Building the evidence

On Friday, I presented at an interstate talkfest on HIV in culturally diverse communities.

The pre-reading for the meeting was heavy with public health strategies focused very tightly on disease reduction, and a mammoth epi report, analysing results from surveillance of HIV notifications, behavioural surveys, and mathematical modelling.

Despite having a massive committee and a very prescriptive action plan, it seemed that, aside from one very capable and energetic agency, actual action had almost come to a standstill.  The workshop was intended to revitalise it, but its title and main objective was “building the evidence”.

Does lack of evidence cause inaction?

I had only eight minutes to describe findings from our consultation report, and answer three questions posed by the organisers — not a lot of time, and not enough for reflection on the knowledge practices involved.  But I managed to squeeze in a provocative suggestion, and I was delighted when it was picked up in question time.

I suggested that health promotion planning is not especially sensitive to variations in the epidemiology.

In other words, whether epi reports there are 10 or 20 new infections in a particular cultural group — double the amount, 100% difference in statistical terms — I’m still going to propose broadly the same plan of action in response.

We’ll hire a project worker, identify partners, convene a reference group, review the literature, undertake community consultation, do some rapid assessment of the causes and most useful activities/messages/channels to use, do the work and then report back on how it went.

Knowing the number of new infections is much less important than knowing the size of the group, and developing a close understanding of what resources exist in that group in our state for undertaking health promotion work.

  • There’s no use planning a social marketing campaign if the target group is really spread out geographically and have no common media channels (like newspapers and radio programs) and habits (like reading and listening to them) and related skills (like print, media and health literacies for reading and learning from social marketing campaigns).
  • There’s no use proposing a key opinion leaders approach if the community is so new or disorganised that it has no institutions and structures for leadership and communication.

That kind of knowledge makes a HUGE difference in health promotion planning; stats on numbers of new infections, not so much.

I pointed this out in my presentation, and sure enough, in question time, there came the obvious objection, from an epidemiologist who does a lot of interesting work in mathematical modelling.

We have to ‘live in the real world’, he said, ‘we can’t ignore the epidemiology’.

Not really what I called for.

Where those stats make a big difference is in public health.  Government funding is the ultimate zero sum game, and epi helps decision-makers objectively assign priority to competing worthy causes.  It is a hugely important tool in rational government. Around the world, where governments have ignored the epi and funded politically convenient work, HIV epidemics have exploded.

And while I’ve said that epi isn’t always terribly relevant for health promotion planning, I still read every paper and every report, cover to cover, and squeeze every last drop of meaning and use out of it. The key thing is where I use it — in my funding submissions and advocacy to government.

I want to draw a strong distinction between (1) health promotion and (2) public health.  They are not the same thing, and shouldn’t be conflated.  They have different vocabularies, pointing to different underlying concepts and philosophies, and they focus on different levels.

Obviously they are connected – since public health people fund health promotion workers.  In spaces where they overlap, however, like the talkfest I was at, you can pretty quickly see communication problems arising between the two different languages.

It’s a problem of articulation – in two senses: how we find the terms to express ourselves, and how our discourses (the languages of our disciplines) can join together and mesh at their points of connection to transmit power.

Power in this case means funding for work, but it can also mean domination, where one can override the other, and alternatively it can mean trust, where two groups who use different language and knowledge practices can still work together effectively.

Epi and behavioural surveillance are vital for the public health functions of commissioning, monitoring and evaluating health promotion activities and outcomes.  As I’ve argued here, health promotion people should know about them, but the inputs into our planning need to be broader.

Culturally diverse communities are mostly migrants, whether temporary (international students, casual workers and visitors) or permanent (skilled migration, family reunion, and humanitarian entrants), and migration patterns change all the time.

Health promotion in this area requires a process of continuous rapid assessment, and instead of dismissing this because it doesn’t look like formal epidemiology, we need to borrow principles for assessing and improving its rigour and validity from qualitative methodologies.

We also need better recognition of the difference in languages, concepts and inputs used by public health and health promotion, and the need for careful and respectful engagement at points where they interface with each other.

Without it, decision-makers and researchers will be left to hold talkfest events, to scratch their heads and wonder why their ‘evidence’ never makes it into practice.