Systematic Reviews in Public Health Research Paper

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Introduction To Evidence-Based Public Health

Public health decision making can concern questions regarding what programs might work; the impact of illness or disease; the causes of disease and health outcomes; barriers to better health; and views people have regarding health, illness, treatments or interventions, and government priorities. Thus, a wide range of evidence is required involving a wide range of methods and processes.

Systematic reviews are now being applied more frequently to questions of intervention effectiveness. The development of methods to assess interventions is closely related to the emergence of evidence-based practice (EBP). EBP has evolved as a process in which ‘best available’ research evidence is incorporated into practice to inform decision making. More recently there has been a focus on studying the process of implementation, establishing what works (or does not), for whom, and why.

Interest in evidence-based public health is prompted by several factors. As with other groups within the health sector and beyond, there has been an increasing public and political expectation to demonstrate outcomes and to prioritize the use of available resources. One of the options available is to synthesize previous research to identify what programs provide the most likely way forward. Thus, as a field of endeavor, researchers engage in the critical appraisal, synthesis, exchange, and translation of knowledge acquired through research investments to provide access to relevant, easily usable, and high-quality public health evidence for consumers, practitioners, researchers, and policymakers.

Systematic Reviews And Their Contribution To Evidence-Based Public Health

Over the past 20 years the generation of information has increased markedly, fueled by information technology advances. This has stimulated the need to develop efficient methods to review, synthesize, and summarize the interventions undertaken in a particular area. In public health, topics range from specific interventions (for instance, a review of school-based driver education) or a broader range of interventions addressing specific problems (such as the social exclusion associated with unintended teenage pregnancy).

A systematic review is defined as ‘‘a review of the evidence on a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise relevant primary research, and to extract and analyze data from the studies that are included in the review’’ (NHS Centre for Reviews and Dissemination, 2001). This type of review provides a comprehensive summary of rigorous studies conducted to address a question of interest. This synthesis is important as single studies, which can generate a large amount of publicity, can be misleading. Systematic reviews are therefore a powerful tool in supporting both policy and practice. They differ from a traditional or narrative review that describes and appraises previous work, but tends to be less comprehensive and transparent in identifying included studies and thus is more prone to bias. They also differ from met analyses, which are simply a statistical combination of results from a number of studies. Where the process for identifying studies included in a meta-analysis is not systematic, meta-analysis may not be considered as a systematic review. Some systematic reviews may, however, include a meta-analysis in their results section.

Systematic review methods can be applied across research questions and methods. The majority of published systematic reviews have sought to address an intervention related question: Does the intervention work (effectiveness)? More recent studies have addressed these questions as well: how and why the intervention works (or not), how acceptable the intervention is, whether there are any unanticipated harms associated with it, and what its costs are in relation to its effectiveness. Systematic reviews of complex health promotion and public health interventions can be extremely challenging methodologically ( Jackson et al. 2005). A systematic review is therefore ideally conducted by a team, in which some members bring knowledge about the topic and others bring skills in the methodology. Users, or stakeholders, increasingly play a role in identifying salient questions, advising on scope, and sometimes participating in other ways in the review process.

The majority of the methodological work regarding the effectiveness of interventions has been undertaken on questions for which the randomized controlled trial (RCT) is considered the strongest possible study design to minimize bias. In these contexts, good RCTs are more likely to provide answers about effectiveness than studies of lower quality (e.g., uncontrolled studies). However, depending on the question the review seeks to answer, the full spectrum of study designs related to public health questions may be included. Systematic reviews of effectiveness have included a range of other study designs, where appropriate, such as quasi-randomized trials, controlled before-and-after studies, and interrupted timeseries studies. For questions of harm, well-conducted cohort or case-control studies may be recommended and included in meta-analyses of observational studies (Egger et al., 1998). It is also becoming more common to see qualitative studies included in systematic reviews of effectiveness that seek to understand people’s experiences (Evans and Fitzgerald, 2002) or views (Harden et al., 2004).

Research findings are often only a small part of the policy debate. Other influences include judgment, resources, values and policy context, habits and traditions, lobbyists and pressure groups, pragmatics and contingencies, and experience and expertise (Davies, 2005). However, rigorously conducted research and high-quality systematic reviews may increase the impact of research evidence on decision making (Petticrew and Roberts, 2006). This impact can be further enhanced by an understanding of the broad processes that link research, knowledge synthesis, translation and distribution of knowledge, and evaluation of public health impacts. By enhancing the capacity for evidence-based practice through its summary of existing knowledge and identification of opportunities for innovation/further research, systematic reviews enable practitioners to respond to the increasing pressure to use evidence to justify their approach and to contribute to the evidence base (Petticrew and Roberts, 2006).

Conducting Systematic Reviews Of Public Health Interventions

This section is based on the Guidelines for Conducting Reviews of Health Promotion and Public Health Interventions developed by the Cochrane Health Promotion and Public Health Field in Victoria, Australia, with the involvement of 16 experienced international public health methodologists and practitioners.

Planning the Review

It may be useful to establish an advisory group to assist with framing the question, determining the scope of the review, and ensuring that the end product meets the needs of users. Defining the scope of the review requires the authors to consider the practical application of the review in question. They must make pragmatic decisions about time and resources available to carry out the review. At this point, they must decide which populations and interventions of interest to review and which outcomes to use to determine intervention effectiveness. The relevance of an outcome for decision making can vary according to one’s point of view as a consumer, practitioner, policymaker, researcher, or member of the public.

Study Designs To Include

The review question will determine the types of study designs to be included. For example, a question about effectiveness is best answered by systematic reviews followed by RCTs, whereas a question about the acceptability of day care for families living in disadvantaged areas is more likely to benefit from a range of qualitative research methods (Petticrew and Roberts, 2006). A broad test search (often referred to as a scoping search) will assist in the identification of study designs used to address the question of interest in a particular topic area. The decisions about which type(s) of study designs to include will influence subsequent phases of the review, particularly searching the literature, quality assessment, and analysis (especially for meta-analyses). Although RCTs may be the ‘gold standard’ for questions of effectiveness, they may not always be appropriate for your question.

Searching The Public Health Literature

Searching for literature on public health interventions is difficult. Studies are often poorly indexed by medical databases, and the terminology used in studies may differ across journals and contexts. Research on interventions may be published in a range of multidisciplinary sources ( Jackson et al., 2005; Petticrew and Roberts, 2006). Many studies of public health interventions are never published in peer-review journals and are referred to as ‘gray literature,’ which may appear as reports to government agencies, books, or chapters in books. As part of the scope of a review, it is important to consider the pros and cons of including these types of studies before devising an appropriate search strategy.

Quality Assessment

Quality assessment of studies to be included in systematic reviews refers to assessing the degree to which the study is free from methodological biases (including selection bias, response bias, and observer bias). If studies of varying levels of quality are summarized together to estimate an effect size, the results of the review may be biased. Authors need to be explicit about the approach used to assess quality and draw conclusions about the strength of evidence. A range of tools have been developed and are appropriate for use in systematic reviews of public health interventions (Petticrew and Roberts, 2006). Currently, there is no single validated checklist to use for all types of qualitative studies. Where possible, authors using checklists should report on their usefulness to advance research methodologies.

Theoretical Framework

Although it is not known whether theoretical frameworks have an impact on the effectiveness of interventions, many interventions are based either explicitly or implicitly on a theory about what works. At the systematic review level, capturing, synthesizing, and interpreting information about the theoretical bases of included studies may provide the decision maker with insight into how the program designer thinks the intervention brings about change. This may be useful information when considering how applicable the intervention is to a particular context or population. When reporting systematic review results, it may be useful to tabulate the theoretical perspectives used in each intervention.

Integrity Of Intervention

The integrity (or fidelity) of the intervention is the degree to which the intervention is implemented as planned. Dane and Schneider (1998) describe six aspects of integrity/fidelity: adherence (whether components were delivered as prescribed), exposure (the number and length of sessions within a program), quality of delivery (related to staff involved in program delivery), participant responsiveness (including participation and enthusiasm), program differentiation (ensuring that participants only received planned interventions), and heterogeneity in public health reviews (the differences in included studies including populations, contexts, and outcomes measured).

Integrating Qualitative And Quantitative Studies

Combining a synthesis of qualitative studies with a synthesis of quantitative data from research trials can provide greater insights into developing, evaluating, and implementing interventions (Oliver et al., 2005). When the synthesis of trials includes a meta-analysis, the method allows the integration of quantitative estimates of benefit and harm with qualitative understanding from people’s lives. The insights gained from the synthesis of qualitative studies allows exploration of statistical heterogeneity in ways that it would be difficult to imagine in advance (Thomas et al., 2004).

Ethics And Inequalities

Systematic review methods for addressing health-care inequalities are in their infancy, and as a result, with some admirable exceptions (Kristjansson et al., 2007) few systematic reviews currently include this type of information. This is primarily because information on equity tends to be underreported in primary studies. Where possible, it may be useful to use PROGRESS (place of residence, race/ethnicity, occupation, gender, religion, education, socioeconomic position [SES] and social capital) to assess issues of equity. It is also important to consider the ethical implications of every decision made throughout the review process. Ethical issues may arise during many stages of the review, including when making these decisions: the topic of the review, who is involved throughout it, and which interventions and outcomes to include.

Sustainability

Users of reviews are often interested in knowing whether the health benefits (e.g., reductions in specific diseases or improvements in health) from an intervention are going to be sustained beyond the life of the intervention.

Shediac-Rizkallah and Bone (1998) present a useful framework for addressing sustainability. It defines key aspects of program sustainability as (1) maintenance of health benefits from the program, (2) institutionalization of a program within an organization, and (3) capacity building in the community. Key factors influencing sustainability are those in the broader environment, those within the organizational setting, and project design and implementation factors.

Context

The context (e.g., political, organizational, social, or economic) in which an intervention is conducted can affect its subsequent success or failure. It is therefore often difficult to make generalizations about whether an intervention included in a review may work in other contexts (Roberts et al., 2006). Often this contextual information is not included in primary studies, and the review author may need to contact the original researchers to obtain it. Systematic reviews of public health interventions should highlight what context-specific information was included in the studies and identify further information required, such as features of the host organization, staff, and healthcare system and characteristics of the target population (e.g., socioeconomic, cultural, literacy levels, place of residence) (Hawe et al., 2004).

Applicability

External validity is the extent to which the findings of a study or a systematic review are relevant to other populations and contexts. Sometimes referred to as generalizability, it allows decision makers to consider how the findings of a systematic review might be adopted or adapted for effective practice or policy within their setting (Wang et al., 2006).

Infrastructure And Activity To Support Systematic Reviews Of Public Health Interventions

Both the development and implementation of systematic reviews need to be supported by appropriate infrastructure. This section of the study describes programs/activities being undertaken to support review production and knowledge translation and exchange. It may include an acknowledgment of the work being conducted by the following groups:

  • Cochrane Collaboration, established in 1993, is an international organization with the aim of preparing and maintaining systematic reviews of the effects of health interventions and making this information available to all practitioners, policymakers, and consumers. The Cochrane Health Promotion and Public Health Field, an organization of the Cochrane Collaboration, was established in 1996 and has been funded by the Victorian Health Promotion Foundation since 2000. The Collaboration and its entities have contributed to the development of methods for conducting reviews and the translation of findings of systematic reviews into policy and practice.
  • The Canadian Institutes of Health Research (CIHR), established in 2000, is the government of Canada’s health research funding agency. Knowledge translation is the cornerstone of CIHRs mandate and involves the exchange, synthesis, and application of knowledge to accelerate use of the best available evidence in the interest of improving the health of Canadians. Within CIHR, the Institute of Population and Public Health actively contributed to the establishment of the National Collaborating Centres for Public Health (NCCs), a Public Health Agency Canada initiative to make public health research more accessible for practice and policy decisions.
  • Health-evidence.ca is a website that forms part of a randomized controlled trial to test the effectiveness of three knowledge translation strategies: website, targeted evidence messages, and a knowledge broker. The trial is funded by several sources including the Canadian Institutes of Health Research. Although there is a significant investment in knowledge translation strategies, very little is known about which strategies are most likely to result in the use of evidence to inform decision making. This project seeks to inform this debate.
  • National Institute for Health and Clinical Excellence in the UK is an independent organization responsible for providing national guidance on promoting good health and preventing and treating ill health. It makes recommendations on interventions to promote a healthy lifestyle or reduce the risk of developing a disease or condition. This guidance may focus on a topic (such as smoking), particular population (such as young people), or a particular setting (such as the workplace).
  • U.S. Guide to Community Preventive Services summarizes what is known about the effectiveness, economic efficiency, and feasibility of interventions to promote community health and prevent disease. Established in 1996, the Task Force on Community Preventive Services, a nongovernmental body whose work is supported by the U.S. Centers for Disease Control and Prevention, makes recommendations for the use of public health interventions based on evidence gathered in systematic reviews of published studies conducted by the review teams of the Community Guide.

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  2. Davies P (2005) Workforce Development to Support Evidence-informed Public Health. Presentation at Cutting Edge Debates, Vic Health, Melbourne. Victoria, Australia: VicHealth.
  3. Egger M, Schneider M, and Davey-Smith G (1998) Spurious precision? Meta-analysis of observational studies. British Medical Journal 316 (7125): 140–144.
  4. Evans D and Fitzgerald M (2002) The experience of physical restraint: A systematic review of qualitative research. Contemporary Nurse 13 (2–3): 126–135.
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