CHALLENGES IN ACHIEVING PUBLIC HEALTH OUTCOMES
The root causes and manifestations of public health challenges reflect the diversity and complexity of human life as well as our living and working environments. For example, tobacco use can have effects on the tobacco user (primary), those nearby through second-hand smoke (secondary), and the immediate environment through accumulation of nicotine and other carcinogens (tertiary). Working to prevent and reduce the health impacts of tobacco use requires a diverse range of interventions. These might include clinical and behavioral interventions with the user in addition to broadly targeted efforts to change social attitudes toward tobacco use and raise awareness of the risks of environmental tobacco exposure for young children. This example is mirrored in many other challenges public health seeks to address, such as obesity, opioid abuse, injury prevention, maternal and infant mortality, among others. In summary, many common public health problems require complex, multifaceted interventions.
Further adding to the complexity are the populations and systems involved. There is a great diversity of cultures within and between national borders and regions, and a rapidly evolving shared culture as our world becomes more connected and urbanized. This variation leads to many ways of understanding and valuing health as well as a wide range of systems to promote health and well-being. The legacy of human history and the impact of a rapidly evolving context have immediate and long-term effects on how interventions are perceived and utilized in various settings. As a result, not only do public health interventions need to be have multiple components, but their delivery also has to be tailored and responsive to the characteristics of each setting.
In the face of such complexity, there is a need to develop evidence based multilevel interventions for public health.1 In the last several decades, a sustained focus on quality and outcomes has expanded the availability of evidence-based public health programs that have demonstrated some effectiveness (e.g., improved child well-being) through research and evaluations.2,3 These programs seek to influence key factors that affect the public’s health.4 For example, Trauma Focused Cognitive Behavioral Therapy (TF-CBT) and the Positive Parenting Program (Triple P) are programs with different approaches seeking to achieve a common outcome of improved child well-being and reduced maltreatment.5,6 TF-CBT is a therapeutic intervention for children and parents delivered by a trained clinicians designed to prevent and address posttraumatic stress, depression, and behavioral challenges.6 Triple P is a system of parenting education programs delivered by professionals and lay people alike designed to have broad community coverage.7
Many of these interventions are widely available on registries and websites and promoted and funded by Federal, state, and private agencies.8–11 The strength of the evidence of effectiveness varies and is often depicted along a continuum running from ineffective through promising to proven. Notwithstanding their proliferation and promotion, there are many areas for which we do not have ...