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

Abstract

The Evidence of Health Promotion ence-Based Medicine). Others duly followed including the EBHP movement which began Effectiveness. Shaping Public Health in a exploring novel evaluative methods and new New Europe approaches to establishing an evidence base. Pub-International Union for Health Promotion lications in this area have mushroomed in the last and Education/Commission of the 5 years, and the International Union for Health European Union Promotion and Education has established an inter-IUHPE, Vanves, France, 1999 est in this area with the publication The Evidence Part 1 Core Document 30 pp. of Health Promotion Effectiveness. Part 2 Evidence Book 164 pp. The publication and research leading up to it was funded by the Commission of the European The justification for health education and health Communities and it is designed to provide decision promotion interventions has had a long and tortuous makers, principally within the EU and the Commis-history. Health education and subsequently health sion, with a crystallized form of evidence that may promotion has had to continually justify its use form the basis for public health action in Europe. of resources in a way that not only satisfies It is an attempt to define health promotion work methodologists, but perhaps more importantly fund and its effectiveness in an effort to stimulate debate holders. Indeed it could be argued that health in Europe prior to the new EU Public Health promotion was in the vanguard of the movement Framework. The book's development was aided that sought evidence of effectiveness. In the early by a 'political witness group' who helped frame days of the discipline and practice this call for the design such that it would be more appealing evidence was half-hearted, and so the methods to policy makers. employed to evaluate interventions were in turn The publication is divided into two parts. The half-hearted and a little limited. Typically they first (Part 1) is a short (30 pages) guide for decision would report on the number of attendees at a makers and the second (Part 2) is a longer (166 health education session or the number of leaflets pages), more detailed examination of the evidence. distributed over a specific time frame. Both parts carry symbols designed to aid or help However, over time, this simplistic view gave the reader determine whether the research evidence way to much more sophisticated attempts at evalu-warranted action or caution. I found them more a ation. The North Karelia Project, Heartbeat Wales hindrance than a help. Part 1, written by David and the Stanford studies all attempted to grapple Boddy, a professional lobbyist, sets out in a clearly with experimental evaluative design, perhaps, at designed and logical way, a brief history of health that time, seduced by the power of the 'scientific' promotion and the part it could play in shaping experimental method. the new public health framework in Europe, with Despite relatively large resources, these inter-short chapters on the evidence of effectiveness. ventions had limited effect on population health. These are viewed as either politically challenging, Perhaps more accurately, it was impossible to and include ageing, mental illness and the 'disen-determine that effect because of problems associ-franchised' (de jure if not de facto); or health ated with control and contamination. challenging, and include heart disease and smok-In the twilight years of these types of quasi-ing; or socially challenging, and include nutrition experimental evaluative methodologies, govern-and keeping safe; or placed within settings. Here ments in many capitalists democracies, worried the workplace, school and health care interventions about spiralling health and social care costs, began are covered. The reason for allocating the seven calling for greater evidence of effectiveness for all topic or target groups into the first three challenge interventions clinical and non-clinical. Medicine categories is not clear, but the settings approach is took a lead and established the Cochrane Collabora-a more easy model to understand. Two case studies, on oral health and equity, are summarized as good tion and the highly visible acronym EBM (Evid-© Oxford University Press 2000 233 Book review examples of where health promotion can make a the area of safety promotion, for example, is convincing, and Svanstrom provides a succinct and difference. The first part of the publication con-cludes by highlighting the health, social and eco-persuasive argument. In the area of disenfranchised youth, the case for effectiveness is less sound. nomic impact health promotion programmes can and do have. These are reformed into a series of Warren concentrates on sexual health promotion and young people, and provides some useful evid-recommendations (15 in total) for policy makers and based on the evidence reported in Part 2. ence of effectiveness, but he draws on examples from Tanzania, Cameroon, Pakistan and the US, The much more substantial Part 2 elaborates on the 10 challenges summarized in Part 1. Academics which may have limited implications for EU policy development. More generally the evidence in this and practitioners from around the globe, but prin-cipally Europe with a distinctive Anglo/London area is questionable since many of the cited refer-ences are not based on empirical studies. Even feel, were asked to assess the evidence for health promotion effectiveness through reviews of pub-where they are, we have no way of knowing the rigour of the methodology or the validity and lished papers. They were asked then to estimate the impact the interventions had on individual, reliability of the data. This fundamental problem pervades all (system-social and economic health and status. A chapter at the beginning of this second book by Nutbeam atic) reviews, meta-analyses or otherwise, in health promotion and this publication is no exception. sets out a possible framework for evidence, essen-tially based on an outcome model. Debates on The problem is, and many contributing authors acknowledge this, the evidence is hard to find, the merits of an outcome-oriented approach to evaluative methodologies is ongoing, as is, indeed, particularly in some critical areas. Academics reviewing papers have to either accept most pub-discussion on the meaning of outcome, but it is a pity that this pivotal chapter does not use the same lications and sacrifice quality for quantity or develop a rigorous vetting procedure a la Cochrane framework and terms utilized by the contributing experts in the subsequent chapters. Nutbeam's and gain quality at the expense of quantity. It appears in the case of this publication that the illustration uses terms such as health literacy, education, advocacy, environment, lifestyles, etc., writing team has erred on the side of the former. This is, in a sense, to be expected, since a within a framework highlighting 'intermediate health outcomes', 'health promotion outcomes' rigorous framework for systematically reviewing published papers in health promotion has not yet and 'health promotion actions'. I am not really clear on the distinction between 'intermediate health been developed, although Cochrane and the Health Development Agency in London are currently outcomes', which are essentially concerned with modifying the determinants of health (i.e. lifestyle attempting this. The second part to the publication concludes health promotion programmes), and 'health promo-tion outcomes', which measure changes in know-with the case studies alluded to in Part 1, i.e. oral health promotion effectiveness, where the evidence ledge and attitudes. Of more concern is the fact that this model, which has its merits, is not replicated in appears straightforward and robust, and equity and health promotion effectiveness, where the evidence the following 10 chapters where examples of health promotion effectiveness are examined. Here the is less straightforward and compelling, unless you include a range of broad social and economic authors with one or two exceptions follow the health, social and economic impact model high-measures as falling into the category of health promotion interventions. Added to these two case lighted in Part 1. Some of the tasks in producing evidence are studies is an informative chapter on the Canadian experience of developing a suitable infrastructure clearly easier for some authors than for others. I can provide two as case exemplars. The evidence for the effective delivery of public health and health promotion. for effective health promotion interventions in 234