Evidencebased Health Promotion Systematic Reviews I 9 October

Evidence-based Health Promotion & Systematic Reviews I 9 October, 2007 / I Introduction to Mastercourse Health. Economics and Health Promotion Fall 2007 Bo J A Haglund Professor E-B Health Promotion / Bo J A Haglund

Definitions Evidence Information that is used in making decisions E-B Health Promotion / Bo J A Haglund 2

Hierarchy of evidence u u u u u 1 - Properly-designed randomised controlled trials - RCTs 2 - Well-designed controlled trials without randomisation 3 - Well-designed cohort or case control analytical studies 4 - Comparisons between times or places with or without the intervention 5 - Opinions of respected authorities based on clinical experience, descriptive studies or reports of expert committees 6 - Surveys of experience, perception and reported impact 7 - Self-report through structured interviews, semi-structured interviews and questionnaires; action research 8 - Observation of practice; case studies 9 - Life histories 10 – “Fictional” accounts composed from scattered and relatively unsystematised information E-B Health Promotion / Bo J A Haglund 3

Appropriate evidence Given these complexities, there can be no single ”right” method or measure to evaluate effectiveness of programmes, and no ”absolute” form of evidence E-B Health Promotion / Bo J A Haglund 4

Appropriate evidence Evidence of effectiveness is inextricably linked to the entry point (health issue, population or setting), method of health promotion intervention and measure of outcome used to judge ”sucess” E-B Health Promotion / Bo J A Haglund 5

The meaning of “evidence” in health promotion u Four questions: Evidence for whom? • Defining “values” for different groups Evidence of what? • How to measure success in health promotion? Evidence from what? • What makes a good intervention? Evidence through what? • What is the best evaluation research method for health promotion interventions? E-B Health Promotion / Bo J A Haglund 6

Evidence for whom? Defining “values” for different groups u u Identify different Stakeholders e. g. policy makers and budget managers “value” the relationship between investment and the achievement of health outcomes in the short-term u health promotion practitioners “value” practicality of implementation of a programme, and the possibilities of engaging people and organisations in action for health. E-B Health Promotion / Bo J A Haglund 7

Evidence for (whom) what purpose? u Biomedical approach • Is health promotion about improving medical treatment? u Behavioural change approach • or. . about changing lifestyles? u Socio-environmental approach • or. . about changing social conditions? E-B Health Promotion / Bo J A Haglund 8

Evidence of what? How to measure success in health promotion? Use of outcome hierarchies which distinguish between: u u u changes to health and social outcomes (usually long term) changes to health determinants (behavioural, economic, environmental, usually medium term) health promotion impacts (changes to knowledge, motivation, capacity, social norms, public policy organisational practice usually in short-term) Implies use of much wider range of indicators E-B Health Promotion / Bo J A Haglund 9

Nutbeam : Outcome model for health promotion Social and Health Outcomes Social Outcomes Measures include: quality of life, functional independence, social capital, equity Health Outcomes Measures include: reduced morbidity, disability, avoidable mortality E-B Health Promotion / Bo J A Haglund 10

Intermediate health outcomes Determinants of health and social outcomes: ¨healthy lifestyles - personal behaviours which provide protection or enhance health status and quality of life ¨healthy environments - physical, social and economic conditions which protect and enhance health and quality of life, and/or make healthy lifestyles more easy ¨effective health services - which provide equitable access and appropriate services for prevention, early detection of disease, treatment and care E-B Health Promotion / Bo J A Haglund 11

Nutbeam : Outcome model for health promotion Intermediate Health Outcomes (modifiable determinants of health) Healthy Lifestyles Measures include: tobacco use, physical activity, food choices alcohol and illicit drug use Effective health service Measures include: provision of preventive services, access to and appropriateness of health services Healthy Environments Measures include: safe physical environment, supportive economic and social conditions, good food supply, restricted access to E-B Health Promotion /tobacco, Bo J A alcohol Haglund Social and Health Outcomes Social Outcomes Measures include: quality of life, functional independence, social capital, equity Health Outcomes Measures include: reduced morbidity, disability, avoidable mortality 12

Health promotion outcomes Personal, social and environmental determinants of intermediate health outcomes ¨health literacy - the cognitive and social skills which determine the motivation and ability of individuals to act to promote their health ¨social actions and influence - the actions and influence of social groups through social action, social support, and social norms ¨healthy public policy and organisational practice - legislation, funding, regulation and incentives which influence organisational practices and environments E-B Health Promotion / Bo J A Haglund 13

Nutbeam : Outcome model for health promotion Health Promotion Outcomes Intermediate Health Outcomes (intervention impact measures) (modifiable Social and Health Outcomes determinants of health) Health Literacy Measures include: health-related knowledge, attitude, motivation, behavioural intentions, personal skills, self-efficacy Healthy Lifestyles Measures include: tobacco use, physical activity, food choices alcohol and illicit drug use Social action & influence Measures include: community participation, community empowerment, social norms, public opinion Effective health service Measures include: provision of preventive services, access to and appropriateness of health services Healthy Environments Healthy public policy & Measures include: organisational practice safe physical environment, Measures include: supportive economic and policy statements, social conditions, good food legislation, regulation, supply, restricted access to resource allocation E-B Health Promotion /tobacco, Bo J A alcohol organisational practices Haglund Social Outcomes Measures include: quality of life, functional independence, social capital, equity Health Outcomes Measures include: reduced morbidity, disability, avoidable mortality 14

Health Promotion Actions u Education - eg peer education, mass media communications u Social mobilisation - eg group facilitation, community development u Advocacy - eg lobbying, political organisation and activism E-B Health Promotion / Bo J A Haglund 15

Nutbeam : Outcome model for health promotion Health Promotion Actions Health Promotion Outcomes Intermediate Health Outcomes (intervention impact measures) (modifiable determinants of health) Education Examples include: patient education, school education, broadcast media communication Health Literacy Measures include: health-related knowledge, attitude, motivation, behavioural intentions, personal skills, self-efficacy Healthy Lifestyles Measures include: tobacco use, physical activity, food choices alcohol and illicit drug use Social mobilisation Examples include: community development, group facilitation, technical advice Social action & influence Measures include: community participation, community empowerment, social norms, public opinion Effective health service Measures include: provision of preventive services, access to and appropriateness of health services Advocacy Examples include: lobbying, political organisation and activism, overcoming bureaucratic inertia Social and Health Outcomes Healthy Environments Healthy public policy & Measures include: organisational practice safe physical environment, Measures include: supportive economic and policy statements, social conditions, good food legislation, regulation, supply, restricted access to resource allocation tobacco, E-B Health Promotion / Bo J A alcohol organisational practices Haglund Social Outcomes Measures include: quality of life, functional independence, social capital, equity Health Outcomes Measures include: reduced morbidity, disability, avoidable mortality 16

Key features of health promotion outcomes model ¨Health outcomes are not an end in themselves, but a means to improved quality of life ¨behaviour change is not the only route to improved health ¨“success” in health promotion should be considered primarily in terms of health promotion outcomes ¨health promotion strategy needs to Health Promotion / Bo J A incorporate E-B combinations of interventions Haglund 17

Evidence from what? What makes a good intervention? Theory based u Proper planning models u Quality assurance of the implementation process u E-B Health Promotion / Bo J A Haglund 18

Two types of theories u Change theories • Development/ Implementation of programs Individual level – Beh. change theory u Organisational level – Org. change theory u Population level – Comm. change theory. u u Explanation theories • Nature of problem Dürkheim Social integration (Sense of belonging (social capital)) u Bowlby Attachment theory (Bonding early in life) E-B Health Promotion / Bo J A u Botl, Wellman Social Network theory Haglund u 19

Evidence through what? What is the best evaluation research method for health promotion interventions? Multi-level interventions require multi- layer evaluations u E-B Health Promotion / Bo J A Haglund 20

Behaviour modification Towards a more integrated model? Health education Legislation/ regulations Attitudes/ beliefs etc. S. norms/ culture Behaviour Environment Health/ wellbeing E-B Health Promotion / Bo J A Haglund Orchestration After: Leif Aaroe 212001

Integrated Theoretical Model after Macdonald 2000 Shape & influence Socio structural factors Culture, Economy, Politics Provide opportunities Social Networks Affect health Psycho-social mechanisms Pathways Structure Social support Lifestyles/Behavio Charactersitics. Social influence Psychological hea Social engagement Physical health Acess to …. . E-B Health Promotion / Bo J A Haglund 22

Systems paradigm “we have to refocus the search for evidence away from individual /population health / illness outcomes towards systems determinants of health” thus from consequences to causes E-B Health Promotion / Bo J A Haglund 23

A New Evidence Paradigm Through a Systems approach to health Social/ Community System Organisational System Collecting new Evidence Policy/ Governance System E-B Health Promotion / Bo J A Haglund Political/ Economic System 24

New Evidence Paradigm Systems Based Health Improvement and Development E-B Health Promotion / Bo J A Haglund Macdonald 200025 25