Evidence use in public health – make-do and mend?

Our review on evidence use in local public health decision-making cast a spotlight on patterns and drivers of evidence use in England^[1]. Locality was the recurring theme running throughout the review: evidence was prioritised where its salience to the local area was easily identified. Local salience included whether the evidence was transferable to the characteristics of the population, the epidemiological context, whether the proposed action was feasible (including economically feasible), but also included the political salience of the evidence.

To some, particularly those working in public health decision-making, these findings may feel all too familiar. The shift of decision-making to local government control in 2013 has served to increase the (local) politicisation of public health, which has consequent impacts on the way in which public health challenges are framed, the proposed actions to tackle these challenges, and the role of evidence in this new culture of decision-making. But these findings help to reinforce other lessons for generators evidence, because in many ways the review highlighted a thriving evidence use culture in local public health, but one that has a ‘make-do and mend’ feel about it.

Locality emerged as a key determinant of evidence use, but one where generators of evidence have only loosely engaged. There are likely good reasons for this, with research funders and publishers encouraging researchers to produce evidence that is relevant to audiences worldwide. However, this status quo means that in many ways, evidence generators may be guilty of adopting something akin to an ‘information deficit model’ around the use of research evidence – which inherently assumes that there is an information gap that can be plugged by ever more peer-reviewed research or systematic reviews that reflect ‘global’ findings^[2]. This perspective overlooks epistemological issues around whether such knowledge is applicable, transferable, or otherwise relevant and useful in the context of local decision-making. It also assumes that decision-making is an event, rather than a cumulative learning process where outcomes are evaluated in different ways by different stakeholders; this perspective was reinforced in our own review by a paucity of studies that engaged with the nitty-gritty of public health decision-making processes.

The expression of a make-do and mend evidence culture is that public decision-makers working in Local Authorities take what they can from existing evidence sources (make-do), and plug the gaps with programs of local research and evaluation (mend), a finding that is also supported in later strands of our work (forthcoming). The fact that Local Authorities are undertaking their own research and evaluation activities to understand local people’s needs and preferences is, in many ways, to be commended. However, it also raises questions around the utility of public health research and how much public health research is being ‘wasted’^[3], or rather its utility is not being maximised, through poor take-up in decision-making. Furthermore, our review shows that the methodological quality of this local research and evaluation activity is relatively unknown, and there exists a convention for much of this locally-conducted research to focus on public health needs and not on the effectiveness, or likely effectiveness, of action(s). Finally, an inward focus, with research being conducted in one site and not being shared across others, impedes on the dissemination of learning between other similar contexts. 

So what’s to be done? As a principle, it is clear that there needs to be more regular dialogue between evidence generators/synthesisers and evidence users to understand decision-making needs and processes. New developments such as a dedicated journal on research stakeholder involvement are likely to advance our knowledge on effective ways of working and developing relationships across boundaries. But new methods are also needed to help understand the parameters of generalisability of research that is based on national or global level research and how (or if) it relates to local areas. We also need to strengthen our knowledge around what effective knowledge translation approaches look like. Our own review found that ‘experts’ were frequently deployed, potentially in a knowledge translation role, although their characteristics and precise function was unclear, and it is welcome to see a review further exploring knowledge translation competencies underway^[4]. Finally we need to explore how we can better support Local Authorities to conduct the type of locally focussed research that they are currently producing, and appear to find the most useful, and to better understand the characteristics and features of this research. Supporting any one of these activities involves ensuring that funding exists, on both sides of the evidence generator/user divide, to foster relationships and to support the development of new methodological advances. But knowledge exchange should be integral to the role of all researchers working in public health. Social scientists in academia spend approximately 9 per cent of their time on knowledge exchange activities; in contrast we spend 23 per cent of our time on administration activities^[5]! More of our time needs to be protected and spent on knowledge exchange activities if we are to better understand and respond to evidence needs in public health, and ensure that applied public health research can actually be applied.

The findings of our review reflected the literature on England, although devolution and localism in health and public health is a feature of many countries^[6]. However, another trend is occurring in English public health that is likely to perpetuate a make-do and mend evidence use culture. Public health spending is shrinking with, for example, an expected £85 million slashed from sexual health and substance abuse by cash strapped Local Authorities in 2017/18 alone^[7]. In times of shrinking budgets, the judicious use of evidence should become all the more important in offering greater access to information on what works, increased opportunities for the effective use of resources, and improved certainty around the likelihood of success. However unless we understand, and can better communicate, the generalisability of research evidence to decision-makers working locally, academic research evidence may fail to make the contribution to public health decision-making that it could, and indeed should, make.

About the authors

Dylan Kneale is a Research Officer at the EPPI-Centre. He is interested in developing methods to enhance the use of evidence in decision-making, focusing on demography, public health and social exclusion.
Antonio Rojas-García is a Research Associate-Systematic Reviewer at the UCL Department of Applied Health Research. Prior to joining UCL, he has been working on several research projects, mostly focused on health inequalities and health systems. Within UCL, he has been part of a number of projects exploring the use of research evidence, the impact of delayed discharges on patient, staff and health systems, among others.

Bibliography

1. Kneale D, Rojas-García A, Raine R, Thomas J: The use of evidence in English local public health decision-making. Implementation Science, 2017, 12(1):53.
2. Marteau TM, Sowden AJ, Armstrong D (eds.): Implementing research findings into practice: beyond the information deficit model. BMJ Publishing; 2002.
3. Wolfenden L, Ziersch A, Robinson P, Lowe J, Wiggers J.: Reducing research waste and improving research impact. Australian and New Zealand journal of public health, 2015, 39(4):303-4.
4. Mallidou AA, Atherton P, Chan L, Frisch N, Glegg S, Scarrow G: Protocol of a scoping review on knowledge translation competencies. Systematic reviews, 2017, 6(1):93.
5. Bullock A, Hughes R: Knowledge Exchange and the Social Sciences: A Report to ESRC from the Centre for Business Research. Cambridge: University of Cambridge; 2016.
6. Ham C, Timmins N: Managing health services through devolved governance: A perspective from Victoria, Australia. London: The King's Fund; 2015.
7. Gulland A. Spending on public health cut as councils look to save money. BMJ: British Medical Journal (Online), 2017 13:358.

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