16 results
Endorsements
- Anne Andermann, McGill University, Montréal
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- Evidence for Health
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- 05 February 2013
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- 20 December 2012, pp xv-xvi
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2 - Strategies for improving health
- Anne Andermann, McGill University, Montréal
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- Evidence for Health
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- 05 February 2013
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- 20 December 2012, pp 5-25
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Summary
Almost 40 years ago, the Declaration of Alma-Ata set forth the aspirational goal of “health for all”. While a great deal of progress has been made in recent decades, there remain many important decisions still to be made if we want to come even closer to achieving this goal. However, if the aim of making more evidence-informed decisions is to improve health, it would be helpful to first know what health is. While this appears to be a rather straightforward question, as Socrates found over two millennia ago, many people, when pressed, have difficulty defining even the most fundamental concepts – like knowledge and justice – that are central to their everyday lives. Similarly, health and health inequities are also basic concepts that should be explored further from the outset. What is health? Why should we want to improve health? What are the most effective strategies for improving health? How can we measure whether there have been health improvements? This chapter provides an overview of the concepts of health and health inequities, of the causes of poor health, and of the various strategies to improve health and reduce health inequities.
Health and health inequities
Health is a complex concept that can be examined and defined in many different ways. A widely used definition is inscribed in the 1948 constitution of the World Health Organization (WHO), which considers health to be “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”. This definition moves away from a strictly biomedical model of health that focuses only on the disease or disability. Instead, the WHO definition adopts a wider bio-psycho-social model to better integrate the importance of the psychological and social dimensions of health. One might go even further and include a spiritual dimension of health. According to the Canadian Royal Commission on Aboriginal Peoples, many indigenous communities consider health to be “a state of balance and harmony involving body, mind, emotions and spirit. It links each person to family, community and the earth in a circle of dependence and interdependence, described by some in the language of the Medicine Wheel”. Health is therefore a holistic and multidimensional concept that must be explored from different angles and perspectives to be fully understood (Fig. 2.1).
6 - Making evidence-informed decisions
- Anne Andermann, McGill University, Montréal
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- Evidence for Health
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- 05 February 2013
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- 20 December 2012, pp 146-174
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Summary
Making evidence-informed decisions with the aim of improving health can be facilitated by using a systematic approach. While there is no single way of summarising or ordering the various elements that should be involved in making such decisions, the algorithm shown in Fig. 6.1 lays out many of the key issues that should be considered. Indeed many different types of evidence and value judgements are needed during the decision-making process to answer a wide range of questions, including: (1) What is the priority health problem? (2) What causes this health problem? (3) What are the different strategies or interventions that can be used to address this health problem? (4) Which of these options as compared to the status quo has an added benefit that outweighs the harms? (5) Which options would be acceptable to the individuals or populations involved? (6) What are the costs and opportunity costs? (7) Would these options be feasible in this specific context? (8) What are the ethical, legal and social implications of choosing one option over another? (9) What do different stakeholders stand to gain or lose from each option? And (10) Taking into account the multiple perspectives and considerations involved, which option is most likely to improve health while minimising harms? The remainder of this chapter will go through each of the steps in the algorithm in greater detail.
Define the priority health problem
Whether seeking to improve the health of individuals, populations or our global society, there are generally multiple health problems that could be addressed. Often many of these health problems are inter-related and intertwined. Yet, it is nonetheless helpful to try and identify the priority health problem (or problems) that, if improved, will have the greatest impact on health overall.
4 - Producing evidence to inform health decisions
- Anne Andermann, McGill University, Montréal
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- Evidence for Health
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- 05 February 2013
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- 20 December 2012, pp 74-120
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Summary
Since the purpose of this book is to help people make better-informed decisions about improving health and reducing health inequities, an important question is what counts as evidence in supporting these decisions? Often, if a person has a health problem, they might ask a family member or a friend for advice. If they are sufficiently concerned that this health problem could be serious, they may make an appointment to go see their family doctor or a local lay health worker and ask them what to do. In this technological age, many people learn about health issues from the media or go on the Internet and use Google to find guidance. In government, high-level officials – who may not have any health training even though they are responsible for important decisions that affect the health of thousands or even millions of people – often turn to their scientific and technical advisors for assistance. Friends, family, newspapers, television, blogs and so on, are all sources of health information. But, will this information lead to better-informed decisions? Doctors and technical advisors may have greater knowledge about what makes individuals and populations healthy, but what evidence do they use as a basis when they provide advice? When a friend recommends chicken soup for a cold because that is what he learned from his grandmother, does this count as evidence? What if the friend says that the chicken soup helped someone else to feel better when they had a cold – now is this evidence? What if the friend says that they read in the newspaper that a randomised controlled trial of chicken soup versus placebo reduced the average length of a cold from seven to five days – now is this evidence? What about when it comes to social policies – what would be the optimal length of parental leave to promote health? Is 3 months enough? What about 12 months? How could one investigate this? The purpose of this chapter is to explore further what counts as evidence, how evidence is produced and how it can be used to make better-informed decisions to improve health.
Evidence for Health
- From Patient Choice to Global Policy
- Anne Andermann
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- 05 February 2013
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- 20 December 2012
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Evidence for Health: From Patient Choice to Global Policy is a practical guide to evidence-informed decision-making. It provides health practitioners and policy-makers with a broad overview of how to improve health and reduce health inequities, as well as the tools needed to make informed decisions that will have a positive influence on health. Chapters address questions such as: What are the major threats to health? What are the causes of poor health? What works to improve health? How do we know that it works? What are the barriers to implementation? What are the measures of success? The book provides an algorithm for arriving at evidence-informed decisions that take into consideration the multiple contextual factors and value judgements involved. Written by a specialist in public health with a wealth of international experience, this user-friendly guide demystifies the decision-making process, from personal decisions made by individual patients to global policy decisions.
5 - Facilitators and barriers to using evidence
- Anne Andermann, McGill University, Montréal
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- Evidence for Health
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- 05 February 2013
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- 20 December 2012, pp 121-145
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Summary
Producing evidence is not the same as using evidence. Notwithstanding the value of creating knowledge for its own sake, it is difficult to justify spending valuable resources on countless research studies, especially research studies where there is potential for causing harm to research subjects (whether human or animal), if it does not contribute to a deeper understanding of the world we live in and how to make that world a better place. Yet, even the highest quality evidence is useless if it is not incorporated into decision-making for health. Indeed, the study of why health practitioners do not use evidence-based clinical practice guidelines has become a field of research in its own right. A systematic review of systematic reviews found that interactive techniques such as audit, feedback, outreach and reminder systems work best to promote the uptake of evidence. Despite this, clinical practice guidelines are often used in an attempt to change physician behaviours, but with much less success. There exists an entire online clearinghouse with thousands of such guidelines, but what good are they if nobody uses them? Therefore, at the core of the research cycle presented in the previous chapter, there is “synthesis, dissemination and utilisation”, which are the driving forces for ensuring that research evidence is used to influence decisions that can improve health. In an ideal world, this is not just an afterthought at the end of the cycle, but something that occurs every step of the way to continually move evidence into policy and practice (Fig. 5.1). However, if our goal is to make more evidence-informed decisions that improve health, it is also important to be aware of the many barriers to using research evidence, such as missing the window of opportunity, controversy over the research findings and vested interests. This chapter therefore describes in greater detail some of the facilitators and barriers to translating research evidence into improved health outcomes.
Index
- Anne Andermann, McGill University, Montréal
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- Evidence for Health
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- 20 December 2012, pp 198-206
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7 - Conclusion
- Anne Andermann, McGill University, Montréal
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- Evidence for Health
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- 05 February 2013
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- 20 December 2012, pp 175-197
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Summary
It is easy enough to propose an algorithm for making evidence-informed decisions to improve health, but the real challenge is putting it into practice. We have already discussed in Chapter 5 the various facilitators and barriers to using evidence in making decisions about health, and Chapter 6 describes the key elements that should be considered as part of the overall decision (i.e. the content), but it is important not to overlook how decisions are made and, in particular, who is involved (i.e. the process). In many ways, the process itself can be just as important as the content. This concluding chapter will therefore look at how to make evidence-informed decisions work in practice, as well as how to ensure that these decisions have the greatest possible impact on improving health.
Making it work in practice
It may appear self-evident, but decisions do not occur in some other realm and then are handed down to us mere mortals to abide by and follow. Rather, everything that structures our lives has been decided by people, and, if we want, these decisions could be changed to create a healthier and more equitable world. Indeed, the recent Rio +20 United Nations (UN) Conference on Sustainable Development asks: What is the Future We Want? Once we define our goals for the future, it is possible to change course and make it a reality. For instance, it was recently announced that “the [Millennium Development Goal (MDG)] drinking water target, which calls for halving the proportion of the population without sustainable access to safe drinking water between 1990 and 2015, was met in 2010, five years ahead of schedule”. Only two decades ago, almost one-quarter of the population on this planet did not have access to clean drinking water – one of the most basic necessities for health and daily life. Yet, with a concerted effort on the part of our global society, in 2010 there were only 11% left who still relied on unimproved sources of water – and that number is continually decreasing. That is not to say that no challenges remain. Nonetheless, it is quite remarkable what can change when the decision is made to make it happen. However, influencing decisions and ensuring that they are implemented requires involving a range of key players from the very outset.
Frontmatter
- Anne Andermann, McGill University, Montréal
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- Evidence for Health
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- 20 December 2012, pp i-v
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Contents
- Anne Andermann, McGill University, Montréal
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- Evidence for Health
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- 20 December 2012, pp vii-viii
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1 - Introduction
- Anne Andermann, McGill University, Montréal
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- Evidence for Health
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- 05 February 2013
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- 20 December 2012, pp 1-4
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Summary
The purpose of this book is to better understand how to improve the health of individuals, populations and the global community. What are the major threats to health? What are the causes of poor health? What works to improve health? How do we know that it works? What are the barriers to implementation? What are the measures of success? These are some of the key questions that will be addressed in this book. The aim is to provide health practitioners and policy-makers with a broad overview of how to improve health and reduce health inequities, as well as the tools to make more evidence-informed decisions that will have a positive influence on health.
Indeed, countless decisions that affect health are made every day, whether at the level of individual health choices made by patients and the general public, population health policies and programmes made by politicians and public health officials, or global health strategies and recommendations made by an increasing number of players at the international level, including civil servants, non-governmental organisations (NGOs), philanthropists, academics, public–private partnerships and so forth. For instance, a mother takes time off from work to bring her child to the local clinic to be vaccinated. A student buys a fruit for an afternoon snack rather than potato chips. A 28-year-old woman who carries the BRCA gene for hereditary breast-ovarian cancer undergoes preventive surgery to remove her breasts and ovaries. A government passes a bill to extend parental leave to one year and to increase funding for early childhood development programmes. The World Health Organization (WHO) recommends increasing universal health coverage and social protection by strengthening primary health care as the foundation for all health systems. In each of the above examples, people were faced with a choice (i.e. to vaccinate or not, to eat a fruit or chips, to have preventive surgery or enhanced screening, to finance social programmes or reduce taxes, to promote vertical programming that focuses on preventing and treating a single disease or a more comprehensive approach based on primary health care), and a decision was made that will either improve or impair health outcomes.
Foreword
- Anne Andermann, McGill University, Montréal
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- Evidence for Health
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- 05 February 2013
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- 20 December 2012, pp ix-x
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Summary
Foreword
Tikki Pang
Visiting Professor, Lee Kuan Yew School of Public Policy
National University of Singapore, Singapore and formerly
Director, Research, Policy and Cooperation World Health Organization
Geneva, Switzerland
In an age of financial crises, diminishing resources and competing priorities, Anne Andermann’s book is very timely and fills an important gap in the critical area of developing sound and sustainable health policies. While many books and manuals have been written on the use of evidence in the development of clinical practice guidelines, there have been very few attempts at a treatise on the use of evidence in policy formulation. Written as a practical guide to evidence-informed decision-making, this book will be an invaluable tool for policy-makers and others, including health practitioners, enabling and empowering them to make rational decisions and better withstand vested interests and political, economic and even ideological pressures, which are so pervasive in the policy sphere.
Based on her own extensive experience, the author takes us systematically through the strategies commonly used to improve health, and the more difficult topic of how decisions are made which impact health outcomes. She then tackles the practical issue of producing evidence and the critical bottleneck which exists between the production and use of evidence. Often, a major challenge is the lack of understanding between researchers and policy-makers, which, I believe, can be overcome to a large extent by giving attention to the issues highlighted in this book. In the chapter on evidence production, the author highlights, for example, the increasing importance of implementation research, which aims to develop strategies for optimising the delivery, uptake and use of new or existing interventions by populations in need. This type of research is particularly important in supplying the kind of evidence which policy-makers appreciate and understand more readily than basic biomedical or even clinical research. The chapter also highlights the importance of evaluating the impact of policy, and how such research can feed back into the “knowledge loop” in an iterative, reinforcing manner. The final chapter cogently tackles the oft-neglected final step of how evidence-informed decisions are actually made, highlighting the necessity of coming up with various options which take into account ethical, social, legal and cultural issues, and the sensitivities and concerns of interested parties who may be affected by the decision.
3 - Understanding how decisions influence health
- Anne Andermann, McGill University, Montréal
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- Evidence for Health
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- 05 February 2013
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- 20 December 2012, pp 26-73
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Summary
Decision-making for health is a complex matter. Some decisions are banal everyday choices that we make at the individual level – decisions that are often shaped by many extrinsic forces. Should I buy sweets or a fruit as a snack? Will I drive or cycle to work today? While each individual decision may have relatively little importance, taken together and multiplied across the entire population, the effects can add up. Nonetheless, we are generally very preoccupied with these small decisions, while large-scale decisions made at a population or global level seem entirely beyond our control and tend to go unnoticed, even though they may have even more profound effects on our collective health. For instance, certain countries are attempting to develop nuclear weapons, other countries have a laissez faire attitude towards the oversight of financial markets risking worldwide economic crises, and others still continue to produce and export harmful products ranging from asbestos to machine guns and cluster bombs, which could have devastating impacts on the health of large numbers of people worldwide. Who is regulating these decisions? How can we better inform these decisions using the best available evidence? The purpose of this chapter is to provide an overview of decision-making for health from patient choice to global policy as a first step towards better understanding how these decisions are made and how we can intervene to improve health.
Individual health decisions
We all make decisions about our health. Some decisions are rather quick and painless, and others are more important and thought through. Some decisions we make for ourselves, and others are for the health of loved ones. Some decisions, particularly those that deal with questions of life and death, we hope that we never have to face, and, if we do, we would want someone well informed and trustworthy to be there to guide us through it. Thus there are a range of different health decisions made at an individual level, and a wide array of factors that influence these decisions. To illustrate these, and to provide an introduction to the extensive but disparate literature on the subject, I will use three case examples.
Preface
- Anne Andermann, McGill University, Montréal
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- Evidence for Health
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Preface
The idea for this book came to me when I was teaching a course on epidemiology to graduate students in the Health and Health Policy (HHP) Programme at Princeton University’s Woodrow Wilson School for Public and International Affairs. Many of my students were completing a Master’s degree in Public Administration (MPA) or Public Policy (MPP). They had already worked in government or for well-known international non-governmental organisations (NGOs) and had been involved in making decisions that could affect the health of hundreds of thousands of people. Yet for the most part they did not have any formal education or training in health sciences upon which to base these decisions. With undergraduate degrees in political science, management and economics, the process of producing, appraising and using scientific evidence was a “black box” that was unveiled during the course so that the students could be more critical readers of the research literature (or even of reports of the literature published in the media, which is where most people read about scientific evidence). Even health practitioners working on the frontlines – including doctors, nurses, midwives, lay health workers and others – are not always well versed in research methods and how research findings can be used to improve health. While evidence is certainly not the only “ingredient” that goes into decision-making for health, making decisions without evidence is like sailing the seas without a map and compass. Therefore, to foster more evidence-informed decision-making, I thought it would be important to write a book targeted towards practitioners and policy-makers that demystifies the process of knowledge production and illustrates the complexity of decision-making so that knowledge users are better able to incorporate the scientific evidence into decisions, to thereby influence health outcomes in a more strategic and informed way. This is by no means an epidemiology textbook, but rather a practical guide to evidence-informed decision-making with the goal of improving health and reducing health inequities.
About the author
- Anne Andermann, McGill University, Montréal
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- 20 December 2012, pp xvii-xviii
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Acknowledgments
- Anne Andermann, McGill University, Montréal
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- Evidence for Health
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- 20 December 2012, pp xix-xx
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