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Evidence-Based Health Promotion

Thomas Elkeles, Ursel Broesskamp-Stone

(last update 02 March 2015)


Evidence and evidence-based practice are terms that have arisen and established themselves very quickly in recent times, especially in the area of medicine and also in Public Health. In health promotion the subject of evidence-based practice has become increasingly significant and relevant in recent years, triggering a wider debate.

In medicine, evidence is understood as a scientifically well-founded, conclusive body of knowledge about the efficacy of medical interventions. It is the basis for the development of quality standards or guidelines for medical practice. The underlying assumption is that there is a hierarchy of evidence. Randomized controlled trials (RCT) are at the top of the hierarchy and are viewed as the ‘gold standard’ of evidence-based studies (see Table 1).

Degree of evidence

Evaluation criteria for medical studies

I

Evidence based on at least one randomized controlled clinical trial of adequate design

II-1

Evidence based on a controlled non-randomized trial of adequate design

II-2

Evidence based on a cohort study or a case-control study of adequate design

II-3

Evidence based on comparative studies of populations in different periods or in different locations with or without intervention

III

Expert opinions based on clinical experience; descriptive studies, reports by expert panels

Table 1. Evaluating medical measures: criteria to assess the rigor of scientific evidence (Canadian Task Force 1994, in: Jakubowski and Krech 2001, 144).

A concept of evidence like that in the medical field is questionable for the area of health promotion. RCTs are considered inappropriate here, even counter-productive. As a result, Noack suggested that in health promotion, evidence should ‘be seen as a comprehensive, plausible body of knowledge about the efficacy of complex health-promoting activities in complex social systems or living environments’. Health promotion requires a concept of evidence that takes into account the multi-dimensional aspects of health promotion as well as the holistic view of health. At the heart of the discussion are questions about the concept of evidence and the question about outcomes and methods.

The concept of ‘evidence’ means first of all the highest degree of certainty regarding a (presumed) fact. How one attains certainty, however, is seen differently in different philosophical and epistemological schools. For evidence-based health promotion, it is, additionally, crucial how firstly health promotion itself and secondly its effectiveness is understood and conceptualized.
As far as the demand for an evidence base means no more than establishing and applying the best available evidence regarding efficacy and economy, there could hardly be any objection. On the contrary: Instead of ‘narrative evidence’ or ‘internal evidence’, systematic, academically supported searches for evidence, e.g. in meta-analyses, should certainly be encouraged.

In contrast to evidence-based medicine, whose database consists of clinical and epidemiological trials with closely defined questions leading to statements about the efficacy of certain medical procedures, in health promotion the database of (complex) programs and their evaluations has to be broader, and above all take account of the relevant context (cf. Elkeles 2012).

Therefore, national and international general surveys on meta-analyses and systematic reviews of the efficacy of health promotion regularly conclude that the study and results situation in the category ‘health promotion’, even in the favorable case, covers a closely-limited class of intervention types, outcomes and results. In the unfavorable case, the method of systematic reviews to ‘measure’ the evidence level of ‘health promotion’ fails as a result of the number and nature of the study documentations. If complex interventions are captured in such reviews at all, then usually on a closely-defined subject measurable with traditional results indicators (accident rates, tobacco-quitting rates, condom use). That is not, however, the core of the actual need to evaluate health-promotion programs and to base them on evidence.

In the continuation or implementation of the Ottawa Charter and in line with current insights into the breadth of the determinants of health (or of the major physical, psychological and social factors that influence health), we think of ‘health promotion’ as interventions in social systems or social programs and strategies, which a) aim at changing living conditions (and not just individual behavior patterns) relevant to health, and which b) for sustainable and useful results, as well as for the management of uncertainty and context dynamics, include the significant element of active involvement on the part of those affected in improving their health opportunities. On this basis, we can say:

  • In the case of health promotion, the interventions tend to be in social systems or social programs that are always context-dependent.
  • A quantitative evidence hierarchy whose evidence ideal deliberately ignores the context of a situation (‘blinding’) is therefore not appropriate.
  • Ideally, health promotion programs are being directly developed in the actual setting/ environment, or  well-known measures are adopted there and combined with other measures, depending on needs and requirements. Dependent (and possible independent) variables are therefore not known at the outset and vary greatly depending on the context or the setting.
  • Health-promotion programs that aim at changing a large number of interacting (social, economic, ecological) health parameters or determinants, including health-related actions, and/or which count on the emancipative potentials for change among those involved in the actual setting, are almost impossible to describe in linear cause-and-effect relationships, or are hard to break down into such relationships because of their multi-factorial complexity. A lot more research is needed to arrive at a sufficiently differentiated understanding of the active processes and corresponding evaluation methods.

Widespread statements such as ‘there is a lot of/not much evidence’ actually say nothing at all, unless they also state: ‘evidence of what?’ In Western countries, the use of the word ‘evidence’ or ‘evidence-based’ often tacitly implies transferring only ‘measures proved to be effective’ to other contexts. The question of what such proof might look like in health promotion (and what it cannot look like), and what limits it comes up against, has been addressed above. Evidence of effectiveness is an important part, but not the only evidence base of health promotion. We must also add the evidence concerning the important influencing factors (determinants) of health and their complex interactions. The understanding of ‘evidence’ is undergoing change in health promotion, and on an international scale a consensus is beginning to emerge. If we understood the establishment of an evidence base as a ‘legitimation science’, however, in order thereby to seek to justify one’s own existence, we would fall behind the standard already achieved (in Germany: statutory legitimation as a service to be provided by (occupational) health promotion by the statutory health funds).

Regardless of whether the concept of evidence is seen in a wider or more narrowly defined sense, it is true that a one-sided focus on ‘evidence-based’ as the general quality criterion, or as a must for ‘acceptable’ decision-making and action, for optimum practice and policy in the field of health promotion and beyond, has been relativized by the increasing use of the term ‘evidence-informed’ instead of ‘evidence-based’ (initially in [Healthy Public] Policy, and later in other areas of health promotion and public health, such as for important decision-making processes). This does not entail rejecting the demand for an evidence base; instead it recognizes that an evidence base is usually not the sole measure on which optimum decisions and measures in the area of health promotion are based. As more recent best-practice approaches reflect, being ‘evidence-based’ is just one of several important criteria for the quality and sustainable effectiveness of interventions.

On the basis of international work and discourse on ‘evidence-based health-promotion’, Gesundheitsförderung Schweiz (Health Promotion Switzerland) developed a new understanding of best practice in health promotion and disease prevention with three dimensions: values, knowledge and context. An evidence base is a significant element in the knowledge dimension. All three dimensions, not just the knowledge base, are to be repeatedly reflected in everyday decisions and actions in the field of health promotion (resembling a radar beam; see Figure 1).

Figure 2. Radar screen model of best practice.

Figure 2. Radar screen model of best practice.

There are seven best-practice criteria, all of which have three to five indicators: one overriding criterion, one each for the ethical base or value base and for the context of measures; three for dealing with knowledge or evidence, and one final overriding criterion.

  • Overriding criterion: When making strategic decisions and when planning, implementing and evaluating health promotion and prevention activities, sufficient time must be spent on reflecting and appropriately considering the three best practice dimensions (values, knowledge,
    context; cf. Figure 1). This should be done systematically, using adequate existing tools.
  • Values: When making strategic decisions and when planning, implementing and evaluating health promotion and prevention activities, the fundamental (ethical) values and principles of health promotion (and public health) are given due consideration (e.g. the avoidance of harm, respecting a person’s autonomy, equal opportunities with regard to health, sustainability, empowerment).
  • Knowledge: a) Decisions and activities are based on current scientific knowledge (systematic research, not taking knowledge into account needs to be well justified); b) Decisions and actions contribute to strengthening the scientific base or evidence base of health promotion and prevention (incl. documenting gaps in knowledge; where necessary/appropriate, contributing to closing these gaps; evaluation); c) In addition to scientific knowledge, decisions and activities are also based on other important knowledge (e.g., expert opinions/own experience; theoretical and practical knowledge are to be weighed up carefully against each other, see Figure 2).
  • Context: When making strategic decisions and when planning, implementing and evaluating health promotion and prevention activities, the context ist given appropriate consideration. e.g. existing capacities for measures (policies, leadership, high degree of professionalization, participation mechanisms); laws, political/cultural factors are to be taken into account (i.e. thought should be given to the transferability of scientific insights and interventions to one’s own context; potential adaptations must be properly justified).
  • Final overriding criterion: The intended positive effects have been achieved and negative effects have been avoided.’
Figure 3. Knowledge cycle.

Figure 3. Knowledge cycle.

Reflecting on the ethical or value base of public health and health promotion before embarking on any knowledge research could have a positive influence on the knowledge base or evidence base of a decision making or planning measure (e.g. the equal-opportunities perspective promotes the search for effective measures for the socially disadvantaged, the sustainability perspective the search for sustainably effective measures). The best-practice criteria and indicators in the area of knowledge promote a differentiated understanding of evidence appropriate to the object of health promotion with its complex interventions: depending on the object (to be examined), a different type of study may be the ‘best’ (evidence prism instead of evidence hierarchy, see Figure 3).

Figure 4. Evidence prism.

Figure 4. Evidence prism.

In general, what matters in all areas of health promotion is that the evidence base is improved through the use of scientific evaluation and quality development. On the basis of the given scientific level of knowledge, a plausibility appraisal should be carried out to determine whether the suggested interventions could produce positive effects to an extent that could be roughly estimated. Generally speaking, this entails sketching an impact model with hypotheses that need to be tested. One model, now widespread, to classify health-promotion results and at the same time a tool to develop such logic models is the Swiss Model for Outcome Classification’ (SMOC) by Health Promotion Switzerland, the further development of Nutbeam’s outcome model. It supports the definition of adequate measuring parameters for health-promotion methods and approaches, taking into account that a) processes as well as the outcomes represent a central success factor, and that b) it is not just positive changes to health, but changes to the determinants or resources for health (e.g. behaviour, circumstances) that constitute important results - and even changes to the factors influencing these determinants/resources (e.g. political decisions). Systematic reference to impact models such as SMOC make a contribution to the necessary formulation and development of theories in health promotion, which in turn makes it easier for those involved in health promotion to develop a better understanding of the implementation processes and success factors.

References:
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Internet addresses:
http://gesundheitsfoerderung.ch/assets/public/documents/1_de/a-public-health/ 1-grundlagen/qualitaet/best_practice/Best-Practice-Konzept.pdf
http://www.eufep.at/ (The European Forum for Evidence-based Health Promotion and Prevention is an international platform for best practice in evidence-based prevention programs.)

Links: Public Health Services and Health Promotion


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