a particular disease or risk factor.  Type 3 evidence describes the contextual conditions under which the interventions were implemented.  While type 1 and 2 evidences exist in sufficient amounts, the scientific community has paid much less attention to type 3 evidence. 
EBPH: Barriers and facilitators
Given the conditions of increasing disease rates, shortage of funds, and failure of interventions, public health decision-making should be based on evidence.  Even when evidence exists, there are various barriers that prevent the transfer of evidence into practice.  These barriers emerge at various stages of EBPH practice. At the policy level, political factors prevent the articulation of evidence into policy.  However, even in the process of implementation, EBIs are either abandoned or modified due to various factors, which leads to unintended outcomes. 
The practice of EBPH requires presentation of evidence by the researcher to the policy makers. However, evidence alone is not sufficient to convince policy makers of the need for new interventions. , Brownson et al.  argued that the factors that underlie decisions in science and politics are different. While science relies on experimental or observational studies, politics relies on popular demand, media reports, personal views, and trusted individuals. ,, Generally, the policy-making in public health is incremental and based on compromise, bargaining, and influence rather than on systematic analysis.  Further, policy makers are more often committed to implementing intervention before any evidence exists to support that intervention.  A classic example is the Drug Abuse Resistance Education (DARE) program, a widely used school-based drug use prevention program in the USA and in 54 other countries around the world. , In the USA, it was implemented in more than 70% of elementary schools, with an expenditure of around $130 per student.  However, recently conducted systematic reviews found the DARE program to be ineffective. ,
Similarly, the Gujarat government launched the Chiranjeevi Yojana scheme to promote institutional delivery among women from below-poverty-line households.  Till 2012, the program had paid over $32 million to designated private-sector hospitals to provide free-of-charge delivery services to poor women. Although some studies had reported substantial benefits from the scheme, ,, a recent systematic evaluation of the program has found little or no association between the Chiranjeevi Yojana and reduced out-of-pocket costs of deliveries for the beneficiaries. 
In addition, elected officials are temporarily elected for 5 years and want to ensure their reelection. Hence, they want immediate and certain solutions to emerging public health issues that can produce favorable results within their tenure.  However, research takes too long to find solutions, and by the time solutions are made available, the issue may have subsided or no longer be receptive to new policy-making due to changes in the politicosocial environment. Further, solutions in public health show results in the long term and thus policy makers often show indifference to such proposals.  While the proposals involve an element of uncertainty (confidence intervals or probabilities), the policy makers want estimates with precision and certainty.  However, with the frequent use of analytical tools such as cost-effectiveness and cost-benefit studies, and health impact assessments, policy makers are becoming more favorable toward EBIs. 
In order to ensure objectivity, researchers generally do not involve themselves in advocacy and policy-making.  This results in a communication gap between researchers and policy makers. As a result, policy makers come closer to groups with vested interests, and their decisions, consequently, are based on external influence.  In contrast, frequent communication between researchers and policy makers facilitates evidence-informed decision-making.  Moreover, public health proposals generally run into hundreds of pages and, because of information overload, policy makers cannot analyze every bit of information.  Some authors have argued that policy makers "read people," not written reports.  Consequently, they prefer taking advice from "expert" lobbyists. , Often, policy makers are interested in data that reflect popular support for an issue, and demonstrate the relevance of the issue at the local (voting) level.  In contrast, research data are reported as being too lengthy, verbose, jargon-laden, unfocused, and technical. Thus public health proposals are, due to the reasons mentioned above, less persuasive in shaping policy decisions.  However, when the information presented is in condensed form, easy to interpret, and supported by brief summaries of complex research findings, evidence-based decision-making is frequently practiced.  When the given information is locally relevant, highlighted, broken down into bullet points, and supplemented with narrative storytelling, then the information becomes relevant not only for policy makers and elected officials, but also for the people who vote for them. 
Contextual factors: Fit vs. fidelity
At the implementation level, the translation of evidence into practice is hindered by various barriers, the primary barrier being the lack of fit between the original intervention and the new target environment.  The interventions, for instance, that have been found effective in the USA may not be effective in the UK or in another, non-English speaking country. When the adopted intervention does not take into account the contextual factors of the new environment, most likely the EBI will either fail or not produce desired outcomes.  Therefore, EBIs must be modified if different contextual factors exist in the new target population. However, little expertise is found in the public health workforce for the adaptation of interventions to new settings.  In addition, much less type 3 evidence exists that informs as to what contextual conditions existed when the interventions were implemented and how they were received by the population.  In the absence of type 3 evidence and/or expertise in adapting interventions to a new environment, the issue of fidelity versus reinvention arises when EBIs are modified by implementing agencies.  Lack of skills among personnel in modifying EBIs often causes changes in the core elements of the EBIs, which may lead to poor outcomes.  Therefore, fidelity to the core element of the EBI should be maintained, and modifications can be made as long as the core elements are preserved.
In addition, a particular organizational culture may also prevent EBPH practice.  It is generally marked by inertia. There is a tendency to continue with ongoing programs because change requires extra effort, funds, new staff, training of the workforce, adaptation of the intervention, and interorganizational communication and coordination.  Moreover, the ongoing programs are popular within the organization and among the target population due to their moderate results. Hence, the uncertainty associated with implementing an altogether new intervention discourages organizations from practicing EBPH.  Under certain conditions, organizations do not promote innovation, and in a hierarchical bureaucracy, very few incentives exist for staff to propose new interventions at the decision-making level.  Further, the funding agencies restrict how funds should be utilized by the implementing organizations. , Some areas of the intervention may require more funds than what is allocated by the funding agency. This inflexibility in expenditure makes the implementing organization a passive participant in the whole process. 
Public health workforce
Another barrier is related to availability, motivation, and expertise of the staff, which play a critical role in EBPH practice.  The original intervention is carried out under intensive supervision, with highly motivated and trained staff. However, when an EBI is implemented in other settings, either there is shortage of staff or the staff are not trained.  The public health workforce have diverse educational and experiential backgrounds. However, more than 50% of them have never gotten any formal training in public health, as a result of which the staff face many difficulties when practicing public health.  In contrast, when the workforce are graduates in public health, generally the interventions achieve the desired health outcomes. ,
The lack of participation of the target population in the formulation, implementation, and evaluation of such a program has been found to be another important barrier to EBPH practice.  The participation of the targeted community (clients, families, neighborhood organizations) from the conceptualization of intervention till its evaluation has been found to be a major facilitator in EBPH practice.  The community possesses critical information related to its needs, existing assets, prevalent attitudes, norms, and prejudices, and its participation allows program-implementing organizations to factor in such conditions.  Moreover, participation of the community in decision-making builds a sense of ownership of the intervention, which minimizes community resistance and increases recruitment-retention of the participants, and promotes more use of locally available resources and the self-sustainability of the intervention. ,
Nature of evidence
Another challenge faced in EBPH practice involves the nature of the evidence. Interventions based on randomized controlled trials (RCTs) are rarely useful in public health practice, as the focus of public health is on a population and not the individuals. Therefore, the external validity (generalization of results) of RCTs is generally poor. , Hence, when RCT-based interventions are applied in public health problems, the results are not very encouraging. , However, EBIs based on observational studies or quasi-experimental designs have been found to be very effective in EBPH practice. 
| Conclusion|| |
To improve population health, widespread adoption of EBIs has been recommended. , However, it is difficult to put EBPH into action, because the transfer of this knowledge often faces significant challenges. When public health practice is based on emotive or uninformed decision-making, there are consequences such as poor health outcomes, wastage of resources, and decreased workforce productivity. There is a high opportunity cost for society when uninformed interventions are implemented. There exists a solid evidence base generated by high-quality systematic reviews, but the EBIs are either not taken into consideration during policy-making or not implemented as intended due to many barriers. EBPH practice not only brings direct benefits to the population's health, but also expands the evidence base with what works, ensures efficient use of resources, and brings success in health programs. EBPH practice should integrate the best available evidence with practitioner skills, available resources, community preferences, and the context for successful transfer of evidence-based knowledge into policy as well as practice.
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