Principles and Application of Evidence-Based Public Health Practice

By Amarjeet Singh

Principles and Application of Evidence-Based Public Health Practice helps clinicians who conduct population-based studies in the community be aware of the principles and ethics involved in public health research. Further, the book helps social scientists involved in public health, especially regarding the medical implication of public health practice. Community-based epidemiological research studies are vital for any public health activities, be it evaluation of health programs, health systems strengthening, surveillance or preventive/promotive trials in the community. While hospital/clinic-based research is conducted in a very controlled setting, community trials are more practical. Community-based studies require a fairly different set of ethical and epidemiological principles to be followed. The same has been reiterated in the ethical guidelines for biomedical research on human subjects released by various national research organizations.

• Facilitates an in-depth understanding of basic principles of public health practice and its practical application.
• Includes the basic principles of public health research and ethics.
• Uses case studies to discuss the public health strategies and approaches to be considered during routine day-to-day practice and a public health emergency.
• Helps build the capacity of public health practitioners with a futuristic view, including technology-based and precision public health practice.

• Language: English
• Publisher: Academic Press
• Release date: Aug 4, 2023
• ISBN: 9780323953559

Book preview

Section I

Introduction to public health practice

Outline

Chapter 1. Principles and approaches in public health practice

Chapter 2. Principles of public health research and writing

Chapter 3. Evidence-based public health practice

Chapter 4. Applying evidence-based strategies for public health preparedness and emergency management

Chapter 1: Principles and approaches in public health practice

Rajavel Saranya, and Soundappan Kathirvel     Department of Community Medicine and School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, Punjab, India

Abstract

Public health is the science and art of preventing disease, prolonging life, and promoting health and efficiency through organized community effort and informed choices of society, organizations, public and private communities, and individuals. The definition and area of public health practice is no more confined to hygiene and sanitation. It deals with the social determinants of health, i.e., from macroeconomic policies to performance of health systems. Understanding the basic principles and approaches in public health practice is essential to develop, implement, evaluate, and scale up various evidence-based public health interventions that deliver the essential services to improve and maintain the health and well-being of the individual and population. Public health practice revolves around subspeciality areas like epidemiology, biostatistics, social and behavioral sciences, environmental and occupational health, health policy, program and management, and health economics. However, it is a dynamic and evolving field due to the ongoing newer understandings and the emergence of newer technologies.

Keywords

Epidemiology; Inclusiveness; Public health practice; Subspeciality; Well-being

Public health and its practice

Public health is the science and art of preventing disease, prolonging life, and promoting health and efficiency through organized community effort and informed choices of society, organizations, public and private communities, and individuals, as defined by CEA Winslow in 1887. It included environmental sanitation, control of communicable diseases, health education to improve personal hygiene, organizing necessary medical care, and social support to ensure a standard of living for everyone to maintain health which ultimately enables any individual to achieve health and longevity as their birthright [1,2]. Several public health associations worldwide attempted to revise this definition since the scope of public health expanded over a period and is no longer confined to hygiene and sanitation. These revisions predominantly included the expanded disease spectrum, community participation, and social determinants of health. These revisions were in line with the World Health Organization's definition of health: a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity [3]. Further, it emphasizes the attainment of the highest standard of health by all, for which the primary health care (PHC) strategy was introduced and scaled up globally. Currently, a subset of PHC strategy, i.e., universal health coverage (UHC), is emphasized as part of the Sustainable Development Goals 2030. Public health is expected to deliver certain essential services or functions as part of the routine practice defined by various agencies. Understanding the basic principles and approaches in public health practice is essential to develop, implement, evaluate, and scale up evidence-based public health interventions that deliver the essential services to improve and maintain the health and well-being of the individual and population.

Principles of public health practice

Public health practice varies within and across countries. However, the fundamental principles of public health practice should stay the same. Due to its dynamic nature and overlap with public health research and, to a certain extent, routine clinical practice, some of the principles of practice are common among them. The basic principles are equity, fairness and inclusiveness, empowerment, effectiveness, evidence-based practice, and public health ethics. Indirectly, the above principles include the availability, accessibility, and affordability components and cultural sensitivity. Other additional principles, like the precautionary principle and solidarity, are not usually considered fundamental principles of public health practice. However, these are applicable in the different contexts of public health practice.

Equity

Health equity is the absence of unfair, avoidable, or remediable differences between individuals and groups, which is defined based on demographics, economics, geography, social groups, or other dimensions of inequalities like sex, gender, sexual orientation, ethnicity, language, disability, religion, and others, in achieving the highest levels of health [4]. Equity and equality are interchangeably used. However, they are different. Equality recommends that everyone in the community is provided the same standard of services. However, not all people in the community are the same and will have the same health needs. Hence, the different needs of the people (combined as various subgroups) in the community need to be addressed to achieve the same level of health and well-being, through which equality in health can be achieved among all community members. This health equity and equality is linked with fair distribution and inclusiveness.

Fairness and inclusiveness

Fairness is the state, condition, or quality of being fair, or free from bias or injustice with anyone or the group in the community [5]. To attain this fairness, public health practitioners must identify the inherent bias or injustice and its nature in the community and make the policies or establish the practices acknowledging the same. Such policies and practices, inclusive of various community subgroups, will address most of the community health needs and hence better population health and well-being. Fairness and inclusiveness are basically from the provider side, whether a healthcare provider or policymaker, irrespective of the level of community participation. It will ensure social justice and equity. Further, community participation and empowerment are needed to exploit fairness and inclusiveness to achieve health equity.

Empowerment

Empowerment enables individuals and communities to take control of their health. Empowerment can be achieved through increasing knowledge, i.e., general and specific health literacy among community members. It further needs effective communication models across different community groups. Fairness and inclusiveness also play a role in using various communication strategies and improving health literacy. Improvement of health literacy is not linearly linked with empowerment, rather community participation is the key to achieving empowerment. The avenues for community participation must be considered and created in routine public health practice and the depth of community participation decides the empowerment. Just providing the information at once or multiple times and taking feedback cannot be called community participation and will not lead to empowerment. It must go beyond providing information and consultation, i.e., involvement and collaboration with the community members, because the health and well-being of a community cannot be defined by the policymakers or practitioners but rather by the community itself.

Empowerment facilitates the social relationship between individuals and the community and the communitization of healthcare services, which is the road to ensuring a better quality of care [6]. It facilitates health activism if the policymakers or practitioners do not practice fairness and inclusiveness.

Effectiveness

Effectiveness is delivering services or interventions and achieving the population health in practical and real-time situations. Of course, it will be lower than the efficacy tested in a controlled or ideal situation. A controlled or ideal situation is mostly possible in clinical practice but not in routine public health practice settings. Hence, considering its nature, the effectiveness is more applicable to public health practice areas. Further, public health practitioners must look for the efficiency of the services or interventions, i.e., how to achieve maximum health using the existing minimal resources. Repeated operational research (implicit or explicit) is needed to achieve such efficiency. Efficiency is considered while implementing or scaling up of public health services or interventions. Effectiveness is usually assessed through public health research that is directly linked with the evidence-based practice principle.

Evidence-based practice

Evidence-based public health practice is collecting, compiling, analyzing, and using the available scientific evidence to make population health decisions. The scientific evidence should not confine to only peer-reviewed publications and include the analysis of routinely collected data since public health practice generates a huge quantity of data. However, the evidence generation in public health practice is low which is due to the complexity of the practice area, funding and other resource availability, research capacity, and others. The available evidence needs to be assessed based on the type or level (systematic review of randomized control trial to case studies or expert opinion), GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) of recommendation and its interpretation level [7]. In the absence of evidence in the concerned field, the available evidence in similar areas can be adopted after necessary modification for the contextual factors and pilot testing. However, the decision-making in evidence-based practice is not just dependent on the availability of evidence. It depends on other contexts like population needs, values and preferences, availability of resources and expertise, and organization and other enabling environments [8]. Further, public health practice must also generate new evidence for future use during the process of the use of evidence.

Ethics in public health practice

Though fundamental ethical principles followed in public health practice are like clinical practice, any breach will affect the whole community. Hence, it must adhere to ethical principles strictly. The fundamental ethical principles are autonomy, beneficence, nonmaleficence, and justice [9]. The autonomy of an individual is relative in public health practice, rather it applies to the autonomy of the community, including the rights and dignity of the community. Beneficence focuses on community benefit against individual benefit. For example, vaccination of a person with a low risk for an infection or disease may not benefit him directly, rather it will benefit the family and community in controlling the transmission.

Nonmaleficence or ‘do-no-harm’ recommends minimal or no harm to any community member. However, it is relative to the context of the practice area. For example, the harm principle, a related principle of nonmaleficence, advocates restricting the liberty of a person or group to prevent harm to others, e.g., banning smoking in public places to prevent exposure among nonsmokers. Public health professionals must assess and quantify the expected and unexpected harms caused to individuals and the community while implementing public health interventions. Such harm must be reported along with the effectiveness of the intervention for informed scale-up of the interventions.

The proportionality principle used in ethics checks the balance between selecting the services or interventions and the burden in the community [10]. Further, there are other ethical principles like social justice (equitable distribution), reciprocity (other benefits), solidarity (for collective welfare), accountability and transparency, and efficiency might be considered during public health practice.

Other overlapping principles

Availability, accessibility, acceptability, and affordability of services or interventions are the overlapping principles in public health practice. Availability and accessibility are predominantly linked to equity, fairness, inclusiveness, and effectiveness principles. Similarly, the acceptability or cultural sensitivity of a service can be linked with inclusiveness and empowerment and hence with equity.

Domains and functions of public health

The domains and scope of public health are wide. Almost everything related to improving and maintaining health and well-being is directly or indirectly linked to public health. The public health practice includes three broad domains: health improvement, protection, and healthcare service quality improvement. All three domains are interdependent and work in cohesion. Health improvement focuses on the wider social determinants to reduce the inequities and psychological aspects of health. Health protection focuses on specific disease control and prevention from environmental, occupational, chemical, radiation, nuclear, and other threats. In a way, health improvement and protection can be linked with primordial and primary prevention in public health practice. Healthcare service quality improvement deals with providing quality and cost-effective clinical care, an efficient healthcare system and the practice of evidence-based care. These domains inform the list of essential functions or services to be delivered by public health (Fig. 1.1) [11].

Figure 1.1  The domains and functions of public health practice [11].

The essential functions of public health are classified under three core areas: assessment, policy development, and assurance. Public health needs to perform a wide range of functions to maintain individual and population health; hence, listing the functions of public health may be difficult. However, certain essential functions are identified globally and in different country contexts [12]. These