Problem-based learning for health improvement: practical public health for every professional
International Journal of Integrated Care, 11 October 2004 - ISSN 1568-4156
Book review
Problem-based learning for health improvement: practical public health for every professional
Edited by John Cornell and Frada Eskin
Radcliffe Medical Press Ltd, 2003, vii, pp 240,
ISBN 1 85775 501 4
Grazyna Teresa Adamiak, PhD, Master of Health and Welfare, Master of Arts Fax: +46 (0) 8 658 21 77, E-mail: g.adamiak@telia.com

The authors state that the objective of all public health work is improvement of health of the population. They develop this initial statement using a metaphor of a public health practitioner who is some kind of “all in one” expertise. As illustrated in various case studies, he/she works with screening and tracing of communicable diseases, maternity care, reorganisation of stroke care, quality improvement, tutorship of students etc. The concept of the “all in one” practitioner is as metaphoric as it is unrealistic in complex health systems where every specialty area requires specific expertise and where project leadership and management are diffused among people not only with different skills but also on various organisational levels. The metaphor is brilliant as it demonstrates that all health related activities have many stakeholders, but only one common objective even if they take place in various places and contexts.

The book is divided into ten chapters, each treating a different area of inquiry into the public health work in practice as outlined by the British Faculty of Public Health Medicine. The approach is pragmatic and behavioural throughout the book, every chapter contains illustrative examples that the authors comment in problem focusing discussions and methodological guidance. Every chapter is linked to the rest theoretically or practically. All chapters provide literature references and recommendations of further readings, including electronic links.

The focus in the book lies mainly on the art of negotiating and acquiring resources and less on resource reductions or unit closures. However, the need of priorities and changes is not omitted, at least on the project management level. A strong side of the book is that it considers both theory and practice of implementation of projects or programmes, the progress and success monitoring as well as the handover to the ordinary activity. On the other hand, quality improvement activities, as they also support health status improvement, should have been addressed as a matter of ongoing activity, not temporary and random projects as they still often are abroad.

The relevance of this book for integrated care is that it frequently points to partnership working, need of coordination and the central role of communication among individuals, teams, units and across agencies in all public health activities. The authors systematically address information needs of different stakeholders and the institutional level of the work with health status improvement of individual patients and populations, involving information and communication with media and policy makers.

Some weak sides of the book… The introduction states that the success of public health practice was the control of communicable diseases. It is true but the improvement began before many of the miracles of medicine emerged, mainly due to improved socioeconomic conditions of populations. The tubercle bacillus was identified in the 1880s. The decline in mortality from tuberculosis started decades before the development of treatment and preventive measures in the 1950s. Chapter 1 on surveillance and assessment of the population's health and wellbeing lacks some classic and recent references, in particular “Modern Epidemiology” by Roothman and Greenland (1998) and “Systematic Reviews in Health Care” by Egger et al. (Eds), (2001); ( www.systematicreviews.com).

This book provides a superficial overview of research methods, contains inaccuracies on epidemiologic terms and methods and lacks a health care or health economics approach despite that the latter disciplines contribute to the evidence on effectiveness of health interventions and prioritisations.

The authors of chapter 9 confuse the concept of efficacy with the concept of effectiveness of therapies in a section on advantages and disadvantages of randomised controlled studies (RCT). A disadvantage of RCT is the problematic external validity due to the selection of younger, in most respects homogenous and healthier patients in experimental situations as opposite to observational studies, conducted in daily contexts, involving individuals with various origins, age and co-morbidities (Egger et al., Eds, 2001). Chapter 9 only mentions focus groups as an example of the qualitative approach and recommends odds ratios as a measure in retrospective case-control studies while relative risk is preferable.

The book deals with public health work as it mainly would an activity taking place in health care organisations. Interventions on policy levels to hinder disrupting effects of the environment on health status of populations such as distances, border crossing traffics, pollution are not illustrated. Such effects may be recognised in large epidemiological studies even if they are small and not easily discernible on the individual level. It would be a mistake if health professionals believed that they alone possess all the necessary measures and interventions to deal with the health of populations.

In summary, this book provides many useful solutions to crucial problems emerging in all work with individuals and smaller groups of people. It is a well written introduction for medical or public health students and less experienced practitioners on technical and operational levels in all health systems. It is less suitable for practitioners on institutional or international levels, for example at the European Union.