The European Journal of Public Health Advance Access originally published online on January 27, 2008
The European Journal of Public Health 2008 18(3):221-223; doi:10.1093/eurpub/ckm127
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Commentary |
Evidence synthesis, upstream determinants and health inequalities: the role of a proposed new Cochrane Public Health Review Group
Elizabeth Waters1, Mark Petticrew2, Naomi Priest1, Alison Weightman3, Angela Harden4 and Jodie Doyle1
1 Cochrane Health Promotion and Public Health Field, The McCaughey Centre, School of Population Health, The University of Melbourne
2 Public and Environmental Health Research Unit, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
3 Support Unit for Research Evidence (SURE), Sir Herbert Duthie Library, Cardiff University, Heath Park, Cardiff CF14 4XN, UK
4 Social Science Research Unit, Institute of Education, University of London, London, WC1H 0NR, UK
Correspondence: Prof. Elizabeth Waters, Cochrane Health Promotion and Public Health Field, and Public Health and Health Equity, The McCaughey Centre, School of Population Health, The University of Melbourne, Australia, tel: 61-3-8344-3183, fax: 61-3-9348-2832 e-mail: ewaters{at}unimelb.edu.au
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Introduction |
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Within public health decision making, there has been an increasing awareness of the need for better syntheses of evidence related to interventions addressing upstream, population-level determinants of health and health inequalities. This includes focusing greater attention on ways of integrating evidence from a range of sources and on best ways of using what evidence is currently available, while remaining aware of its limitations.1 Inherent within this is the need to consider further the contribution and value of multiple forms of evidence to the evidence base rather than a stringent focus on ranking evidence by more traditional scientific measures. Whilst we would argue that well-conducted experimental studies provide strong evidence on intervention effectiveness it is not always possible to carry out such studies when evaluating complex public health interventions. Accordingly, exploring ways of incorporating diverse evidence sources into systematic reviews, together with a realistic view of the scope, strengths and limitations of such evidence, needs consideration if public health is to make an effective contribution to impacting health inequalities and the social determinants of health. High quality systematic reviews can inform both the development of further primary research as well as policymaking, which does not absolve the need for better primary research on the effectiveness and economic efficiency of interventions and policies with regards to health inequalities,2 but primary research must be informed by better understanding of what research already exists and hence where the gaps are.
Global initiatives such as the UN Millennium Development Goals and the WHO Commission on Social Determinants of Health have raised the profile of the need to address health inequalities within the international policy context. A key issue seems to be how to balance the need to make the best use of multiple sources of evidence in the absence of a strong experimental evidence base with a realistic view of the scope and limitations of these other sources of evidence. In turn, this has increased the demand for evidence to inform policy and decision making on these issues. High quality syntheses and systematic reviews of evidence, incorporating multiple forms and sources of evidence, have a vital role to play in this context.
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Public health developments in the Cochrane Collaboration |
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The Cochrane Collaboration is internationally recognized as a leader in the production of high quality systematic reviews of the effects of healthcare and related interventions. The overall effects have resulted in spectacular international results. There are over 3000 reviews on the Cochrane Libray, 15 000 authors and contributors and the library is freely available to over 3 billion people worldwide. Cochrane Health Promotion and Public Health (HPPH) Field was established in 1996 to represent the needs and concerns of health promotion and public health within and external to the Cochrane Collaboration. This did not include an editorial role; instead health promotion and public health reviews were published by other review groups with advice and support from the HPPH Field. However, it has increasingly been recognized by those within and outside of the Collaboration that this process does not adequately provide for the complexities of public health intervention research and synthesis. As a result, a new Cochrane public health collaborative review group (PHCRG) has been proposed to provide leadership and editorial direction in this area within the Collaboration.
The scope of this proposed PHCRG are systematic reviews of interventions and programs, which seek to address upstream determinants of health, targeted to whole populations or particular target groups rather than individuals (which are covered by existing Cochrane Review Groups). Upstream or distal determinants of health are considered ‘those that are distant either in time or place from any change in health status’ (p. 54).3 Upstream interventions affect material factors and social structural conditions, such as equity, social gradients, poverty, social exclusion, racism and discrimination, housing and social environments.3 Figure 1 visually represents the planned scope of the new PHCRG overlaid in red on Lynch's model of life-course epidemiology.4 Given the population health focus and the underlying principles of public health, it is planned that reviews published by the PHCRG contribute to furthering understanding of what works, for whom, why and at what cost and what works specifically in improving health equity and reducing health inequalities.
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We recognize that there are other important areas of public health research and practice that may not be covered by this scope. These will continue to be supported by relevant Cochrane review groups such as tobacco and addiction, HIV/AIDS, injury, effective practice and organization of care, oral health, infectious diseases and others. The formation of the new PHCRG is intended to fill the gap regarding systematic reviews of upstream interventions rather than to take away from the work already being done within the Collaboration in other areas of public health. Further development of collaborative relationships between the PHCRG and these groups are ongoing.
Ensuring that issues of equity are considered within systematic reviews is also increasingly on the agenda. The formation of the Cochrane Health Equity Field (co-registered as the Campbell Equity Methods Group) in June 2005 is leading this work, including the development of an equity checklist to assist with facilitating an equity focus within all Cochrane reviews. The new PHCRG will work closely with this group to advance this work.
Another aspect of ensuring an equity focus within public health evidence that the new PHCRG is keen to address is consideration of the evidence needs of low- and middle-income countries. This includes working with researchers, policymakers and other key stakeholders to establish priority review topics, mentoring reviewers and potential editors, and consideration of the most appropriate ways of incorporating context-specific evidence and recommendations within reviews.
Developing high quality and rigorous systematic reviews also requires consideration of published and unpublished information from across the globe. Effort is needed to identify and source such evidence, particularly from low- and middle-income countries and where it is not published in English. The PHCRG is exploring the establishment of comprehensive information registries, including prospective registration of studies,5 to facilitate the identification of all possible sources of relevant evidence for inclusion in systematic reviews.
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Conclusions |
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A global public health effort is needed to address issues of health inequalities and social determinants of health. We believe that evidence synthesis, with its role in informing policymaking and primary research, must be a vital part of this effort. This means that the new PHCRG has a critical role to play. Global involvement and support is needed from the public health community in order for the group to have optimal impact. The PHCRG can provide editorial support and leadership but does not have the resources to achieve all that needs to be done. People are needed to be involved in reviews as authors, review advisory group members (to inform the content parameters of specific reviews to ensure end-user utility), peer-reviewers, editors and users. Assistance is needed to hand search journals and other grey literature, and to translate both primary papers and reviews into other languages. Of prime importance is the need for reviews to be used by policymakers, practitioners and researchers, thus fueling the need for development of methods to enhance knowledge translation and uptake of evidence across a range of settings and to ensure that the systematic reviews produced have maximum impact.
We are keen to have a strong European contribution in the work of the proposed PHCRG in any of the ways listed earlier. It is also possible to register as a member of the new group without taking on a formal role, but with the option of increasing involvement as capacity allows. For more information please visit our website www.ph.cochrane.org or e-mail cochrane{at}vichealth.vic.gov.au.
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Acknowledgements |
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The Cochrane HPPH Field acknowledges the support of VicHealth (Victorian Health Promotion Foundation), the McCaughey Centre, School of Population Health, University of Melbourne and the English Department of Health.
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References |
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TopIntroductionPublic health developments in...ConclusionsAcknowledgementsReferences |
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1 Petticrew M. ‘More research needed’: plugging gaps in the evidence base on health inequalities. Eur J Public Health (2007) 17:411–3.
2 Hawe P, Shiell A. Use evidence to expose the unequal distribution of problems and the unequal distribution of solutions. Eur J Public Health (2007) 17:413.
3 Keleher H. The drivers for health lie outside the health sector. In: Understanding health promotion—Keleher H, MacDougall C, Murphy B, eds. (2007) Melbourne: Oxford University Press. 47–60.
4 Lynch J. Social-epidemiology some observations on the past, present and future. Australas Epidemiol (2000) 7.
5 Waters E, Priest N, Armstrong R, et al. The role of a Prospective Public Health Intervention Study Register in building public health evidence: proposal for content and use. J Public Health (Oxford, England) (2007) 29:322–7.
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