What is our objective when we conduct research in public health? We conduct public health research to reduce disease and injury incidence. We conduct public health research to have a real impact on people on the ground and save lives. Our field is full of passionate, talented researchers who have dedicated their lives to bettering those of others.
In order for public health research to be impactful on the ground, it needs to be applied in contexts where it is most needed. A key concept in the implementation of solutions to public health problems is contextual adaptability, where policy and ground-level interventions need to be adapted to the local context in which they are implemented. Hence, each time a public health solution is developed for a region or population group, a range of studies need to be conducted in that local context to understand it. We need to understand specific patient needs of the population, ways of setting up supply chains, appropriate methods of staff recruitment and training, and a range of other factors that change between contexts. We need to do this through conducting policy analyses, using co-design processes with local communities, conducting pilot programs, and undertaking process evaluations. These findings aren’t necessarily generalisable to other contexts but can provide some useful insights to other implementers for what issues may emerge.
Despite the importance of this research in ensuring public health research has ground impact, the development and publishing of context-specific research appears to be disincentivised in the academic system, with increasing focus on the external validity of studies.
Academia is obsessed with novelty. Unfortunately, local research may not always add some new theoretical insight – often it provides insights on how existing and well-established public health solutions and principles may be applied to a new context. Many journals and peer reviewers may not find this novel enough as its additional contribution to the literature is limited. However, I argue that these articles should be recognised for what they are – the actual application of public health to the real world, and evidence of the usefulness of our discipline in affecting people’s lives.
Academia is also overly interested in generalisability – reviewers often want to know where else study findings can apply. The underlying assumption to this question is that by finding generalisable evidence for the development and effectiveness of public health solutions, we can skip a few steps in other contexts when applying public health solutions. However, often even when we think our findings from one context can be applied to another, this still needs to be checked in case there are contextual differences we are not aware of. In the end, even findings that appear generalisable may not be until they are validated in a new setting. Hence, the focus on generalisability is in some ways obsolete.
Another issue with disincentivising local and contextual research is that it is inequitable against local researchers. Much of the local research is done by researchers based in low-and middle-income countries (LMICs) with lower levels of funding, but who have great depth of knowledge in their context. By not allowing them opportunities to publish in high-impact journals, we perpetuate the cycle of high-income country supremacy in academia. It is essential that good research that impacts lives through sound methods be rewarded. Enabling these researchers to publish local research also develops their track records and provides opportunities for LMIC researchers to be more competitive in much-needed grants for these low-resource contexts.
Lastly, disincentivising local and contextual research prevents us from building a strong evidence base for effective interventions. Take my own field of study, child drowning. Most of the ‘effective’ interventions identified by the World Health Organization have not been rigorously evaluated through the gold standard of randomised controlled trials (RCTs), or even non-randomised trials. For example, children’s swim and rescue classes are often cited as an important intervention for drowning reduction, but there is no published trial of this intervention measuring its effect on drowning risk. The lack of support for localised trials means we do not have the evidence to solve health problems in the most effective way possible. How can we build the evidence base we need unless localised trials are repeatedly run, published and compared across a range of contexts? These trials need to be incentivised by the academic ecosystem.
Public health research can benefit from addressing discrimination against local and context-based research. It is an issue of equity, a requirement in order to build stronger evidence bases for effective interventions, and an opportunity for the field to showcase the real change it can bring to people’s lives.
Conflict of Interest
The author declares no conflict of interest.
About the author
Medhavi Gupta is a PhD student at the George Institute for Global Health. She specialises in injury prevention research focussing on drowning and road traffic injuries and has applied a range of innovative methods in her work. Her current PhD project involves the design and evaluation of drowning prevention programs in India and Bangladesh.
Handling Editor: Neha Faruqui