To effectively tackle population health challenges, we must address the fundamental determinants of behaviour and health. Among other things, this will entail devoting more attention to the evaluation of upstream intervention strategies. However, merely increasing the supply of such studies is not enough. The pivotal link between research and policy or practice should be the cumulation of insight from multiple studies. If conventional evidence synthesis can be thought of as analogous to building a wall, then we can increase the supply of bricks (the number of studies), their similarity (statistical commensurability) or the strength of the mortar (the statistical methods for holding them together). However, many contemporary public health challenges seem akin to herding sheep in mountainous terrain, where ordinary walls are of limited use and a more flexible way of combining dissimilar stones (pieces of evidence) may be required. This would entail shifting towards generalising the functions of interventions, rather than their effects; towards inference to the best explanation, rather than relying on binary hypothesis-testing; and towards embracing divergent findings, to be resolved by testing theories across a cumulated body of work. In this way we might channel a spirit of pragmatic pluralism into making sense of complex sets of evidence, robust enough to support more plausible causal inference to guide action, while accepting and adapting to the reality of the public health landscape rather than wishing it were otherwise. The traditional art of dry stone walling can serve as a metaphor for the more ‘holistic sense-making’ we propose.
- prevention strategies
- public health
- intervention study
- systematic review
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Handling editor Seye Abimbola
Twitter @dbogilvie, @adrianbauman, @loudoestweet, @connyguell, @dkhumphreys, @jennapanter
Contributors DO conceived the original idea and drafted the manuscript. AB provided critical feedback during the initial drafting. LF, CG, DH and JP undertook the studies used as worked examples in tables 2 and 4 in collaboration with DO; and together with AB provided critical feedback during later drafting and contributed to the final version of the manuscript. DO is the guarantor.
Funding DO and JP are supported by the Medical Research Council (Unit Programme number MC_UU_12015/6). LF is funded by the National Institute for Health Research (NIHR) Global Health Research Group and Network on Diet and Activity, for which funding from NIHR is gratefully acknowledged (grant reference 16/137/34). CG is funded by the Academy of Medical Sciences and the Wellcome Trust (Springboard—Health of the Public 2040, grant reference HOP001/1051). The paper was initially developed in the course of a visiting appointment as Thought Leader in Residence at the School of Public Health at the University of Sydney, for which the intellectual environment and financial support provided by the Prevention Research Collaboration is gratefully acknowledged. It was further developed under the auspices of the Centre for Diet and Activity Research (CEDAR), a UKCRC Public Health Research Centre of Excellence at the University of Cambridge, for which funding from the British Heart Foundation, Economic and Social Research Council, Medical Research Council, National Institute for Health Research and the Wellcome Trust, under the auspices of the UK Clinical Research Collaboration, is gratefully acknowledged (grant reference MR/K023187/1).
Disclaimer The views expressed in this publication are those of the authors and not necessarily those of the National Health Service (NHS), the NIHR, the Department of Health and Social Care or any other funder.
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement There are no data in this work.
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