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As I generally say to my students in a very early lecture in my introduction to public health class, public health is the nexus of science and politics. Generally I illustrate this with a teen pregnancy example. A needs assessment shows that your health district has an unusually high rate of teen pregnancy. While the science suggests making birth control available to teenagers, who are going to experiment with sex, notwithstanding any other intervention, including abstinence education, the latter will appeal to the community and the first will not make it through your board of health. The birth control works and the abstinence education does not and is a waste of money. But, abstinence education is what the school and local board of health will allow and in fact want, but you know it does not work. Welcome to public health administration!!
This illustrates graphically the dilemma faced on a daily basis by the director of many health departments. But it assumes a couple of things; first, the director is aware that abstinence education does not work. That, in turn, assumes she or he keeps up with the scientific literature in public health. Second, the director makes decisions on the basis of science, rather than some subjective judgment. Both of those assumptions, based on an article in this issue, are testable.1 The assumption that objective decision tools, at least for setting priorities, are used by directors is questionable, particularly when the director has no scientific background. It also assumes that science is available to the director in a usable format.
Several of these assumptions are false. First, according to the most recent survey, only 57 percent of top local public health directors had either a master's degree or a doctoral degree.2 While it is possible that those without advanced level training would be capable of examining and making decisions based on science about how best to make decisions as the health department director, we know the vast majority of those without a master's degree or doctorate will not have had detailed exposure to the research educational experiences that prepares them to use science to make decisions and have the capacity to read and understand the scientific literature. Second, such literature exists for decisions to be made by the director who is capable of using science for decision making. There is good news and bad news here. In the case of clinical preventive services, there is a body of literature and it is a growing literature. Not only that, but it is compiled in the Guide to Clinical Preventive Services.3 While the guide's findings may be controversial and prone to public debate, the science, at least, is laid out for the scientifically astute reader to understand and sort out in order to make decisions. The knowledgeable individual may deviate from the recommendations, but that is likely the result of the situation, the wisdom and experience of the decision maker, or the desire of the patient, all reasonable responses to reviewing the science.
There is also science in the area of community preventive services, specifically the Guide to Community Preventive Services.4 Unfortunately we deal here with two issues. First, the amount of science is not nearly as pervasive or helpful as the situation with the Guide to Clinical Preventive Services. The depth and breadth of community intervention research is woefully inadequate, so the services and the ability to make judgments about them are not nearly as pervasive as the clinical services guide. However, it is available to the average public health practitioner. The second issue is the use of the guide by those same practitioners. Work by Brownson and colleagues5,6 demonstrates that even if you lead the proverbial horse to water with community preventive services, it is still hard to get him or her to drink. Green and his colleagues7 have made a major observation about the guide as well. In almost every situation where we ask local health practitioners about the programs they implement from the guide they are concerned about the lack of fidelity of the intervention and if it works with this decreased fidelity. The issue of efficacy and effectiveness is alive and well in community prevention intervention research.
We have now embarked on a new scientific endeavor important to the public health director. This is public health systems and services research (PHSSR). Recently in a major special issue of health services research (HSR), the AcademyHealth Special Interest Group tried to better develop the definition of PHSSR, so they concluded the following8:
PHSSR is a field of study that examines the organization, financing, and delivery of public health services within communities, and the impact of these services on public health.
PHSSR is a multidisciplinary field of study that recognizes and investigates system-level properties and outcomes that result from the dynamic interactions among various components of the public health system and how those interactions affect organizations, communities, environments, and population health status.
The public health system includes governmental public health agencies engaged in providing the 10 essential public health services, along with other public and private sector entities with missions that affect public health.
The term services broadly includes programs, direct services, policies, laws, and regulations designed to protect and promote the public's health and prevent disease and disability at the population level.
Work to help the director of the local health department in finding scientifically derived data to help define the optimum organization, finance, governance, and administration character of the health department is in its infancy. The HSR special issue represented to some a high watermark in the discipline as it demonstrated that the discipline has achieved credibility with the larger HSR community.
Data and research in this new discipline are now beginning to be published, prompted by a variety of efforts of the Robert Wood Johnson Foundation, the Centers for Disease Control and Prevention (CDC), and a few brave souls willing to risk their professional career on a new and very untried venture. This issue of the Journal of Public Health Practice and Management illustrates that the editors of many of our major public health journals, particularly those focused on practice, are willing to lend a hand to this new venture. This is a much-appreciated contribution to the growth of the discipline.
But this also raises some questions and issues that need to be addressed. The first is how we get this information that comes from this research into the hands of those who make administrative and policy decisions about how their health department is run. The average turnaround time for a journal article suggests that many of the findings will take months before they even come to the attention of the average practitioner, even if she or he does keep up with the literature. That is not acceptable. Information that can improve the practice of public health needs a mechanism for rapid dissemination to the community that can use it. What of the fidelity and effectiveness of our research? Many PHSSR research efforts are efficacy research, done in well-controlled conditions with university researchers and handpicked interventions. How will it work in the real world? I work on a daily basis with a large number of local health departments in Kentucky and across the United States and there is substantial variation in the conditions in which they work. Notwithstanding the work that Mays and Scutchfield have done to create a typology of health departments, fidelity and effectiveness of administrative interventions will remain an issue, depending on the character of the site where they are implemented.9
This work, like most research in the United States, could and should benefit from the current movement to translational research efforts. Recently, several of us have written about the leadership that we should demonstrate in the public health and preventive medicine community to the implementation of the National Institutes of Health's (NIH's) efforts in clinical and translational research.10 It would be a real mark of hypocrisy if we criticize NIH and then are unable to make the translation ourself. There are several ways to avoid that. One is the notion of practice-based research networks, networks that link practitioners and their practical questions to academic researchers and the skills they have to work with practice to answer these questions. The development of public health practice-based research networks is important in the field. One caution is that it takes funding to maintain the infrastructure of these organizations, and after they are established, it is imperative that funding flow to answer the questions that come from a rich dialogue between research and practice.
The field is new and the first meta-analysis of a PHSSR topic has yet to be done. The notion of a Guide to Public Health Administrative Services is a vision for the future. Only when adequate funding is made available to do the research that allows for meta-analysis and critical review of the literature will we really be at the threshold of a major breakthrough in how we should practice public health. Moreover, the lessons of the Guides to Clinical and Community Services continue to be a specter in the background. If we build it, will they come? Until the research demonstrating how best to practice public health is used then all of our research is for naught. We must draw from the experience of our medical colleagues in putting into practice the Guide to Clinical Preventive Services. They labored long and hard at getting clinicians to do the "right thing" and have only recently come up with how best to ensure the utilization of knowledge that has been codified in the guide. Let us quickly figure out what worked there and apply it to the practice of public health administration. I think it would be remiss to leave this topic without one other comment. The role of the Public Health Accreditation Board and the forthcoming accreditation of state and local health departments has the potential to make a major impact on PHSSR. At the risk of being stoned for pointing to the emperor's lack of clothing, I would observe that precocious few of the standards for accreditation are evidence-based. The ability to build an evidence-based set of standards for accreditation of health departments is a challenging but exciting opportunity to make a real contribution to public health.
For those few of us in the basement of the CDC in the early part of this century talking about how we could begin to use health service research methods and the knowledge of HSR applied to public health systems and services, it is a heady time. Most thought we would never achieve what has been accomplished in less than a decade. The existence of the special interest group in AcademyHealth, the publication of special issues of major health services, and public health journals focusing on PHSSR, with good manuscripts, new young researchers coming to the field to contribute and the seeming hunger of the practice community for information to facilitate their practice were merely dreams. I am, like many of my colleagues in the field, reminded of Thoreau's comment, "if you have built castles in the air, your work need not be lost; that is where they should be. Now put the foundations under them."11(p315)
1. Platonova EA, Studnicki J, Fisher JW, Bridger C. Local health department priority setting: an exploratory study. J Public Health Manag Pract. 2010;16(2): xx-xx. [Context Link]
2. National Association of County and City Health Officials. 2008 National Profile of Local Health Departments. Washington, DC: National Association of County and City Health Officials; 2009. [Context Link]
3. US Preventive Services Task Force. http://www.ahrq.gov/CLINIC/uspstfix.htm. Published 2009. Accessed November 23, 2009. [Context Link]
4. The Guide to Community Preventive Services. http://www.thecommunityguide.org/index.html. Published 2009. Accessed November 23, 2009. [Context Link]
5. Brownson RC. Evidence-Based Public Health. New York: Oxford University Press; 2003. [Context Link]
6. Brownson RC, Fielding JE, Maylahn CM. Evidence-based public health: a fundamental concept for public health practice. Annu Rev Public Health. 2009;30:151-174. [Context Link]
7. Green LW, Ottoson JM, Garcia C, Hiatt RA. Diffusion theory and knowledge dissemination, utilization, and integration in public health. Annu Rev Public Health. 2009;30:151-174. [Context Link]
8. Scutchfield FD. To build on the discipline of health services research focused on the public health system (Foreword). Health Serv Res. 2009;44(5, Pt 2):1773-1774. [Context Link]
9. Mays GP, Scutchfield FD, Bhandari MW, Smith SA. Understanding the organization of public health delivery systems: an empirical typology. Milbank Q. In press. [Context Link]
10. Michener L, Scutchfield FD, Aguilar-Gaxiola S, et al. Clinical and translational science awards and community engagement: now is the time to mainstream prevention into the nation's health research agenda. Am J Prev Med. 2009;37(5):464-467. [Context Link]
11. Thoreau HD. Walden: A Fully Annotated Edition. New Haven: Yale University Press; 2004. [Context Link]
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