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Health Promotion International, Vol. 14, No. 2, 99-101,
June 1999
© Oxford University Press 1999
Editorial |
The challenge to provide ‘evidence’ in health promotion
The 1998 World Health Assembly not only elected a new Director General, Dr Bruntland, but also endorsed the first ever WHO resolution specifically on health promotion (WHO, 1998). Such resolutions are of importance for both practical and symbolic reasons. They signal relative priority, and commit WHO and member states to take action. The resolution on health promotion was derived largely from the Jakarta Declaration on Health Promotion into the 21st Century (WHO, 1997). It urges WHO member states to take action on the five priorities from the Declaration, and among other things requests that the Director General supports the development of evidence-based health promotion policy and practice within the organization (WHO, 1998).
The insertion of the words ‘evidence-based’ is significant. It may be interpreted as emphasizing the need to better justify health promotion actions on the basis of research information on their effectiveness in achieving pre-determined outcomes, and implies that this has not always been the case.
Health promotion activities are not alone in being subjected to this type of scrutiny. Within the health sector worldwide there has been greater attention on outcomes (as distinct from processes), and on evidence of effectiveness (as in evidence-based medicine). This interest in ‘evidence’ has fuelled the development of databases that provide systematic reviews of research, often leading to the development of evidence-based guidelines for action. The best example of this phenomenon is the Cochrane collaboration that provides systematic reviews of evidence for a wide range of clinical practices (Cochrane Collaboration Index, 1998).
Most contemporary health promotion actions are multi-level, and often more complex than the types of intervention which have been typically addressed through the Cochrane Collaboration. Consequently, this challenge to provide ‘evidence’ of the effectiveness of health promotion activities in achieving pre-determined outcomes should not be underestimated. It is a challenge to assemble ‘evidence’ in ways which are relevant to the complexities of contemporary health promotion, and to avoid the possibility that this may lead action down a narrow, reductionist route. Three issues need to be carefully considered.
Firstly, it is important to be clear about what is meant by effectiveness in health promotion. In contemporary health promotion, a range of measures is used to define ‘effectiveness’. These have been developed into outcome hierarchies which emphasize the difference between short-term impact and longer-term health outcomes (Nutbeam, 1998
). The most immediate measures of effectiveness include changes in individual knowledge and skills that follow educational interventions, social action and changes in social norms that follow social mobilization/community development interventions, and changes in policy or organizational practices that follow health advocacy.
Effectiveness will also be judged by longer-term outcomes in the form of changes in the determinants of health which flow from the short-term outcomes indicated above. These include changes in individual health behaviours, as well as changes in socio-economic and environmental conditions that have both a direct and indirect impact on health. Ultimately, change in the determinants of health will lead to change in health outcomes, although the time lag between intervention and outcome will usually mean that measurement of health outcomes is too distant to be of practical use in judging effectiveness.
Secondly, evidence of effectiveness will come from interventions that have a reasonable chance of success. Growing practical experience in contemporary health promotion is leading to improved understanding of what represents ‘best practice’ in health promotion, and provides some guidelines on how to maximize chances of success (Nutbeam, 1996).
These include the following needs.
- Plan on the basis of an analysis of epidemiological, behavioural and social research that indicates reasonable linkages between the short-term impact of interventions, subsequent changes in the determinants of health, and health outcomes. Such an analysis will usually indicate the scope and feasibility of successful intervention.
- Develop intervention programmes that are informed by established theory, relevant to the type of intervention planned.
- Create the necessary conditions for successful implementation of a programme. This could include ensuring that there is sufficient public and political awareness of the issue and the need for action; developing capacity for programme delivery, e.g. through training of health personnel; and securing the resources required to implement and sustain a programme.
- Ensure that the intervention programme is of sufficient size, duration and sophistication to be detectable above the ‘background noise’ of more general changes in society. Programmes which combine different intervention methods rather than relying on a single methodology are most likely to be successful.
A systematic approach to programme planning such as indicated above will greatly improve the chances of a successful outcome being detected and the possibility of linking observed outcomes to the programme interventions. Proper attention to these issues will do much to avoid circumstances where programmes are implemented before being sufficiently developed, or are too small against a background of activity to produce any detectable difference (rather like testing the effectiveness of a drug in homeopathic doses). There now exist several guidelines and models that can assist in the development of sophisticated and successful health promotion programmes (e.g. Green and Kreuter, 1990; Hawe et al., 1990).
Third, establishing evidence not only requires that the intervention is an appropriate response to the problem, but also that the evaluation research method is appropriate for the intervention. The research method must be dictated by the intervention, and not vice versa.
The systematic review process utilized in evidence-based medicine has placed randomized controlled trials (RCT) as the ‘gold standard’ in intervention evaluation. The effect of this can be seen in an examination of the Cochrane Collaboration site on ‘health promotion’ which lists mostly systematic reviews of interventions that have been evaluated using an RCT methodology. Not surprisingly, the list of reviews is very narrow in scope, limited to relatively simple interventions with well-defined target populations, in specific settings, e.g. smoking cessation interventions with pregnant women in health care settings.
For community-based and community-wide programmes utilizing multiple intervention strategies, RCTs are generally too restrictive. The more effective forms of health promotion action are those that are comprehensive in scope, responsive to the needs of the targeted population, and sustained over the long term. Such interventions are much less easily predicted, controlled and evaluated by conventional experimental designs, e.g. controlled trials (e.g. Tudor-Smith et al., 1998).
Correspondingly, in developing ‘evidence-based health promotion’ there is currently a wide spectrum of methods and measures used in evaluation studies. The relative importance given to the different types of outcome measures (behavioural, structural), and research method (qualitative, quantitative, economic, participative) which are used to establish evidence of effectiveness will vary according to the type of intervention.
This reality for the evaluation of health promotion programmes is becoming more widely recognized. For example, some recent systematic reviews from the Cochrane Collaboration have included both experimental and quasi-experimental studies, and guidelines for assessing the methodological quality of non-RCT outcome evaluation studies in health promotion are being developed.
Evaluation of health promotion is a complex enterprise. The most compelling evidence of effectiveness comes from studies that combine different research methodologies—quantitative with qualitative. The use of a diverse range of data and information sources will provide more relevant and sensitive evidence of the effects of multi-dimensional health promotion interventions than a single ‘definitive’ study.
Given these complexities, there can be no single ‘right’ method or measure to evaluate the effectiveness of programmes, and no ‘absolute’ form of evidence. Evidence of effectiveness is inextricably linked to the entry point (issue, population or setting), method of health promotion intervention and measure of outcome used to judge ‘success’.
The move towards evidence-based health promotion should not be perceived as a threat. It is rather an opportunity to engage in debate about means and ends in health promotion interventions, and the fit between intervention and evaluation methods. We should reject the clumsy and crude application of evaluation methods that have been designed for static forms of medical intervention, and promote the application of research methods that are relevant to the complexities of contemporary health promotion.
REFERENCES
Cochrane Collaboration (1998) Index. www.nihs.go.jp/acc/cochrane/index.htm
Green, L. and Kreuter, M. (1990) Health Promotion Planning: An Educational and Environmental Approach, Mayfield, Mountain View, CA, USA.
Hawe, P., Degeling, D. and Hall, J. (1990) Evaluating Health Promotion: A Health Workers Guide. McLennan and Petty, Sydney, Australia.
Nutbeam, D. (1996) Achieving ‘best practice’ in health promotion: improving the fit between research and practice. Health Education Research, 11, 317–325.
Nutbeam, D. (1998) Evaluating health promotion—progress, problems and solutions. Health Promotion International, 13, 27–43.
Tudor-Smith, C., Nutbeam, D., Moore, L. and Catford, J. (1998) Effects of the Heartbeat Wales Programme over five years on behavioural risks for cardiovascular disease: quasi experimental comparison of results from Wales and a matched reference area. British Medical Journal, 316, 818–822.
World Health Organisation (1997) The Jakarta Declaration on Leading Health Promotion into the 21st Century. Health Promotion International, 12, 261–26.
World Health Organisation (1998) Resolution of the Executive Board of the WHO on health promotion. Health Promotion International, 13, 266.
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