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Appropriate Research Methods

5. Where to Now

Where to Now – Back to the Future?

Having said so much about what is inappropriate and mis-focused, it is important to discuss what is appropriate: where should we be focusing instead and what research methods should be employed?

Arguing for a refocusing of efforts towards upstream population health is not, of course, to suggest that everything should be invested upstream. That, obviously, can never occur and resource allocation would be as distorted as it is presently (some 90 percent of effort and resources are concentrated downstream). A balanced distribution of research effort and resources across the whole range of possible points of intervention is required to accommodate the likely continuous distribution of the phenomena in question. Exercise 1 illustrates the range of interventions at different levels that are possible for a major illness condition, like diabetes.
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It is useful to distinguish three levels of public health intervention as follow:

  1. Upstream Healthy Public Policy, which includes Governmental, institutional, and organizational actions (mainly through social policies) directed at entire populations (whole population public health), with adequate support through tax structures, legal constraints, and reimbursement mechanisms, for health promotion and primary prevention.
  2. Midstream Prevention Activities are of two main types: (a) secondary prevention (to modify the risk levels of those individuals and groups who are very likely to experience some untoward outcome); and (b) primary prevention (actions to encourage people not to commence behaviors that may unnecessarily increase their chances of experiencing untoward events).
  3. Downstream Tertiary Care comprises curative treatments, rehabilitation counseling and patient education for those already experiencing disease and disability.  This is the level which, while consuming most of the available resources, encompasses a relatively small segment of the general population (those already occupying the sick role).