Public Health Programs: Where is the evidence?

I was driving home from the gym this evening, and I heard a radio commentator reference a tongue-in-cheek article written by The Onion with the headline of “Report: 98% of U.S. Commuters Favor Public Transportation For Others”. Why does it feel like we often know what the problem is and have the solution in hand... we just can’t get people to use it?

A recent study published in the Journal of Public Health Management Practice reported that this same phenomenon is happening in my field of public health. The article reported that even though there are evidence-based programs and practices that in many cases are accessible, customizable, and available to public health workers, too few people are using them!

What does evidence based mean?
“Evidence based” is a term that describes programs that have been rigorously tested and can demonstrate that they have actually improved health. Public health programs are activities that are created to solve some kind of health problem in a community - they can be anything from a small series of health education classes about healthy eating habits to seat belt laws implemented nationwide. Evidence-based in these two examples could mean that the education classes actually changed eating habits, and the seatbelt law actually increased the number of people buckling up. The thing that unites all public health programs is that we use them because we think they will improve the health of many people at a time.

Unfortunately, even though public health programs are created with the best of intentions, they sometimes flop. In some cases, they just don’t work and we may or may not know why. In the worst of cases, the program actually made things worse for the people who were supposed to benefit from them. At a time when public health need is growing and funding sources are shrinking, it’s more important than ever to make wise investments by using programs that have been demonstrated to work in the past and are known not to make the situation worse.

So, what’s the problem?
The problem is that, as this article reported, even though public health workers know a lot about evidence-based programs, and even though they think that using those programs are a good idea, less than half of them had ever used them! Many of them didn’t even know how to find evidence-based programs, even though lots of public health workers have spent time, money, and effort into making them available at no cost. (Check out The Guide for Community Preventive Services, Cancer Control P.L.A.N.E.T., R-TIPS and DEBI for examples of websites that make evidence-based programs available to public health workers.)  I think that this is something that everyone - not just the public health community - should care about because in many cases our tax dollars helped to fund the development of these programs. I don’t know about everyone else, but if I invested my tax dollars into these programs, then I want them to be put into practice and used!

What can we do about this?
The article proposed a couple of solutions that I think are really great, though they are really directed at the public health community. The first one is to create a simple online decisions tool that is easy-to-use and completely free so that public health workers can be guided step by step through the process of matching an evidence-based program with their needs and customizing it to fit their community. The second one is to add more content on those websites (DEBI does a great job of this, by the way), so that program manuals, protocols, and materials can be downloaded and customized. The third - and this is a big one - is to have funders require that grantees use evidence-based programs OR that they’re given dedicated money to make sure that new programs they’re proposing can be tested to make sure they actually work. These are great solutions, but they aren’t geared towards people without specialized training in public health.

One other idea is that the general public demand that evidence-based programs be implemented in their communities. Are you a member of a PTA? Are you on a church vestry? Are you interested in improving health conditions at your workplace? Well... one question I’d encourage everyone to ask when a new initiative related to health is put forward is to ask, “Why do you think this will work? Has it been shown to work in the past? What are the alternatives and why should we choose this program?”

Hannon, P. A., Fernandez, M. E., Williams, R. S., Mullen, P. D., Escoffery, C., Kreuter, M. W., . . . Bowen, D. J. (2010). Cancer Control Planners' Perceptions and Use of Evidence-Based Programs. Journal of Public Health Management Practice, 16(3), E1-E8.

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Rebecca Woodruff is a first-year doctoral student at the Rollins School of Public Health at Emory University, where she studies in the Behavioral Sciences and Health Education department. Unlike her peers, who focus on preventing disease and death in the population at large, Rebecca hopes to prevent bad programs from making their way into our schools, homes, and workplaces.