Evidence-based public health: what does it offer developing countries?

Celia McMichael, Elizabeth Waters and Jimmy Volmink


전 세계의 질병부담의 상당부분은 개발도상국이 지고 있다. 개발도상국은 자원이 부족하고, 특히 효과적인 공공보건 또는 건강증진 전략에 투자할 자원이 부족하다. Systematic reviews는 근거중심 공공보건과 건강증진활동 및 정책에 핵심이다. 개발도상국의 건강우선순위에 대한 systematic review는 별로 없으며, 지금껏 시도된 많은 intervention들은 자원이 부족한 상황에서는 적용하기 어려운 것이 많다. 또한 개발도상국에서는 primary research도 적다.

The global burden of disease and illness is primarily situated in developing countries. As developing countries have limited resources, it is particularly important to invest in public health and health promotion strategies that are effective. Systematic reviews are central to evidence-based public health and health promotion practice and policy. This paper discusses issues surrounding the relevance of evidence-based public health and systematic reviews to the health of developing countries. It argues that there is a lack of systematic reviews relevant to the health priorities of developing countries; many interventions reviewed can not be implemented in resource-poor situations; and, a limited amount of primary research is conducted in developing countries.


본 논문에서는 공공보건의 향상을 위해서는 효과적인 의료서비스와 개입 뿐만 아니라 더 넓은 범위의 구조적, 시스템적 장벽을 허무는 것이 중요하다고 주장하고자 한다. Human development가 가지고 있는 사회적 복잡성과 서로 다른 개발 목표간의 중첩(inter-section)을 감안하면, 개발도상국의 공공보건을 향상시키기 위해서는 systematic review 외에도 여러 영역의 협력과 사회적 정책 도입이 반드시 필요하다. 그럼에도 불구하고 intervention의 효과성에 대하 근거가 개발도상국의 health priorities를 해소하는데 중요한 역할을 할 수 있다. 

The paper further argues that improvements in public health are determined not only by effective health services and interventions, but through an approach that includes other sectors and influences broader structural and systematic barriers to health. Given the social complexity of human development, and the inter-sections amongst different development goals, there is no question that gains in developing country public health are unlikely to emerge from systematic reviews alone, but will require decisions about inter-sectoral collaboration and social policy initiatives. Nonetheless, evidence around intervention effectiveness has an important role to play in addressing health priorities in developing countries and resource-poor areas. The public health evidence base urgently needs strengthening, with dedicated effort towards increasing the relevance of primary evidence and systematic reviews.



Background

기존의 연구들은 개발도상국에 있어서 effective intervention에 대한 가이드를 제공하는 데 한계가 있다.

However, a key concern for those promoting evidence-based public health, and relying on systematic reviews of research to inform decisions about public health interventions, either from the Cochrane Library or those published elsewhere, is that often the available reviews are unable to provide guidance on effective interventions,6 particularly in relation to the health of developing countries. 


그 이유는 다음과 같다.

Some reasons why systematic reviews have had a limited role in providing evidence relevant to developing countries are: 

(1) there is a lack of systematic reviews that are relevant to the health priorities of developing countries; 

(2) many interventions that have been reviewed and shown to be effective can not be implemented in resource–poor situations; 

(3) there is a limited amount of primary research conducted in developing countries as compared to high–income countries. 


이런 이유로 인해 현재까지의 systematic review를 개발도상국에 적용하는 것이 어렵다.

These issues limit the usefulness of currently available systematic reviews (and primary research) for decision-makers in developing countries. This paper discusses the above challenges, critically considering the role of evidence–based public health and the relevance of systematic reviews within the context of international health, and makes some suggestions as to how these challenges could be overcome.



Systematic review의 부족

Systematic reviews and international health

Currently available systematic reviews do not reflect developing world priorities. Two-fifths of the world’s population live in high mortality developing countries, where relatively few risk factors account for the high rates of disease and injury. The 10 leading factors threatening health globally are underweight, unsafe sex, high blood pressure, tobacco consumption, alcohol consumption, unsafe water, sanitation and hygiene, iron deficiency, indoor smoke from solid fuels, high cholesterol, and obesity.9 In high mortality developing regions, underweight, unsafe water, sanitation and hygiene, and indoor smoke from solid fuels are leading risks to health. Approximately one–sixth of the entire disease burden in these regions is attributable to underweight and micronutrient deficiencies, unsafe sex accounts for around one-tenth of all disease burden, and unsafe water for a further 4–5 per cent of the burden (Fig. 1).9







A possible reason for the lack of review questions addressing priority issues for developing areas is that there is a discernible difference in output between reviewers from developing countries (or with significant developing world experience) and those from developed countries. A survey of the place of residence of Cochrane reviewers from 1997 to 2003 suggests that although the number of reviewers from developing countries has increased since the beginning of the period, the relative proportion of reviewers from developing countries compared to developed countries has declined from 16 per cent in 1997 to 8 per cent in 2003 (Fig. 2). This highlights the need for a programme of training and support for reviewers from developing countries.




intervention이 개발도상국 상황에 도입되기 어렵다.

Many interventions reviewed cannot be implemented in resource-poor situations


primary research가 적다.

Limited amount of primary research is conducted in developing countries




Conclusion

Evidence-based public health promotes use of the best available evidence on the effectiveness and lack of effectiveness of interventions. Significant efforts are required, however, to increase the relevance of systematic reviews to public health priorities in developing countries and resource–poor areas: the questions and scope need to consider heterogeneous contexts to ensure relevance, and difficult decisions need to be made about the availability and adequacy of the primary research to address the question. Given the social complexity of human development, and the inter-sections amongst different development goals, there is no question that gains in developing country public health are unlikely to emerge from systematic reviews alone, but will require decisions about inter-sectoral collaboration and social policy initiatives.4 However, evidence around intervention effectiveness has an important role to play in efforts to improve developing country health, as it can distinguish what is a worthwhile intervention and what are the relative costs, benefits and anticipated outcomes. The public health evidence base urgently needs strengthening, and requires international collaboration and dedicated effort towards understanding and improving the factors which influence the relevance of primary evidence and systematic reviews to international health.




 2005 Jun;27(2):215-21. Epub 2005 Apr 8.

Evidence-based public health: what does it offer developing countries?

Abstract

The global burden of disease and illness is primarily situated in developing countries. As developing countries have limited resources, it is particularly important to invest in public health and health promotion strategies that are effective. Systematic reviews are central to evidence-based public healthand health promotion practice and policy. This paper discusses issues surrounding the relevance of evidence-based public health and systematic reviews to the health of developing countries. It argues that there is a lack of systematic reviews relevant to the health priorities of developing countries; many interventions reviewed can not be implemented in resource-poor situations; and, a limited amount of primary research is conducted indeveloping countries. The paper further argues that improvements in public health are determined not only by effective health services and interventions, but through an approach that includes other sectors and influences broader structural and systematic barriers to health. Given the social complexity of human development, and the inter-sections amongst different development goals, there is no question that gains in developingcountry public health are unlikely to emerge from systematic reviews alone, but will require decisions about inter-sectoral collaboration and social policy initiatives. Nonetheless, evidence around intervention effectiveness has an important role to play in addressing health priorities in developing countries and resource-poor areas. The public health evidence base urgently needs strengthening, with dedicated effort towards increasing the relevance of primary evidence and systematic reviews.

PMID:
 
15820994
 
[PubMed - indexed for MEDLINE] 

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