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European Journal of Public Health
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Lipper L, Mann W, Meybeck A, et al. ‘‘Climate-Smart’’ Agriculture—Policies, Practices and Financing for Food Security, Adaptation and Mitigation. Available at: http://www.fao.org/docrep/013/i1881e/i1881e00.pdf (July 2015, last date accessed).
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Gerber PI, Steinfeld H, Henderson B, et al. Tackling Climate Change Through Livestock—A Global Assessment of Emissions and Mitigation Opportunities. Available at: http://www.fao.ord/docrep/018/i3437e/i3437e.pdf (July 2015, last date accessed).
......................................................................................................... European Journal of Public Health, Vol. 25, No. 5, 752–753 ß The Author 2015. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved. doi:10.1093/eurpub/ckv003
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Evidence on the effectiveness of public health practice: how should we proceed? Sijmen A. Reijneveld Department of Health Sciences, University Medical Center Groningen, University of Groningen, The Netherlands Correspondence: Sijmen A. Reijneveld, University Medical Center Groningen, The Netherlands, e-mail:
[email protected]
......................................................................................................... vidence on effectiveness is pivotal for public health practice and
Epolicy making. Despite, the journal publishes pretty few papers
on effectiveness research, and this holds for other major public health journals as well. This paradox should be solved. To jump to my conclusion: the return on investments leading to evidence on public health interventions should be increased, both for researchers and for developers. I provide some considerations, also based on personal experiences with this type of research.
The researcher: investments and profits Research on effectiveness is expensive. First, public health interventions are typically large enterprises. Examples concern the provision of a series of lessons and trainings to students on prevent smoking initiation,1 or training parents to increase their parenting skills regarding the behavioural problems of their child.2 Moreover, effectiveness studies are hard to realise, with e.g. participation rates in randomised controlled trials being as low as 10%.2, 3 In short, effectiveness research requires researchers to invest. Such investments are more likely if the potential benefits are big as well, and this may be the problem. Typically, benefits mostly concern publications in major journals. However, effectiveness studies typically yield only a few papers, whereas the same investment in, e.g. a cohort may yield many more publications. For the journal, the question to be asked is whether we are not too critical regarding effectiveness research as compared with other types of studies.
Development and maintenance: who owns? Developers and interventionists engaging in effectiveness research are the other major type of actors. Regarding them, a core question is ‘who owns the intervention?’. Pharmaceuticals without an owner are rare, but not so for public health interventions. This in particular regards behavioural interventions, such as many anti-tobacco interventions. Their core components are public domain behavioural techniques, which cannot be patented. Their continued use typically requires maintenance: adaptation of the
intervention to new social norms, to new media, etc. Without ownership, the intervention will die within a few years, prohibiting a proper accumulation of evidence on effectiveness. Appropriate ownership may also be a major driver for effectiveness research by yielding funding. This is very obvious in research on pharmaceuticals: the owner has an economic interest in effectiveness data as the pharmaceutical will only be remunerated if proven to be effective. In public health for many interventions, such as the behavioural ones, this is much more difficult. Ownership is rarely exclusive, making it difficult to harvest the profits of an intervention.
Brand names for public health as a solution? A partial solution for this dilemma may be the branding of behavioural interventions, i.e. the use of brand names to denote an intervention with specific features—no patenting, but a protection of the brand name. The owner of the brand then does the marketing, takes care of materials for the intervention, of trainings of people who shall deliver the intervention, and of quality systems to maintain treatment integrity, may support interest groups, etc. Next, users of the branded intervention have to pay a fee to be allowed to use the brand. This approach may drive and fund the research and development cycle. Use of brand names for instance occurs in community-based parenting support for parents of youth with behavioural problems. In that domain, a series of branded interventions exist, such as PMTOTM, PCITTM and MSTTM. An example of these is the Positive Parenting Programme, Triple PTM: the holder of the brand name asks a fee for use of the branded product, and in turn provides supporting service, see www.triplep.net. Revenues out of the branding can then be used to obtain further evidence regarding effectiveness. Branding may offer a solution to not only strengthen the evidence-base of public health interventions, but also has risks, as shown in the recent debate around Triple P.3, 4 That debate goes on conflicts of interests that may not have been adequately reported and on the quality of the effectiveness research. The first reflects that the developer gets an economic interest in the product. That may not be
Editorials
a problem, but requires transparency.5 The second may be due to revenues of this branding typically being much lower than in case of pharmaceuticals. That may lead to cheap and weaker evaluation designs, casting doubt on the soundness of the evidence-base. My assumption is that this is a sort of learning process—the model is interesting, but we should learn how to best work with it.
References
A brighter future: increasing return on investment in public health R&D An increase of the return on investment may help to reinforce the evidence-base of public health practice. Branding may contribute to this, the same holds for an editorial policies that favour effectiveness research. In both, we should learn, but preferably also proceed quickly—effectiveness is a core issue in any public enterprise, including public health.
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1
Crone MR, Reijneveld SA, Willemsen MC, et al. Prevention of smoking in adolescents with a low educational level: a school-based intervention study. J Epidemiol Community Health 2003;57:675–80.
2
Spijkers W, Jansen DE, Reijneveld SA. Effectiveness of Primary Care Triple P on child psychosocial problems in preventive child healthcare: a Randomized Controlled Trial. BMC Med 2013;11:240.
3
Wilson P, Rush R, Hussey S, et al. How evidence-based is an ‘evidence-based parenting program’? a PRISMA systematic review and meta-analysis of Triple P. BMC Med 2012;10:130.
4
Kleefman M, Jansen DE, Stewart RE, Reijneveld SA. The effectiveness of Stepping Stones Triple P parenting support in parents of children with borderline to mild intellectual disability and psychosocial problems: a randomized controlled trial. BMC Med 2014;12:191.
5
Reijneveld SA. Public-private partnerships in public health research: does it work and if yes, how? Eur J Public Health 2012;22:165–6.
