Medicine, Health Care and Philosophy

, Volume 17, Issue 3, pp 459–465 | Cite as

Complexity and indeterminism of evidence-based public health: an analytical framework

  • Francesco AttenaEmail author
Scientific Contribution


Improving the evidence in public health is an important goal for the health promotion community. With better evidence, health professionals can make better decisions to achieve effectiveness in their interventions. The relative failure of such evidence in public health is well-known, and it is due to several factors. Briefly, from an epistemological point of view, it is not easy to develop evidence-based public health because public health interventions are highly complex and indeterminate. This paper proposes an analytical explanation of the complexity and indeterminacy of public health interventions in terms of 12 points. Public health interventions are considered as a causal chain constituted by three elements (intervention, risk factor, and disease) and two levels of evaluation (risk factor and disease). Public health interventions thus differ from clinical interventions, which comprise two causal elements and one level of evaluation. From the two levels of evaluation, we suggest a classification of evidence into four typologies: evidence of both relations; evidence of the second (disease) but not of the first (risk factor) relation; evidence of the first but not of the second relation; and no evidence of either relation. In addition, a grading of indeterminacy of public health interventions is introduced. This theoretical point of view could be useful for public health professionals to better define and classify the public health interventions before acting.


Causality Complexity Epidemiology Epistemology Public health 


  1. Attena, F. 1999. Causal models in conventional and non-conventional medicines. Medical Hypotheses 53: 177–183.CrossRefGoogle Scholar
  2. Briss, P.A., S. Zaza, M. Pappaioanou, J. Fielding, L. Wright-De Agüero, B.I. Truman, et al. 2000. Developing an evidence-based guide to community preventive services–methods. The task force on community preventive services. American Journal of Preventive Medicine 18(Suppl. 1): 35–43.CrossRefGoogle Scholar
  3. Brownson, R.C., J.E. Fielding, and C.M. Maylahn. 2009. Evidence-based public health: A fundamental concept for public health practice. Annual Review of Public Health 30: 175–201.CrossRefGoogle Scholar
  4. Bunge, M. 1979. Causality in modern science, Third revised edition ed, 17–19. New York: Dover.Google Scholar
  5. Buring, J.E. 2002. Special issues related to randomized trials of primary prevention. Epidemiologic Reviews 24: 67–71.CrossRefGoogle Scholar
  6. Campbell, M., R. Fitzpatrick, A. Haines, A.L. Kinmonth, P. Sandercock, D. Spiegelhalter, et al. 2000. Framework for design and evaluation of complex interventions to improve health. BMJ 321: 694–696.CrossRefGoogle Scholar
  7. Craig, P., P. Dieppe, S. Macintyre, S. Michie, I. Nazareth, M. Petticrew, et al. 2008. Medical Research Council Guidance. Developing and evaluating complex interventions: The new Medical Research Council guidance. BMJ 337: a1655.CrossRefGoogle Scholar
  8. Dobrow, M.J., V. Goel, and R.E. Upshur. 2004. Evidence-based health policy: Context and utilisation. Social Science and Medicine 58: 207–217.CrossRefGoogle Scholar
  9. Galea, S., M. Riddle, and G.A. Kaplan. 2010. Causal thinking and complex system approaches in epidemiology. International Journal of Epidemiology 39: 97–106.CrossRefGoogle Scholar
  10. Haddix, A.C., S.M. Teutsch, P.A. Shaffer, and D.O. Dunet. 1996. Prevention effectiveness in health and medicine, 8–9. New York: Oxford University Press.Google Scholar
  11. Hawe, P., A. Shiell, and T. Riley. 2004. Complex interventions: How “out of control” can a randomized controlled trial be? BMJ 328: 1561–1563.CrossRefGoogle Scholar
  12. Jackson, N., E. Waters, and for the Guidelines for Systematic Reviews in Health Promotion and Public Health Taskforce. 2005. Criteria for the systematic review of health promotion and public health interventions. Health Promotion International 20: 367–374.CrossRefGoogle Scholar
  13. Jenicek, M. 1997. Epidemiology, evidenced-based medicine, and evidence-based public health. Journal of Epidemiology 7: 187–197.CrossRefGoogle Scholar
  14. Joffe, M., M. Gambhir, M. Chadeau-Hyam, and P. Vineis. 2012. Causal diagrams in systems epidemiology. Emerging Themes in Epidemiology. doi: 10.1186/1742-7622-9-1.Google Scholar
  15. Karhausen, L.R. 2000. Causation: The elusive grail of epidemiology. Medicine, Health Care and Philosophy 3: 59–67.CrossRefGoogle Scholar
  16. Kemm, J. 2006. The limitations of evidence-based public health. Journal of Evaluation in Clinical Practice 12: 319–324.CrossRefGoogle Scholar
  17. Kohatsu, N.D., J.G. Robinson, and J.C. Torner. 2004. Evidence-based public health: An evolving concept. American Journal of Preventive Medicine 27: 417–421.Google Scholar
  18. MacMahon, B., and T.F. Pugh. 1996. Epidemiology: principles and methods, II Edition ed, 26–29. Boston: Little, Brown and Company.Google Scholar
  19. Oakley, A., V. Strange, I.C. Bonel, E. Allen, and J. Stephenson. 2006. Process evaluation in randomised controlled trials of complex interventions. BMJ 332: 413–416.CrossRefGoogle Scholar
  20. Olsen, J. 2003. What characterises a useful concept of causation in epidemiology?. Journal of Epidemiology and Community Health 57: 86–88.CrossRefGoogle Scholar
  21. Parascandola, M., and D.L. Weed. 2001. Causation in epidemiology. Journal of Epidemiology and Community Health 55: 905–912.CrossRefGoogle Scholar
  22. Parascandola, M. 2011. Causes, risks, and probabilities: Probabilistic concepts of causation in chronic disease epidemiology. Preventive Medicine 53: 232–234.CrossRefGoogle Scholar
  23. Pearce, N., and F. Merletti. 2006. Complexity, simplicity, and epidemiology. International Journal of Epidemiology 35: 515–519.CrossRefGoogle Scholar
  24. Petticrew, M., Z. Chalabi, and D.R. Jones. 2012. To RCT or not to RCT: Deciding when ‘more evidence is needed’ for public health policy and practice. Journal of Epidemiology and Community Health 66: 391–396.CrossRefGoogle Scholar
  25. Pickett, K.E., and M. Pearl. 2001. Multilevel analyses of neighbourhood socioeconomic context and health outcomes: A critical review. Journal of Epidemiology and Community Health 55: 111–122.CrossRefGoogle Scholar
  26. Plsek, P.E., and T. Greenhalgh. 2001. Complexity science: The challenge of complexity in health care. BMJ 323: 625–628.CrossRefGoogle Scholar
  27. Rickles, D., P. Hawe, and A. Shiell. 2007. A simple guide to chaos and complexity. Journal of Epidemiology and Community Health 61: 933–937.CrossRefGoogle Scholar
  28. Rychetnik, L., M. Frommer, P. Hawe, and A. Shiell. 2002. Criteria for evaluating evidence on public health interventions. Journal of Epidemiology and Community Health 56: 119–127.CrossRefGoogle Scholar
  29. Rychetnik, L., P. Hawe, E. Waters, A. Barratt, and M. Frommer. 2004. A glossary for evidence based public health. Journal of Epidemiology and Community Health 58: 538–545.CrossRefGoogle Scholar
  30. Rychetnik, L., A. Bauman, R. Laws, L. King, I.C. Risse, D. Nutbeam, et al. 2012. Translating research for evidence-based public health: key concepts and future directions. Journal of Epidemiology and Community Health 66: 1187–1192.CrossRefGoogle Scholar
  31. Susser, M. 1973. Causal thinking in the health sciences, 68–69. New York: Oxford University Press.Google Scholar
  32. Tang, K.C., B.C. Choi, and R. Beaglehole. 2008. Grading of evidence of the effectiveness of health promotion interventions. Journal of Epidemiology and Community Health 62: 832–834.CrossRefGoogle Scholar
  33. Tremblay, M.C., and L. Richard. 2011. Complexity: A potential paradigm for a health promotion discipline. Health Promotion International. doi: 10.1093/heapro/dar054.Google Scholar
  34. Victora, C.G., J.P. Habicht, and J. Bryce. 2004. Evidence-based public health: Moving beyond randomized trials. American Journal of Public Health 94: 400–405.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media Dordrecht 2014

Authors and Affiliations

  1. 1.Second University of NaplesNaplesItaly

Personalised recommendations