2. Evidence-based Health Promotion & Systematic Reviews I9 October, 2007 / I Introduction to Mastercourse HealthEconomics and Health Promotion Fall 2007 Bo J A Haglund Professor

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

4. E-B Health Promotion / Bo J A Haglund 3 Hierarchy of evidence  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

5. E-B Health Promotion / Bo J A Haglund 4 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

6. E-B Health Promotion / Bo J A Haglund 5 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”

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

8. E-B Health Promotion / Bo J A Haglund 7 Evidence for whom? Defining “values” for different groups  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  health promotion practitioners “value” practicality of implementation of a programme, and the possibilities of engaging people and organisations in action for health.

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

10. E-B Health Promotion / Bo J A Haglund 9 Evidence of what? How to measure success in health promotion? Use of outcome hierarchies which distinguish between:  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

11. E-B Health Promotion / Bo J A Haglund 10 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

12. E-B Health Promotion / Bo J A Haglund 11 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

13. E-B Health Promotion / Bo J A Haglund 12 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 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 tobacco, alcohol Nutbeam : Outcome model for health promotion

14. E-B Health Promotion / Bo J A Haglund 13 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

15. E-B Health Promotion / Bo J A Haglund 14 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 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 tobacco, alcohol Health Promotion Outcomes (intervention impact measures) Health Literacy Measures include: health-related knowledge, attitude, motivation, behavioural intentions, personal skills, self-efficacy Social action & influence Measures include: community participation, community empowerment, social norms, public opinion Healthy public policy & organisational practice Measures include: policy statements, legislation, regulation, resource allocation organisational practices Nutbeam : Outcome model for health promotion

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

17. E-B Health Promotion / Bo J A Haglund 16 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 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 tobacco, alcohol Health Promotion Outcomes (intervention impact measures) Health Literacy Measures include: health-related knowledge, attitude, motivation, behavioural intentions, personal skills, self-efficacy Social action & influence Measures include: community participation, community empowerment, social norms, public opinion Healthy public policy & organisational practice Measures include: policy statements, legislation, regulation, resource allocation organisational practices Health Promotion Actions Education Examples include: patient education, school education, broadcast media communication Social mobilisation Examples include: community development, group facilitation, technical advice Advocacy Examples include: lobbying, political organisation and activism, overcoming bureaucratic inertia Nutbeam : Outcome model for health promotion

18. E-B Health Promotion / Bo J A Haglund 17 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 incorporate combinations of interventions

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

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

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

22. E-B Health Promotion / Bo J A Haglund 21 Health/ wellbeing BehaviourEnvironment Attitudes/ beliefs etc. S.norms/ culture Towards a more integrated model? Behaviour modification Health education Legislation/ regulations Orchestration After: Leif Aaroe 2001

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

24. E-B Health Promotion / Bo J A Haglund 23 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

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

26. E-B Health Promotion / Bo J A Haglund 25 New Evidence Paradigm Systems Based Health Improvement and Development Macdonald 2000