The Evidence of Health Promotion Effectiveness. Shaping Public Health in a New Europe

The justification for health education and health promotion interventions has had a long and tortuous history. Health education and subsequently health promotion has had to continually justify its use of resources in a way that not only satisfies methodologists, but perhaps more importantly fund holders. Indeed it could be argued that health promotion was in the vanguard of the movement that sought evidence of effectiveness. In the early days of the discipline and practice this call for evidence was half-hearted, and so the methods employed to evaluate interventions were in turn half-hearted and a little limited. Typically they would report on the number of attendees at a health education session or the number of leaflets distributed over a specific time frame. However, over time, this simplistic view gave way to much more sophisticated attempts at evaluation. The North Karelia Project, Heartbeat Wales and the Stanford studies all attempted to grapple with experimental evaluative design, perhaps, at that time, seduced by the power of the `scientific' experimental method. Despite relatively large resources, these interventions had limited effect on population health. Perhaps more accurately, it was impossible to determine that effect because of problems associated with control and contamination. In the twilight years of these types of quasi- experimental evaluative methodologies, governments in many capitalists democracies, worried about spiralling health and social care costs, began calling for greater evidence of effectiveness for all interventions clinical and non-clinical. Medicine took a lead and established the Cochrane Collaboration and the highly visible acronym EBM (Evidence-Based Medicine). Others duly followed including the EBHP movement which began exploring novel evaluative methods and new approaches to establishing an evidence base. Publications in this area have mushroomed in the last 5 years, and the International Union for Health Promotion and Education has established an interest in this area with the publication The Evidence of Health Promotion Effectiveness. The publication and research leading up to it was funded by the Commission of the European Communities and it is designed to provide decision makers, principally within the EU and the Commission, with a crystallized form of evidence that may form the basis for public health action in Europe. It is an attempt to define health promotion work and its effectiveness in an effort to stimulate debate in Europe prior to the new EU Public Health Framework. The book's development was aided by a `political witness group' who helped frame the design such that it would be more appealing to policy makers. The publication is divided into two parts. The first (Part 1) is a short (30 pages) guide for decision makers and the second (Part 2) is a longer (166 pages), more detailed examination of the evidence. Both parts carry symbols designed to aid or help the reader determine whether the research evidence warranted action or caution. I found them more a hindrance than a help. Part 1, written by David Boddy, a professional lobbyist, sets out in a clearly designed and logical way, a brief history of health promotion and the part it could play in shaping the new public health framework in Europe, with short chapters on the evidence of effectiveness. These are viewed as either politically challenging, and include ageing, mental illness and the `disenfranchised' (de jure if not de facto); or health challenging, and include heart disease and smoking; or socially challenging, and include nutrition and keeping safe; or placed within settings. Here the workplace, school and health care interventions are covered. The reason for allocating the seven topic or target groups into the first three challenge categories is not clear, but the settings approach is a more easy model to understand. Two case studies, on oral health and equity, are summarized as good examples of where health promotion can make a difference. The first part of the publication concludes by highlighting the health, social and economic impact health promotion programmes can and do have. These are reformed into a series of recommendations (15 in total) for policy makers and based on the evidence reported in Part 2. The much more substantial Part 2 elaborates on the 10 challenges summarized in Part 1. Academics and practitioners from around the globe, but principally Europe with a distinctive Anglo/London feel, were asked to assess the evidence for health promotion effectiveness through reviews of published papers. They were asked then to estimate the impact the interventions had on individual, social and economic health and status. A chapter at the beginning of this second book by Nutbeam sets out a possible framework for evidence, essentially based on an outcome model. Debates on the merits of an outcome-oriented approach to evaluative methodologies is ongoing, as is, indeed, discussion on the meaning of outcome, but it is a pity that this pivotal chapter does not use the same framework and terms utilized by the contributing experts in the subsequent chapters. Nutbeam's illustration uses terms such as health literacy, education, advocacy, environment, lifestyles, etc., within a framework highlighting `intermediate health outcomes', `health promotion outcomes' and `health promotion actions'. I am not really clear on the distinction between `intermediate health outcomes', which are essentially concerned with modifying the determinants of health (i.e. lifestyle health promotion programmes), and `health promotion outcomes', which measure changes in knowledge and attitudes. Of more concern is the fact that this model, which has its merits, is not replicated in the following 10 chapters where examples of health promotion effectiveness are examined. Here the authors with one or two exceptions follow the health, social and economic impact model highlighted in Part 1. Some of the tasks in producing evidence are clearly easier for some authors than for others. I can provide two as case exemplars. The evidence for effective health promotion interventions in the area of safety promotion, for example, is convincing, and Svanstrom provides a succinct and persuasive argument. In the area of disenfranchised youth, the case for effectiveness is less sound. Warren concentrates on sexual health promotion and young people, and provides some useful evidence of effectiveness, but he draws on examples from Tanzania, Cameroon, Pakistan and the US, which may have limited implications for EU policy development. More generally the evidence in this area is questionable since many of the cited references are not based on empirical studies. Even where they are, we have no way of knowing the rigour of the methodology or the validity and reliability of the data. This fundamental problem pervades all (systematic) reviews, meta-analyses or otherwise, in health promotion and this publication is no exception. The problem is, and many contributing authors acknowledge this, the evidence is hard to find, particularly in some critical areas. Academics reviewing papers have to either accept most publications and sacrifice quality for quantity or develop a rigorous vetting procedure a la Cochrane and gain quality at the expense of quantity. It appears in the case of this publication that the writing team has erred on the side of the former. This is, in a sense, to be expected, since a rigorous framework for systematically reviewing published papers in health promotion has not yet been developed, although Cochrane and the Health Development Agency in London are currently attempting this. The second part to the publication concludes with the case studies alluded to in Part 1, i.e. oral health promotion effectiveness, where the evidence appears straightforward and robust, and equity and health promotion effectiveness, where the evidence is less straightforward and compelling, unless you include a range of broad social and economic measures as falling into the category of health promotion interventions. Added to these two case studies is an informative chapter on the Canadian experience of developing a suitable infrastructure for the effective delivery of public health and health promotion. These two sister publications provide a useful and, it has to be said that within the constraints outlined above, a thorough guide to impact effectiveness in health promotion across the globe. However, it needs to be treated with caution. The guide was written by advocates of health promotion, on behalf of an agency charged with representing the needs of health promoters around the world. Top-quality interventions with or supported by rigorous evaluations are hard to find. This point could have been made more forcefully. We do not want science and rigour confused with self-promotion and evangelism. These two books gather together a worthwhile record of the usefulness of a multitude of health promotion interventions world-wide and, with the collective wisdom of major academic authorities in the area of public health, have provided an invaluable base for evidence of effectiveness. That base is malleable at the moment and we should think of evidence in the same way. It will never be absolute in the case of health promotion, but persuasive. We need to use and interpret it judiciously. Copies of the publications can be obtained from the IUHPE offices at: 2 Rue Auguste Comte, 92170 Vanves, France.