Evidence for policy
The notion of evidence-based policy is widely accepted, but what counts as evidence for policy? First, there are epistemological arguments such as ‘If science (and therefore evidence) is considered not to be absolute (there is no one truth), what does it take to change policy?’ Or, if the social context of health behaviours is dynamic (that is, they are always changing), how can health policy-makers ensure the correct setting? There is a hierarchy of evidence, but evidence needs to be interpreted and translated in a meaningful way (see also Chapter 10). So, what is the evidence for effectiveness of interventions, and how can this be used for population health outcomes? One study, however good, does not influence policy. A body of evidence is required to enact policy changes and influence the political determinants of health.
Evidence for effectiveness
A body of evidence can be found in systematic reviews, meta-analyses and meta-ethnographies. These meta-syntheses can be found in databases like the Cochrane Collection but there is contention about inclusion criteria. A new wave of thought about what constitutes evidence and how it should be used is known as translational research – how policy-makers (and practitioners) translate evidence to policy and practice. Ironically, evidence can also offer justification for economic rationalisation, which may influence funding for public health. Again, public health is vulnerable because it is difficult to provide outcomes in short policy cycles. For example, in the area of drug and alcohol, harm minimisation policy frameworks were implemented in the early 1990s. One of the most notable of these was the needle exchange programs and services. More recently, controversial ‘lockout laws’ have been designed, along with other measures such as the ‘One punch can kill’ campaign, to address alcohol-fuelled violence. While there are claims of success, there is significant debate about the evidence for effectiveness.
Policy practice gap
There is a sufficient body of evidence to suggest a gap between policy and practice. This lack of action is often attributed to the political will or politicians’ apathy. Think back to the idea of political will you discussed earlier. Perhaps public health and health promotion are not important enough to politicians. Several factors could influence the importance of health promotion for politicians: (1) politicians’ activity in health promotion will increase as the level of health promotion in the public agenda increases; (2) politicians’ activity in health promotion will grow as the results of their actions are expressed more quickly; (3) politicians’ activity in health promotion will increase when there is tangible evidence of health promotion outcomes; and (4) politicians’ activity in health promotion will decrease as the political price for intervening in health promotion increases (Zalmanovitch & Cohen, 2013). The gap between policy and practice may be addressed if public health improves its relationship with politicians and the political cycle.
Now let’s think about the role of evidence in the water fluoridation debate. There are significant oral health disparities across socio-economic groups in Australia. For example, endentulism rates in young children are higher in low socio-economic areas and the visits to the school dental van are higher in high socio-economic areas. Oral health experts agree about the positive effect of water fluoridation on oral health outcomes. Yet Australia does not have a national approach to water fluoridation because the control of water varies across states. In states where water is controlled by the state government, water fluoridation has been implemented in most or all local government areas, but in states where water is controlled by local governments, water fluoridation is patchy. While oral and public health experts advocate water fluoridation because it is a cost-effective strategy to reduce oral health disparities, especially tooth decay in children, there are other groups who oppose water fluoridation. For example, anti-fluoride lobby groups oppose water fluoridation on the civil rights platform that people have no choice and have not consented to ‘mass medication’. These groups argue water fluoridation needs to be proved unequivocally safe because there are risks, such as fluorosis. In view of the opposing arguments, oral and public health experts suggest that there is a lack of good quality evidence to convince governments to invest in water fluoridation.
What evidence do you think has the most power to influence politicians and policy for a national approach to water fluoridation?
Ethical advocacy
Advocacy is identified in global documents such as the Ottawa Charter (1986) and the Galway Consensus (2008) as a core competency for public health practitioners. Public health has a vital advocacy role to enact change for the political determinants of health and reduce health inequities in vulnerable and marginalised populations. Advocacy is driven by professionals, consumer groups, communities and populations, and is underpinned by four ethical principles: autonomy, beneficence, non-maleficence and justice. It is a political process about challenging those who hold power to force action for change. It is underpinned by coalitions, collective action and evidence. Community-based bottom up advocacy is about community connectedness, social capacity building and empowering communities and populations to engage with the political process to enact change.
Political advocacy
Advocacy can influence broader societal reform (for example, sexual health promotion in the early 1970s). The ‘Grim Reaper’ advertisements were the face of an intense sexual health promotion campaign to address the HIV/AIDS epidemic. This political and social change was supported by a number of public health initiatives such as condom vending machines in nightclubs and testing for those in the sex worker industry. Despite, or maybe because of, the evidence for success across a number of social and health outcome indicators, the campaign lost funding. Another example saw the ‘morning-after pill’ become available over the counter to girls over 14 years of age in pharmacies. Today, innovative technologies offer advocacy an efficient means of mobilising sentiment. Social media platforms are effective mechanisms to harnesses the collective power of those with shared beliefs and values though forming coalitions and alliances (for example, the not-for-profit organisations GetUp! and Crikey).
Seminal health promotion documents, such as the Lalonde Report (1974), the Declaration of Alma-Ata (1978) and the Ottawa Charter (1986) implicitly and explicitly express concepts of the political determinants of health: power and control, governance and resource distribution, systems and decision-making, and inequities and empowerment. And health promotion practitioners working passionately at the grass roots level are political advocates by the nature of their work – forming alliances to enact change. But advocacy is compromised because many health promoters work for the government, and feel they have little power to influence policy (Sparks, 2009). This may be an underlying problem for advocacy in public health.
Ethics-based advocacy
Ethics underpins advocacy. Ethics in public health advocacy is about action and inaction, rights and liberties, power and inequalities. Public health ethics are grounded in consequentialism, where ethics are determined by the outcome of an action. Population-based polices are created for the social or collective good so most people have better health outcomes. These policies may affect people’s rights by restricting behaviour and infringing on civil liberties. Think back to our discussion about the Nuffield Ladder of Intervention. In developing this model, the Nuffield Council on Bioethics explored the ethical issues surrounding public health interventions and proposed a stewardship model to balance liberty and collectivism, underpinned by principles related to harm, vulnerability, autonomy and consent (Calman, 2009). Other examples are vaccinations for children to achieve 90% herd immunity and protect the 10% who are not immunised, and fluoride in the drinking water supply. International bodies such as the United Nations and the World Health Organization have been instrumental in global polices (for example, the 1948 Universal Declaration of Human Rights), for the right of all people to health.
But are coercive policies always universally beneficial and do they justify overriding values such as personal freedom? Legislation relating to, for example, alcohol licensing, food labelling and junk food advertising provoked debate in the UK. Opponents argue on a civil rights platform that people should have the freedom to make their own choice about what they to eat and drink. Proponents of public health argue the government can, and should, alter environments to influence the behavioural determinants of health (see also Chapter 6). Internationally, there is strong evidence to suggest government policy on taxation (for example, increasing the tax excise on alcohol), access (for example, smoke-free workplaces), advertising, (for example, comprehensive bans for tobacco), and behaviour (for example, seatbelts and drink driving) impact population based health outcomes. The evidence suggests population based health outcomes outweigh small limitations on freedom of choice (Jochelson, 2006).
