Barriers to a Successful Shift towards an Evidence-Based Public Health
by Adedamola Akinbode
Evidence-based public health (EBPH) is the prudent use of current best evidence in making decisions about the well-being of populations regarding disease prevention, health promotion, health protection as well as health maintenance (Jenicek, 1997). Brownson et al (2009) described EBPH as “making decisions based on the best available scientific evidence, using data and information systems systematically, applying program-planning frameworks, engaging the community in decision making, conducting sound evaluation, and disseminating what is learned”. Simply put, EBPH is concerned with the use of best available evidence (from journals, books, reports, surveillance data, policy statements and so on) to address a defined public health problem as well as evaluate its implementation.
The shift towards an evidence-based approach in public health has been proven to be more beneficial than its alternative- the use of randomised trials (Victoria et al, 2004). A typical example of this is in Nigeria’s response to the Ebola epidemic. The success of the Ebola intervention in Nigeria has been attributed to its use of evidence from the Polio Emergency Operations Centre (Tilley-Gyado and Ritgak, 2015). The adoption of an evidence-based approach that is underpinned by population characteristics, needs, values and preferences while considering the best use of resources would manifest in cost-effective public health interventions. Some other established advantages of EBPH include; strengthening of public health surveillance, stimulating the dissemination of quality evidence, encouraging economic evaluation of public health interventions and health impact assessments (Brownson et al, 2009). However, certain factors such as the political environment, nature of the workforce and lack of evidence hinder the use of EBPH approach in addressing public health problems in Nigeria.
A major barrier to evidence-based public health practice in health policy is the communication gap that exists between researchers and policy makers. To enhance the validity of their studies, academic researchers tend to avoid being involved in advocacy and policy making (Brownson et al, 2009). This dissociation limits their understanding of the political economy of the public health problems which they investigate, consequently leading to recommendations that do not align with the interests of the policymakers. On few occasions when both parties communicate, research outputs are sometimes lengthy and technical, making them potentially difficult to interpret by policy makers.
Additionally, political decisions in Nigeria are based on personal views, advice from trusted individuals and media reports, mostly aimed at grabbing the attention of citizens of for future political benefits. However, the use of EBPH practice in health policy will require that policies are based on experimental and observational studies which may not necessarily align with the short term interest of the population. The democratic nature of governance run in Nigeria discourages lengthy tenures in government while encouraging representative democracy. Therefore, to make a sufficient impact for re-election, health policies which have immediate impacts are chosen irrespective of their long-term effectiveness. Given that most EBPH focuses more on the long-term effect of a health problem, policy makers are usually indifferent to such alternatives.
Lack of Evidence
Evidence-based public health as described above is underpinned on the availability of evidence, hence, the non-availability of evidence limits the shift towards an EBPH approach. Evidence in public health is categorised into three; type one evidence which relates to determinants of the diseases and the preventability of risk factors and diseases, type two evidence which comprises of evidence relating to the relative effectiveness of specific interventions and strategies for a particular disease or risk factor, type three which describes the contextual conditions under which the interventions were implemented (Singh, 2015). As the time of this write-up, the most comprehensive type one evidence at the national level was supplied by the National Population Commission in form of a National Demographic and Health Survey (NDHS, 2013). The evidence supplied in the data is limited to a few health matters and does not show the true burden of diseases at the time of this paper. Thus, interventions designed in 2016 based on the evidence provided by the most recent NDHS would most likely be ineffective as a result of shifting pattern of diseases over time. Additionally, the National Primary Health Care Development Agency (NPHCDA) identified lack of accurate evidence necessary for the planning of immunisation programme as a major challenge affecting immunisation project (Channels, 2016).
The absence of reliable evidence in Nigeria’s Public health field hinders the effective shift towards a more EBPH approach. An alternative methodology to the problem of evidence practised in Nigeria is the use of evidence from other populations without accessing its external validity. This situation presents itself with the use of evidence that will eventually lose their contextual effectiveness as a result of dissimilarities in disease patterns and strains, economy, political environment and cultures among countries. The absence of type three evidence in Nigeria has contributed to the lack of modification which will enhance the ease of effectively transforming evidence into practice.
Nature of workforce
Additionally, having public health evidence that considers the impact on and influence of a variety sectors on the populations’ health requires a public health workforce with diverse educational and experiential background. However, Nigeria Field Epidemiology and Laboratory Training Program (NFELTP) and other interventions necessary for building public health workforce in Nigeria through experiential training are designed strictly for individuals with medical backgrounds. The University of Ibadan’s 2016 NFELTP, like many others, limits its application to only individuals with a medical background (medical microbiology, medicine, veterinary medicine and so on). The result of this would be a public health workforce whose research interest lies explicitly in medical research. Thus, the potential of a lack of public health type one and type two evidence in other disciplines like sociology, statistics, arts and so on.
As evidenced by the success of Nigeria’s Ebola response, the shift towards an EBPH in Nigeria is a necessary imperative. However, certain barriers (discussed above) hinders the use of an evidence-based public health approach to solving identified population health problems. The underpinning factor identified is the lack of evidence required for the proper transition to an EBPH. This could be addressed by creating incentives for publishing evidence which meets a set of required standard. Incentives could include research grants based on previous research impact, postgraduate research scholarships linked to areas identified as research gaps and the development of a public national database that contain different types of high-quality, independent evidence to inform healthcare decision-making.
Furthermore, the communication gap between researchers and policy makers could be bridged by using cost-based evaluation tools to provide public health evidence for that could aid policy considerations (Brownson et al, 2009). These tools include cost-benefit analysis, social returns on investment, cost-effectiveness analysis and health impact assessments. These analytical tools reduce the technicality of the health problems and break them down into economic values that could be easily understood by policy makers as well as serve as tools for future political campaigns.
Brownson, R. C., Fielding, J. E., & Maylahn, C. M. (2009). Evidence-based public health: a fundamental concept for public health practice. Annual review of public health, 30, 175-201.
Channels TV (2016) NPHCDA Blames Lack of Data for Immunisation Setbacks available at https://www.channelstv.com/2016/10/04/nphcda-blames-lack-data-immunisation-setbacks/
Jenicek, M. (1997). Epidemiology, evidenced-based medicine, and evidence-based public health. Journal of epidemiology, 7(4), 187-197.
Singh, K. K. (2015). Evidence-based public health: Barriers and facilitators to the transfer of knowledge into practice. Indian journal of public health, 59(2), 131.
Tilley-Gyado, Ritgak Dimka (2015) When Institutions Work: Nigeria’s Ebola Response. World Bank, Washington, DC
Victora, C. G., Habicht, J. P., & Bryce, J. (2004). Evidence-based public health: moving beyond randomised trials. American journal of public health, 94(3), 400-405.