Public programmes have absorbed huge amount of money for health improvement, social welfare, education, and justice. However, the result of the programmes are still unkown whether improve people’s lives or not and experts knowledge is not used in policy decisions (Oxman, et al. 2010). Gaps between research of effectiveness and policy implementation are also clearly seen (Brownson, Chriqui, Stamatakis 2009). These gaps occur because policy makers have different priorities. Black (cited in Wallace 2006) argued that ‘ideological blinders, economic pressures (both in governmental budgets and their own campaign coffers), electoral realities, bureaucratic inertia, and a host of other factors that can make good data irrelevant, influence policy maker in decisions making. Wallace (2006) also stated that political concerns lead to ‘immune to facts’ in policy makers. Brownson, Chriqui, Stamatakis (2009) stated that the process of making public policies can be complex and messy and the policies are not only ‘technically sound, but also politically and administratively feasible’.
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The first step of health-policy making-process is problem identification and agenda setting. In this stage, public problems will be political agenda if the problems are converted into political issue (Palmer & Short 2000). Evidence-based public health enable to influence policy makers in public health decisions because evidence-based practice use a particular type of evidence and focus on clear reasoning in the process of appraising and evidence interpretation (Rychetnik et al 2004). Evidence-based practice rises evidence from research which encompass a wide variety of public health research. Rychetnik et al (2004) also mentioned several type of studies which used in evidence-based public health such as decriptive, taxonomic, analytic, interpretive, explanatory and evaluative. Prinja (2010) asserted that evidence and information contribute to policy making process through research and consultative process or published documents or reports. Moreover, Rychetnik et al., expanding on earlier Brownson’s argument (cited in Fielding & Briss 2006) argued that evidence-based public health decisions can be supported by three types of scientific evidence. Type 1 evidence is that ‘something should be done’ is determined by causes and magnitude of disease, severity and preventibility. Type 2 evidence shows that ‘which intervention or policies should be done’ may effective in specific intervention to promote health. Type 3 evidence describe ‘how something should be done’ that how and under what circumstances interventions were implemented and how they were received. Those type of evidence are useful in public health decision because they may improve the quality and availability of the evidence (Rychetnik et al 2004).
Evidence for evidence-based policy can be determined into two categories, quantitative evidence and qualitative evidence. Both of them are important for policy relevant evidence (Brownson, Chriqui, Stamatakis 2009). Quantitative evidence for policy making, which provides data in numerical quantities, is collected from many sources, such as scientific information in peer-reviewed journals, public health surveillance systems, or evaluations of individual programs or policies (Brownson, Chriqui, Stamatakis 2009). Quantitative evidence, for example prevalence, incidence and cumulative incidence, may express the magnitude and severity of public health problems through frequency or proportion and rates measurments (Rychetnik et al 2004) but this type of evidence presents little understanding of why some relationships exists (Brownson, Fielding, Maylahn 2009). On the other hand, qualitative evidence or non numerical data may be taken from methods such as participants, group interviews, or focus group. Qualitative evidence may influence policy deliberations, setting priorities and proposing policy solutions by telling persuasive stories (Brownson, Chriqui, Stamatakis 2009). However, according to Rychetnik et al (2004) one of qualitative evidence that is expert opinion is positioned at the lowest level in ‘levels of evidence’ hierarchies and identified as the least reliable form of evidence on the effectiveness of interventions. Nevertheless, the combination between two type of evidence leads to a stronger persuasive impact in policy making process than using only one type of evidence (Brownson, Chriqui, Stamatakis 2009).
Evidence-based practitioner shoul build strong evidence to convince public health policy makers. Brownson, Fielding, Maylahn (2009) proposed three concept to achieve a more evidence-based approach to public health policy. First, scientific information on the programs and policies is required to make more effective in health promotion. Second, combination between information on evidence-based interventions from the peer-reviewed literature and the realities of a specific real-world environment is required to translate science to practice. Third, the prove of effectiveness of interventions must be informed in wide-scale consistently at state and local levels. Brownson, Chriqui, Stamatakis (2009) also recommended that evidence should show public health burden, identify priority of an issue over many others, present relevance at the local level, show benefits and harm from intervention, explain the issue by how many peoples’ lives are affected, and estimate the cost of intervention.
In the article example (Lee&Park 2010) which is about HBV immunisation policy in the US, it is clear that the policy was based on convincing evidence, in this case was epidemiological data. According to these data which taken from different sources, such as American Cancer Society (ACS) and Centers for Disease Control and Prevention (CDC) showed that chronic HBV infection is responsible for the majority HBV-related morbidity and mortality. Some quantitative evidence was provided such as 1.4-2 million (0.4%) people had chronic HBV invection. The policy also relied on other successful policy intervention which might produce similar result if the HBV immunisation was implemented in population. The CDC reported that the incidence of acute HBV infection decreased 80% which was largely due to universal vacination programs for children. Characteristic of the HBV infected population was also identified such as 2.7-11% among injecting drug users, 1.1%-2.3% in homosexual, 1.5% among pregnant women. The data convincingly showed that there was corelation between HBV and HIV infection. The natural history of the disease also clearly identified led to assumption that HBV vaccination was important for community.
The next stage of the health policy making process is policy formation. In this stage, policies are formulated or changed to a new policies. The formation stage, which is also referred to policy design or development, specific attention will be provided when policies are examined relating to the issues (Palmer & Short 2000). According to Brownson, Chriqui, Stamatakis (2009) that formulation of health policies in public health practice is complex and depends on ‘variety of scientific, economic, social, and political forces’. However, huge number of people want policy and practice to be relied on the best scientific evidence. Maximising policy effectiveness and efficiency depend on evidence base (Wallace 2006). On the other hand, policy makers require a reasonable and justifiable policy solution. Hence, health public practice should develop a convincing message based on research evidence to explain policy makers how the intervention may solve the public health problems (Goldstein 2009).
To develop policy formulation, research evidence should be reviewed and evaluated before being proposed to policy makers. The aim of the research evaluation is to determine the degree of credibility (validity and reliability) of information and usefulness (relevance and generality) in a different context (Rychetnik et al 2004). Systematic Reviews and Critical Appraisal are required in evidence review processes as a guide to understand the research methods (Rychetnik et al 2004). Systematic review implementation leads to practitioners and policymaker to understand all of relevant information, how the evidence was collected and assembled, and how the conclusions and recommendations relate to the information (Fielding & Briss 2006). Then, the result of evidence review will be integrated with social consideration which obtained from practitioners, policy makers and consumer to produce evidence based recommendations (Rychetnik et al 2004). Through systematic appraisal of research, public health practice enable to demonstrate the effectiveness of interventions based on available evidence (McMichael, Waters, Volmink 2005). In other words, the evidence-based recommendations are based on the nature and strenghth of the evidence. Furthermore, the recommendations should be evaluated with respect to the balance of advantages and disadvantages (Rychetnik et al 2004) or the benefits of interventions must be weighed against the costs (Cookson 2005). However, systematic review tend to have narrow and regressive interpretation of the nature of evidence which leads to exclude a wide range of research-based information and professional experience that may be important to policy development (Nutbeam 2001). Therefore, combination between systematic review and narrative review may bring convincing evidence rather than systematic review alone.
Iit is obvious in the article example that the recommendation of HBV immunisation in the US was based on previous research evidence. For example, in June 1982, the CDC Advisory Committee on Immunization Practices (ACIP) released the first inactivated HBV vaccines for individuals at a high risk for HBV infection (Lee & Park 2010). The reason why the first HBV vaccine recommendation only for high risk community because epidemiological data showed that the distribution of hepatitis B cases was not uniform across populations. Large and urban immigrant-dense areas had higher prevalence of chronic HBV infection. The CDC concluded that high morbidity and mortality from chronic HBV infection in the US would be unavoidable if those high risk populations were not interfered by immunisation programs. In 1989, the recommendation of HBV vaccine were expanded to health care workers after obtaining surveillance data of the HBV infection prevalence and input from health professionals through public and private requests (Lee & Park 2010).
The third stage of the health-policy-making process is adoption. In this stage the policy formulation is enacted and brought into force, such as state legislation (Palmer & Short 2000). Public health practice requires advocacy and lobbying to influence policies, change practice and achieve public health action. Nevertheless, the process of achieving influence is often difficult rather than appraising evidence and formulating recommendations because the process requires more complex social and political negotiations and often detrmined by social, political and commercial factors (Rychetnik et al 2004). Brownson, Fielding Maylahn also argued that translation from research to community applications may require many years. Moreover, evidence-based policy and practice inform the policy maker through evidence consideration whereas policy making will depend on prevailing values and priorities. Therefore, it is challenging for public health practice to close the gap between research and practice (Rychetnik et al 2004).
According to Nutbeam (2001), policy development is a political process rather than scientific-based process. Hence, evidence-based public health requires a strong public health voice and advocacy supports within political system in which may be obtained from public and mass media. Another support may come from public servants who have skill in critical appraisal of evidence to use research evidence in the policy development.
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The article example of HBV immunisation programs in the US shows that several groups influenced the US government decisions in HBV immunisation programs. From inside of the government, such as National Health and Nutrition Examination Surveys (NHANES), American Cancer Society (ACS), Centers for Disease Control and Prevention (CDC), the CDC Advisory Committe on Immunization Practices (ACIP), supported the HBV immunisation proposals by providing convincing data to the government. WHO, as an outside of government institution, might influence the US government to consider the spread of the disease by presenting international data of HBV prevalence. Health professional also forced the government to expand the HBV immunisation program not only for infant and high risk groups but also children and all adolescents.
The next step of the health-policy-making process is implementation of the policy. In this stage, policy document is changed into reality (Palmer & Short 2000). Evidence-based public health is challenged to translate research evidence to practice among organisations, practitioner groups, or general public. Evidence-based practitioners enable to identify the most important component of an intervention to bring effective actions to the community (Brownson, Fielding, Maylahn 2009). Interventions in public health should focus on the benefit of communities or populations rather than individuals, although many intervention bring secondary advantages to individuals (Frommer & Rychetnik 2003). Rychetnik et al (2004) stated that public health interventions include ‘policies of governments and non-government organisations; laws and regulations; organisational development; community development; education of individuals and communities; engineering and technical developments; service development and delivery; and communication, including social marketing.’ In the example article, the recommendation of HBV immunisation in the US was implemented by ACIP whereas the federal provided vaccine for health care workers and children.
The final step of the health-policy-making process is evaluation which include monitoring, analysis, criticism and assessment of existing or proposed policies. The result of the evaluation is used as data sources in agenda setting and policy formation. The goal of the evaluation is to bring policy implementation in effective and efficient ways (Palmer & Short 2000). Evidence-based policy requires documenting the effect of implemented policies to undertand the impact of interventions on community and individual which may change people’s behaviour (Brownson, Chriqui, Stamatakis 2009). McMichael, Waters, Volmink (2005) believed that evidence around intervention effectiveness plays important role to address health priorities for the next policies particularly in developing countries or resource-poor areas. Evidence-based practice use evidence as valuable sources in evaluation to maximise the benefits and limits the harms of public health policy and practice. The evidence enable to inform evaluation planning to improve the quality and relevancew of new research (Rychetnik 2004). Evaluation may also be useful to explain failures in policy implementation, unintended side effects, and monitoring the policy application towards achieving the policy goal (Wallace 2006).
Evidence-based practice also evaluate public health policy in economic perspective because it can provide information about the association between economic investment on public health programs and policies and health impacts, such the prevelance of prevented disease or years of life saved. This method, named ‘cost-effectiveness analysis (CEA), can explain the relative value of alternative interventions on public health programs and policies (Brownson, Fielding, Maylahn 2009).
Another important evaluation of evidence-based policy is ‘health impact assessment (HIA)’ that enables to estimate the possibility impacts of policies or interventions in out side of health perspective, such as ‘agriculture, transportation, and economic development, on population health’. HIA also analyse the envolvement of stakeholders in the policy interventions. Evidence-based practitioner use this method because there is much evidence that population health and health disparities are influenced by many determinants such as social and physical environments (Brownson, Fielding, Maylahn 2009). Therefore, it is essential to evaluate health policy implementation in different ways.
In the article of HBV immunisation in the US, CDC always conducted evaluation and found that the incidence of HBV infection had declined after releasing recommendation of HBV vaccination. The CDC also identified that education of health care providers was clearly important to make the program successful (Lee & Park 2010). The result of CDC’s evaluation, which formulated into epidemiological data, can help to build new strategies to eliminate HBV infection, such as expansion of HBV immunisation recommendation for other groups and routine screening for HBV positive persons.
In conclusion, evidence-based public health is important in public health policy making because evidence-based approach enables to provide policy suggestion based on convincing evidence generated from rigorous research. Since many determinants influence public health, analysis of quality and quantity evidence is essential to convince policy makers in identification of policy priorities and the best public health interventions. This essay also suggest that faster and better scientific information may influence public assumption in public health which leads to support evidence-based policy making in public health interventions.
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