How public health research translates into policy and practice

For some time there has been a strong official commitment to 'knowledge-transfer' and 'evidence-based policy' in the UK, yet there is now a substantial literature indicating that practical decisions are rarely based directly on research evidence. Building on my PhD, this Post-Doctoral Fellowship explored this puzzle, chiefly within public health, where the need for better connections between research, policy and practice is felt to be particularly strong. My PhD research employed interviews and policy analysis to explore the relationship between health inequalities research and policy in Scotland and England (1997-2007). The findings suggested that it was ideas, rather than evidence, that tend to influence policy (though persuasive ideas have often been informed by research). This is a simple but important distinction because ideas are far more malleable than evidence so the ways in which they influence policy depends on a range of factors beyond the quality of the evidence. The PhD illustrates that the policy impact of the most prominent research-based ideas about health inequalities has varied extensively; some ideas have remained remarkably influential, despite changes in the evidence-base, whilst others, with a stronger evidence-base, have faltered and splintered as they moved into policy. The result is that ideas often influence decisions in ways which researchers are unlikely to anticipate. To understand the contrasting journeys of different ideas about health inequalities, I distinguished between three idea-types: institutionalised ideas; charismatic ideas; and vehicular (chameleonic) ideas. My PhD research data suggested that some ideas about public health had become so deeply institutionalised in the decade following 1997 that the ideas which were able to move from research into policy were either those which reinforced already institutionalised ideas or those which were malleable enough to alter conveniently as they moved into policy. Despite important developments in the evidence-base, few, if any, really challenging ideas became embedded in policy. The data suggest this can be partly explained by the constant pressure on academics to secure future research funding/posts. Paradoxically, then, in a context in which academics are being increasingly exhorted to be original and to have significant impact, a conservative and diluted relationship between research ideas and 'policy messages' has developed. This Post-Doctoral Fellowship involved publishing and promoting this work as well as building on it by undertaking further, related research. This involved updating the policy analysis until 2010 and undertaking (54 further interviews in the UK plus 8 in Canada and one in the US).

• Ideas, rather than evidence, represent the appropriate unit of analysis in studies exploring the relationship between public health research and policy;
• It is important to study and understand how policy influences research (as well as the other way round);
• Research funders play a crucial, and under-explored, role in mediating the relationship between research and policy;
• Between 1997-2007, contrasting research-informed ideas about health inequalities experienced markedly different journeys into policy – whilst some ideas seem to achieve more influence than the research suggests they ought to have done, others have faltered (influencing rhetoric but not actions) or become fractured and re-interpreted as they travelled into policy contexts;
• The following four idea-types help explain the relationship between public health research and policy: (i) institutionalised ideas (embedded within organisations and/or discourses); (ii) critical ideas (which directly challenge, and focus on problematising, institutionalised ideas); (iii) charismatic ideas (which persuasive challenge institutionalised ideas through the creation of visions of alternative, future realities); and (iv) chameleonic ideas (the successful dissemination of which is dependent on metamorphic qualities which enable the idea to be interpreted in contrasting ways by different audiences).
• This ideational typology (informed by the theories of Max Weber and Bruno Latour) has broader public health relevance including for tobacco control, where the contrasting idea types help explain: (i) the long time-lag between the emergence of evidence about the harms caused by smoking and significant UK policy action to reduce those harms; and (ii) the flurry of policy activity in this area since 1997.
• There were three significant differences between the interviews undertaken for the PhD (in 2003-2006) and those undertaken during the Post-Doctoral Fellowship (2011-2012): (i) an increase in the levels of pessimism amongst policymakers and researchers about the prospects for reducing health inequalities in the UK (although there was rather more optimism in Scotland compared to the rest of the UK); (ii) a growing number of references to knowledge brokers, knowledge exchange and the research impact agenda (which were largely favourable); and (iii) an increase in the number of health inequalities researchers who identified themselves as public health advocates.
• The somewhat more optimistic perspective on health inequalities of interviewees based in Scotland appeared to be linked to a belied that policymakers in Scotland were more committed to state intervention to reduce health inequalities and to an equitable society. This requires further exploration in the context of current debates concerning Scottish independence.
• Whilst knowledge brokers were positively referred to by policymakers, all of the public health knowledge translation organisations identified in the research are small-scale and dependent on short-term funding. The data suggest these organisations are aiding public health knowledge translation to the extent that they are supporting inter-personal relationships and can serve as an accessible point of research contact for people in the policy world. However, the research suggested these organisations were hampered by their uncertain future, limited resources and confusion and uncertainty within the public health community about the best approaches to promoting knowledge translation. There were no examples of structural changes to the relationship between public health research and policy emanating from these organisations. Further research might usefully explore: (i) the longer-term trajectories and impacts of organisations with a remit for public health knowledge translation; and (ii) the impacts of the ‘research impact’ agenda (e.g. by analysing the REF impact case studies, due to be published in 2014).
• In the PhD interviews (2003-2006), it was notable that researchers involved in tobacco control were far more comfortable with their relationships to the advocacy and third sector community than health inequalities researchers (who struggled to name any relevant advocacy or third sector organisations). In contrast, in the more recent, Post-Doctoral interviews (2011-2012), most health inequalities researchers identified themselves as public health advocates and reflected that this was a recent change. Most researchers and policymakers also identified at least some relevant advocacy organisations, notably The Equality Trust. This suggests there has been a change in how health inequalities researchers view their role and that further research could usefully examine how different actors perceive public health advocacy and its relationship to academic work and to public health knowledge translation.